Other·April 27, 2026

California Code of Regulations. Title 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. Code of Federal Regulations, Title 42, Section §483.15(c) Transfer and discharge- §483.15(c)(1) Facility requirements- §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; (C)The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident; (D)The health of individuals in the facility would otherwise be endangered; (E)The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. Nonpayment applies if the resident does not submit the necessary paperwork for third party payment or after the third party, including Medicare or Medicaid, denies the claim and the resident refuses to pay for his or her stay. For a resident who becomes eligible for Medicaid after admission to a facility, the facility may charge a resident only allowable charges under Medicaid; or (F)The facility ceases to operate. Code of Federal Regulations, Title 42, Section §483.15(e)(1) Permitting residents to return to facility. A facility must establish and follow a written policy on permitting residents to return to the facility after they are hospitalized or placed on therapeutic leave. The policy must provide for the following. (i)A resident, whose hospitalization or therapeutic leave exceeds the bed-hold period under the State plan, returns to the facility to their previous room if available or immediately upon the first availability of a bed in a semi-private room if the resident- (A) Requires the services provided by the facility; and (B) Is eligible for Medicare skilled nursing facility services or Medicaid nursing facility services (ii)If the facility that determines that a resident who was transferred with an expectation of returning to the facility, cannot return to the facility, the facility must comply with the requirements of paragraph (c) as they apply to discharges. On 2/26/2026, the Department made an unannounced visit to the facility to investigate a complaint regarding a resident discharge. The department determined the facility failed to ensure a resident's right to return to the facility was protected for Resident 1 when Resident 1 was transferred to the hospital on 1/31/26 and was not allowed to return to the facility on or after 2/18/26 when a female bed became available. This failure resulted in Resident 1 being discharged from the facility on 2/18/26 and placed Resident 1 at risk for psychosocial harm (mental and emotional suffering) due to separation from the resident's home and familiar environment. Review of Resident 1's "ADMISSION RECORD," indicated Resident 1 was admitted to the facility in late 2025 with diagnoses including non-ST elevation myocardial infarction ( a type of heart attack), type 2 diabetes mellitus (a condition that causes high blood sugar), Alzheimer's disease ( a disease that caused memory loss and affects thinking and behavior), hypothyroidism (an underactive thyroid gland that slows the body's metabolism), difficulty in walking, muscle weakness, hypertension (a chronic condition where the force of blood against blood vessels is consistently too high), and anxiety disorder (excessive, persistent, and uncontrollable fear, dread, or worry that interferes with daily life). Review of Resident 1's "MINIMUM DATA SET (MDS [resident assessment tool]) RESIDENT ASSESSMENT AND CARE SCREENING Nursing Home Discharge (ND) Item Set," dated 1/31/26, in section A "... Entry/discharge reporting" indicated Resident 1 was discharged from the facility with a return anticipated to the facility. Review of Resident 1's "General Notes Report," dated 2/2/26, indicated that Resident 1 was sent out to hospital on 1/31/26 due to an unwitnessed fall and was admitted to the hospital. The notes indicated Resident 1's representative stated she would like Resident 1 to return to the facility. Review of Resident 1's referral communication record dated 2/18/26 at 10:41 AM, indicated the facility's Director of Marketing (DM) sent a message to the hospital stating Resident 1 required a higher level of care and the facility could not provide the level of care needed. Review of Resident 1's hospital record titled, "Physician Progress Note," dated 2/26/26, indicated Resident 1 was admitted to the hospital after an unwitnessed ground-level fall and was diagnosed with syncope (fainting), left frontal hematoma (a collection of blood under the skin on the forehead), status post fall, Alzheimer's disease, diabetes mellitus, and hypothyroidism. The notes indicated physical therapy evaluated Resident 1 and recommended physical therapy five times per week. During concurrent interview and record review on 2/26/26 at 3:16 PM with the Director of Nursing (DON), Resident 1's care plans and the facility census were reviewed. The DON stated the facility had a bed capacity of 99 with a confirmed facility census of 94 and one bed hold. The DON stated the facility could not accept Resident 1 back to the facility despite bed availability because Resident 1 required a higher level of care due to safety concerns such as aggressiveness, wandering, and risk for falls. The DON stated a non-clinical facility staff member checked Resident 1's status at the hospital on 2/17/26 and there was no nurse-to-nurse communication between the hospital and the facility for a nursing assessment. Resident 1's care plan initiated on 10/8/26 in the section titled "Focus" indicated "...