Health inspection·December 3, 2025

California Code of Regulations, Title 22, Section 72523 (a) 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. Code of Federal Regulations, Title 42, § 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 reduction of factors leading to preventable readmission. 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. (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. On October 13, 15, and 20, 2025, unannounced visits were conducted at the facility to investigate two complaints concerning unsafe discharge. It was determined that the facility failed to ensure a safe and appropriate discharge when Patient A, who required constant supervision and a pureed diet due to dementia (memory loss and confusion) and dysphagia (difficulty or discomfort in swallowing), was discharged to an unlicensed room and board with no caregivers and no understanding of her medical requirements and that the facility did not verify that the receiving facility could meet the patient’s care needs. This failure of the facility resulted in Patient A being discharged to an unlicensed room and board without necessary supervision. Patient A was transferred to the general acute care hospital (GACH) seven days after the patient was discharged from the skilled nursing facility to the unlicensed room and board. In addition, this failure of the facility to ensure safe and appropriate discharge is a substantial factor that can cause serious harm, injury, or death to Patient A. Patient A’s record was reviewed. Patient A was admitted to the facility on August 8, 2025, with diagnoses which included dysphagia and dementia. Patient A’s “History and Physical,” dated June 16, 2025, indicated Patient A did not have the decision-making capacity. Patient A’s “Progress Notes,” indicated the following: a. June 20, 2025, Patient A lived with her (Family member) prior to her hospitalization and the goal was for Patient A to return home once medically stable; and b. July 11, 2025, Patient A attempted to leave the facility and was placed on close monitoring with 1:1 sitter (a person providing one-on-one supervision to ensure patient safety). A review of the SBAR (Situation, Background, Assessment, and Recommendation – a communication framework used to structure conversations about patient updates between team members) dated July 17, 2025, indicated a Certified Nursing Assistant (CNA) called the Licensed Vocational Nurse (LVN) to the room stating Patient A had difficulty swallowing. Patient A was observed by the LVN coughing and had to perform the Heimlich maneuver (a first aid method for choking). A review of the “Care Plan,” dated July 18, 2025, indicated, “Focus…Elopement: Resident is at risk for elopement/exit seeking/wandering related to…dementia or other cognitive impairment…Interventions/Tasks…1:1 Sitter provided 24 hours…Administer medications as ordered, monitor for side effects…” A review of the “Care Plan,” dated August 8, 2025, indicated, “…Focus…Falls: Resident is at risk for falls…Interventions/Tasks…Anticipate and meet needs…Keep within supervised view as much as possible…” A review of the “Care Plan,” dated August 9, 2025, indicated, “…Focus…PT (Physical Therapy)…Interventions/Tasks…Pt (patient) will be able to safely ambulate with Supervision using FWW (front wheel walker)…” A review of the care plans dated July 18, August 8, and August 9, 2025, indicated Patient A had difficulty in swallowing, at risk for elopement, and at risk for falls. A review of Patient A’s “Minimum Data Set (MDS – an assessment tool),“ Section C: Cognitive Patterns, dated September 30, 2025, indicated a Brief Interview of Mental Status (BIMS – a cognitive assessment tool), score of 5 (severely impaired). A review of Patient A’s “MDS,” Section GG (Functional Abilities), dated September 30, 2025, indicated the following: a.) Requires supervision or touching assistance (Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently) related to safe-care (Eating, Oral hygiene, toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear, and personal hygiene); and b.) Requires supervision or touching assistance related to mobility (roll left and right, sit to lying, lying to sitting on side of the bed, sit to stand, chair/bed-to-bed/chair transfer, toilet transfer, tub/shower transfer, car transfer, walk 10 feet, walk 50 feet with two turns, and walk 150 feet). A review of Patient A’s “Progress Notes,” dated September 25, 2025, indicated the Speech Therapist (a speech-language pathologist, a professional who assess, diagnose, and treats speech, language, voice, and swallowing disorders) recommended diet downgrade to pureed diet (soft, smooth, pudding-like foods that require no chewing), due to difficulty swallowing. A review of the “Physician Discharge Order,” dated September 25, 2025, indicated, “…Fortified (with added essential nutrients such as vitamins, minerals, or proteins to enhance nutritional values), NAS (no