Health inspection·August 12, 2025

F 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) was provided with correct information regarding the specific location where Resident 1 was being discharged in the Notice of Transfer or Discharge the facility provided to Resident 1. This deficient practice had the potential to result in confusion and affect the delivery of care and services to Resident 1.Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted the resident on 6/6/2024 and readmitted on [DATE] with diagnoses including epilepsy (a brain condition that causes recurring seizures[a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness]), ileostomy (a surgical procedure that creates an opening, called a stoma, on the abdomen to allow waste [stool and gas] to exit the body when the colon or rectum is not working properly), and acute respiratory failure (a serious condition that makes it difficult to breathe on your own) with hypoxia (when your body, or a part of your body, does not get enough oxygen).During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 6/6/2025, the MDS indicated Resident 1's cognitive function was intact (an individual's mental abilities, including thinking, learning, and remembering, are functioning at a normal level for their age and without significant decline). The MDS indicated Resident 1 required partial assistance (helper does less than half the effort) with toileting, requires supervision (helper provides verbal cues and or touching and or contact guard assistance) with showering, required set up (helper sets up or cleans up) with personal hygiene, and was independent (completes activity on own) with eating, oral hygiene, upper and lower body dressing, putting on and taking off shoes.During a review of Resident 1's Physician Order, dated 6/5/2025, the Physician Order indicated to discharge Resident 1 to Assisted Living Facility (AL) 1 on 6/6/2025 at 2 p.m.During a review of Resident 1's Physician Order, dated 6/6/2025, the Physician Order indicated to discharge Resident 1 to AL 2.During a review of Resident 1's Notice of Transfer or Discharge, dated 6/6/2025, the Notice of Transfer or Discharge indicated Resident 1 had a planned discharge to AL 1. The Notice of Transfer or Discharge indicated it was signed by facility representative and Resident 1.During an interview on 8/12/2025 at 11:32 a.m. with the Social Services Director (SSD), the SSD stated Resident 1 had met with a placement coordinator and agreed to be discharged to AL 1. The SSD stated on 6/6/2025 when transportation came to pick up Resident 1 for Resident 1's discharge. SSD stated verified AL 1's address and transportation notified SSD that Resident 1 was being transferred to AL 2. The SSD stated contacted the placement coordinator who notified SSD AL1 did not have a room for Resident 1, but AL 2 did have a room for Resident 1. The SSD stated verified verbally with Resident 1 if he (Resident 1) was okay with being discharged to AL 2. The SSD stated Resident 1 agreed to the discharge.During a concurrent interview and record review on 8/12/2025 at 2 p.m., Resident 1's Notice of Transfer or Discharge was reviewed with the Director of Nursing (DON). The DON Page 1 of 2 056333 056333 08/12/2025 Mountain View Conv Hosp 13333 Fenton Avenue Sylmar, CA 91342

F 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated Resident 1 received the notice of discharge. The DON stated Resident1 had agreed to be discharged to AL 1. The DON stated was notified by SSD that Resident 1 was placed in a different facility (AL 2), the DON stated she (DON) verified with the SSD that Resident 1 had agreed to the placement and SSD stated Resident 1 had agreed to the placement. The DON stated the Notice of Transfer or Discharge is provided by the Registered Nurse (RN) when the resident is being discharged , the medications are reviewed, any follow up visit and home health are reviewed, then it is signed by both the resident and the RN. The DON reviewed the Notice of Transfer or Discharge, and the DON stated the notice indicated Resident 1 was discharged to AL 1. The DON stated the facility did not provide Resident 1 with the Notice of Transfer or Discharge for the new facility (AL 2). There was no documented evidence there were changes made to Resident 1's Notice of Transfer or discharge before Resident 1's discharge. The DON reviewed the facility policy titled, Transfer or Discharge, Facility-Initiated, and the DON stated per the facility policy the resident should be given the specific location they (residents) are going to. The DON stated the signed Notice of Transfer or Discharge is not accurate because there is a potential to not have accurate records. The DON stated the facility needs to communicate with home health because there is a potential with home health to not be aware of Resident 1 going to AL 2, potentially resulting in Resident 1 missing on services.During a review of the facility's policy and procedure (P&P) titled, Transfer or Discharge, Facility-Initiated, last reviewed on 9/2024, the P&P indicated the resident and representative are notified in writing of the following information:c. The specific location (such as the name of the new provider or description and or address if the location is a residence) to which the resident is being transferred or discharged .During a review of the facility P&P titled, Charting and Documentation, last reviewed on 9/2024, the P&P indicated documentation in the medical record will be objective, complete, and accurate. 056333 Page 2 of 2