Health inspection·December 26, 2025

Mountainview HealthCare Center Provider Number: 055316 Survey ID: 1D91C6-H1 Intake Number: 2639344 F627 §483.15(c)(7) Orientation for transfer or discharge. A facility must provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility. This orientation must be provided in a form and manner that the resident can understand. §483.21(c)(1) Discharge Planning Process The facility must develop and implement an effective discharge planning process that focuses on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions. The facility's discharge planning process must be consistent with the discharge rights set forth at 483.15(b) as applicable and- (i) Ensure that the discharge needs of each resident are identified and result in the development of a discharge plan for each resident. use is relevant and applicable to the resident's goals of care and treatment preferences. (ix) Document, complete on a timely basis based on the resident's needs, and include in the clinical record, the evaluation of the resident's discharge needs and discharge plan. The results of the evaluation must be discussed with the resident or resident's representative. All relevant resident information must be incorporated into the discharge plan to facilitate its implementation and to avoid unnecessary delays in the resident's discharge or transfer. §483.21(c)(2) Discharge Summary When the facility anticipates discharge, a resident must have a discharge summary that includes, but is not limited to, the following: (iv) A post-discharge plan of care that is developed with the participation of the resident and, with the resident's consent, the resident representative(s), which will assist the resident to adjust to his or her new living environment. The post-discharge plan of care must indicate where the individual plans to reside, any arrangements that have been made for the resident's follow-up care and any post-discharge medical and non-medical services. California Health and Safety Code - § 1599.78 (a) A contract of admission shall state that, except in an emergency, a resident may not be involuntarily transferred or discharged from a long-term health care facility unless the resident and, if applicable, the resident's representative, are given reasonable notice in writing and transfer or discharge planning as required by law. The written notice shall meet both of the following conditions: (1) The notice shall state the reason for the transfer or discharge. (2) The notice shall include the following statement: "At the time of admission, this facility is an enrolled provider with the following: _____ Medi-Cal______ Medicare. Title 22 California Code of Regulations § 72527 - Patient 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. On 10/10/25, an unannounced visit was conducted at the facility for an abbreviated survey regarding a complaint investigation. The facility failed to provide sufficient preparation and orientation to ensure a safe and appropriate discharge for one of three residents (Resident 1) when: 1. The facility's against medical advice (AMA, a patient's decision to leave a healthcare facility or discontinue treatment despite the recommendations of their doctor) policy was not followed for Resident 1 when Resident 1 was discharged AMA when he did not return to the facility from being out on pass (a temporary absence for an inpatient who has received official permission to leave a hospital or care facility but is not being officially discharged) for several hours. 2. The facility did not provide Resident 1 with the discharge notice (a written notice in advance to the resident and the resident's representative in a language and manner they understand and an opportunity to appeal) timely (30 days before discharge or as soon as possible). 3. Resident 1 also did not have a discharge care plan to that would include his discharge needs such as medication management (the process of ensuring prescription drugs and other medications are used correctly to maximize safety and effectiveness), a Home Health (services provided by health care provider to resident after discharge to home) referral , DME (durable medical equipment, is medical equipment that is durable, can be reused, and is prescribed by a doctor for use in a patient's home)needed. The post-discharge plan of care did not address Resident 1's limitations and his ability to care for himself. 4. Facility did not have any interdisciplinary care team (IDT, interdisciplinary team, a group of professionals from different fields who collaborate to achieve a common goal)meeting to discuss Resident 1's discharge plan /needs, did not identify the location of his discharge, and/or complete a referral to appropriate community agency placement (is the arrangement of an individual with a community-based program or service to meet a specific need, such as for care and housing). 