Health inspection·October 14, 2025

F627 §483.15(c) Transfer and discharge- §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. (ii)Include regular re-evaluation of residents to identify changes that require modification of the discharge plan. The discharge plan must be updated, as needed, to reflect these changes. (iii)Involve the interdisciplinary team, as defined by §483.21(b)(2)(ii), in the ongoing process of developing the discharge plan. (iv)Consider caregiver/support person availability and the resident's or caregiver's/support person(s) capacity and capability to perform required care, as part of the identification of discharge needs. (v)Involve the resident and resident representative in the development of the discharge plan and inform the resident and resident representative of the final plan. (vi)Address the resident's goals of care and treatment preferences. (vii)Document that a resident has been asked about their interest in receiving information regarding returning to the community. HSC § 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. On 6/16/25, an unannounced visit was conducted at the facility to investigate a complaint regarding Admission, Transfer and Discharge Rights. The facility failed to prepare and ensure a safe and appropriate discharge for Patient 1 when: 1. Patient 1's fall risk level was not updated. 2. Patient 1's discharge minimum data set (MDS, a clinical assessment tool) was not accurately coded. 3. The facility did not provide discharge notice (a written notice in advance to the patient and the patient's representative in a language and manner they understand and an opportunity to appeal) to Patient 1 and/or her son (Patient 1's co-health care decision maker). Patient 1 also did not have a discharge care plan and did not have discharge notes on the day of her discharge; and 4. The facility did not verify the license and the care capabilities of the discharge placement facility. These failures resulted in Patient 1 who had severe cognitive impairment (a significant decline in a person's ability to think, learn, remember, use judgement, and make decisions that can lead to a point where the individual is incapable of living independently because of the inability to plan and carry out activities of daily living [ADL, the tasks of everyday life] and apply judgment), poor recent memory, poor insight and judgment, mental illness, required a Preadmission Screening and Resident Review Level 2 (PASRR Level 2, a comprehensive, person-centered evaluation conducted for individuals identified by a Level 1 screening as having or potentially having a Serious Mental Illness [SMI], Intellectual Disability [ID, a condition that involves limitations on intelligence, learning and everyday abilities necessary to live independently], Developmental Disability [DD, a group of conditions due to an impairment in physical, learning, language, or behavior areas], or related condition), and required moderate to maximal assistance or dependent on the staff for ADL was discharged to an unlicensed Room and Board (Independent Living, living accommodations and dining services) on 5/22/25. Patient 1 fell at the discharge placement facility and was sent to acute care on 6/11/25. 1. Patient 1's Admission Record indicated she was admitted to the facility on 4/14/20 with diagnoses including malignant neoplasm (cancer, an abnormal growth of cells) of left breast, diabetes (high blood sugar levels), protein-calorie malnutrition (an imbalance between the nutrients the body needs to function and the nutrients it gets), hyperlipidemia (high level of fats in the blood), hypertension (HTN, high blood pressure), reduced mobility (limitations in movement), muscle weakness, osteoporosis (a disease that weakens the bones; it makes the bones thinner and less dense than they should be), and depression (a persistent feeling of sadness and loss of interest and can interfere with the daily life). Patient 1's clinical record indicated she did not have quarterly fall risk assessments from 8/22/24 to the day of her discharge on 5/22/25 (two quarterly assessments). During an interview with the director of nursing (DON) on 7/28/25, at 4:10 p.m., he reviewed Patient 1's clinical record and confirmed that Patient 1 did not have quarterly fall risk assessments from 8/22/24 to the day of her discharge on 5/22/25. The DON stated the patient fall risk assessment should be done every quarter. 