Health inspection·June 24, 2025

State B citation was written. §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. §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. 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. Cal. Code Regs. Tit. 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. 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. (d) For the purposes of this section, a "facility-initiated transfer or discharge" is a transfer or discharge that is initiated by the facility and not by the resident, whether or not the resident agrees to the facility's decision. On 5/30/25, at 8:31 a.m., the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to investigate a complaint regarding a resident discharge. The department determined the facility failed to provide a written discharge notice (also known as a 30-day notice) when, Resident 2, Resident 2's representative (FM; family member), and the Office of the Long-Term Ombudsman (OMB, a person who assists residents with resolving conflicts or concerns at the facility) did not receive written notification of Resident 2's impending discharge within 30 days or as soon as practicable when an impending discharge date had been determined by the facility. This failure violated Resident 2's right to be informed in writing of a pending discharge and how to appeal the decision of a facility-initiated discharge. This failure also resulted in Resident 2's representative and the State Long-Term Care Ombudsman uninformed of the discharge decision in writing and removed the opportunity for Resident 2's representative and/or the State Long-Term Care Ombudsman to advocate on Resident 2's behalf in a timely manner. The failure also had the potential for Resident 2 to be discharged to an unsafe location. A review of Resident 2's "ADMISSION RECORD," indicated Resident 2 was admitted to the facility with diagnoses which included cerebral infarction (also known as a stroke, damage to tissues in the brain due to a loss of oxygen to the area), muscle weakness, abnormalities of gait and mobility (when a person is unable to walk in the usual way), dysphagia (difficulty swallowing foods or liquids), major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and anxiety disorder (intense, excessive, and persistent worry and fear about everyday situations). A review of Resident 2's "Physician Order Summary," dated 4/29/25, indicated "...discharge to home with support on 5/1/25 following cessation [stopping] of skilled services [medical and therapeutic services that can only be safely and effectively performed by or under the supervision of licensed professionals, such as nurses or therapists]..." A review of Resident 2's "Social Services Progress Notes," dated 4/30/25, indicated, "...Discharge disposition was discussed with daughter...Daughter was advised to continue to coordinate...even if resident return home...Referral was also made for meals...to see if she will qualify for services...referral for supplemental caregiver support also emailed..." A review of Resident 2's "Social Services Progress Notes," dated 5/1/25, indicated, "...Per daughter...resident will be moved to...as disposition. Discharge will be coordinated once the process is approved..." During an interview by phone on 5/29/25 at 4:13 p.m., with the Long-Term Ombudsman Representative (OMB) 1, OMB 1 stated that he had not heard anything about Resident 2's impending discharge from the facility. During an interview on 5/30/25 at 10:05 a.m., with the facility Social Services Director (SSD), the SSD stated that residents received discharge notices from Social Services. The SSD stated that the notice might be given to the resident one day or one week ahead of time. The SSD stated that a discharge notice was given to a resident with a copy placed in their electronic medical record (EMR) and a copy was sent to the OMB afterwards. The SSD confirmed that Resident 2 did not receive a notice of discharge. The SSD stated that it was because the discharge was still pending, so she was not able to give a notice of transfer or discharge to Resident 2. During an interview on 5/30/25 at 11 a.m., Resident 2 stated that the facility staff came to her room one week before the discharge date and told her that she would be discharged on 5/1/25. Resident 2 stated that her FM (daughter) appealed the discharge. During an interview by phone with Resident 2's FM on 5/30/25 at 11:08 a.m., the FM stated that the facility notified her that Resident 2 was to be discharged one week before the discharge date of 5/1/25. The FM stated that she filed an appeal of the discharge. The FM confirmed that neither she nor Resident 2 received a formal discharge notice from the facility. The FM stated that the SSD told her that Resident 2 was to be discharged, and that she could appeal the discharge. The FM stated that she felt that the discharge was not safe. The FM stated that the facility staff told Resident 2 that she would be discharged 5/1/25. The FM stated that she called the OMB's office on 4/30/25, and OMB 2 helped her file to appeal the discharge from the facility. The FM stated that OMB 2 came to the facility and spoke with the SSD and told the SSD that the FM filed an appeal, and that Resident 2 was not to be discharged from the facility pending the appeal. The FM stated that a licensed nurse (LN) came