Health inspection·June 6, 2025

State Citation B was written. F628 Discharge Process §483.15(c)(2) Documentation. §483.15(c)(3) Notice before transfer. Before a facility transfers or discharges a resident, the facility must- (i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman. (ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and (iii) Include in the notice the items described in paragraph (c)(5) of this section. §483.15(c)(4) Timing of the notice. (i) Except as specified in paragraphs (c)(4)(ii) and (c)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged. (ii) Notice must be made as soon as practicable before transfer or discharge when- (A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section; (B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section; (C) The resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(i)(B) of this section; (D) An immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (c)(1)(i)(A) of this section; or (E) A resident has not resided in the facility for 30 days. California Code, Health and Safety Code - HSC § 1439.6 (a) Except as provided in subdivision (b), if a resident is notified in writing of a facility-initiated transfer or discharge from a long-term health care facility, the facility shall also send a copy of the notice to the local long-term care ombudsman at the same time notice is provided to the resident or the resident's representative. (c) The copy of the notice shall be sent by fax machine or email, as may be directed by the local long-term care ombudsman, unless the facility does not have fax or email capability, in which case the copy of the notice shall be sent by first-class mail, postage prepaid. A facility's failure to timely send a copy of the notice shall constitute a class B violation, as defined in subdivision (e) of Section 1424. On 5/14/25, at 10:22 a.m., the California Department of Public Health (CDPH) conducted an unannounced visit to the facility to investigate a complaint regarding resident discharge rights. The Department determined the facility failed to provide the proper notice for discharge for Resident 1 and Resident 2 when, a written notice of discharge for Resident 1 and Resident 2 was not sent to the State Long-Term Care Ombudsman's office (a government appointed person who actively supports the rights of the long-term care residents). a. Review of Resident 1's "ADMISSION RECORD," indicated Resident 1 was admitted to the facility in 2024 with diagnoses which included, but not limited to necrotizing fasciitis (a serious bacterial infection that destroys tissue under the skin), and acquired absence of left leg below knee (a condition where the leg is removed below the knee joint due to injury, disease or medical necessity). During a concurrent observation and interview on 5/14/25, at 11:10 a.m., Resident 1 confirmed he received a Notice of Discharge (a document given by the facility to the resident indicating an upcoming discharge from the current facility to another location) with an effective date of discharge on 4/30/25. b. Review of Resident 2's "ADMISSION RECORD," indicated Resident 2 was admitted to the facility in 2022 with diagnoses which included but not limited to type 2 diabetes mellitus (a chronic condition with elevated blood sugar levels) with diabetic neuropathy (nerve damage caused by diabetes), cellulitis of left lower limb (a bacterial infection of skin and the tissue beneath skin). During a concurrent observation and interview on 5/14/25, at 3:01 p.m., Resident 2 confirmed she received a Notice of Discharge from the facility with an effective date of discharge on 4/30/2025. During an interview on 5/14/25, at 3:32 p.m., with the Business Office Manager (BOM), the BOM stated she was unaware if the facility provided written notification to the Ombudsman's office for Resident 1 and Resident 2's discharge notices. During a phone interview on 5/15/25, at 9:37 a.m., with the Ombudsman (OMB), the OMB confirmed the Ombudsman's office did not receive a written notification for Resident 1 and Resident 2's discharge notices. During a concurrent interview and record review on 5/15/25, at 1:32 p.m., with the Director of Nursing (DON), Resident 1 and Resident 2's "REVISED Notice of Discharge," both dated 3/31/2025, and the facility policy and procedure (P&P) titled, "Transfer or Discharge, Facility-Initiated," dated October 2022 were reviewed. The DON confirmed the facility did not provide a written copy of Resident 1 and Resident 2's discharge notice to the Ombudsman. The DON stated it was necessary to send a copy of the notification to the Ombudsman on the same day. The DON further stated the role of the Ombudsman was supporting and defending residents' rights and well-being to ensure residents were receiving proper care, feeling safe, and for their needs to be met in the facility. Review of the P&P indicated, "...Once admitted to the facility, residents have the right to remain in the facility. Facility-initiated transfers and discharges, when necessary, must meet specific criteria and require resident/representative notification and orientation, and documentation as specified in this policy...Notice of Transfer or Discharge (Planned)...3. A copy of the notice is sent to the Office of the State Long-Term Care Ombudsman at the same time the notice of transfer or discharge is provided to the resident and representative..." The DON confirmed the facility P&P was not followed. During a phone interview on 5/15/25, at 2 p.m., with the Administrator (ADM), the ADM confirmed the facility did not send a copy of Resident 1 and Resident 2's discharge notices to the Ombudsman's office. The ADM further stated the Ombudsman was a voice for the residents and their role included dealing with conflict situations to protect the residents' rights. Therefore, the Department determined the facility failed to provide the proper notice for discharge for Resident 1 and Resident 2 when, a written notice of discharge for Resident 1 and Resident 2 was not sent to the State Long-Term Care Ombudsman's office. This violation had a direct or immediate relationship to the health, safety, or security of Resident 1 and Resident 2.