5. Resident 1 did not have a discharge summary (a medical document that provides a comprehensive overview of a patient's hospitalization, including their diagnosis, treatment, procedures, and follow-up care instructions to serve as an important communication tool between healthcare providers, ensuring that the patient's primary care physician or other healthcare professionals have all the necessary information to continue their care effectively) that included assistance needed for him to adjust to his new living environment. These failures endangered the health and safety of Resident 1 who was unexpectedly discharged from the facility without proper preparation for appropriate placement and/or home health referral, medication management, medical equipment set up, and follow-up medical appointments. The above violation had a direct or immediate relationship to the health, safety, or security of Resident 1. Findings: 1. A review of iQIES complaint received on 10/9/2025, indicated, "(Resident 1) called to report that he was discharged from the facility on 10/07/25 because the facility stated that he no longer needed that level of care. On this day he had left the facility to run errands. His car broke down, and he was gone for 5 - 6 hours. When he returned, he was discharged. They did not want to provide medication at the facility. After going back and forth for over an hour with the facility some medication was provided..." During a review of Resident 1's facesheet (a document that summarizes a patient's key demographic and medical information for quick access) it indicated he was admitted to the facility on 9/3/25 and was discharged AMA on 10/7/25. He had diagnoses including polyneuropathy (is a condition in which multiple peripheral nerves (A nerve is an organ composed of multiple nerve fibers bound together by sheaths of connective tissue) throughout the body become damaged or dysfunctional (means a state of not functioning normally, or a problem that disrupts a system's normal operations), acute on chronic systolic (congestive) heart failure (a sudden worsening of symptoms in individuals with an existing condition of chronic systolic heart failure (a lifelong condition for heart muscle weakens and difficult for the heart to pump blood effectively)), shortness of breath (SOB, is an uncomfortable feeling of not being able to breathe well enough), chronic obstructive pulmonary disease (COPD, a common lung disease causing restricted airflow and breathing problems), obstructive sleep apnea (is a sleep-related breathing disorder ) and need for assistance with personal care, hypertension (HTN, high blood pressures, a condition where the force of blood against artery walls is consistently too high, making the heart work harder and increasing the risk of heart, brain, and kidney diseases ), pacemaker (is a small, battery-powered device that prevents the heart from beating too slowly), Atherosclerotic cardiovascular disease (ASCVD, is a hardening of your arteries from plaque (a small, abnormal patch of tissue on a body part or an organ) building up gradually inside them to cause cardiovascular diseases ). During a review of Resident 1's minimum data set (MDS, an assessment tool), dated 9/6/25, it indicated his brief interview for mental status (BIMS, is a quick, mandatory cognitive screening tool used in long-term care to assess a person's orientation, attention, and memory) was intact with score of 15 and his functional abilities (the skills and capacities a person has to perform daily tasks, ranging from basic self-care like dressing and eating to more complex activities such as financial management, communication, and professional work) for self-care (is the practice of deliberately taking actions to protect and improve one's own physical, mental, and emotional health) required setup or clean-up assistance for eating, oral hygiene, toileting, dressing, personal hygiene and putting and taking off footwear. He required supervision or touching assistance (is a level of support where a helper provides verbal cues, steadying, or light physical contact as a person completes an activity) for chair or toilet transfer, and car transfer shower transfer or walk 10 feet were not attempted due to medical condition or safety concerns. During a review of Resident 1's "Temporary Absence Release" form indicated he went out on pass on the following dates and time: 9/11/25 at 15:40 (3:40 p.m.), 9/25/25 at 4:07 p.m., 9/26/25 at 10:22 a.m., 9/30/25 at 11 a.m., 10/2/25 at 11:30 a.m., 10/3/25 at 3:23 p.m., 10/4/25 at 11 a.m. and 10/6/25 at 1:30 p.m. During a review of Resident 1's progress notes, dated 10/6/25 at 9 p.m., it indicated, "Patient went out in the morning and had not returned to the unit until late at night. Contacted patient by phone; patient stated he was on the way back. Instructed patient to obtain prior approval before going out and to notify the medical staff if returning late. Education provided." During a review of Resident 1's progress notes, dated 10/7/25 at 1:17 a.m., it indicated," ---"It is now 1:15 AM, patient hasn't come back yet..." Called resident on his personal phone left a message. He called back after a few minutes; he said his car broke down and he was stuck at a (store) waiting for it to open. He said he was trying to go to DMV (Department