Health inspection·October 15, 2025

42 C.F.R. §483.15(c) Transfer and discharge- (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; (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. (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. (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. 42 C.F.R. §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. (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. Cal. Code Regs., tit. 22, § 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. Cal. Code Regs., tit. 22, § 72303. Physician Services--General Requirements. (b) Physician services shall mean those services provided by physicians responsible for the care of individual patients in the facility. Physician services shall include but are not limited to: (4) Advice, treatment and determination of appropriate level of care needed for each patient. Cal. Code Regs., tit. 22, § 72521 - Administrative Policies and Procedures. (a) Written administrative, management and personnel policies shall be established and implemented to govern the administration and management of the facility. (b) All policies and procedures required by these regulations shall be in writing and shall be carried out as written. They shall be made available upon request to patients or their agents and to employees and the public. Policies and procedures shall be reviewed at least annually, revised as needed and approved in writing by the governing body or licensee. (c) Each facility shall establish at least the following: (2) Policies and procedures for patient admission, leave of absence, transfer, pass and discharge, categories of patients accepted and retained, rate of charge for services included in the basic rate, type of services offered, charges for extra services, limitations of services, cause for termination of services and refund policies applying to termination of services. On 8/26/2025, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a complaint regarding transfer and discharge rights and a quality of care allegation. The facility failed to provide a safe and orderly discharge to Resident 2, who required staff assistance for all Activities of Daily Living (ADL – basic tasks that individuals perform to maintain their daily lives), by failing to: 1. Ensure that the post-discharge destination and continuing care provider were capable of meeting the needs of Resident 2 prior to discharge. 2. Develop and implement an effective discharge plan addressing the health and safety needs of Resident 2 when numerous and significant sections of the Post-Discharge Plan of Care for Resident 2 were left blank. 3. Ensure that the physician for Resident 2 documented a determination of the appropriate level of care for Resident 2 including information about the basis for Resident 2’s discharge in Resident 2’s medical records. 4. Implement the following facility discharge policies and procedures (P&P): - “Transfer or Discharge, preparing a Resident for” - indicating residents will be prepared in advance for discharge. - “Discharge Summary and Plan” – indicating a discharge summary and post-discharge plan will be developed and re-evaluated by the Interdisciplinary Team (IDT - a group of health care professionals with various areas of expertise who work together toward the goals of their resident) to assist the resident to adjust to his/her new living environment. As a result, Resident 2 was discharged to an unlicensed Board and Care (BC 1 - a facility that provides room, meals and assistance with ADL to two or more unrelated individuals needing care, but don’t require 24-hour skilled nursing care) on 8/8/2025. On 8/19/2025, Resident 2 required transfer from BC 1 to General Acute Care Hospital 2 (GACH 2) and was treated for hyperkalemia (abnormally high potassium [an essential mineral crucial for the proper functioning of the body including nerve function, muscle contractions and maintain a regular heartbeat, normal range: 3.5 to 5.2 milliequivalent per liter {mEq/l – unit of measure}] levels in the blood and can be life-threatening, especially if it develops quickly, as it can cause serious heart problems like irregular rhythms, muscle weakness, or even paralysis [inability to move]). Resident 2 was then transferred back to Skilled Nursing Facility 1 (SNF 1) on 8/21/2025. A review of Resident 2’s Admission Record indicated the facility admitted Resident 2 on 7/11/2025 with diagnosis that included encephalopathy (a disease in which the functioning of the brain is affected by an illness or condition), fracture of the right humerus (upper arm bone), and atrial fibrillation (irregular heartbeat that increases the risk of stroke and heart disease). A review of Resident 2’s History & Physical (H&P – a comprehensive assessment of a resident’s medical condition), dated 7/13/2025 indicated Resident 2 has the capacity to understand and make decisions. A review of Resident 2’s Minimum Data Set (MDS- a resident assessment tool), dated 7/7/2025, indicated Resident 2’s cognition was intact. The MDS further indicated Resident 2 needed maximal assistance from staff for toileting hygiene, upper and lower body dressing, putting on/taking off footwear and moderate assistance with personal hygiene. The MDS also indicated Resident 2 occasionally exhibited urine incontinence (the involuntary loss of bladder [muscular organ that stores urine] control, ranging from minor leaks to complete loss of urine) and frequently exhibited bowel incontinence (inability to control bowel movements). A review of Resident 2’s Physician’s Order, dated 8/7/2025, timed at 5:31 p.m., indicated to discharge Resident 2 to BC 1 tomorrow (8/8/2025), per the resident’s request. A review of Resident 2’s Notice of Proposed Transfer and Discharge, dated 8/8/2025, indicated