Health inspection·March 11, 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. §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. §483.21(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. (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 §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 1/30/2026, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a complaint regarding an unsafe discharge. The facility failed to ensure Resident 1 was discharged in a safe and orderly manner, by failing to: 1. Ensure that Resident 1’s post-discharge destination was able to meet Resident 1’s needs prior to the discharge on 5/16/2025. 2. Involve Resident 1’s Representative, who holds Power of Attorney (POA- a legal document that authorizes a trusted person to act on behalf of another regarding financial, legal or medical matters) in the development of the discharge plan and ensure Resident 1’s Representative is informed of the final discharge plan. As a result, Resident 1 was placed at significant risk for harm, inadequate care management, and the potential to not receive necessary care and services, which could negatively affect Resident 1’s well-being. A review of Resident 1’s Admission Record indicated the facility admitted Resident 1, a 77-year-old male, on 5/14/2025 with diagnoses including heart failure (a progressive condition where the heart muscle is too weak or stiff to pump enough oxygen-rich blood to meet the body's needs), encounter for palliative care (specialized medical care for people with serious illnesses, focusing on relieving symptoms, pain, and stress to improve quality of life), unspecified dementia (a progressive state of decline in mental abilities), and chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing). A review of Resident 1’s Minimum Data Set (MDS - a resident assessment tool), dated 5/15/2025, indicated Resident 1’s cognitive functioning (mental processes that enable people to think, understand, make decisions, and complete tasks) was severely impaired. The MDS indicated Resident 1 required moderate assistance (helper does less than half the effort) from facility staff with oral hygiene, toileting hygiene, upper and lower body dressing, and personal hygiene. A review of Resident 1’s Order Summary Report indicated the following Physician’s Order: - 5/15/2025 at 6:49 p.m.: Transfer resident to Board and Care 1 (a small residential home providing 24-hour non-nursing care, meals, and supervision to residents). During an interview on 2/2/2026 at 1 p.m., with the Director of Nursing (DON), the DON stated there was no documented evidence indicating that facility staff had evaluated Board and Care 1 and communicated with the facility (Board and Care 1) prior to Resident 1’s discharge on 5/16/2025. The DON stated facility staff failed to verify and ensure that Resident 1 was discharged to a facility that met the required standards and was capable of providing the necessary care. The DON further stated that facility staff relied on information provided by the palliative care provider (a specialized healthcare professional who focuses on relieving symptoms, pain, and stress for patients with serious illnesses) and did not complete a proper assessment or evaluation of the receiving facility. The DON stated Resident 1 was inappropriately discharged. The DON stated Resident 1 was placed at risk of not receiving the necessary care to meet his (Resident 1) needs. The DON further stated there was potential for Resident 1 not to receive the correct medications, as well as appropriate pain assessment and management, which could negatively affect Resident 1’s well-being. During an interview on 2/2/2026 at 1:17 p.m., with Resident 1's Representative, Resident 1’s Representative stated that on 5/15/2026, the facility's previous Administrator (Administrator 1) contacted him (Representative) to inform him that Resident 1 would be transferred back to the previous Skilled Nursing Facility 1 (SNF 1). Resident 1’s Representative stated that the facility did not notify him (Representative) that the discharge plans had changed and that Resident 1 would be discharged to a different facility. Resident 1’s Representative stated that Resident 1 was discharged without his (Representative) consent and knowledge. Resident 1’s representative further stated that two days after Resident 1's discharge, he (Representative) contacted Administrator 1 and was informed that Resident 1 had been discharged on 5/16/2025 to Board and Care 1. Resident 1’s Representative stated that after multiple attempts, he (Representative) was able to contact Board and Care 1 and requested that Resident 1 be transferred to a General Acute Care Hospital (GACH). During a concurrent interview and record review on 2/2/2026 at 2:10 p.m., with the DON, Resident 1’s “Notice of Transfer or Discharge” form, dated 5/15/2025, and “Discharge Summary,” dated 5/15/2025, were reviewed. The “Notice of Transfer or Discharge” form indicated that Resident 1 was unable to sign to acknowledge receipt of the form. The “Discharge Summary” indicated that Resident 1 was unable to sign to confirm receipt of the discharge summary. The DON stated there was no documented evidence that Resident 1’s Representative was provided with the “Notice of Transfer or Discharge” form and the “Discharge Summary.” The DON stated that Resident 1 was unable to make decisions, and the risks and benefits of the discharge plan should have been discussed with Resident 1’s Representative. The DON stated that facility staff failed to uphold Resident 1’s rights and placed Resident 1 at risk of being transferred to a facility without his (Resident 1’s) representative's knowledge. The DON further stated that Resident 1's Representative should have been involved in the discharge process to ensure that Resident 1's wishes were followed. The DON stated there was potential for Resident 1 to be transferred to a facility that was not appropriate for his (Resident 1) care needs. A review of the facility’s policy and procedure (P&P) titled, “Discharge,” last revised on 5/30/2025, indicated, “1. When the facility anticipates a resident’s discharge to a private residence, another nursing care facility (i.e., skilled, intermediate care, ICF/IID, etc.), a discharge summary and post-discharge plan will be developed to assist the resident to adjust to his or her new living environment….4. Every resident will be evaluated for his or her discharge needs and will have an individualized post-discharge plan. 5. The post discharge plan will be developed by the Care Planning/Interdisciplinary Team with the assistance of the residents and his or her family and will include: a. Where the individual plans to reside; b. Arrangements that have been made for follow-up care and services; A description of the resident’s stated discharge goals; d. The degree of caregiver/support person availability, capacity and capability to perform required care; e. How the IDT will support the resident or representative in the transition to post-discharge care; f. What factors may make the resident vulnerable to preventable readmission, and g. How does factors will be addressed…. 7. The resident/representative will be involved in the post-discharge planning process and informed of the post-discharge plan.” The facility failed to ensure Resident 1 was discharged in a safe and orderly manner, by failing to: 1. Ensure that Resident 1’s post-discharge destination was able to meet Resident 1’s needs prior to the discharge on 5/16/2025. 2. Involve Resident 1’s Representative, who holds POA, in the development of the discharge plan and ensure Resident 1’s Representative is informed of the final discharge plan. As a result, Resident 1 was placed at significant risk for harm, inadequate care management, and the potential to not receive necessary care and services, which could negatively affect Resident 1’s well-being. The above violations had direct or immediate relationship to the health, safety, or security of Resident 1.