Health inspection·February 8, 2024

42 CFR §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. (ii) Record the reasons for the transfer or discharge in the resident’s medical record in accordance with paragraph (c)(2) of this section; and (iii) Include in the notice the items described in paragraph (c)(5) of this section. §483.15(c)(4) Timing of the notice. (i) Except as specified in paragraphs (c)(4)(ii) and (c)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged. (ii) Notice must be made as soon as practicable before transfer or discharge when— (A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section; (B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section; (C) The resident’s health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(i)(B) of this section; (D) An immediate transfer or discharge is required by the resident’s urgent medical needs, under paragraph (c)(1)(i)(A) of this section; or (E) A resident has not resided in the facility for 30 days. §483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following: (i) The reason for transfer or discharge; (ii) The effective date of transfer or discharge; (iii) The location to which the resident is transferred or discharged; (iv) A statement of the resident’s appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request; (v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman. On 12/18/2023, the California Department of Public Health made an unannounced visit to the facility to investigate a complaint about resident rights. The facility failed to ensure a copy of the Notice of Proposed Transfer or Discharge (NPTD) Form for facility-initiated transfer (the resident expects to return to the facility) or discharge (when return to the facility is not expected) was sent to a representative of the Office of the State Long-Term Care (LTC) Ombudsman Program (assist residents in LTC facilities with issues related to day-to-day care, health, safety, and personal preferences) at the same time the notice was sent to the residents or the resident’s representatives before transfer or in emergency situations as soon as practicable for Residents 5, 6, 7, 8, 9, 10, 11, 12, 13, 16, 17, 18, 22, and 24. As a result, Residents 5, 6, 7, 8, 9, 10, 11, 12, 13, 16, 17, 18, 22, and 24 were denied protection and advocacy in the event residents were inappropriately or involuntary transferred or discharged from the facility. 1. A review of Resident 5’s Admission Record indicated the facility originally admitted the resident on 12/4/2022 and re-admitted Resident 5 on 12/28/2022. A review of Resident 5’s Physician’s Order dated 1/10/2023, indicated Resident 5 had an order to be discharged home on 1/13/2023 with Home Health (HH – health care services provided at home) services. A review of Resident 5’s NPTD Form with a notification date of 1/11/2023 indicated the discharge was appropriate because Resident 5's health improved sufficiently and no longer required services provided by the facility. A review of the facility’s fax verification form indicated that the facility faxed a copy of Resident 5’s NPTD Form to the LTC Ombudsman on 4/24/2023. 2. A review of Resident 6’s Admission Record indicated the facility admitted Resident 6 on 2/3/2023. A review of Resident 6’s Physician Order dated 2/6/2023 indicated Resident 6 had an order to be discharged home on 2/6/2023 with HH services. A review of Resident 6’s NPTD Form with a notification date of 2/12/2023 indicated the discharge was appropriate because Resident 6's health improved sufficiently and no longer required services provided by the facility. During a review of the facility’s NPTD Form binder, there were no fax verifications found indicating a copy of Resident 6’s NPTD Form was faxed to the LTC Ombudsman. 3. A review of Resident 7’s Admission Record indicated the facility admitted the Resident 7 on 2/9/2023. A review of Resident 7’s Physician Order dated 2/15/2023 indicated Resident 7 had an order to be discharged to a Board and Care Home (BC Home - houses in residential neighborhoods that are equipped and staffed to care for a small number of residents) on 2/18/2023 with HH services. A review of Resident 7’s NPTD Form with a notification date of 2/18/2023 indicated the discharge was appropriate because Resident 7's health improved sufficiently and no longer required services provided by the facility. During a review of the facility’s NPTD Form binder, there were no fax verifications found indicating a copy of Resident 7’s NPTD Form was faxed to the LTC Ombudsman. 4. A review of Resident 8’s Admission Record indicated the facility admitted Resident 8 on 2/28/2023. A review of Resident 8’s Physician’s Order dated 3/6/2023, indicated Resident 8 had an order to be discharged home on 3/6/2023 with HH services. A review of Resident 8’s NPTD Form with a notification date of 3/6/2023 indicated the discharge was appropriate because Resident 8's health improved sufficiently and no longer required services provided by the facility. A review of the facility’s fax verification form indicated that the facility faxed a copy of Resident 8’s NPTD Form to the LTC Ombudsman on 5/24/2023. 