added salt) diet, pureed texture, thin consistency…” A review of the “Physical Therapy Discharge Summary,” dated September 29, 2025, indicated there was a discharge recommendation for home health (skilled medical care provided in a person’s home/place, prescribed by a doctor to help them recover, manage an illness, or improve their function) services and 24-hour care. A review of the “Occupational Therapy (a healthcare profession that focuses on assisting people in regaining or improving their ability to perform everyday tasks such as dressing and personal care) Discharge Summary,” dated September 29, 2025, indicated, “Constant supervision recommended for safety…” A review of the “Physician Discharge Order,” dated September 29, 2025, indicated, “…DC (discharge) to board and care [B & C- a type of Residential Care Facility for the Elderly – RCFE] on Tuesday 9/20/25 per family request, dme [durable medical equipment – medical supplies and equipment] will be provided by hospice…” On October 13, 2025, at 11:23 a.m., the Social Service Director (SSD) was interviewed and stated the following: a. If the family were unable to care for the patient at home, she would begin assisting the patient and work with the family to find an appropriate placement; b. She uses an outside company to aid in the placement process such as Board and Care facility or Assisted Living (AL – setting which provides housing, meals, and personal care support for individuals who need assistance with Activities of Daily Living [ADL – basic self-care tasks that individuals perform to maintain their daily lives such as bathing or showering, dressing, toileting, eating or transferring] but do not require the intensive medical care provided by a nursing home); c. She utilized a placement agency (a third-party agency), not contracted with the skilled nursing facility (SNF – a healthcare facility offering 24-hour medical care and rehabilitation services to patients needing assistance with daily activities and medical treatments post-hospitalization or surgery ) to evaluate the patient’s needs, communicate with the patient and their family, and refer the patient to other facilities for placement; d. Specifically, for Patient A, the placement agency assisted in searching for a suitable Board and Care or AL facility; e. She forwarded Patient A’s information to the placement agency, expecting that a representative from the agency would contact Patient A and her family; f. A representative from the placement agency was supposed to come and assess Patient A, this assessment did not take place; g. She (SSD) did not communicate with the unlicensed room and board facility where Patient A was discharged; and h. She (SSD) did not verify if the facility could meet Patient A’s needs, instead relied on the "assumption" that such facilities would not accept patients they are not capable to care for. On October 13, 2025, at 2:02 p.m., the Placement Specialist (PS) from the placement agency was interviewed. She stated she had contacts with facilities like B & C, AL, memory care (specialized support and living options for individuals with Alzheimer’s disease [a specific type of dementia] or other forms of dementia), room and boards, and shelters. The PS stated she received a call from the SSD requesting assistance for Patient A’s placement. She indicated, that normally, she would assess the patient or get report from the SSD or the nurses. The PS stated she did not go to the SNF to see Patient A to assess her needs. The PS acknowledged Patient A went to a room and board and not a board and care facility. On October 13, 2025, at 2:56 p.m., the SSD was interviewed. The SSD indicated she just clarified with the PS that Patient A was transferred to an unlicensed room and board. She stated she was not aware that the place where Patient A transferred was not a B & C facility. According to the California Code of Regulations, Title 22, Division and Licensing of Community Care Facilities, Chapter 8, Residential care Facilities for the Elderly (RCFE), Article 1 defines a room and board as “…a living arrangement where care and supervision is neither provided nor available…” According to the California Code of Regulations, Title 22, Division 6, Licensing of Community Care Facilities, Chapter 8, Residential Care Facilities for the Elderly (RCFE), Article 1 defines a RCFE as a housing arrangement chosen voluntarily by the resident, the resident’s guardian, conservator or other responsible person where varying levels of care and supervision are provided. According to the California Code of Regulations, Title 22, Division 6, Licensing of Community Care Facilities, Chapter 8, Residential Care Facilities for the Elderly (RCFE), Article 1 defines care and supervision as “…those activities which if provided shall require the facility to be licensed. It involves assistance as needed with activities of daily living and the assumption of varying degrees of responsibility