Health inspection·January 28, 2026

42 CFR §483.15(c) Transfer and discharge- 42 CFR §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; 42 CFR §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. 42 CFR §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. 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. (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. (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. 42 CFR §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 § 72521. Administrative Policies and Procedures. (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. 22 CCR § 72519. Patient Transfer. (b) When a patient is transferred to another facility, the following shall be entered in the patient health record: (1) The date, time, condition of the patient and a written statement of the reason for the transfer. (2) Informed written or telephone acknowledgement of the patient, patient's guardian or authorized representative except in an emergency or as provided in Section 72527(a)(5). 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. 22 CCR § 72433. Social Work Service Unit--Services. (b) Social work services unit shall include but not be limited to the following: (5) Discharge planning for each patient and implementation of the plan. On 12/9/2025 at 9:31 AM, the California Department of Public Health (CDPH) conducted an unannounced visit to the facility to investigate a complaint regarding an allegation of a resident was discharged to another skilled nursing facility, which was against the resident’s wishes, and the resident’s rights were violated. The facility failed to ensure a safe and orderly transfer or discharge for two residents (Residents 1, and 19) by failing to: 1. Obtain the discharge order and Resident 1’s consent when staff discharged Resident 1 to Skilled Nursing Facility (SNF) 2 on 12/5/2025. 2. Discharge Resident 19, who needs assistance with dressing and personal hygiene, to a facility with appropriate level of care. Staff discharged Resident 19 to an Independent Living Home (ILH) 1 on 8/1/2025, which did not meet the resident’s care needs. As a result, the facility violated Residents 1 and 19's rights and had the potential to result in impairing Residents 1’s physical well-being, and possible readmission of Resident 19. 1. A review of Resident 1’s Admission Record (AR) indicated Resident 1, a 50-year-old-male, was admitted to facility on 9/10/2025 with diagnoses including depression, anxiety disorder, and schizophrenia. The AR indicated Resident 1 was self-responsible. A review of Resident 1’s Minimum Data Set (MDS, a resident assessment tool), dated 9/16/2025 indicated Resident 1 was mildly impaired in cognitive skills. The MDS indicated the resident required partial/moderate assistance with toileting hygiene, shower/bathe self, upper and lower body dressing, and personal hygiene. A review of Resident 1’s Order Summary (OS), dated 12/5/2025 indicated discharge Resident 1 with home health. The OS did not indicate the facility or location where Resident 1 would be discharged. The OS indicated there was no physician order to discharge Resident 1 to SNF 2. A review of Resident 1’s Notice of Transfer/Discharge (NTD), dated 12/5/2025 indicated there is no resident/representative’s signature to verify the facility provided the NTD to Resident 1 to get consent prior to discharge. During a phone interview on 12/9/2025 at 3:43 PM with Resident 1, Resident 1 stated Resident 1 did not get the NTD form to sign prior to his discharge on 12/5/2025 to SNF 2. Resident 1 stated Resident 1’s discharge goal was to be discharged to a lower-level care facility, not the same level care (SNF 2). During an interview on 12/10/2025 at 2:55 PM with the Registered Nurse (RN) 2, RN 2 stated RN 2 did not provide the NTD form to Resident 1 prior to Resident 1’s discharge on 12/5/2025. During an interview on 12/10/2025 at 3:39 PM with the Social Service Director (SSD), the SSD stated, "it was social service’s responsibility to assess the discharge goal and do the discharge plan for residents." The SSD stated Resident 1’s discharge plan was to be discharged to a lower-level care facility, not another SNF since admission until 12/4/2025. During an interview on 12/12/2025 at 10:28 PM with the Assistant Director of Nursing (ADON), the ADON stated Resident 1’s discharge plan was to be discharged to a lower-level care facility on 12/5/2025. The ADON stated SNF 2 is the same level care facility as this facility, not a lower-level care facility.  During an interview on 12/12/2025 at 3:31 PM with the Director of Nursing (DON), the DON stated Resident 1 is self-responsible and there was no resident’s signature to verify the consent to discharge Resident 1 to SNF 2 on 12/5/2025. The DON stated it is important to get resident’s signature on the NTD form to make sure residents agree, understand, and involve in the appropriate orientation and preparation for the discharge. The DON stated it is important to follow the discharge process and get an appropriate physician’s discharge order to discharge the resident prior to discharge. 2. A review of Resident 19’s AR indicated Resident 19, an 88-year-old-male, was originally admitted to facility on 1/31/2023, readmitted on 3/11/2025 with diagnoses including hypertension, chronic kidney disease, and schizophrenia. A review of Resident 19’s MDS, dated 6/6/2025 indicated Resident 19 was severely impaired in cognitive skills. The MDS indicated that the resident required partial/moderate assistance with shower/bathe self, personal hygiene and lower body dressing. A review of Resident 19’s OS, dated 7/31/2025 indicated there is an order to discharge the resident to ILH 1 with home health. A review of Resident 19’s Discharge Summary/Comprehensive Assessment (DSCA), dated 8/1/2025, indicated Resident 19 needs assistance on dressing and personal hygiene upon discharge on 8/1/2025. During an interview on 12/12/2025 at 10:55 AM with the SSD, the SSD stated that Resident 19 needs assistance on activities of daily living (ADL) and it was inappropriate to discharge Resident 19 to ILH 1. During a concurrent interview and record review on 12/12/2025 at 3:31 PM with the DON, the DON stated it was important to follow the discharge process and ensure the resident (Resident 19) is independent on ADL prior to discharge the resident to ILH 1 to ensure an appropriate discharge. A review of the facility’s policy and procedure (P&P) titled, “Discharge Process,” revised 10/2017, indicated “The discharge planning process must focus on discharge planning goals and should prepare a resident to be an active partner is their post-discharge care and the transition process in an attempt to reduce factors leading to preventable readmission.” The P&P indicated, “Before the facility transfers or discharges a resident, the facility will notify the resident and the resident’s representatives of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand.” The P&P indicate, “The facility will provide and document sufficient preparation and orientation to residents for transfer or discharge to ensure a safe and orderly transfer or discharge from the facility in a form and manner that the resident can understand.”   A review of the facility’s policy and procedure (P&P) titled, “Notice Before Transfer of a Resident,” revised 5/2016, indicated that the written notice of transfer or discharge must include “The reason for transfer or discharge; The effective date of transfer or discharge; The location to which the resident is to be transferred or discharged…” The facility failed to ensure a safe and orderly transfer or discharge for two residents (Residents 1, and 19) by failing to: 1. Obtain Resident 1’s physician order and Resident 1’s consent when staff discharged Resident 1 to SNF 2 on 12/5/2025. 2. Discharge Resident 19, who needs assistance with dressing and personal hygiene, to a facility with appropriate level of care. Staff discharged Resident 19 to an Independent Living Home (ILH) 1 on 8/1/2025, which did not meet the resident’s care needs. As a result, the facility violated Residents 1’s and Resident 19's rights and had the potential to result in impairing Residents 1’s physical, mental, and psychosocial well-being, and possible readmission of Resident 19. These violations, jointly, separately or in any combination, had a direct or immediate relationship to the health, safety, or security of Residents 1 and 19.