Health inspection·July 25, 2025

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. On May 22, 2025, at 10:15 a.m., an unannounced visit was conducted to the facility to investigate allegations on transfer and discharge process. It was determined that the facility failed to provide the proposed transfer and discharge notice to the Office of the State Long-Term Care (LTC) Ombudsman at the same time as the notice was provided to the patient or patient’s representative for Patient 3. This failure resulted in the missed opportunity for the LTC Ombudsman to advocate for the patient to ensure a safe and appropriate discharge. A review of Patient 3's record indicated the patient was admitted to the facility on March 13, 2025, and re-admitted on April 11, 2025, with diagnoses which included fracture of the pelvis (hip bones fracture). A review of Patient 3's physician's order dated May 14, 2025, indicated, "DC (discharge) to board and care on hospice Wednesday 5/14/2025..." A review of the Social Service notes dated May 13, 2025, indicated, "...DC to board and care on hospice Wednesday 5/14/2025..." A review of Patient 3's proposed discharge/transfer notice indicated the patient signed the notice on May 13, 2025. A review of the fax document sent to the Ombudsman on May 14, 2025, indicated Patient 3's proposed discharge/transfer notice was sent to the Ombudsman on May 14, 2025, (1 day after the notice was given to the family member). On May 22, 2025, at 1:30 p.m., during interview, the Director of Social Services (DSS) stated a copy of the proposed transfer/discharge notice was usually sent via fax to the Ombudsman on the day of discharge. She stated the proposed transfer/discharge notice was not provided to the patient or patient’s representative when the notice of Medicare Non-Coverage was signed by the patient's representative or acknowledged by telephone. She stated she should have given the Notice of Proposed Transfer/Discharge earlier. A review of the facility's policy and procedure titled, "Transfer or Discharge, Facility-Initiated," dated October 2022, indicated, "...Notice of Transfer or Discharge (Planned)...the resident and his or her representative are given a thirty (30) -day-advance written notice of an impending transfer or discharge from the facility...A copy of the notice is sent to the Office of the State Long -Term Care Ombudsman at the same time the notice of transfer or discharge is provided to the resident and representative..." It was determined that the facility failed to provide the proposed transfer and discharge notice to the Office of the State LTC Ombudsman at the same time the notice was provided to the patient or patient’s representative for Patient 3. This failure resulted in the missed opportunity for the LTC Ombudsman to advocate for the patient to ensure a safe and appropriate discharge. This violation had a direct or immediate relationship to the health, safety, and security of Patient 3.