Health inspection·March 19, 2026

§483.15(c) Transfer and discharge- §483.15(c)(1) Facility requirements- (i) The facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless- (B) The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility; §483.15(c)(2) Documentation. When the facility transfers or discharges a resident under any of the circumstances specified in paragraphs (c)(1)(i)(A) through (F) of this section, the facility must ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institution or provider. (i) Documentation in the resident's medical record must include: (A) The basis for the transfer per paragraph (c)(1)(i) of this section. (B) In the case of paragraph (c)(1)(i)(A) of this section, the specific resident need(s) that cannot be met, facility attempts to meet the resident needs, and the service available at the receiving facility to meet the need(s). (ii) The documentation required by paragraph (c)(2)(i) of this section must be made by- (A) The resident's physician when transfer or discharge is necessary under paragraph (c) (1) (A) or (B) of this section; and (B) A physician when transfer or discharge is necessary under paragraph (c)(1)(i)(C) or (D) of this section. §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. (B) Facilities must update a resident's comprehensive care plan and discharge plan, as appropriate, in response to information received from referrals to local contact agencies or other appropriate entities. (viii) For residents who are transferred to another SNF or who are discharged to a HHA, IRF, or LTCH, assist residents and their resident representatives in selecting a post-acute care provider by using data that includes, but is not limited to SNF, HHA, IRF, or LTCH standardized patient assessment data, data on quality measures, and data on resource use to the extent the data is available. The facility must ensure that the post-acute care standardized patient assessment data, data on quality measures, and data on resource use is relevant and applicable to the resident's goals of care and treatment preferences. (ix) Document, complete on a timely basis based on the resident's needs, and include in the clinical record, the evaluation of the resident's discharge needs and discharge plan. The results of the evaluation must be discussed with the resident or resident's representative. All relevant resident information must be incorporated into the discharge plan to facilitate its implementation and to avoid unnecessary delays in the resident's discharge or transfer. §483.21(c)(2) Discharge Summary When the facility anticipates discharge, a resident must have a discharge summary that includes, but is not limited to, the following: (iv) A post-discharge plan of care that is developed with the participation of the resident and, with the resident's consent, the resident representative(s), which will assist the resident to adjust to his or her new living environment. The post-discharge plan of care must indicate where the individual plans to reside, any arrangements that have been made for the resident's follow up care and any post-discharge medical and non-medical services. 72523 (a) Patient Care Policies and Procedures Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. On 2/2/2026, the California Department of Public Health (CDPH) received a complaint alleging that Resident 1 was inappropriately discharged to a lower level of care. On 1/30/2026 at 3:39 a.m., Resident 1 was found wandering in the street and was subsequently transferred to a general acute care hospital (GACH). On 2/3/2026, CDPH conducted an unannounced visit to the facility to investigate the complaint allegation. Upon investigation, CDPH determined the facility failed to: 1.Ensure a safe discharge for Resident 1, who was a Regional Center client (a person with a developmental disability receiving care in a state-sponsored facility), with diagnoses including schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior) bipolar type (mood swings that range from the lows of depression [persistent feeling of sadness] to elevated periods of emotional highs), unspecified psychosis (mental health condition characterized by a loss of contact with reality), anxiety disorder (intense and persistent worry that is difficult to control and interferes with daily life) and seizures (sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness). 2.Notify Resident 1's conservator (a court-ordered arrangement that appoints a responsible individual to manage the financial affairs, personal care, or both, of an adult who is unable to do so due to incapacity or severe disability) of Resident 1's discharge plan. 3. Ensure the conservator was actively involved in selecting the facility and consenting prior to discharging Resident 1 to a recuperative care home ([RCC] a temporary safe place for people to heal after discharge from the hospital) on 1/28/2026. 4. Ensure an Interdisciplinary (IDT group of health care professionals who work together on the same plan of care) were involved and meeting was held to assess Resident 1's cognitive (ability to think, understand, learn, and remember), medical, physical, and psychosocial (emotional wellbeing) needs prior to discharging the residents to a lower level of care. 5. Ensure the RCC was notified by Licensed Vocational Nurse (LVN) 1 of Resident 1's medical condition including the resident's diagnoses, medications, history of wandering (walk around without any clear purpose or direction), and risk for falls/seizures prior to discharging the resident. These deficient practices resulted in Resident 1 being transferred to a RCC without proper discharge planning by the facility and without input or permission from Resident 1's Conservator to transfer Resident 1 to the RCC on 1/28/2026. On 1/30/2026 at 3:39 a.m., Resident 1 was found wandering approximately 9.1 miles from the RCC without any shoes on. Resident 1 was transported via the fire department to a General Acute Care Hospital (GACH). This placed Resident 1 at risk for experiencing uncontrolled seizures, falls, hallucinations (sights, sounds, smells, tastes, or touches that a person believes to be real but are not real), harsh weather conditions, environmental dangers including motor vehicle accidents, and assault. There was a likelihood Resident 1, did not receive any medication after she was discharged to the RCC. As of 2/20/2026 Resident 1 remains in the GACH. Resident 1 a 43-year-old female who was initially admitted to the facility on 11/8/2025 and readmitted on 11/12/2025. Resident 1's diagnoses included schizoaffective disorder bipolar type, unspecified psychosis seizures, anemia (a condition where the body does not have enough healthy red blood cells), and anxiety disorder. The Face Sheet indicated Resident 1's Conservator was her Responsible Party (RP). A review of Resident 1's Elopement Risk Assessment dated 11/8/2025, indicated Resident 1 