Health inspection·March 13, 2025

F622 §483.15(c) Transfer and discharge- (ii) The facility may not transfer or discharge the resident while the appeal is pending, pursuant to § 431.230 of this chapter, when a resident exercises his or her right to appeal a transfer or discharge notice from the facility pursuant to § 431.220(a)(3) of this chapter, unless the failure to discharge or transfer would endanger the health or safety of the resident or other individuals in the facility. The facility must document the danger that failure to transfer, or discharge would pose.

F623 §483.15(c)(3) Notice before transfer. Before a facility transfers or discharges a resident, the facility must— (i) Notify the resident and the resident’s representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman. On 1/29/2025 at 9 AM, an unannounced visit by California Department of Public Health (CDPH) was made to the facility to investigate a complaint regarding inappropriate discharge. The facility (Skilled Nursing Facility [SNF] 1) failed to allow Resident 1 to remain in the facility and does not initiate a facility-initiated discharge (a discharge which the resident objects to or did not originate through a resident’s verbal or written request, and/or is not in alignment with the resident’s stated goals for care and preferences) to another facility (SNF 2) based on SNF 1’s inability to meet the resident’s need for supervision due to wandering (residents who aimlessly move about within the building or grounds unaware of their personal safety) and risk for elopement (a resident who is incapable of adequately protecting himself, and who departs a health care facility unsupervised and undetected). Furthermore, SNF 1 failed to ensure SNF 1 and Resident 1’s physician (Physician 1) documented the information about the basis for Resident 1’s discharge to SNF 2, that included the specific resident needs the facility could not meet, the facility’s efforts to meet those needs, and the specific services SNF 2 would provide to meet the needs of Resident 1 which could not be met at the current facility (SNF 1), in accordance with the facility’s policy and procedures (P&P) on “Transfer or Discharge, Facility-Initiated.” SNF 1 also failed to provide Resident 1’s responsible parties (RP 1 and RP 2) a written discharge notice and send a copy of the notice to the Ombudsman prior to discharging Resident 1 to SNF 2. Consequently, SNF 1 discharged Resident 1 to SNF 2 on 1/29/2025 timed at 12 PM, without Resident 1 and his responsible parties (RP 1 and RP 2) knowledge and approval. As a result of these deficient practices, on 1/29/2025, upon Resident 1’s arrival to SNF 2, Resident 1 refused to go inside SNF 2. Resident 1 verbalized feeling scared being discharged at a new facility (SNF 2) without RP 1’s knowledge. Resident 1 was screaming and under distress, refused any type of care, including medications and food at SNF 2. Resident 1 verbalized wanting to go back to “his home” at SNF 1. On 1/29/2025, at 6:30 PM, after 6.5 hours of being out of SNF 1, SNF 2 returned Resident 1 back to SNF 1 due to Resident 1 refusing to stay and receive care and services at SNF 2. A review of Resident 1 a 87 years old male’s “Admission Record (AR),” the AR indicated Resident 1 was admitted to the facility with diagnoses that included dementia [the loss of cognitive functioning (thinking, remembering, and reasoning) to such an extent that it interferes with a person's daily life and activities], altered mental status (a change in how well the brain is working, which can cause a variety of behavioral changes), difficulty walking, and abnormalities of gait and mobility. A review of Resident 1’s “Wandering Assessment,” dated 11/11/2024, the Assessment indicated Resident 1 was at risk for wandering. The Assessment indicated Resident 1 could communicate and follow instructions, could move without assistance while in wheelchair, had no history of wandering, diagnosed with dementia/cognitive impairment and diagnosis impacting gait/mobility or strength. The Assessment indicated Resident 1 had wandering episodes in the previous month. A review of Resident 1’s “Minimal Data Set (MDS-a federally mandated resident assessment),” dated 11/21/2024, the MDS indicated Resident 1’s cognition (ability to think, remember, and reason with no difficulty) was severely impaired and walking was not attempted due to “medical condition or safety concern.” A review of Resident 1’s “Nurses Progress Notes,” dated 1/13/2025, the Progress Notes indicated after Resident 1 was found walking down the ramp in front of the facility by SNF 1 lobby on 1/11/2025, SNF 1 recommended Resident 1 to be transferred to a Memory Care Facility (a type of facility that provides specialized residential care for people living with other forms of dementia and need for around the clock supervision). The Progress Notes indicated the recommendation was made because Resident 1 was at “high risk” for wandering/elopement. A review of Resident 1’s “Admission Summary Progress Notes,” dated 1/27/2025, the Notes indicated Admissions Coordinator (ADC) 1 sent a referral (the act of directing someone to