Health inspection·July 24, 2025

§483.15(c(1)(2)(i)(ii)(7)(e)(1)(2) Transfer and discharge- §483.15(c)(1) Facility requirements- §483.15(c)(1)(i) The facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless §483.21(c)(1)(2)(iv) 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 §483.21(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 (a)Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. On 5/29/2025, the California Department of Public Health (CDPH) received a complaint alleging a resident (Resident 1) was discharged from the facility and transferred to another facility without disclosing Resident 1's information and location to Resident 1's Responsible Party (RP) and Family Member (FM). The complaint alleges that Resident 1 passed away on 4/13/2025 but Resident 1's FM/RP were not made aware of Resident 1's death until 5/26/2025 when she received a call from the funeral home. On 6/6/2025, CDPH conducted an unannounced visit to the facility to investigate the complaint allegations. Upon investigation, CDPH determined Resident 1, who was diagnosed with dementia (a progressive state of decline in mental abilities), and lacked the capacity to understand and make decisions was discharged inappropriately from the facility to a Board and Care ([B&C] a type of small, residential facility that provides housing and personal care services to individuals who need assistance with activities of daily living [ADLs] activities such as bathing, dressing and toileting a person performs daily) facility on 1/17/2025 and was then transferred from the B&C to an Extended Care facility ([ECF] a healthcare institution that provides ongoing medical care, rehabilitation services, and assistance with ADLs to individuals who require prolonged or specialized attention) sometime in 2/2025 and expired at the ECF on 4/13/2025 without the RP and/or FM's knowledge. The facility failed to: 1. Ensure an Interdisciplinary Team ([IDT] a team comprised of healthcare professionals from different disciplines collaborating to develop and coordinate the residents' care plans such as a discharge plan with a goal to optimize the resident outcomes) meeting was conducted prior discharge planning and discharge of Resident 1 from the facility. 2. Ensure Resident 1's RP and/or FM were provided a Notice of Proposed Discharge/Transfer 30 days prior to Resident 1's transfer, 3. Ensure Resident 1's assessment was conducted prior to transferring Resident 1 to the B&C, and communicated to the continuing care provider, per the facility's Policy and Procedure (P/P), titled "Discharge and Transfer of Residents." 4. Ensure an inventory list with Resident 1's personal effects was sent with Resident 1 upon discharge to the B&C. 5. Follow their P/P titled "Discharge and Transfer of Residents" revised 2/2018, that indicated the facility must ensure: a. The resident's discharge planning is complete and appropriate, and the necessary information is communicated to the continuing care provider. b. The resident/resident representative will be provided with a Notice of Proposed Transfer and Discharge 30 days prior to discharge or as soon as practicable. c. The IDT will complete a discharge summary/post discharge plan of care when a resident is near a planned discharge and a copy of the discharge plan of care and/or discharge summary be provided to the resident, resident representative or the receiving facility. d. The social services or the nursing department must provide the resident and their representative with the Notice of Proposed Transfer and Discharge document and the social service department will provide a copy of the same document to the resident and their representative and a copy shall be placed in the resident's medical record. e. The Discharge Summary/Post Discharge Plan should include the resident's discharge destination including the address and phone number and the resident's representative and/or family contact information f. The resident's actual discharge must be documented in the resident's medical record to indicate the following: g. The date, time, and condition of the resident upon discharge h. Condition and diagnoses of the resident upon discharge or final disposition i. Discharge planning notes; and j. The resident's medications shall be reconciled and the disposition of the resident's drugs during discharge should be prepared, labelled and endorsed to the resident and/or the responsible party and/or to the representative of the incoming facility, according to the orders of the resident's primary care physician. 6. Follow their P/P titled "NP03 Discharge and Transfer of Residents" revised 12/21/2023, that indicated the facility shall ensure the residents' discharge planning is complete and appropriate and that necessary information is communicated to the continuing care provider to prevent inappropriate, unnecessary and untimely transfer and discharges. 