that Resident 2 was discharged to BC 1 on 8/8/2025. The Notice of Proposed Transfer and Discharge also indicated that the reason for discharge was that Resident 2’s health had improved sufficiently, and Resident 2 no longer required the services provided by the facility. A review of Resident 2’s Discharge Summary Report, dated 8/8/2025, indicated Resident 2 was discharged to BC 1 on 8/8/2025 at 2:20 p.m. A review of Resident 2’s Active Discharge Planning Notes (from GACH 2), dated 8/19/2025, indicated that Resident 2 was transferred to GACH 2 from an unlicensed board and care facility and was treated for hyperkalemia. Laboratory test results dated 8/19/2025 at 7:13 p.m. indicated an elevated potassium level of 5.8 mEq/L. The notes indicated that Resident 2 appeared weak and required transfer to a skilled nursing facility for continued care. The notes indicated that Resident 2 cannot return to the board and care facility due to its unlicensed status. During an interview on 8/26/2025 at 12:45 p.m. with Resident 2, Resident 2 stated he (Resident 2) was not involved in any discharge planning. No one asked him (Resident 2) where he (Resident 2) wanted to go after his (Resident 2) stay at the facility and that he (Resident 2) was unaware he (Resident 2) had any choice or input in the matter. Resident 2 stated that he (Resident 2) trusted the facility to make decisions on his (Resident 2) behalf. He (Resident 2) does not clearly remember being discharged to BC 1 but does recall being taken to GACH 2, although he (Resident 2) does not remember the reason for the transfer. Staff (unable to recall who) at GACH 2 informed him he (Resident 2) could not return to the place he came from (BC 1) because it was unlicensed. Resident 2 stated that following his (Resident 2) stay at GACH 2, he (Resident 2) was transferred back to SNF 1. During a concurrent interview and record review on 8/26/2025 at 1:32 p.m., with the SSAT, Resident 2’s Social Services Notes from 7/11/2025 to 8/8/2025 were reviewed. The SSAT stated that there were no discharge planning notes found, and no documented evidence found in Resident 2’s medical record indicating who arranged Resident 2’s transfer to BC 1. There should have been documentation in Resident 2’s medical records reflecting coordination between the facility and BC 1. She (SSAT) was not aware of Resident 2’s discharge to BC 1 until after Resident 2 was discharged, when she (SSAT) was asked to make a follow-up call on 8/12/2025. She (SSAT) made several follow-up calls to Resident 2 on 8/12/2025 and kept getting a busy signal so she (SSAT) was unable to speak to Resident 2. She (SSAT) was not informed of the discharge plan and was not involved in Resident 2’s discharge process at any point. The SSAT further stated that she (SSAT) does not know who coordinated Resident 2’s discharge with BC 1 and who arranged Resident 2’s transportation to BC 1. During a concurrent interview and record review on 8/26/2025 at 3:10 p.m., with the ADON, Resident 2’s Post Discharge Plan of Care dated 8/8/2025 was reviewed. The Post Discharge Plan of Care for Resident 2 did not indicate the following: * What type of destination Resident 2 was being discharged to, * The phone number of the location Resident 2 was being discharged to. * The information regarding Resident 2’s responsible party (RP), * Resident 2’s insurance information, * The name and phone number for Resident 2’s continuing care physician, * Resident 2’s skin condition, * Resident 2’s height, * Resident 2’s diagnostic tests (includes both laboratory tests [done using blood, urine, stool or other body fluids to check for abnormalities] and imaging tests [create pictures of structures inside the body], used to diagnose medical conditions) * Resident 2’s intake patterns and eating habits, * Resident 2’s medical equipment or supplies, * Resident 2’s assistive devices (refer to tools, equipment used to help residents maintain or improve their mobility, independence, safety and quality of life in daily activities), * Resident 2’s care preferences, * Resident 2’s specific care needs, safety precautions, treatment instructions, * Date and time of Resident 2’s last meal, * Resident 2’s last bowel elimination, * If Resident 2’s inventory checklist was completed, * If Resident 2 had advance directive (a legal document that allows a person to communicate their wishes about medical care in advance, in case they become unable to speak or make decisions for themselves in the future due to illness, injury or incapacity) papers, * Resident 2’s community health services, * If Resident 2 could administer his own medications, * Any additional discharge planning notes for Resident 2, * The address of the state ombudsman (advocate for residents in facility). The ADON confirmed that Resident 2’s Post Discharge Plan of Care was missing the information above. The ADON stated that Resident 2’s Post Discharge Plan of Care should have been completed to ensure that the accepting facility has all the necessary information to appropriately care for Resident 2. Resident 2’s Post Discharge Plan of Care must be accurate and thorough to help ensure that Resident 2’s needs are met after discharge. Regarding the timing of reviewing the Post Discharge Plan of Care with residents, the ADON stated that it is usually reviewed with residents on the day of discharge. He (ADON) was unaware that the facility’s P&P indicated that the Post-Discharge Plan of Care was to be reviewed with the resident and/or the resident’s RP at least 24 hours prior to discharge. He (ADON) understands the importance of reviewing the Post Discharge Plan of Care at least 24 hours prior to discharge to allow the resident time to understand the discharge plan, ask questions, and address any c