5. A review of Resident 9’s Admission Record indicated the facility admitted Resident 9 on 1/5/2023. A review of Resident 9’s Physician’s Order dated 3/6/2023, indicated Resident 9 had an order to be discharged home on 3/9/2023 with HH services. A review of Resident 9’s NPTD Form with a notification date of 3/9/2023 indicated the discharge was appropriate because Resident 9's health improved sufficiently and no longer required services provided by the facility. A review of the facility’s fax verification form indicated that the facility faxed a copy of Resident 8’s NPTD Form to the LTC Ombudsman on 5/24/2023. 6. A review of Resident 10’s Admission Record indicated the facility admitted Resident 10 on 2/6/2023. A review of Resident 10’s Physician’s Order dated 4/11/2023, indicated Resident 10 had an order to be discharged home on 4/11/2023 with HH services. A review of Resident 10’s NPTD Form with a notification date of 4/11/2023 indicated the discharge was appropriate because Resident 10's health improved sufficiently and no longer required services provided by the facility. A review of the facility’s fax verification form indicated that the facility faxed a copy of Resident 10’s NPTD Form to the LTC Ombudsman on 7/5/2023. 7. A review of Resident 11’s Admission Record indicated the facility admitted Resident 11 on 4/9/2023. A review of Resident 11’s Physician’s Order dated 4/17/2023, indicated Resident 11 had an order to be discharged home on 4/20/2023 with HH services. A review of Resident 11’s NPTD Form with a notification date of 4/20/2023 indicated the discharge was appropriate because Resident 11's health improved sufficiently and no longer required services provided by the facility. A review of the facility’s fax verification form indicated that the facility faxed a copy of Resident 11’s NPTD Form to the LTC Ombudsman on 7/5/2023. 8. A review of Resident 12’s Admission Record indicated the facility admitted Resident 12 on 5/8/2023. A review of Resident 12’s Physician’s Order dated 5/9/2023, indicated Resident 12 had an order to be discharged home on 5/14/2023 with HH services. A review of Resident 12’s NPTD Form with a notification date of 5/14/2023 indicated the discharge was appropriate because Resident 12's health improved sufficiently and no longer required services provided by the facility. A review of the facility’s fax verification form indicated that the facility faxed a copy of Resident 12’s NPTD Form to the LTC Ombudsman on 10/13/2023. 9. A review of Resident 13’s Admission Record indicated the facility admitted Resident 13 on 4/20/2023. A review of Resident 13’s Physician’s Order dated 5/16/2023, indicated Resident 13 had an order to be discharged to an Assisted Living Facility (ALF - a residence for older people or people with disabilities who require help with some of the routines of daily living as well as access to medical care when needed) on 5/17/2023 with HH services. A review of Resident 13’s NPTD Form with a notification date of 5/17/2023 indicated the discharge was appropriate because Resident 13's health improved sufficiently and no longer required services provided by the facility. A review of the facility’s fax verification form indicated that the facility faxed a copy of Resident 13’s NPTD Form to the LTC Ombudsman on 10/13/2023. 10. A review of Resident 16’s Admission Record indicated the facility originally admitted Resident 16 on 2/4/2023 and re-admitted Resident 16 on 6/23/2023. A review of Resident 16’s Physician’s Order dated 7/3/2023, indicated Resident 16 had an order to be discharged home on 7/7/2023 with HH services. A review of Resident 16’s NPTD Form with a notification date of 7/7/2023 indicated the discharge was appropriate because Resident 16's health improved sufficiently and no longer required services provided by the facility. A review of the facility’s fax verification form indicated that the facility faxed a copy of Resident 16’s NPTD Form to the LTC Ombudsman on 10/19/2023. 11. A review of Resident 17’s Admission Record indicated the facility admitted Resident 17 on 6/22/2023. A review of Resident 17’s Physician’s Order dated 7/3/2023, indicated Resident 17 had an order to be discharged home on 7/7/2023 with HH services. A review of Resident 17’s NPTD Form with a notification date of 7/7/2023 indicated the discharge was appropriate because Resident 17's health improved sufficiently and no longer required services provided by the facility. A review of the facility’s fax verification form indicated that the facility faxed a copy of Resident 17’s NPTD Form to the LTC Ombudsman on 10/19/2023. 