Health inspection·February 26, 2026

F627 §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— (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) The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident; (D) The health of individuals in the facility would otherwise be endangered; (E) The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. Nonpayment applies if the resident does not submit the necessary paperwork for third party payment or after the third party, including Medicare or Medicaid, denies the claim and the resident refuses to pay for his or her stay. For a resident who becomes eligible for Medicaid after admission to a facility, the facility may charge a resident only allowable charges under Medicaid; or (F) The facility ceases to operate. (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. §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. §483.15(e)(1) Permitting residents to return to facility. A facility must establish and follow a written policy on permitting residents to return to the facility after they are hospitalized or placed on therapeutic leave. The policy must provide for the following. (i) A resident, whose hospitalization or therapeutic leave exceeds the bed-hold period under the State plan, returns to the facility to their previous room if available or immediately upon the first availability of a bed in a semi-private room if the resident— (A) Requires the services provided by the facility; and (B) Is eligible for Medicare skilled nursing facility services or Medicaid nursing facility services (ii) If the facility that determines that a resident who was transferred with an expectation of returning to the facility, cannot return to the facility, the facility must comply with the requirements of paragraph (c) as they apply to discharges. §483.15(e)(2) Readmission to a composite distinct part. When the facility to which a resident returns is a composite distinct part (as defined in § 483.5), the resident must be permitted to return to an available bed in the particular location of the composite distinct part in which he or she resided previously. If a bed is not available in that location at the time of return, the resident must be given the option to return to that location upon the first availability of a bed there. §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. (A) If the resident indicates an interest in returning to the community, the facility must document any referrals to local contact agencies or other appropriate entities made for this purpose. (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. (C) If discharge to the community is determined to not be feasible, the facility must document who made the determination and why. (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. 22 CCR §72311. Nursing Service - General. (a) Nursing service shall include, but not be limited to, the following: (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. 22 CCR §72523. 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. 22 CCR § 72527. Patients' Rights. (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (6) To be transferred or discharged only for medical reasons, or the patient's welfare or that of other patients or for nonpayment for his or her stay and to be given reasonable advance notice to ensure orderly transfer or discharge. Such actions shall be documented in the patient's health record. On 1/6/2026, the California Department of Public Health made an unannounced visit to the facility to investigate a complaint about an unsafe discharge. The facility failed to ensure safe and orderly discharge and implement its policies and procedures regarding discharge planning for Resident 1. The facility failed to: 1. Provide the Notice of Medicare Non-Coverage ([NOMNC] - a form from the Centers of Medicare & Medicaid Services (CMS) that skilled nursing facilities must provide to residents that informs residents when Medicare-covered services are ending and explains their right to appeal) Notice to Resident 1 or Resident 1’s responsible party, including information on how to file an appeal. 2. Provide discharge instructions and education to Resident 1 or the responsible party to support a safe transition to home. 3. Develop and implement an individualized discharge care plan that addressed Resident 1’s specific medical and supportive care needs, with involvement of Resident 1’s responsible party. 