Health inspection·May 21, 2025

CFR §483.15 Transfer and discharge (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- (A) The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility; (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. (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 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). (iii) Information provided to the receiving provider must include a minimum of the following: (A) Contact information of the practitioner responsible for the care of the resident. (B) Resident representative information including contact information (C) Advance Directive information (D) All special instructions or precautions for ongoing care, as appropriate. (E) Comprehensive care plan goals; (F) All other necessary information, including a copy of the resident's discharge summary, consistent with §483.21(c)(2) as applicable, and any other documentation, as applicable, to ensure a safe and effective transition of care. CCR §72523 - Patient Care Policies and Procedures Written patient care policies and procedures shall be implemented to ensure that patient-related goals and facility objectives are achieved. On 4/7/2025, the California Department of Public Health (CDPH) received a complaint indicating Resident 1 was transferred to a facility that didn't exist. On 4/8/2025 at 9:13 a.m., CDPH conducted an unannounced visit to investigate the allegation. The facility failed to: 1. Ensure an Interdisciplinary Meeting ([IDT] gathering where healthcare professionals from different disciplines collaborate to discuss a patient's care, develop shared understandings, and coordinate treatment plans) for discharge planning was conducted for Resident 1. 2. Ensure Resident 1's discharge location (house) could meet the resident's needs. 3. Follow up with Resident 1 after his discharge from the facility to the house, to ensure Resident 1 was safe and comfortably settled. 4. Ensure Resident 1 had a designated individual to safely administer his medications including Risperdal (medication to treat mental health conditions) and gabapentin (medication to treat nerve pain). 5. To contact the Local Contact Agency (a state-designated entity that provides options counseling to individuals in long-term care facilities interested in exploring community-based services and supports) to notify of Resident 1's discharge. 6. Implement its Policies and Procedures (P&P) titled, "Transfer or Discharge, Facility-Initiated," which indicated facility-initiated transfers and discharges, must meet specific criteria, and require resident/representative notification, orientation, and documentation. As a result, Resident 1 was discharged to a house in which her needs could not be met, and the resident was placed at risk for falls, injuries, and worsening medical and psychiatric conditions. Resident 1 was an 85-year-old female, admitted to the facility on 4/26/2022, with diagnoses of dementia (progressive decline in cognitive abilities, such as memory, thinking, and problem-solving,) traumatic fracture (a break in a bone caused by a forceful impact or injury, like a fall or car accident), and schizophrenia (chronic mental health condition characterized by disruptions in thought processes, perceptions, emotions, and behavior.) A review of Resident 1's Care Plan titled "Falls/Injury because of behavioral problems, dementia, and impaired cognition" dated 5/8/2022, indicated to provide 1:1 (one-on-one patient care, where a healthcare professional provides constant attention to a single patient) every shift, as ordered, due to poor safety awareness. A review of Resident 1's Minimum Data Set ([MDS], a resident assessment tool), dated 1/29/2025, indicated Resident 1 was sometimes able to understand and be understood by others. The MDS indicated Resident 1 required supervision for eating, and upper body dressing. The MDS indicated Resident 1 required moderate assistance (helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with oral hygiene, toileting hygiene, showering/bathing, lower body dressing, putting on/taking off footwear and personal hygiene. The MDS indicated Resident 1 required supervision with rolling left to right, sitting to lying, lying to sitting on side of bed, chair/bed-to-chair transfer, tub/shower transfer, and walking 10, 50 and 150 feet. The MDS indicated Resident 1 required moderate assistance to sit, stand and for toilet transfer. The MDS indicated Resident 1 required a mechanically altered diet (change in texture of food or liquids e.g. pureed food, thickened liquids.) The MDS indicated Resident 1 was on antipsychotic (medications used to treat mental health conditions characterized by psychosis [mental health condition characterized by a loss of touch with reality], such as schizophrenia and bipolar [mental health condition characterized by extreme mood swings between periods of high energy, elevated mood, and low mood, loss of interest, and fatigue] disorder) medications. A review of Resident 1's Order Details dated 1/22/2025, indicated Risperidone (drug used to treat certain mental disorders, such as