12. A review of Resident 18’s Admission Record indicated the facility admitted Resident 18 on 7/25/2023. A review of Resident 18’s Physician’s Order dated 8/3/2023, indicated Resident 18 had an order to be discharged home on 8/8/2023 with HH services. A review of Resident 18’s NPTD Form with a notification date of 8/8/2023 indicated the discharge was appropriate because Resident 18's health improved sufficiently and no longer required services provided by the facility. A review of the facility’s fax verification form indicated that the facility faxed a copy of Resident 18’s NPTD Form to the LTC Ombudsman on 10/20/2023. 13. A review of Resident 22’s Admission Record indicated the facility admitted Resident 22 on 10/1/2023. A review of Resident 22’s Physician’s Order dated 10/5/2023, indicated Resident 22 had an order to be discharged home on 10/10/2023 with HH services. A review of Resident 22’s NPTD Form with a notification date of 10/6/2023 indicated the discharge was appropriate because Resident 22's health improved sufficiently and no longer required services provided by the facility. A review of the facility’s fax verification form indicated that the facility faxed a copy of Resident 22’s NPTD Form to the LTC Ombudsman on 12/19/2023. 14. A review of Resident 24’s Admission Record indicated the facility admitted Resident 24 on 11/18/2023. A review of Resident 24’s Physician’s Order dated 11/27/2023, indicated Resident 24 had an order to be discharged home on 11/30/2023 with HH services. A review of Resident 24’s NPTD Form with a notification date of 11/29/2023 indicated the discharge was appropriate because Resident 24's health improved sufficiently and no longer required services provided by the facility. A review of the facility’s fax verification form indicated that the facility faxed a copy of Resident 24’s NPTD Form to the LTC Ombudsman on 12/19/2023. During an interview on 12/18/2023 at 3:00 p.m., with the Social Services 1 (SS 1), when SS 1 was asked how soon the facility notifies the LTC Ombudsman of a facility-initiated transfer or discharge, SS 1 stated she received instructions from the former Social Services Director (SSD) that the facility needed to fax a copy of the residents’ NPTD on a monthly basis for all transfers or discharges to the LTC Ombudsman. During a concurrent interview and record review on 12/22/2023 at 11:16 a.m. with SS 1, SS 1 reviewed the facility’s NPTD binder and stated the fax verifications indicated copies of residents’ NPTD for the year of 2023 were faxed to LTC Ombudsman as follows: 1. Residents’ NPTD for January 2023 were faxed on 4/24/2023 2. Residents’ NPTD for February 2023 no fax verifications found 3. Residents’ NPTD for March 2023 were faxed on 5/24/2023 4. Residents’ NPTD for April 2023 were faxed on 7/5/2023 5. Residents’ NPTD for May 2023 were faxed on 10/13/2023 6. Residents’ NPTD for June 2023 were faxed on 10/17/2023 7. Residents’ NPTD for July 2023 were faxed on 10/19/2023 8. Residents’ NPTD for August 2023 were faxed 10/20/2023 9. Residents’ NPTD 9/2023, 10/2023, 11/2023, and 12/2023 were faxed on 12/19/2023. During an interview with the Director of Nursing (DON) on 12/22/2023 at 1:52 p.m., the DON stated, as soon as a last coverage date was decided, the facility issues the NPTD to the residents or responsible parties notifying them of ending skilled insurance benefits. The DON stated these cases fall under the category of facility-initiated discharges and the facility should have notified the LTC Ombudsman as soon as practicable. A review of the facility’s policy and procedures titled, “Transfer or Discharge Notice”, dated June 2020, last reviewed on 5/18/2022, indicated, “A resident and/or his or her representative (sponsor) will be given a 30-day notice of an impending transfer or discharge from our facility. Under the following circumstances, the notice will be given as soon as it is practicable of the transfer or discharge…. The transfer of discharge is appropriate because the resident’s health has improved sufficiently so the resident no longer needs the services provided by the facility…. A copy of the notice will be sent to the Office of the State Long-Term Care Ombudsman.” The facility failed to ensure a copy of the NPTD Form for facility-initiated transfer or discharge was sent to a representative of the Office of the State LTC Ombudsman Program at the same time the notice was sent to the residents or the resident’s representatives before transfer, discharge or in emergency situations as soon as practicable for Residents 5, 6, 7, 8, 9, 10, 11, 12, 13, 16, 17, 18, 22, and 24. As a result, Residents 5, 6, 7, 8, 9, 10, 11, 12, 13, 16, 17, 18, 22, and 24 were denied protection and advocacy in the event residents were inappropriately or involuntary transferred or discharged from the facility. The above violations had a direct relationship to the health, safety, or security of Residents 5, 6, 7, 8, 9, 10, 11, 12, 13, 16, 17, 18, 22, and 24.