4. Ensure that Resident 1 was discharged without an intravenous ([IV] - an access point for administering medication directly into the bloodstream) device remaining in place. As a result of these failures, Resident 1 was placed at significant risk for harm, including infection related to the retained IV access, inadequate care management in the home setting, and potential rehospitalization. A review of Resident 1’s Admission Record, indicated the facility originally admitted Resident 1, a 88-year-old female, on 12/1/2025 with diagnoses that included periprosthetic fracture around the internal prosthetic left knee joint (a broken bone in the leg or knee near an artificial joint, commonly resulting from a fall), type 2 diabetes mellitus (a chronic condition characterized by high blood sugar due to insulin [controls the amount of sugar in the blood by turning food into energy] resistance), history of falling, difficulty in walking, and retention of urine (the inability to empty urine from the body). A review of Resident 1’s History and Physical (H&P – a comprehensive assessment of a resident’s medical condition), date unreadable, indicated that Resident 1 had the capacity to understand information and make decisions. A review of Resident 1’s Minimum Data Set (MDS – a resident assessment tool), dated 12/6/2025, indicated Resident 1 had moderately impaired cognitive functioning (the ability to think, learn, remember, use judgment, and make decisions). The MDS further indicated Resident 1 required substantial/maximal assistance (helper does more than half the effort) with toileting, showering or bathing, and dressing of lower body clothing, including footwear. A review of Resident 1’s Order Summary Report indicated the following physician’s order: - 12/25/2025: Discharge Destination: Home with Home Health Services A review of Resident 1’s NOMNC Notice, dated 12/22/2025, indicated Resident 1’s Medicare coverage for skilled nursing facility services was to end on 12/24/2025, with discharge scheduled for 12/25/2025. The notice included a contact number and instructions for requesting an immediate appeal, which indicated: Ask for the appeal as soon as possible. You must request a timely appeal no later than noon of the day before the date listed above. However, the signature section of the NOMNC indicated “Temporarily incapacitated,” and there was no documentation indicating the notice was provided to Resident 1 or the responsible party. During an interview on 1/7/2026 at 1:54 p.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated he (LVN 1) recalled discharging Resident 1 with an IV access device still in place. LVN 1 further stated if a resident is discharged with an IV, he (LVN 1) would assume it is for continued treatment. The IV access site can lead to infection or possible bleeding. If the bleeding is not controlled, it could require emergency medical care. During a phone interview on 1/7/2026 at 2:20 p.m., with Resident 1’s Responsible Party 3 (RP 3), RP 3 stated, “I kept telling them (facility staff) that my mother was not ready for discharge.” RP 3 also stated, “The discharge was incompetent and extremely unorganized. I have never seen a more unorganized, unsafe discharge in my life. She (Resident 1) was sent home with an intravenous port still in her arm. No discharge instructions were provided to anyone. RP 3 stated, “I did not receive any information about how to appeal the discharge decision.” During a concurrent interview and record review on 1/8/2026 at 1:18 p.m., with Admissions Coordinator 1 (AC 1), Resident 1's Progress Note titled, “Administrative Note,” dated 12/22/2025 at 10:25 a.m., entered by AC 1, was reviewed. AC 1 stated that Resident 1 expressed a preference for her responsible party(ies) to make decisions on her (Resident 1’s) behalf. AC 1 stated that the Administrative Note indicated a telephone conversation with RP 3 indicating the insurance is issuing a last covered day of 12/24/2025 with a discharge date of 12/25/2025. Explained options, including discharge to home, caregiver resources, and the right to appeal if she felt the resident was not ready to discharge to a lower level of care. Stated that she will appeal. The note further indicated that “patient” was given a copy of the NOMNC that was left at bedside and the number to appeal. AC 1 stated per the note, the family intended to file an appeal however, we failed to obtain the family’s signature confirming receipt of the NOMNC notice. During an interview with Admissions Director 1 (AD 1) on 1/9/2026 at 2:11 p.m., AD 1 stated that the resident or responsible party must sign to acknowledge receipt of the NOMNC, as the signature confirms they received the notice. The NOMNC includes information in multiple languages and explains the right to appeal, which must be initiated no later than noon on the day before the last covered day. AD 1 also stated that the facility cannot file an appeal on behalf of the resident or the family’s behalf, it has to be from the resident or responsible party. If the NOMNC was not provided, an appeal cannot be filed because you wouldn’t know what phone number to call. The appeal also requires the resident’s Medicare identification number and without this information, the appeal cannot be started. AD 1 stated the failure was not obtaining a signature from the resident (Resident 1) or from the responsible party, which prevented them from filing an appeal or potentially extending the resident’s stay at the facility. AD 1 also stated, “I am not too familiar with the 30 day notice requirement. I have never heard of the 30 day notice, and I have worked on admis