Other·April 17, 2026

B citation Code of Federal Regulations, Title 42, §483.15(c) Transfer and discharge- §483.15(c)(1)(i) The facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless- (A)The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility; (B)The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility; Cal. Code Regs. Tit. 22, § 72527 - Patients' Rights (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (6) To be transferred or discharged only for medical reasons, or the patient's welfare or that of other patients or for nonpayment for his or her stay and to be given reasonable advance notice to ensure orderly transfer or discharge. Such actions shall be documented in the patient's health record. CCR T- 22, § 72523 - Patient Care Policies and Procedures (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. On 02/09/2026, the Department made an unannounced visit to the facility to conduct the annual Federal Recertification survey. The facility failed to ensure Resident 7 was appropriately discharged when Resident 7 was discharged back to a General Acute Care Hospital (GACH) for insurance purposes. This deficient practice resulted in an inappropriate GACH admission. A review of Resident 7's clinical record titled, "ADMISSION RECORD" indicated Resident 7 was admitted on 10/1/25, with diagnoses that included but not limited to type 2 diabetes (the body's inability to control sugar levels), shortness of breath, and muscle weakness. A review of Resident 7's clinical record titled, "Progress Notes" dated 10/2/25, at 12:25 p.m., documented by Licensed Nurse (LN) 1 indicated, "...Writer notified by Admin [administrator] that resident needed to get sent out back to GACH d/t [due to] insurance purposes no clinical [health] changes noted family aware MD aware..." A review of "SNF/NF [Skilled Nursing Facility/Nursing Facility] to Hospital Transfer form" with a "Date Transferred to hospital 10/2/2025 11:13," indicated Resident 1 had capacity for decision making. A review of Resident 7's GACH Report (ED [Emergency Department] Note - Physician), dated 10/2/25, at 12:31 p.m., indicated, "...patient presents from rehab without medical complaints. Patient sent back due to what seems to be a medical billing problem after being discharged from our hospital yesterday..." During an interview on 2/11/26, at 10:41 a.m., with LN 1, LN 1 stated, Resident 7 was sent back to the GACH due to insurances purposes. LN 1 further stated there was no clinical reason for returning the resident back to the GACH. During a concurrent interview and record review on 2/11/26 at 12:10 p.m., with the Director of Nursing (DON), Resident 7's clinical record titled, "Progress Notes" was reviewed. The DON stated Resident 7 was stable and had no clinical indication to be sent back to GACH. During an interview on 2/11/26 at 3:18 p.m., Resident 7, Resident 7 stated if she had to be sent back to the GACH for no clinical reason, that would upset her. During a concurrent interview and record review on 2/12/26 at 11:10 a.m., with the Administrator (ADM) the facility policy and procedure (P&P) titled, "Transfer or Discharge" with a revision date 3/2025, was reviewed. The ADM verified Resident 7's discharge on 10/2/25 did not follow the facility's P&P. During a review of the facility's P&P titled, "Transfer or Discharge" revision date 3/2025, the P&P indicated, "...Each resident is permitted to remain in the facility, and not be transferred or discharged unless:... the transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in this facility...the transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by this facility...the safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident...the health of the individuals in the facility would otherwise be endangered...the facility ceases to operate...the resident has failed, after reasonable and appropriate notice, to pay for a stay at this facility..." Therefore, the facility failed to ensure Resident 7 was appropriately discharged when Resident 7 was discharged back to a General Acute Care Hospital (GACH) for insurance purposes. This deficient practice resulted in an inappropriate GACH admission. This violation had a direct or immediate relationship to the health, safety or security of Resident 1 and is a B citation.