Health inspection·April 9, 2024

F 0624 Prepare residents for a safe transfer or discharge from the nursing home. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure one of three sample selected residents (Resident 1) had a safe and orderly discharge from the facility, when the facility discharged Resident 1 to home without preparation and orientation to the discharge and did not provide complete discharge medication for Resident 1. Residents Affected - Few This failure resulted in Resident 1 suffering from pain and did not have pain medication as ordered by the physician (MD). Findings: A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility with multiple diagnoses including joint replacement surgery on left knee and chronic pain. During an interview on 4/5/24 at 11:17 a.m. with Resident 1, Resident 1 stated she was at the facility for one day and the facility discharged her home without giving her pain medication for home use as ordered by MD. Resident 1 stated she suffered from too much pain and the next day staff from the facility picked up Resident 1's pain medication from the pharmacy and dropped it off at her house. Furthermore, Resident 1 stated the discharge was not initiated by her, and it was the facility's decision. A review of Progress Notes, dated 10/3/23, indicated Patient (Resident 1) discharged home at 19:45 via private transport accompanied by daughter. Patient signed discharge paperwork. Medications given to discharge home with patient . A review of the MD order, dated 10/3/24, indicated Hydromorphone HCL (narcotic analgesics, pain medication) oral tablet 4 mg (milligram) give 1 tablet by mouth every 4 hours as needed for moderate pain. During an interview on 4/9/24 at 1:11 p.m., with Clinical Liaison (CL), CL stated when Resident 1 was discharged home, the facility did not have the pain medication (hydromorphone) ordered by MD and they had to send the order to the pharmacy. The next day, CL picked up the pain medication from the pharmacy and dropped it off at Resident 1's house. A review of non-visit MD order on 10/3/24 at 19:10 p.m., indicated MD discharged Resident 1 from the facility. During an interview on 4/9/24 at 1:00 p.m., with MD, MD stated he discharged Resident 1 home without visiting him, however MD did not remember why Resident 1 was discharged home. Page 1 of 3 056399 056399 04/09/2024 LA Casa via Transitional Care Center 1449 Ygnacio Valley Road Walnut Creek, CA 94598

F 0624 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a concurrent record review and interview on 4/9/24 at 12:35 p.m. with the Clinical Manager (CM), CM reviewed Resident 1's documents and was unable to find the discharge papers signed by Resident 1 and reviewed the progress notes and stated there were no notes that indicated why and how Resident 1 was discharged home. CM was not able to find the list of the medications or any other documents that the facility gave to Resident 1. CM also did not find any discharge care plan for Resident 1. CM stated Resident 1's discharge was not planned correctly. A review of Resident 1's care plan indicated the facility did not create a care plan for Resident 1's discharge. A review of the facility's policy and procedure titled Discharge Medication, undated, indicated . Medication shall be sent with the resident upon discharge . The nurse shall review medication instruction with the resident, family member or representative before the resident leaves the facility . A review of the facility's policy and procedure titled Discharging the resident, undated, indicated .The resident should be consulted about the discharge . 056399 Page 2 of 3 056399 04/09/2024 LA Casa via Transitional Care Center 1449 Ygnacio Valley Road Walnut Creek, CA 94598

F 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide care and services for hygiene and bathing for one of three sample selected residents (Resident 1) when Resident 1 did not receive a shower as scheduled by the facility. Residents Affected - Few This failure resulted in Resident 1 being uncomfortable and complained about not receiving the services that she was supposed to receive from the facility. Findings: A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility, located at room [ROOM NUMBER] A with multiple diagnoses including joint replacement surgery on left knee and chronic pain. During an interview on 4/5/24 at 11:17 a.m., with Resident 1, Resident 1 stated the facility's staff did not give her a shower while she resided at the facility. She felt uncomfortable and needed to take a shower. During a concurrent interview and record review on 4/9/24 at 2:00 p.m. with the Clinical Manager (CM), CM reviewed the Activities of Daily Living (ADL)'s documents and confirmed that Resident 1 was supposed to receive shower services on 10/3/23 in the morning and did not receive that. CM stated Resident 1 should have received a shower service as scheduled. A review of the facility's policy and procedure titled Discharging the resident, undated, indicated . Discharging the resident to home .2. Give the resident a bath. Follow established bath care procedure . A review of the facility's policy and procedure titled Shower/Tub Bath, undated, indicated . The purposes of this procedure are to promote cleanliness, provide comfort to the resident, and to observe the condition of the resident's skin . 056399 Page 3 of 3