Health inspection·October 6, 2023

F623 42 CFR §483.15(c)(3) Notice before transfer. Before a facility transfers or discharges a resident, the facility must- (i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman. (ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and (iii) Include in the notice the items described in paragraph (c)(5) of this section. 42 CFR §483.15(c)(4) Timing of the notice. (i) Except as specified in paragraphs (c)(4)(ii) and (c)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged. (ii) Notice must be made as soon as practicable before transfer or discharge when- (A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section; (B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section; (C) The resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(i)(B) of this section; (D) An immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (c)(1)(i)(A) of this section; or 42 CFR §483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following: (i) The reason for transfer or discharge; (ii) The effective date of transfer or discharge; (iii) The location to which the resident is transferred or discharged; (iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request; (v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman; (vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and (vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act. 42 CFR §483.15(c)(6) Changes to the notice. If the information in the notice changes prior to effecting the transfer or discharge, the facility must update the recipients of the notice as soon as practicable once the updated information becomes available.

F624 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. 22 CCR § 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. 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 8/18/2023, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a complaint about the transfer and discharge of Resident 1. The facility failed to permit Resident 1 to remain in the facility and not transfer or discharge her for unnecessary and inappropriate reasons. The facility failed to: -Ensure Resident 1 was only discharged for one of the following reasons: o the resident's welfare and the resident's needs could not be met in the facility; o her care needs could not be met at the facility o her health had improved and no longer needed the services provided by the facility o for the safety of individuals in the facility due to Resident 1's clinical or behavioral status o because of Resident 1's lack of payment, or o because the facility ceased operation -Provide and document sufficient preparation and orientation to Resident 1 or Resident 1’s responsible party, for a safe and orderly discharge from the facility, and ensure the preparation and orientation accounted for Resident 1’s diagnoses including dementia (loss of memory, thinking and reasoning), secondary bone cancer (cancer that started somewhere else in the body has spread to the bones), and gait and mobility abnormalities. - Notify Resident 1 or Resident 1’s responsible party in writing and in a manner that Resident 1 understood at least 30 days, or as soon as practicable, before Resident 1 was discharged to her home. - Complete Resident 1’s discharge summary and provide it to Resident 1 or Resident 1’s responsible party prior to discharge from the facility. -Implement its own policies and procedures related to the transfer and discharge of residents. On 8/1/2023, the facility discharged Resident 1 to her home where her medical and nursing needs could not be met, as Resident 1 required extensive assistance with activities of daily living (ADL), including eating, toileting, bathing, and walking. As a result, on 8/15/2023 (two weeks after leaving the facility), Resident 1 was found in her home, by emergency services, covered in feces, after having fallen and sustaining a fracture. Resident 1 required immediate transfer to a general acute care hospital (GACH) where she was admitted same day for failure to thrive (a syndrome of weight loss, decreased appetite, poor nutrition, and inactivity, often accompanied by dehydration, depressive symptoms, and impaired immune function) and sternum (breastbone) fracture. A review of Resident 1's Admission Record indicated the facility admitted the 72 year old female resident, on 5/9/2023 with diagnoses including dementia, secondary bone cancer, gait and mobility abnormalities, and muscle weakness. The admission record listed both Resident 1 and Family Member 1 (FM 1) as a Responsible Party and FM 1 as the Medical Power of Attorney (POA). A review of Resident 1's Physical Therapy (PT) Evaluation & Plan of Treatment, dated 5/10/2023, indicated the resident felt unsteady when standing and walking, and was worried about falling. The PT Evaluation indicated Resident 1 had decreased coordination, decreased strength, decreased functional mobility, reduced ADL participation, increased physical exertion during daily living tasks and an increased need for assistance from others. A review of the Skilled Nursing Facility Follow-Up Visit form, dated 5/11/2023 indicated Resident 1's anticipated discharge arrangement was either custodial care at the facility (non-medical care that assists one with ADLs [including walking, getting in and out of bed, bathing, dressing, eating, and using the toilet]), home with home health, or discharge to another long-term care facility. The Follow Up Visit form indicated Resident 1 had chronic pain and Stage IV breast cancer (spread to different organs or lymph nodes far from breast) with extensive vertebral (relating to the spine) metastases status post-surgery and radiation. A review of Resident 1's ADL Care Plan, initiated 5/11/2023 indicated the resident had a self-care performance deficit related to her gait disorder, a history of falls, lack of coordination and gait abnormalities. The care plan interventions included to discuss with resident/family/POA any concerns related to the loss of independence or the decline in function, to encourage the resident to use the call bell for assistance and PT and Occupational Therapy (OT) evaluation and treatment per Physician's Order. According to a review of the Care Plan, initiated 5/11/2023, Resident 1 was at risk for a pathological bone fracture (break in a bone that is caused by an underlying disease) related to osteoporosis (a bone disease when bone mass / density decreases) and the resident had a previous pathological fracture. The care plan interventions included Physical Therapy/Occupational Therapy to evaluate and treat as indicated, handle gently when moving or positioning, maintain body alignment and to support injured area with pillows and immobilize part as appropriate. A review of Resident 1's Cognitive (thinking, reasoning, and memory) Function Care Plan, initiated 5/11/2023, indicated the resident had impaired cognitive function or impaired thought processes related to diagnosis of dementia. The interventions included to communicate with the resident/family/caregivers regarding resident's capabilities and needs. The interventions also included to cue, reorient, and supervise as needed. A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 5/16/2023, indicated the resident's cognition (able to understand and make decisions) was intact. This was a discrepancy from the Cognitive Function Care Plan. The MDS indicated Resident 1 had a planned discharge and the facility did not anticipate her return. The MDS further indicated the resident required extensive assistance with one-person physical assist with bed mobility, transfer, walking, dressing and toilet use. The MDS indicated Resident 1 required limited assistance with one-person physical assist for personal hygiene, was not steady and only able to stabilize with staff assistance when moving from a seated to standing position, walking, turning around, getting on or off the toilet and when transferring between bed and chair or wheelchair. A review of the Physician's Orders, dated 6/6/2023 indicated Resident 1 was to continue: -Skilled PT services daily five times a week for four weeks for treatment diagnosis of gait abnormality with current plan of care. -Skilled OT services daily five times a week for four weeks with treatment diagnosis of lack of coordination. The treatment plan includes therapeutic exercises, therapeutic activities, self-care training and safety awareness training. A review of Resident 1's "Detailed Explanation of Non-Coverage" Letter from the GACH, dated 6/28/2023, indicated why the current Medicare coverage should end. The GACH letter indicated according to the medical doctor, nurse practitioner, case management assessment and facility team, the resident was medically stable for discharge to custodial care or home, with 24-hour caregiver support. The letter indicated Resident 1's therapist reported the resident had reached new levels in bed mobility with caregiver assistance and transfers with caregiver assistance. The letter indicated if Resident 1 was discharged home with a 24-hour caregiver, she would receive home health skilled nursing, PT and OT services with close follow up from the primary care physician. The letter indicated continued recuperation from Resident 1's illness could be safely provided with custodial care or home health services, if dischar