Health inspection·October 1, 2025

California Code of Regulations. Title 22 CCR § 72527 (a)(6) 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. Code of Federal Regulation, Title 42, §483.21(c)(1)(i) 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 (i) Ensure that the discharge needs of each resident are identified and result in the development of a discharge plan for each resident. An unannounced visit was conducted by California Department of Public Health (CDPH) on 8/15/2025 to investigate a Facility Reported Incident (FRI) regarding an allegation that Resident 1 was improperly discharged from the facility. The facility failed to discharge Resident 1 safely by failing to provide proper oxygen equipment - durable medical equipment (DME, refers to medical devices prescribed by healthcare providers for long-term or everyday use in the home) in accordance with the facility’s Facility-Initiated Transfer or Discharge policy and procedure (P&P). This deficient practice has the potential to result in the resident’s failure to recover and respiratory complications. A review of Resident 1’s Admission Record indicated Resident 1, a 61-year-old female, was admitted to the facility on 6/24/2025 with the diagnoses including but not limited to acute respiratory failure (an inability to maintain adequate oxygenation for tissues or adequate removal of carbon dioxide from tissues) with hypoxia (lack of oxygen in the tissues to sustain bodily function), dependence on supplemental oxygen, and chronic obstructive pulmonary disease (COPD, disease that causes obstructed airflow from the lungs) with acute exacerbation (sudden worsening of symptoms of the disease). A review of Resident 1’s care plan, dated 6/24/2025, indicated Resident 1 had oxygen therapy related to diagnosis of COPD, hypoxic respiratory failure, and hypertensive (high blood pressure) heart disease. The staff interventions were to ensure oxygen was administered to the resident via nasal prongs (plastic tubes inserted into the nostrils to provide a measured increased supply of oxygen) at 2 liters (L, unit of volume)/minute continuously. A review of Resident 1’s Minimum Data Set (MDS, a resident assessment tool), dated 7/1/2025, indicated the resident’s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making were intact. The MDS also indicated Resident 1 received oxygen therapy. A review of Resident 1’s Physician Order Summary Report indicated as follows: - On 6/24/2025, oxygen at 2 liters via nasal cannula (NC, device used to deliver supplemental oxygen placed directly on a resident's nostrils) continuous. - On 6/25/2025, Budesonide Suspension (a drug that reduces inflammation in the lungs which helps to keep the airways open and improve airflow) 0.5 milligrams (mg, unit of measurement/2 milliliters (ml, unit of volume): 1 dose inhale orally every 12 hours for COPD. - On 8/7/2025, the report indicated discharge Resident 1 to Recuperative Care (a short-term residential care for residents who no longer require hospitalization but still need to heal from an injury or illness) with current medications, home health for Registered Nurse (RN) medication management, and durable medical equipment portable oxygen tank as needed. A review of Resident 1’s care plan, dated 8/7/2025, indicated Resident 1 wished to be discharged to a lower level of care. The staff interventions were to make arrangements with the required community resources to support independence post-discharge. A review of Resident 1’s Nursing Note, dated 8/7/2025, indicated Resident 1 was discharged from the facility with a portable oxygen tank. A review of Resident 1’s Notification of Approval for Requested Services/Treatment, dated 8/8/2025, indicated Resident 1 was authorized for an oxygen concentrator and portable oxygen (one day after discharge). During an interview on 8/20/2025 at 11:08 AM with Recuperative Care Clinical Director (RCCD), RCCD stated Resident 1 did not have all the appropriate DME when Resident 1 was discharged from the facility and admitted to Recuperative Care. RCCD stated Resident 1 should have been admitted to Recuperative Care with all DME needed upon arriving at Recuperative Care. RCCD stated Resident 1 needed a concentrator (a medical device that concentrates environmental air and delivers it in the form of supplemental oxygen), oxygen tank, and nebulizer (a device for breathing mist treatment) upon admission to Recuperative Care. RCCD stated Resident 1 was sent to Recuperative Care with an almost empty oxygen tank. RCCD stated the facility did not provide a safe discharge for Resident 1. RCCD stated Resident 1 was discharged to Recuperative Care on 8/7/2025 and the DME was delivered on 8/11/2025 (4 days after being discharged). RCCD stated Resident 1 had also still not received her nebulizer equipment for nebulizer treatment since being admitted to Recuperative Care (13 days). During an interview on 8/20/2025 at 11:24 AM with Resident 1, Resident 1 stated Resident 1 was not provided with a nebulizer when she was discharged from the facility. Resident 1 stated she had not received her breathing treatment twice a day through a nebulizer since 8/6/2025. Resident 1 stated she was only given a half full portable oxygen tank and was rushed to be discharged from the facility on 8/7/2025. Resident 1 stated, “I did not want to be transferred out like that cause my health was important to me.” During an interview on 8/20/2025 at 2:14 PM with the Director of Nursing (DON), the DON stated the Case Manager (CM) and Social Worker (SW) would arrange and inform the facility when the DME had been delivered, prior to discharging the resident from the facility. During a concurrent record review of Resident 1’s Physician’s Order, the DON stated Resident 1 was on continuous oxygen and received Budesonide via a nebulizer. The DON stated the concentrator, oxygen tank, and nebulizer were supposed to be ready at the Recuperative Care Center before Resident 1 was transferred out from the facility. The DON stated the DME was needed for Resident 1 to use the DME when Resident 1 needed them. The DON stated Resident 1 may experience shortness of breath due to diagnoses of COPD if Resident 1 did not have the required DME. The DON stated the CM and SW were responsible for verifying that all DME items were available at the Recuperative Care Center prior to transferring Resident 1 from the facility. During an interview on 8/20/2025 at 4:47 PM with CM, CM stated CM ordered a concentrator and oxygen tank on the day Resident 1 was discharged from the facility. CM stated the concentrator and oxygen tank were not at the Recuperative Care Center when Resident 1 was discharged. CM stated Resident 1 received the concentrator and oxygen tank on 8/9/2024 (2 days after discharge). CM stated CM did not place an order for a nebulizer for Resident 1. CM stated CM had reviewed Resident 1’s Physician’s order and did not see any orders for nebulizer treatment or continuous oxygen. CM stated DME should be made available and was not made available to Resident 1 prior to discharging Resident 1. CM stated the facility needed to wait and did not wait until the delivery of the DME at the Recuperative Care Center before discharging the resident from the facility. CM stated if Resident 1 required continuous oxygen per the physician’s order, then the oxygen tank provided to Resident 1 upon discharge would not have lasted Resident 1 the whole day. CM stated that when residents were on continuous oxygen, the residents would also need a concentrator while receiving oxygen. CM stated that without the oxygen tank, concentrator and nebulizer provided to Resident 1 could potentially result in Resident 1 experiencing respiratory distress and being sent out to the hospital. A review of the facility’s P&P titled, “Facility-Initiated Transfer or Discharge,” dated 10/2022, indicated should a resident be transferred or discharged for any reason that all special instructions or precautions for ongoing care as appropriate such as treatments and devices (oxygen) should be conveyed to the receiving provider to ensure a safe and effective transition of care. The facility failed to discharge Resident 1 safely by failing to provide proper oxygen equipment – DME in accordance with the facility’s Facility-Initiated Transfer or Discharge policy and procedure. This deficient practice has the potential to result in the resident’s failure to recover and respiratory complications. This violation had a direct or immediate relationship to the health, safety, or security of Resident 1.