7. Follow their P/P titled, "Discharge and Transfer of Residents" revised 2/2018, that indicated the facility must ensure the facility staff will prepare the resident's inventory at the time of discharge and the facility will provide the resident and their representative a copy of the Resident's Inventory and have the recipient sign. As a result of these deficient practices, Resident 1 was discharged to a B&C facility on 1/17/2025 without an IDT meeting or prior discharge planning. Resident 1's RP and/or FM were not provided a Notice of Proposed Discharge/Transfer 30 days prior to the Resident 1's transfer, there was no assessment of Resident 1 on transfer to the B&C, confirmation that Resident 1's contact information was received at the B&C, a list of the Resident 1's medication or an inventory list with Resident 1's personal affects sent with her. Resident 1 was transferred from the B&C to an ECF sometime in 2/2025 and expired at the ECF on 4/13/2025 without the RP and/or FM's knowledge. These deficient practices had the potential for Resident 1 to become depressed and feel isolated prior to her death on 4/13/2025 A review of Resident 1's Admission Record (Face Sheet), indicated Resident 1, a ninety-year-old female, was admitted to the facility on 3/8/2023 with a diagnosis of dementia and depression. A review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 12/13/2024, indicated Resident 1 was unable to make decisions that were consistent and reasonable, and she required a one person assist to complete her activities of daily living (ADLs). A review of Resident 1's History and Physical (H&P) dated 10/2/2023, indicated Resident 1 did not have the capacity to understand and make decisions because of dementia. The H&P indicated that her family member (RP) was the surrogate (a substitute) decision maker for her care needs and medical decisions. A review of Resident 1's untitled Care Plan dated 6/15/2023, indicated Resident 1 had impaired cognitive function (difficulty with thinking, learning and remembering) and impaired thought processes related to dementia. The Care Plan's goals were for Resident 1 to maintain her current level of cognitive function and to develop skills to cope with cognitive decline and maintain safety, with interventions that included communicating with Resident 1 and her family and/or caregivers regarding Resident 1's needs and capabilities. A review of Resident 1's Physician's Progress Notes dated 6/24/2024, indicated Resident 1's physician communicated with the nursing staff and the case management/discharge planner that Resident 1's discharge plans and procedures would be discussed/notified/permitted by Resident 1 and her family to ensure Resident 1's safe discharge from the facility. A review of Resident 1's Medical Record indicated there was no documented evidence the facility conducted a discharge planning IDT that involved Resident 1 and her RP/FM. A review of the Social Service Progress Notes dated 1/17/2024 (the corrected date was 1/17/2025), indicated Resident 1 was to be discharged to a B&C facility on that same day (1/17/2025) and Resident 1's RP was informed via telephone call. A review of Resident 1's Medical Record indicated there was no documented evidence that a Notice of Proposed Transfer and Discharge was completed 30 days prior to Resident 1's discharge to the B&C facility on 1/17/2025. A review of Resident 1's Discharge Planning Review Form dated 1/17/2025 and timed at 4:38 p.m., indicated there was no reason documented why Resident 1 was to be discharged. Continued review of the Discharge Planning Review Form indicated the following: 1. A Post discharge medication list was discussed with the resident/family, then contradicting previous documentation indicated the reconciled medication list was not provided to the resident family and/or care giver. 2. A walker (front wheel walker [FWW] a mobility aid with two wheels at the front and two legs with glides or rubber tips at the back) was provided to Resident 1. 3. Medications were sent with Resident 1. 4. Contact information to include the name, relations and phone numbers of Resident 1's RP were provided. Continued review of the Discharge Planning Review Form indicated there were no signatures by Resident 1 and/or the RP to indicate that either one of them understood the discharge instructions. A review of Resident 1's Medical Records indicated there was no documented evidence that Resident 1's status on discharge from the facility (1/17/2025) was assessed. A review of Resident 1's Inventory of Personal Effects dated 9/29/2023, indicated a blank/unsigned receipt on discharge by Resident 1 and/or Resident 1's RP/FM. The Inventory of Personal Effects indicated Resident 1 had the following items at the facility: a. four blouses (no description) b. one underpants (no description) c. one coat (no description) d. two pairs of short pants (no description) e. four pairs of slippers (no description) f. two sweaters (no description) g. six undershirts (no description) h. six pairs of socks (no description) i. two pillows (no description) j. two blankets (no description) k. two pairs of