schizophrenia and bipolar disease) 3 milligrams ([mg] unit of measurement), give 1 tablet by mouth at bedtime, for schizophrenia. A review of Resident 1's Order Details dated 2/21/2025, indicated Gabapentin (medication for seizures or nerve pain) oral capsule 300 mg by mouth, two times a day for neuropathy (condition where nerves are damaged or malfunctioning), hold for drowsiness. A review of Resident 1's "Multidisciplinary Progress Record" dated 2/26/2025, indicated Resident 1 remained disorganized, delusional with positive agitation. A review of Resident 1's Order Details dated 3/14/2025, indicated may discharge Resident 1 to an Assisted Living Facility. A review of Resident 1's "Los Angeles Fire Department (LAFD) Patient Care Report" dated 4/7/2025 at 6:29 p.m., indicated Resident 1 was unconscious, and her mental status was deteriorating (to become worse in condition). The LAFD report indicated a private ambulance was called but upon arriving at the house, 911 had been called due to Resident 1's altered level of consciousness. The LAFD report indicated Resident 1 was not alert and oriented and her vital signs were normal. A review of Resident 1's GACH records titled "Emergency Room (ER) template" dated 4/8/2025 at 8:20 a.m., indicated, Resident 1 was brought for altered mental status. The report indicated Resident 1 was non-verbal and did not follow commands or open her eyes and move to pain. A review of Resident 1's GACH records titled "Resident Family Medicine History and Physical (H&P)" dated 4/8/2025 at 2:39 p.m., indicated Resident 1 was stuporous (confused and slow to react ) with a Glasgow Coma Scale ([GCS] tool used to assess a patient's level of consciousness after a brain injury or other neurological issue) of 10 (score of 10 suggests the person is drowsy, reduced alertness or consciousness, but may still be able to open their eyes and respond to painful stimuli). The H&P indicated Resident 1 was non-verbal and not following commands. Resident 1 was able to open her eyes and move to pain. The H&P indicated Resident 1's laboratory (lab) results indicated the resident had a urinary tract infection ([UTI] bacterial infection that affects any part of the urinary system,). The report indicated Resident 1 was started on empiric (used when the cause of an illness is uncertain) antibiotics (medications that kill or stop the growth of bacteria). During an interview on 4/8/2025 at 8:26 a.m., with Resident 1's Family Member (FM 1), FM 1 stated the facility called him on 3/14/2025 to inform him Resident 1 was being transferred to another facility because Resident 1 no longer needed the services at facility. FM 1 stated the facility gave him the name and address of the new facility (house) but when he attempted to google the address, he could not find it. FM 1 stated he then attempted to find the name of the facility (house) provided to him and he could not find it either. FM 1stated he called the Skilled Nursing Facility ([SNF] long-term care facility that provides specialized nursing care and rehabilitation services to individuals who need medical or nursing care, or rehabilitation services due to injury, disability, or illness), but the facility told him Resident 1 was no longer under their care and they were no longer responsible for the resident. FM 1 stated Resident 1 did not have a cell phone and was unable to use one because the resident had dementia. During an interview on 4/8/2025 at 8:49 a.m., with the Ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities), the Ombudsman stated she had received a complaint from FM 1 stating he could not locate Resident 1. The Ombudsman stated FM 1 called the facility, but the facility was not responding. The Ombudsman stated she had not received a discharge notification for Resident 1. During an interview on 4/8/2025 at 10:48 a.m., with Certified Nurse Assistant (CNA 1), CNA 1 stated Resident 1 had a sitter because she was confused and would try to get out of bed without assistance. CNA 1 stated Resident 1 was at high risk for falling which was the reason the facility had to keep a close eye on her. During a concurrent interview and record review on 4/8/2025 at 11:00 a.m., with Licensed Vocational Nurse (LVN 1), Resident 1's "Social Services (SS) Note" dated 3/14/2025 at 2:41 p.m., was reviewed. LVN 1 stated the note indicated Resident 1 was accepted at an assisted living facility. LVN 1 attempted to look up the address provided in the SS note through a google search but could not find the listed address. LVN 1 stated she did not know the location of the assisted living facility. LVN 1 stated FM 1 called to inquire about the where abouts of Resident 1, but the facility did not have the information. LVN 1 stated there were no IDT notes, or discharge care plans noted in Resident 1's medical record. During a concurrent interview and record review on 4/8/2025 at 12:17 p.m., with the SS, Resident 1's "Social Services IDT Resident Discharge Planning" dated 10/30/2024 at 9:26 a.m., was reviewed. The SS stated the record indicated Resident 1 was in the facility without a discharge potential (the