[Resident 1] is risk for unavoidable falls r/t [related to] confusion...poor safety awareness..." Resident 1's care plan initiated on 11/27/26 in the section titled "Focus" indicated, "...[Resident 1] has episodes of aggressive behaviors..." and Resident 1's care plan initiated on 12/2/26 in the section titled "Focus," indicated, "...[Resident 1] exhibits wandering behaviors..." The DON stated that Resident 1's behaviors including risk for falls, aggression, and wandering were present before Resident 1 was transferred to the hospital and stated if the facility had known Resident 1 had these behaviors, the facility would not have admitted Resident 1. The DON stated Resident 1 was a long-term care resident in the facility and the facility was Resident 1's home. The DON further stated residents who could not return to their home were at risk of emotional distress. During an interview on 2/26/26, at 4:02 PM, the Admissions Coordinator (AC) stated when the initial referral was received from the hospital for Resident 1, the facility agreed to accept Resident 1 back to the facility for long-term care placement. The AC stated Resident 1's referral from the hospital was reviewed, including the restraint documentation. The AC stated the facility protocol required a resident to be off restraints for a 24-hour period prior to returning to the facility. The AC stated on 2/18/26, the hospital reported Resident 1 had been off restraints for 24 hours. The AC explained that the facilities Marketing Director went to the hospital to check on Resident 1. The AC explained, the facility communicated to the hospital that there were no available female beds at the time, and the facility expressed significant concerns due to Resident 1's exit-seeking behaviors and high risk for falls. The AC stated the facility was not a secure unit and could not safely meet Resident 1's level of care needs. The AC stated the facility declined Resident 1's readmission due to safety concerns. The AC noted that residents who were unable to return to their home (facility) may be upset due to changes in their routine and environment. During a concurrent interview and record review on 2/26/26 at 4:15 PM, Resident 1's discharge care plan, dated 10/15/25, was reviewed with the Social Services Director (SSD). Resident 1's discharge care plan, initiated on 10/15/25, indicated, "...[Resident 1] is long term with no plans for discharge..." The SSD stated that there was no discharge plan in place for Resident 1. The SSD stated Resident 1 was a long-term resident and considered the facility as Resident 1's home. The SSD stated Resident 1 staying in the hospital for longer periods could cause sadness, confusion, and depression and made the hospital a less suitable placement for Resident 1. During an interview on 2/26/26 at 4:23 PM, with the Administrator (ADM), the ADM stated if a resident was a long-term resident and could not return to her home, it could disrupt the resident's regular routine and could have negative emotional and psychosocial impacts (effects on mental and emotional well-being). During an interview on 3/9/26 at 9:53 AM, with the hospital's Social Worker (SW), the SW stated Resident 1 remained in the hospital as of 3/9/26 and had no aggressive or behavioral issues but remained confused due to Alzheimer's. Review of facility's policy and procedure (P&P) titled "Bed-Holds and Returns," revised on 10/22, the P&P indicated "...The requirement that residents be permitted to return to the facility following hospitalization or therapeutic leave applies to all residents...Residents who seek to return to the facility after the state bed-hold period has expired...are allowed to return to their previous room if available or immediately to the first available bed...provided that the resident...still requires services provided by the facility, and...is eligible for Medicare skilled nursing facility or Medicaid nursing facility services..." Therefore, the department determined the facility failed to ensure a resident's right to return to the facility was protected for Resident 1 when Resident 1 was transferred to the hospital on 1/31/26 and was not allowed to return to the facility on or after 2/18/26 when a female bed became available. This failure resulted in Resident 1 being discharged from the facility on 2/18/26 and placed Resident 1 at risk for psychosocial harm (mental and emotional suffering) due to separation from the resident's home and familiar environment. This violation caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to Resident 1 and is a B citation.