was a high risk for elopement. A review of Resident 1's Fall Risk Assessment dated 11/8/2025, indicated Resident 1 had a balance problem while standing, walking and a decreased muscular coordination. A review of Resident 1's Social Services Discharge Plan dated 11/10/2025 and timed at 2:46 p.m., indicated Resident 1 came from a homeless environment and might need additional help once discharged home with the support of her Conservator. A review of Resident 1's IDT Conference notes dated 11/14/25, indicated Resident 1's Conservator attended the IDT meeting via telephone and there was no discharge planning discussed during the meeting. The IDT Conference Notes indicated the bed hold policy and discharge plan would be reviewed with Resident 1's Responsible Party (RP)/Conservator. A review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 11/19/2025, indicated Resident 1 had severely impaired cognitive skills (ability to think, understand, learn, and remember) for daily decision making. The MDS indicated Resident 1 was dependent (helper does all the effort and the resident makes none of effort to complete the activity) on staff to complete her activities of daily living ([ADL] activities such as bathing, dressing and toileting a person performs daily) Resident 1 did not have the ability to ambulate. The MDS indicated had no functional limitation in range of motion (ROM- is the extent of movement of a joint, measured in degrees of a circle) for upper and lower extremity. A review of Resident 1's Physician's Order dated 1/28/2026 the Physician's Order indicated to discharge Resident 1 to RCC. A review of Resident 1's Progress Note dated 1/28/2026 and timed at 1:20 p.m., indicated Resident 1 was discharged from the facility and picked up by an emergency transport team (EMT) personnel member. The Progress Note indicated prior to Resident 1's departure, all standard safety checks were completed, including identity verification, confirmation of transfer destination, ensuring all necessary documents were attached to the transfer packet and securing the resident safely on a gurney (hospital bed with wheels) with straps. It also indicated Resident 1 was transferred to the RCC and a voice mail was sent to Resident 1's conservator notifying them of Resident 1's transfer. During a telephone interview on 2/3/2026 at 8:18 a.m., the Lead Coordinator at the GACH stated Resident 1 was found wandering in the streets on 1/30/2026, at 3:39 a.m. (approximately 9.1 miles from the RCC) with no shoes on, by the Fire Department and transferred to the GACH. A review of Resident 1's Emergency Medical Service (EMS) Report dated 1/30/2026, indicated Resident 1 was found wandering around the street, not alert or oriented, wearing a helmet with insect eggs all over her clothes and hands. The report indicated Resident 1 was transported to a GACH. A review of the GACH's Admission Record (Emergency Documentation), dated 1/30/2026, indicated Resident 1 was admitted to the GACH on 1/30/2026 with active diagnoses of acute psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality) and altered mental status ([AMS] a changed level of awareness or mental state that falls short of unconsciousness). During an interview on 2/3/2026 at 9:37 a.m., Social Services Staff (SSS) 1 stated Resident 1 was conserved under a Public Guardian and was discharged from the facility to a RCC on 1/28/2026. SSS 1 stated the facility did not discuss the discharge planning and Resident 1's transfer to the RCC, with Resident 1's Conservator. SSS 1 stated the facility should have discussed Resident 1's discharge plan and subsequent discharge prior to Resident 1's discharge on 1/28/2026. SSS 1 stated IDT were not involved, and IDT meeting was not held related to Resident 1's discharge plan prior to Resident 1's discharge. SSS 1 stated this was the first time she used this RCC. During an interview on 2/3/2026 at 10:47 a.m., the Director of Nursing (DON) stated Resident 1 was 43 years old, impulsive (the tendency to act or react quickly without planning, forethought, or consideration of potential consequences), had a one to one (a safety intervention where a dedicated staff member is assigned to monitor a single patient at all times), due to her fall risk, from the time of her admission (11/8/2025) until she was discharged (1/28/2026), she had no rehabilitation potential and did not meet the skill criteria needed to remain at the facility. The DON stated Resident 1 required a lower level of care where her medications would be managed, so she (DON) met with SSS 1, and the decision was made to transfer Resident 1 to the RCC. The DON stated Resident 1's physician was notified and an order obtained to discharge Resident 1 to the RCC for 24-hour care. The DON stated Resident 1's Conservator was not involved in Resident 1's discharge planning or discharge and there was no IDT meeting conducted related to Resident 1's discharge plan/discharge. The DON stated the facility should have waited for authorization from Resident 1's public guardian before discharging the resident to another level of care. During an interview on 2/3/2026 at 12:41 p.m., Resident 1's Conservator stated she visited Resident 1 in the facility (date unknown) and discussed transferring Resident 1 to a locked facility with SSS 1, but SSS1 never followed up with her regarding Resident 1's transfer. The Conservator stated she was responsible for making decisions for Resident 1 and the facility should not have transferred Resident 1 to another facility without her knowledge, involvement and approval, or the approval of someone else in the Public Guardian's office if she was not available. The Conservator stated Resident 1 was a Regional center client who had a mental disability and was developmentally delayed (a child not reaching developmental milestone compared to others of the same age). The Conservator stated transferring Resident 1 to an inappropriate facility placed the resident at risk for neglect and harm. During an interview on 2/3/2026 at 1:52p.m., Certified Nurse Assistant (CNA) 1 stated Resident 1 was alert to person only, could follow instructions, had a one to one sitter, required assistance getting dressed, and could not be left alone because she (Resident 1) was a high risk for falls and a wanderer (when a person with cognitive challenges leaves a safe place and walk away where they can be endangered and cannot trace back). During an interview on 2/4/2026, at 3:38 p.m., Licensed Vocational Nurse, (LVN) 1 stated to discharge a resident out of the facility, the licensed nurse was to obtain a physician's discharge order, perform a skin assessment, notify the resident's family or conservator, prepare discharge paperwork, print the face sheet and medication summary, and contact the receiving facility. LVN 1 stated these steps were not fully completed during Resident 1's discharge to the RCC. LVN 1 stated he was unable