2. During an interview with certified nursing assistant A (CNA A) on 7/30/25, at 1:40 p.m., CNA A stated before the discharge of Patient 1 was dependent on staff for shower and upper and lower body dressing and needed maximal assistance (the helper does more than half the effort) for personal hygiene. During an interview with certified nursing assistant B (CNA B) on 7/30/25, at 2 p.m., CNA B stated before the discharge Patient 1 was dependent on staff for shower, upper and lower body dressing, and personal hygiene. During an interview with certified nursing assistant C (CNA C) on 7/30/25, at 2:15 p.m., CNA C stated before the discharge Patient 1 was dependent on staff for shower and upper and lower body dressing and needed maximal assistance for personal hygiene. During an interview with certified nursing assistant D (CNA D) on 7/30/25, at 3:20 p.m., CNA D stated before the discharge Patient 1 needed moderate assistance (the helper does less than half the effort) for upper and lower body dressing and needed maximal assistance for shower and personal hygiene. During an interview with certified nursing assistant E (CNA E) on 7/30/25, at 3:50 p.m., CNA E stated before the discharge Patient 1 needed a lot of help; Patient 1 was dependent on staff for shower, upper and lower body dressing, and personal hygiene. Patient 1's 5/2025 Document Survey Report V2 (Patient 1's Daily ADL status reported by the CNAs) indicated that for the last three days of her stay (from 5/20/25 to 5/22/25) at the facility she needed maximal assistance for bathing and needed moderate to maximal assistance for upper and lower body dressing and personal hygiene. However, Patient 1's discharge MDS on 5/22/25 indicated it was coded that Patient 1 needed moderate assistance for bathing and supervision for upper and lower body dressing and personal hygiene. During an interview with the MDS director (MDSD) on 7/30/25, at 2:45 p.m., she reviewed Patient 1's 5/2025 Document Survey Report V2 and discharge MDS dated 5/22/25 and confirmed that Patient 1's discharge MDS on 5/22/25 was not accurately coded. 3. Patient 1's clinical record indicated she did not have a discharge notice and discharge care plan before her discharge, and there were no discharge notes on the day of her discharge. During an interview with the social service director (SSD) on 7/30/25, at 4:10 p.m., she confirmed that Patient 1 did not have a discharge care plan. The SSD stated the discharge notice was for short-term patients. Patient 1 was a long-term patient, so she did not have discharge notice. During an interview with the director of nursing (DON) on 7/30/25, at 4:50 p.m., he reviewed Patient 1's clinical record and confirmed that there were no discharge notes on the day of her discharge. The DON stated when the patients were discharged, there should be notes on how the patients were, the patients discharged with whom and to where, and what had been done during discharge. 4. Patient 1's MDS, dated 2/20/25, indicated her cognition was severely impaired. Patient 1's "Che Behavioral Health" Note (Che-Outside Consultant Note), dated 2/14/25, indicated her recent memory and her insight/judgment were poor. Patient 1's result of PASRR Level 1 Screening (the initial screening tool), dated 7/23/23, indicated it was positive (requires Level 2 evaluation), and a PASRR Level 2 Screening was required for her. Patient 1's Admission Record indicated Patient 1 and her son, were both health care decision makers for her. Patient 1's Social Services Notes, dated 5/6/25, indicated that Patient 1's son stated that he didn't remember having any conversation on wanting to move Patient 1 out of the facility. Patient 1's Lease Agreement that the facility asked Patient 1 to sign and not her son on the day of her discharge, 5/22/25, indicated the discharge placement was to provide medication assistance to Patient 1 by medication reminder. Patient 1's Physician's Orders Upon Discharge, dated 5/21/25, indicated her discharge medications were acetaminophen (for left knee pain) 325 milligrams (mg, a metric unit of mass) two tablets every 6 hours as needed, anastrozole (for breast cancer treatment) 1 mg one time day, aspirin (blood thinner) 81 mg one time a day, atorvastatin (for hyperlipidemia) 40 mg one time a day, docusate sodium (for bowel management) 250 mg two times a day, loratadine (for itching) 10 mg one time a day, melatonin (for supplement to maintain the natural 24-hour cycle) 3 mg at bedtime, metformin (for diabetes) 500 mg two times a day, optic-Vites with lutein (for eye health) one tablet one time a day. Patient 1's Physician's Report (Patient 1's primary physician's report/notes for referral to the placement agency) for Residential Care Facilities for the Elderly (RCFE, a non-medical facility that provides housing, meals, supervision, and personal assistance with daily activities to seniors who need help but not 24-hour nursing care; these facilities, also known as assisted living or board and care homes, to help seniors maintain independence in a homelike setting, with services like help with bathing, dressing, and medication management), dated 2/17/25, the physician indicated that Patient 1 could not administer own prescription medications. During an interview with