to Resident 2's room while OMB 2 was there and began to pack her things for discharge on 5/1/25, so she told the LN that the discharge appeal was pending. The FM stated that after OMB 2 left the facility, another LN came to Resident 2's room with her medications and discharge papers a short time later, and she refused to sign them and told the LN that the discharge appeal was pending. The FM stated that Resident 2 was anxious and thought that the facility was going to put her out on the street. The FM stated that she notified OMB 2, and OMB 2 made calls to the facility, and the discharge was put on hold. The FM stated that the appeal of the discharge was later granted. During an interview by phone with OMB 2 on 5/30/25 at 2:36 p.m., OMB 2 confirmed that the OMB's office did not receive a notice of discharge for Resident 2. OMB 2 stated that Resident 2 was anxious because the staff approached her about the discharge, but her FM was making the discharge arrangements, and the staff did not include the FM in the discharge conversations. OMB 2 stated that she came to the facility on 5/1/25 and talked with the SSD. OMB 2 stated that the SSD stated that Resident 2 could make her own decisions. OMB 2 stated that the SSD stated that Resident 2 had a safe place to be discharged to. OMB 2 stated to the SSD that Resident 2's FM stated that the place that the facility attempted to discharge Resident 2 to was not safe. OMB 2 stated that the SSD stated that the facility was not attempting to discharge Resident 2 since the discharge appeal was pending. OMB 2 stated that after she left the facility, she received a call from Resident 2's FM stating that the facility staff was attempting to discharge Resident 2. OMB 2 stated that she called the SSD, and the discharge attempt was stopped. A review of a facility policy and procedure (P&P) titled, "Transfer or Discharge Documentation," revised 12/16, the P&P indicated, "...Policy Statement...When a resident is transferred or discharged, details of the transfer or discharge will be documented in the medical record and appropriate information will be communicated to the receiving health care facility or provider...2. If a resident exercises his or her right to appeal a transfer or discharge notice he or she will not be transferred or discharged while the appeal is pending..." A review of a facility P&P titled, "Transfer or Discharge, Preparing a Resident for," revised 12/16, the P&P indicated, "...Residents will be prepared in advance for discharge...2. A post-discharge plan is developed for each resident prior to his or her transfer or discharge. This plan will be reviewed with the resident, and/or his or her family..." Review of an online article published by the California Advocates for Nursing Home Reform (CANHR) titled "TRANSFER AND DISCHARGE RIGHTS," updated 9/4/24, the article indicated, "...Written Notice Before transferring or discharging a resident, the facility must provide written notice to the resident and the resident's representative in a language and manner they understand... The facility must send a copy of the notice to the long-term care ombudsman program. Except when specified below, the notice must be given at least 30 days before the resident is transferred or discharged... Exceptions to 30-Day Notice...there are a few exceptions to the 30-day notice requirement. Federal regulations permit notice to be made "as soon as practicable" before transfer or discharge when: the health or safety of individuals in the facility would be endangered; the resident's urgent medical needs require a more immediate transfer; the resident's health has improved sufficiently to allow a more immediate transfer or discharge; or the resident has resided in the facility less than 30 days... Even if an exception to the 30-day notice requirement is satisfied, the facility must nevertheless provide written notice in advance of a proposed transfer or discharge and an opportunity to appeal. A nursing home cannot transfer or discharge a resident while an appeal is pending, unless delay would endanger the health or safety of the resident or other individuals in the facility... California law requires nursing homes to give "reasonable advance notice" in writing in all cases of transfer or discharge..." (https://canhr.org/transfer-and-discharge-rights/) Therefore, the department determined the facility failed to provide a written discharge notice when, Resident 2, Resident 2's representative, and the Office of the Long-Term Ombudsman did not receive written notification of Resident 2's impending discharge within 30 days or as soon as practicable when an impending discharge date had been determined by the facility. This failure violated Resident 2's right to be informed in writing of a pending discharge and how to appeal the decision of a facility-initiated discharge. This failure also resulted in Resident 2's representative and the State Long-Term Care Ombudsman uninformed of the discharge decision in writing and removed the opportunity for Resident 2's representative and/or the State Long-Term Care Ombudsman to advocate on Resident 2's behalf in a timely manner. The failure also had the potential for Resident 2 to be discharged to an unsafe location. This violation had a direct or immediate relationship to the health, safety, or security of Resident 2.