a different place or person) to SNF 2 and was approved with a bed available. A review of Resident 1’s “Order Summary Report,” the Summary Report indicated a physician order dated 1/28/2025, for a “Lateral transfer to SNF 2.” A review of Resident 1’s “Notice of Transfer/Discharge,” dated 1/28/2025, the Notice indicated a notification date of 1/28/2025 with an effective date of 1/31/2025, for Resident 1 to discharge to SNF 2. The Notice indicated that “The transfer/discharge was necessary for the resident’s welfare and that the resident’s needs could not be met in the facility.” The Notice indicated the resident had the right to appeal the transfer/discharge and could file an appeal within ten calendar days of being notified. The Notice indicated “The facility may not transfer or discharge the resident while the appeal is pending, unless the failure to discharge or transfer would endanger the health or safety of the resident or other individuals in the facility.” A review of Resident 1’s “Admission Summary Progress Notes,” dated 1/28/2025, one day prior to Resident 1’s discharge to SNF 2, the Progress Notes indicated at 2:47 PM, ADC 1 spoke to RP 1 over the phone to notify her of Resident 1's discharge plan that would take place on 1/31/2025. The Notes indicated “Lateral SNF placement was recommended to attend to patient's (Resident 1) medical necessity - Memory Care/Secure Unit Transfer order made necessary for the patient's (Resident 1) welfare and safety, and these cannot be met at the current SNF (SNF 1).” A review of Resident 1’s “Nurses Progress Notes,” documented by RN 1, dated 1/28/2025 timed at 6:30 PM, the Progress Notes indicated that on 1/28/2025, a transportation arrived at SNF 1 to pick up Resident 1 to be discharged to SNF 2. The Notes indicated RP 1 was at bedside and verbalized how RP 1 was not notified and unaware of Resident 1’s discharge plan to SNF 2 on 1/28/2025. The Progress Notes indicated the DON spoke to RP 1 on the phone on 1/28/2025 and the discharge was cancelled on that same day (1/28/2025). The Progress Notes indicated RP 1 requested to further discuss the situation with the DON and Administrator but was informed to call back SNF 1, the next day (1/29/2025) after 9 AM. A review of Resident 1’s “Nurses Progress Notes,” dated 1/28/2025, indicated on 1/28/2025 documented by RN 1 at 10:14 PM, the Progress Notes indicated that during the evening shift (time not mentioned) RP 2 and the Ombudsman Representative (OMB 1- a patient advocate who assists individuals and groups in the resolution of conflicts or concern) arrived at SNF 1 asking for an explanation why Resident 1 was getting discharged to SNF 2 and requested to speak to the Administrator and the DON. The Notes indicated RN 1 informed RP 2 and OMB 1 that they would be able to speak to the Administrator and DON during normal office hours. A review of Resident 1’s “Discharge (DC) Summary/Comprehensive Assessment,” dated 1/29/2025, documented by Registered Nurse (RN) 1, the DC Summary indicated the section to confirm if the DC assessment was given to Resident 1 or Resident 1’s RP was left blank. A review of Resident 1’s “Nurses Progress Notes,” dated 1/29/2025, the Notes indicated Resident 1 left SNF 1 at 12 PM for a “lateral transfer to SNF 2.” A review of Resident 1’s “Case Management Notes,” dated 1/29/2025, the Case Management Notes indicated Case Coordinator (CC) 1 called RP 1 to inform her of Resident 1’s discharge because it was “Medically necessary (memory care/secure unit) for resident's welfare and safety.” During an interview on 1/29/2025 at 10:40 AM with OMB 1, OMB 1 stated that on 1/28/2025, OMB 1 received a call that Resident 1 was being discharged against his will and his family’s approval, so she went to SNF 1 to intervene on 1/28/2025 at around 7:30 PM. OMB 1 stated, she requested to speak with the DON, but the DON refused to speak to her. OMB 1 stated, she reviewed Resident 1’s medical records and confirmed there was no written Notice of Resident 1’s transfer/discharge to SNF 2 for 1/28/2025. During an interview on 1/29/2025 at 10:50 AM with RP 1, RP 1 stated, on 1/27/2025, RP 1 received a call from SNF 2’s Business Development (BD) 1, BD 1 informed RP 1 that SNF 1’s ADC 1 asked SNF 2’s BD 1 to ask RP 1 for her authorization to “transfer” Resident 1 to SNF 2. RP 1 stated, she had not heard from SNF 1 and was unaware of this “transfer,” so she told SNF 2’s BD 1 that she needed to speak with SNF 1’s Social Worker (SSW) 1 first before giving discharge authorization for Resident 1. RP 1 stated, she called ADC 1 on 1/27/2025 and left a message for ADC 1 to call her back. RP 1 stated, on 1/28/2025, ADC 1 called her back stating that Resident 1 would be discharged on 1/31/2025. RP 1 stated, she had been working with SNF 1’s SSW 1 regarding Resident 1’s discharge plans and was not informed about the discharge plan to SNF 2. RP 1 stated, ADC 1 informed her that SSW 1 was no longer employed for SNF 1, and ADC 1 took over SSW 1’s SNF 1 responsibility. RP 1 stated, she informed ADC 1 that she did not agree to Resident 1’s planned discharge to SNF 2 and came to visit Resident 1 in the afternoon of 