of Motor Vehicles, a state-level government agency responsible for managing driver's licenses, vehicle registrations, and state identification cards) but didn't make it on time. He said he would come back in the morning. Told him staff was wondering why he didn't come back? asked him if he was safe, he said" Oh yes, I'm safe". Will endorse to next shift. Called emergency contact #2, left VM to (emergency contact person) Will let supervisor know." During a review of Resident 1's progress notes, dated 10/7/25 at 10 :40 a.m., it indicated, "(Resident 1) left facility to go to social security office on 10/6 at 13:30 (1:30 p.m.). Per (Resident 1) he will return within 2 (two) hours. Resident did not return as scheduled. Contact was made at approximately 2230 (10:30 p.m.) with (Resident 1) who informed him would be back to facility by 2330 (11:30 p.m.). He did not come back to facility and did not establish contact before midnight 10/7 at approximately 1040 (10:40 a.m.) Call placed to (Resident 1) to inform that he has been discharged for AMA, and all personal belongings will be available to pick up with social services. " During a review of Resident 1's progress notes, dated 10/7/25 at 2:30 p.m., it indicated," Pt (patient) asked to speak with SS (social service). Writer went outside to speak with them. Writer explained to pt that they did not come back when they said they would and that it was already explained to them they would be discharged under our system under AMA, which they already verbalized understanding to. Pt asked, "Where am I supposed to go?" Writer told pt they should reach out to the placement specialist we placed them with. Pt said, "I can't afford that." Explained to pt that they could base off of previous conversations with pt and they were only choosing not to. Pt said, "What about food?" Writer explained that the Room and Boards presented to them already provide food and a bed. Writer said, "Their food wouldn't be enough for me; it's not enough at this facility anyways." Writer reiterated that it is their decision not to continue to the search for placement and SS has presented all they could to them. Pt said, " What about my meds(medications), I cannot take my meds." Writer explained to pt that if they discharge under AMA, they don't receive their medication, and we could give them a list of what they were taking. Pt agreed to wanting the medication list. Writer printed out the list and gave it to PT (patient). Pt kept saying "My phone was dead, how do you expect me to call you guys?" Writer informed pt that this explanation wasn't a valid excuse due to them being able to answer the phone when our nursing staff called them in the middle of the night. Pt asked to speak with admin, this writer informed supervisor." During a review of Resident 1's AMA release form, dated 10/7/25, it indicated that Resident 1 refused to sign. During an interview on 10/10/25, at 10:40 a.m., with registered nurse (RN) A, RN A stated Resident 1 had an order for out on pass for four hours and was required to complete the sign in sheet (is a document used to record the names, contact information, and arrival and departure times of individuals attending an event, entering a facility, or participating in an activity) before and after with a licensed nurse. During an interview on 10/10/25, at 12:34 p.m., with licensed vocational nurse (LVN) B, LVN B stated she was working the morning shift on 10/6/25 when Resident 1 went out on pass at 1:30 p.m. LVN B confirmed she was aware Resident 1 went out on pass at 1:30 p.m. of 10/6/25 and Resident 1 "in the past always returned on time with no problems". LVN further stated Resident 1 "was very independent; alert and oriented and he was short stay (is a temporary period of care, typically lasting from a few days up to several months, for individuals recovering from surgery, illness, or injury) in the facility for rehabilitation (a type of short-term therapy focused on helping a patient regain independence after an illness or injury, often through a coordinated care plan involving multiple therapists)." During an interview on 10/10/25, at 1 p.m., with the social service director (SSD), the SSD stated, when Resident 1 did not return after midnight (on 10/6/25), he was already considered discharged from the facility. The SSD also stated, Resident 1 "passed the time frame for out on pass; hence, he was discharged from the facility". The SSD further stated that Resident 1 was in transition looking placement, they offered him the placement, but he refused, because he did not want to pay any money... So, on the next day of 10/7/25 when he returned to the facility it was afternoon already and Resident 1 was informed that he had been discharged for AMA in the morning by our assistant director of nursing (ADON). Resident 1 came back to pick up his belongings; we explained to him the reason why he was discharged AMA because he did not return as scheduled. The SSD stated Resident 1's medication list had been printed out and was given to him when he came back to pick up his belongings. During an interview on 10/10/25, at