for the safety and well-being of residents. “Care and Supervision” shall include, but not be limited to, any one or more of the following activities provided by a person or facility to meet the needs of the residents: (A) Assistance in dressing, grooming, bathing and other personal hygiene; (B) Assistance with taking medication; (C) Central storing and distribution of medications; (D) Arrangement of and assistance with medical and dental care; (E) Maintenance of house rules for the protection of the residents; (F) Supervision of resident schedules and activities; (G) Maintenance and supervision of resident monies or property; (H) Monitoring food intake and special diets…” During a telephone interview on October 13, 2025, at 3:01 p.m., in the presence of the SSD, with the owner of the room and board (ORB), he stated he had five patients in the house where he also lives and he did not have a 24-hour caregiver. He stated the other patients have IHSS (In-Home Supportive Services – a program that provides in-home help for eligible aged, blind, or disabled individuals to enable them to remain safely in their home) provided by their families, or the family themselves would come to assist the patients. He stated Patient A did not have IHSS and her family did not visit. The ORB stated he was not aware Patient A was on a pureed diet and that he (the ORB) provided her with regular food (regular consistency food, not pureed consistency food as recommended by the Speech Therapist and ordered by the practitioner upon discharge - related to choking risk). On October 13, 2025, at 3:12 p.m., the SSD was interviewed. She stated she should have called (Name of the room and board) and verify if they could meet Patient A’s care needs. The SSD acknowledged she did not ensure Patient A had a safe discharge and moving forward that she would check and verify the agency’s (placement agency) referral before discharging the patient. During a telephone interview on October 15, 2025, at 10:28 a.m., with the ORB, he stated the following: a. He received telephone calls from the placement agency on September 23, 24, and 25, 2025, informing him he would be receiving a patient with dementia on hospice care (a specialized type of care for people with a life-limiting illness, focusing on comfort, pain relief, and symptom management rather than cure) and that Patient A’s family would come and talk to him; b. He did not have any information regarding the care needed for the patient (Patient A) before the patient was transferred to his house (referring to the room and board) on September 30, 2025; and c. He received a call from the SSD on October 1, 2025, to check on Patient A. In addition, he stated it was the first time he received a call from the SSD. During a concurrent interview and record review on October 15, 2025, at 1:20 p.m., with the Director of Nursing (DON), she stated Patient A had a 1:1 sitter until she was discharged from the facility on September 30, 2025. The DON stated the mobility assessment on September 30, 2025, indicated Patient A needed supervision with self-care and mobility. She stated, “needs supervision,” meant “somebody needs to be present,” with the patient when performing a task. She explained when Patient A used the restroom, somebody should be with her going to the restroom because she was high risk for, and could fall. The DON stated the expectation was for the receiving facility to have the knowledge, training, and skills needed to care for the patient, including her mobility needs. During a telephone interview on October 15, 2025, at 1:40 p.m., with the Administrator (ADM), he stated the placement agencies were used as a resource to assist with patient placement, and his expectation was for the facility staff to verify that the receiving facility can meet the patient’s needs to ensure a safe and appropriate discharge. Seven days after the patient was discharged from the skilled nursing facility to the room and board, Patient A’s family had her (Patient A) transferred via ambulance to the GACH on October 7, 2025. A review of Patient A’s GACH record titled, “Emergency Record,” dated October 7, 2025, indicated, “…from SNF (sic)…Family AMA’d (against medical advice – leaving the facility against the advice of a medical professional ) pt (patient) due to disappointment regarding care at the facility…” A review of Patient A’s “Urinalysis (a laboratory test that examines a sample of urine),” and “Bacteriology (a laboratory test that detects bacteria),” at the GACH, dated October 7, 2025, indicated Patient A had a urine infection. A review of the facility’s policy and procedure titled, “Transfer or Discharge Notice,” revised March 2021, indicated, “…In determining the transfer location for a resident, the decision to transfer to a particular location is determined by the needs, choices and best interests of the residents…” It was determined that the facility failed to ensure a safe and appropriate d