Health inspection·December 16, 2025

F 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. Based on observation, interview and record review, the facility failed to implement the discharge plan to ensure a safe discharge for one of one sampled residents (Resident 1) by failing to provide a written form of discharge notice to the resident and family members and re-evaluate resident 1's condition for discharge.These deficient practices placed Resident 1 at risk for unsafe discharge.During a review of Resident 1's History and Physical (H&P), dated 5/31/25, the H&P indicated the facility admitted Resident 1 on 5/31/2025 with diagnoses that included chronic hypoxic respiratory failure (lungs consistently cannot get enough oxygen into the blood, leading to low blood oxygen and often normal or low CO2, causing symptoms like breathlessness, bluish skin, fatigue, and fast heart rate, stemming from lung damage or blood flow issues), recent subdural hemorrhage status post craniotomy (surgery to treat a collection of blood between the brain), and protein malnutrition (conditions from insufficient intake or absorption of protein and energy [calories], leading to impaired growth, weakened immunity, muscle wasting, and severe health issues).During a review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 9/10/2025, the MDS indicated Resident 1 was dependent that helper does all the effort, or two helpers' assistance is required to perform activities including eating, oral hygiene, personal hygiene, toileting hygiene, shower/bathe self, upper and lower body dressing, and personal hygiene.During an interview on 12/16/2025 at 2:15 p.m. with Responsible Party (RP) 1, RP 1 stated he had a conversation with Resident 1's physician (MD 1) on 12/1/2025. RP 1 stated he expressed his concerns to the facility staff that Resident 1 was not ready to be discharged home. RP stated on 12/1/2025, he had a conversation at Resident 1's bedside with MD 1. During the conversation, MD 1 stated Resident 1 was going to be discharged to either home or a skilled nursing facility (SNF). RP 1 stated that around 11/26/2025, Resident 1 and family were told by the staff that Medicare would pay for the 100-day stay in the facility, and Resident 1 had exhausted all skilled days for SNF and therefore, after 12/1/2025, and present the amount of the monthly payment that the family was responsible for to continue Resident 1's stay in the facility. RP 1 stated the facility did not provide a 30 days written discharge notice prior to the discharge date and did not have a safe discharge plan for Resident 1. Concurrently, RP 1 stated they called the ombudsman (OM 1) and OM 1 also came to the facility and attended the interdisciplinary team meeting on 12/11/2025. In that meeting, OM 1 pointed out that that the facility had to give 30 days' written notice prior to discharge the Resident home or a skilled nursing facility (SNF).During an observation and interview on 12/16/2025 at 2:45 PM in Resident 1's room, Resident 1 was lying on bed and had limited range of motion of upper and lower extremities. Resident 1 stated he needed assistance to most of the activity of daily living (ADL) and he could only sit up on the bed edge with two-person assistance, and he was not able to walk.During an interview on 12/16/2025 at 3:00 PM with the clinical manager (RN 1), RN 1 stated that MD 1 informed family and Resident 1 regarding the discharge verbally, however, there was no written notice provided to Resident 1's family. Page 1 of 2 555237 555237 12/16/2025 San Gabriel Valley Medical Ctr D/P Snf 438 W. Las Tunas Drive San Gabriel, CA 91776

F 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few RN 1 stated that they have been verbally telling the discharge planning. RN 1 stated that when OM 1 was onsite attending the weekly meeting with 1's family on 12/2/2025, OM1 pointed out that 30 days' written notice was required prior to discharge. RN 1 stated they did not provide the 30-day written notice to Resident 1 or family. RN 1 stated that the facility's discharge policy did not mention the 30 days' discharge written notice was required and they would revise the policy per regulation.During an interview on 12/16/2025 at 3:20 PM with the case manager (CM 1), CM stated RP 1 wanted to take Resident 1 to a SNF when Resident 1 exhausted her 100-day Medicare coverage during the IDT meeting when Resident 1 was admitted to the facility in May 2025. CM 1 stated the facility had a weekly staff meeting to discuss the discharge plan for Resident 1 and CM 1 always learnt from RP 1 that they preferred going to SNF than discharge home, regardless of whether Resident 1 was planned for dual planning, so she thought everyone was at the same goal to discharge Resident 1 was the plan. CM 1 stated she has been trying to place Resident 1 to a SNF and faxed Resident 1 information to about 84 different SNFs; however, only 2 SNFs accepted Resident 1 but both were declined by the family. CM 1 stated that they did not provide the 30-day written notice to Resident 1.During a review of the facility's subacute unit (a unit in the hospital that provides specialized, transitional care bridging the gap between intensive hospital stays [acute care] and returning home) policy and procedures (P&P) titled, Discharge Planning/Notice of Discharge, dated 2/5/2019, the P&P indicated, Once the need for discharge planning has been determined the Case Manager or Social Worker is responsible for coordinating with the resident/responsible party and appropriate disciplines/services (i.e. physician, home health coordinator, dietary, therapy, nursing, etc.). The Case Manager or Discharge Planner will initiate the Notice of Transfer or Discharge including the reason for discharge and provide it to the resident. Currently in this policy, there is no indication of 30 days of written discharge notice required to provide to the resident or resident representative. 555237 Page 2 of 2