the SSD on 7/28/25, at 3 p.m., she stated she asked the placement agency (an organization that helps to find suitable residential care options for seniors, such as independent living, assisted living, memory care, or skilled nursing facilities) for the license of Patient 1's discharge placement, but she didn't receive it, and she did not verify it. The SSD stated she thought Patient 1's discharge placement was a Board and Care (a small, residential facility, that provides room, board, and assistance with daily living activities for individuals who need non-medical supervision but cannot live independently). She did not know Patient 1's discharge placement was a Room and Board (Independent Living, living accommodations and dining services) until Patient 1 was brought to acute care after her fall. During an interview with the SSD on 8/19/25, at 12:25 p.m., she stated the placement agency came to the facility, assessed Patient 1, and determined that they could provide care to her at their place. The SSD stated she would look for that document or request from the placement agency for that document. During an interview with the SSD on 9/11/25, at 11:45 a.m., she confirmed that she could not find the document on Patient 1's assessment by the placement agency. The SSD also confirmed that she requested it, but the placement agency didn't provide it for her. Patient 1's Social Services Notes, dated 6/11/25, indicated on 5/29/25 Patient 1 had an unwitnessed fall in the bathroom at the discharge placement. Patient 1's acute care History and Physical, dated 6/11/25, indicated Patient 1 was found on the floor sitting against her bed at the discharge placement and was brought into the acute care by ambulance. It also indicated that Patient 1's discharge placement was an unlicensed Room and Board (Independent Living). Patient 1's acute care History and Physical, dated 6/11/25, indicated Patient 1's discharge placement refused to take her back. The acute care also determined that they didn't want to send Patient 1 back to her discharge placement, an unlicensed Room and Board (Independent Living), because it was not appropriate for Patient 1, and it would be liability on them if they sent her back there. The acute care determined that Patient 1 would be appropriate for skilled nursing home placement. The facility's policy, "Fall Prevention and Response," dated 8/2023, indicated "... 1. ... Utilizing the Resident Assessment Instrument (RAI- a guide that facility staff use for coding and transmission) 3.0 User's Manual Version 1.19.1," dated October 2024) process, facility will identify and address potential for fall accidents, environmental factors, individual risk factors, need for supervision, care, and assistive devices." The "Long-Term Care Facility Resident Assessment Instrument (RAI), indicated, "It is important to note that information obtained should be validated for accuracy, what the resident's actual status was during the observation period." The facility's policy, "Admissions, Transfer, Discharge and Bed-Holds," dated 12/2016, indicated "... Transfer and Discharge: ... Before a resident is transferred or discharged, the facility will notify the resident and the resident's representative of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. Notice will be made at least 30-days prior to transfer or discharge, or as soon as practical ... The facility will provide sufficient preparation and orientation to residents and resident representatives in order to ensure a safe and orderly discharge from the facility." In violation of the above cited standards, the facility failed to provide and document sufficient preparation and orientation in a form and manner that each patient can understand to ensure safe and orderly transfer or discharge from the facility, including but not limited to: the facility failed to prepare and ensure a safe and appropriate discharge for Patient 1 when: 1. Patient 1's fall risk level was not updated. 2. Patient 1's discharge minimum data set was not accurately coded. 3. The facility did not provide discharge notice to Patient 1 and/or her son. Patient 1 also did not have a discharge care plan and did not have discharge notes on the day of her discharge; and 4. The facility did not verify the license and the care capabilities of the discharge placement facility. These failures resulted in Patient 1 who had severe cognitive impairment, poor recent memory, poor insight and judgment, mental illness, required a Preadmission Screening and Resident Review Level 2, and required moderate to maximal assistance or dependent on the staff for ADL was discharged to an unlicensed Room and Board (Independent Living) on 5/22/25. Patient 1 fell at the discharge placement facility and was sent to acute care on 6/11/25. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of patients.