1/28/2025. RP 1 stated, while she was at SNF 1 on 1/28/2025, a person came and asked Resident 1 to get ready for the discharge to go to another facility (SNF 2). RP 1 stated, being in disbelief that SNF 1 still pursed the plan to discharge Resident 1 to SNF 2 despite RP 1 not authorizing ADC 1 to discharge Resident 1 to SNF 2 on 1/28/2025. RP 1 stated, she told RN 1 that she was not aware and did not approve Resident 1 to be discharges to SNF 2 on 1/28/2025. RP 1 stated, due to the incident, Resident 1 verbalized on 1/28/2025 to RP 1 that he was surprised, scared, and anxious and asked RP 1 why somebody would want to take him (Resident 1) out of his home. RP 1 also stated, she did not receive any written notification of transfer/discharge and was not given any list or resources or options of any SNFs to choose from prior to Resident 1 being picked up by a transportation to another SNF on 1/28/2025. During an interview on 1/29/2025 at 12:07 PM with RP 1, RP 1 stated that CC 1 just called RP 1 saying “(Resident 1) is being discharged now,” then hung up the phone. RP 1 stated, she did not receive any explanation or family meeting since the night before (1/28/2025) when the facility tried to discharge Resident 1 to SNF 2 for the first time without her approval. RP 1 stated, she was terrified how the facility treated Resident 1 given that SNF 1 already tried to discharge Resident 1 the first time on 1/28/2025 and again today (1/29/2025) without her authorization/approval as Resident 1’s RP. RP 1 stated, she was worried that Resident 1 would be under emotional distress because he was already scared and anxious from the first attempt to discharge out of SNF 1, the night before (1/28/2025). During an interview on 1/29/2025 at 12:20 PM with CC 1, CC 1 stated, ADC 1 had been in contact with RP 1. CC 1 stated, she just got involved in the case “this morning” (1/29/2025) to discharge Resident 1 to SNF 2. CC 1 stated, she called RP 1 after the driver took Resident 1 to SNF 2. CC 1 stated, RP 1 was upset, stating that she did not sign any paperwork or agreeing to the transfer and wanted to hold off the discharge. CC 1 stated, CC 1 told RP 1 that the facility had to transfer Resident 1 for his safety. During an interview on 1/29/2025 at 12:30 PM with ADC 1, ADC 1 stated, SSW 1 had been in contact with RP 1 but no longer working in the facility. ADC 1 stated, she took over Resident 1’s discharge planning on 1/27/2025. ADC 1 stated, SNF 2 approved SNF 1’s referral on 1/28/2025 so ADC 1 attempted to discharge Resident 1 on the same day (1/28/2025) because SNF 2 had a bed available. ADC 1 stated, ADC 1 did not receive any endorsements from SSW 1 when ADC 1 took over. ADC 1 stated, she based her decisions to discharge Resident 1 on SSW1’s progress notes and did not confirm if SSW 1 already provided RP 1 a list of SNF options for Resident 1 to transfer to. ADC 1 stated, she did not give RP 1 the resources for the plan to transfer/discharge to another facility. ADC 1 stated, she did not have any documented evidence that she gave SNF 2’s information to RP 1 prior to the attempt to discharge Resident 1 to SNF 2 on 1/28/2025 and again the actual discharge on 1/29/2025 (at 12 PM). ADC 1 stated, the discharge plan had been going on and planned since he was found outside SNF 1 unsupervised for the second time on 1/11/2025 as indicated in Resident 1’s progress notes. During a concurrent record review and interview on 1/29/2025 at 12:45 PM with ADC 1, Resident 1’s “Notice of Transfer/Discharge,” dated 1/28/2025, was reviewed. The Notice indicated ADC 1 informed RP 1 about the transfer on 1/28/2025 over the phone with the effective date of transfer was 1/31/2025. ADC 1 stated, she transferred Resident 1 on the same day because a bed was available at SNF 2. ADC 1 stated, she did not provide RP 1 a copy of the written Notice because she only notified RP 1 over the phone. During an interview on 1/29/2025 at 1 PM with the DON, the DON stated, the facility did not have a wander guard system (bracelets that residents wear, sensors that monitor doors and a technology platform that sends safety alerts in real time), so facility staff only supervise the residents. The DON stated, if a resident attempted to leave the facility, the facility staff would redirect the resident, contact the physician to check for any infection and monitor the resident’s behavior. The DON stated, they could not meet Resident 1’s needs for safety measures due to Resident 1’s dementia and two occasions that Resident 1 was found just outside the facility unattended some time in November 2024 and on 1/11/2025. The DON stated, they conducted an IDT meeting on 1/13/2025 regarding the incident and explained to RP 1 that transferring Resident 1 to a Memory Care Facility would be better for Resident 1’s safety. During an interview on 1/29/2025 at 1:30 PM with RP 1, RP 1 stated, there was no IDT and Family meeting for Resident 1’s discharge planning. RP 1 stated, the facility did not discuss with her for any care plan or interventions that they would do regarding his dementia and confusion. RP 1 stated, the facility did not inform her the interventions the