glasses (no description) l. two perfume bottles (no description) m. one black cellular phone During a telephone interview on 6/5/2025 at 10:48 a.m., Resident 1's FM stated she was called by the facility's Social Services Worker Director (SSD) on 1/17/2025 (time unspecified) informing her that Resident 1 would be discharged from the facility later that day. The FM stated the SSD did not provide her with information where Resident 1 would be going because she (FM) was not the RP. The FM stated she contacted the RP a few days after Resident 1 was discharged from the facility (1/17/2025) to ask him about Resident 1's discharge location but the RP had no information about Resident 1's location. The FM stated on 5/27/2025, she received a call from the County Public Administrator's Office notifying her that Resident 1 passed away at an ECF. The FM stated she was devastated that the facility discharged Resident 1 from the facility without providing Resident 1's location to the RP and no one knew where in the community Resident 1 was. The FM stated Resident 1's condition was unknown, Resident 1 was subjected to an undignified situation at the ECF, she lived the rest of her life without her personal belongings that were necessary for a comfortable life, and Resident 1 died alone without the presence of her family and was not given the proper respect/compassion during her last days. During a telephone interview on 6/6/2025 at 2:28 p.m., Resident 1's RP stated he did not know about and had not been involved in any discharge plans for Resident 1 until 1/17/2025 when the facility's SSD called to inform him that Resident 1 would be discharged to a B&C facility that day. The RP stated he told the SSD to notify Resident 1's FM of Resident 1's discharge information. The RP stated the facility did not call him when Resident 1 was being discharged from the facility and he (RP) was not told anything about Resident 1's personal belongings. The RP stated at the end of 5/2025 he received a letter from the County Public Administrator's Office, when he called the County Public Administrator's Office, he was informed that Resident 1 passed away at an ECF. The RP stated he was dismayed that Resident 1 was alone after her discharge from the facility up until the time she took her last breath. The RP stated this could have been avoided if the facility had notified him (RP) and Resident 1's FM where Resident 1 was discharged. During a telephone interview on 6/9/2025 at 8:27 a.m., the Extended Care Owner (ECO) stated she was contacted by a person from a B&C facility (information unknown) and asked if she had an available female room. The ECO stated the first week of 2/2025 Resident 1 came to her facility in a car and was dropped off. Resident 1 had no personal belongings, only the clothes she wore, a list of medications and an insurance card. The ECO stated the contact person from the B&C told her Resident 1 had no family. The ECO stated Resident 1 expired on 4/13/2025 in her sleep and she (ECO) called a local funeral home to pick up Resident 1's body. During an interview on 6/9/2025 at 9:49 a.m., the SSD stated there was no Notice of Proposed Transfer and Discharge completed by the facility for Resident 1 prior to being discharged to a lower level of care (B&C). During a subsequent interview on 6/10/2024 at 2:50 p.m., the SSD stated the facility had not conducted a discharge planning IDT meeting with Resident 1 and/or her RP before Resident 1 was discharged from the facility on 1/17/2025 and Resident 1's inventory list was not signed for receipt by Resident 1 and/or her RP on discharge from the facility. The SSD stated she faxed Resident 1's information to the B&C facility prior to her discharge on 1/17/2025 but there was no confirmation receipt that the B&C facility received the documents. The SSD stated she should have confirmed with the B&C facility that Resident 1's information was received prior to her discharge from the facility and documented her communication with the B&C in Resident 1's medical record. During a telephone interview on 6/9/2025 at 11:02 a.m., Registered Nurse Supervisor (RNS) 2 stated on 1/17/2025 during the 7 a.m. to 3 p.m. shift, she prepared and signed Resident 1's discharge planning review form (discharge instructions) in preparation for Resident 1's discharge to a B&C facility. RNS 2 stated Resident 1 was not transferred to the B&C during her shift, and she did not call Resident 1's RP or FM regarding Resident 1's discharge information/instructions. RNS 2 stated she did not prepare and complete Resident 1's Notice of Transfer and Discharge Form because that was the SSD's responsibility to complete the form. During a telephone interview on 6/10/2025 at 3:36 p.m., the Funeral Director (FD) of a cremation company stated Resident 1 arrived at the funeral home with a top and bottom on and two metal rings on her fingers. The FD stated he called the County Public Administrator's (CPA) office because Resident 1 did not have family to take charge of Resident 1's