likelihood to be discharged). The SS stated the record indicated Resident 1 preferred not to return to the community. The SS stated Resident 1 required a dementia unit, and she (the SS) had not conducted an IDT meeting regarding sending Resident 1 to a house or assisted living facility. The SS stated the facility's marketer initiated Resident 1's transfer and the discharge location were not a dementia unit. The SS stated she received an incorrect address from the marketer, which she provided to FM 1 on 3/14/2025. The SS stated the facility's process was to conduct an IDT meeting on admission, quarterly, and as needed to identify the needs and goals for a resident and create a care plan with interventions that would assist the staff to achieve each resident's goals. The SS stated she did not conduct an IDT meeting for Resident 1 discharge on 3/14/2025. The SS stated she did not notify the Local Contact Agency (not known), or Ombudsman and she did not follow up to ensure Resident 1 was comfortably settled after discharge. The SS stated it was important to inform the Ombudsman because the Ombudsman was the resident's advocate and could follow up on Resident 1's concerns if there were any. The SS stated the facility met Resident 1's needs and she did not know why the resident was discharge to a house, where his needs could not be met. The SS stated Resident 1 or FM 1 and 2 were not involved in selecting the new location because the marketer found it (the house). The SS stated on 3/14/2025, she informed Resident 1, of the transfer but she was not sure Resident 1 understood. The SS stated with transfers or discharges, the facility was supposed to provide discharge documents to the new (receiving) facility, where Resident 1 was discharged, but no one answered her calls, so she did not provide any discharge documents or information about Resident 1 to the discharge location. The SS also stated that she never followed up to ensure Resident 1 was comfortably settled after discharge. During an interview on 4/8/2025 at 1:33 p.m., with FM 2, FM 2 stated when he visited the house on 4/7/2025 (time unknown), he noticed Resident 1 looked pale (when the skin appears whiter than usual, often due to illness or fear), like she had lost weight, and the resident could not even talk. FM 2 stated he asked the Landlord (owner of the house) to call 911 for Resident 1 to be transferred to a GACH for evaluation and treatment. During an interview on 4/9/2025 at 10:08 a.m., with the Landlord, the Landlord stated it was his home, and he was not running an assisted living facility. The Landlord stated he advertised to rent a bedroom on craigslist (free online classified ads platform where individuals can post and browse listings for jobs, housing, items for sale, services, and more) to help him pay his mortgage. The Landlord stated he was contacted by a Marketer (MK) about a resident (Resident 1) at the facility looking for a place to live. The Landlord stated MK told him (the Landlord) that Resident 1was to be discharged and the resident had no medical issues. The Landlord stated he was not in the healthcare profession and only accepted Resident 1 into his home for rent. The Landlord stated FM 2 requested Resident 1 be sent to a GACH because Resident 1 bruises and FM wanted the GACH to document the bruises. Landlord stated even though he did not observe any bruises on Resident 1's body, he agreed to send Resident 1 to GACH for safety. During an interview on 4/9/2025 at 2:18 p.m., with Physical Therapist (PT), PT stated Resident 1 was unsteady and required someone to always walk with her, for safety. PT 1 stated that was the reason she had a sitter otherwise she would fall. During an interview on 4/9/2025 at 1:03 p.m. with Registered Nurse (RN), RN 1 stated on 3/14/2025 around 3:10 p.m., he discharged Resident 1 to what he thought was an assisted living facility. RN 1 stated he attempted to call the receiving facility (house) to give a handoff report on the resident, but the facility (house) did not answer the phone, and he did not call back. RN 1 stated Resident 1's verbal report was not provided to the facility. RN 1 stated on 3/14/2025 at 3:10 p.m., he gave the Emergency Medical Technician (EMT) Resident 1's verbal medication administration information and a printout list of the resident's medications. RN 1 stated he did not document the medications Resident 1 was discharged with and did not remember how many pills he gave the resident. RN stated Resident 1 was given important medications like Risperdal and Gabapentin. RN 1 stated if Resident 1 did not take her medications it could lead to worsening of symptoms. RN 1 stated there was also a potential for Resident 1 to overdose, and it was important to educate the resident about his medications, administration times, dosages, and side effects. During an interview on 4/9/2025 at 4:05 p.m., with Resident 1's Physician (MD 1), MD 1 stated she did not give an order for Resident 1 to be discharged because Resident 1 was not ready for discharge to a lower level of care. MD 1 stated no staff notified her that Resident 1 was di