Health inspection·August 22, 2025

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the physician documented the clinical rationale for the discharge for one of three sampled residents (Resident 1). This failure had the potential to result in an inappropriate discharge without medical justification, compromising the resident's health, safety, and continuity of care. Findings:On July 18, 2025, Resident 1's record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnoses which included fusion of the spine and depression (more than just feeling sad or having a bad day).A review of Resident 1's progress notes dated June 1, 2025, indicated, .Assessment and Plan.Pt (Resident 1) is recommendedfor [sic] f/u (follow-up) imaging within one year due to presence of polyp [small growth that can form on the lining of organs inside the body] .Pt (Resident 1) increasing tolerance to ambulance and functionality.Pt (Resident 1) would benefit from continued care.A review of Resident 1's Notice of Proposed Transfer/ Discharge, dated June 3, 2025, indicated, .Effective Date.July 3, 2025.The documentation indicated Resident 1 required ongoing care; however, the facility issued a Notice of Proposed Transfer/discharge on [DATE]. Further review of Resident 1's progress notes dated June 26, 2025, indicated .The patient is very independent and cares for herself. The patient is getting discharged , and the patient is cleared for discharge.The documentation did not provide clinical justification that Resident 1 no longer required facility services or that discharge was in the best interest of the resident's health and safety.On August 21, 2025, at 2:16 p.m., the Social Service Director (SSD) was interviewed. She stated, discharge planning begins when the physician orders the discharge. The SSD stated Resident 1 was under custodial care, and together with the IDT and the physician, it was decided the resident required a lower level of care. The SSD stated, Resident 1 received a written notice of discharge on [DATE].On August 22, 2025, at 1:19 p.m., a concurrent interview and review of Resident 1's progress notes with the Nurse Practitioner (NP) was conducted. The NP stated assessments are performed prior to discharge and should be documented in the resident's medical record. The NP stated that on June 1, 2025, she documented Resident 1 would benefit from continued care. The NP stated the determination to discharge the resident was not reflected in the record.On August 22, 2025, at 2:30 p.m., the Director of Nursing (DON) was interviewed during a record review of Resident 1. The DON stated, Resident 1 was provided notice of transfer/discharge on [DATE]. The DON stated, the NP's documentation did not support discharge readiness. The DON stated, Resident 1 should not have issued a notice of proposed transfer/discharge without physician documentation of the rationale.A review of the facility policy and procedure titled Transfer or Discharge Documentation, dated December 2016, indicated, .When a resident is transferred or discharged , details of the transfer or discharge will be documented in the medical record and appropriate information to the receiving healthcare facility or provider.Should the resident be transferred or discharged for any of the following reasons, the basis for the transfer or discharge will be document in the resident's clinical Page 1 of 2 555566 555566 08/22/2025 Corona Post Acute Center 2600 South Main Street Corona, CA 92882

F 0627 records by the resident's Attending Physician. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 555566 Page 2 of 2