Health inspection·June 4, 2025

CFR §483.15 Transfer and discharge (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)(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 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). (iii) Information provided to the receiving provider must include a minimum of the following: (A) Contact information of the practitioner responsible for the care of the resident. (B) Resident representative information including contact information (C) Advance Directive information (D) All special instructions or precautions for ongoing care, as appropriate. (E) Comprehensive care plan goals. (F) All other necessary information, including a copy of the resident's discharge summary, consistent with §483.21(c)(2) as applicable, and any other documentation, as applicable, to ensure a safe and effective transition of care. CCR §72523 - Patient Care Policies and Procedures (a) Written patient care policies and procedures shall be implemented to ensure that patient-related goals and facility objectives are achieved. On 4/15/2025, the California Department of Public Health (CDPH) received a complaint indicating Resident 1 was wrongly discharged from the facility to a Board and Care ([B&C] a small residential home that provides lower-level of care and supervision to seniors who need assistance with daily living tasks but do not require 24-hour nursing care). On 4/28/2025, an unannounced visit was conducted at the facility to investigate the allegations. The facility failed to: 1.) Follow its policy and procedure (P&P) titled, "Discharge and Transfer of Residents," which indicated the facility may discharge a resident if the services provided by the facility were no longer required, when Resident 1, who required the services provided by the facility was discharged to a B&C. 2.) Ensure Resident 1 was safely discharged to B&C 1. B&C 1 was not a licensed B&C and could not provide ambulation (walking) assistance, epilepsy (recurrent seizures) management and response, or assistance with medication administration and storage. 3.) Ensure Resident 1's discharge planning was conducted by the Interdisciplinary Team ([IDT] group of healthcare professionals, including resident/ resident representative, working together to provide residents with needed care) prior to discharging the resident to a Board and Care facility on 3/24/2025. 4.) Ensure the Board and Care facility was provided with a hand-off report (a structured communication tool used to transfer patient care information from one healthcare provider to another) regarding Resident 1's medical conditions to ensure the facility could meet the resident's needs prior to his discharge. 5.) Ensure Resident 1 continued receiving prescribed medications at the B&C including Seroquel (medicine for schizophrenia [a mental illness that is characterized by disturbances in thought]), Depakote (medicine for seizures [sudden, uncontrolled electrical disturbances in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness]), klonopin (antianxiety medicine), and Zonisamide (medicine for epilepsy) 6.) Follow-up with the Board and Care to ensure Resident 1 was safe and comfortably settled, post discharge. As a result, Resident 1 fell at B&C 1, sustained a laceration (a deep cut or tear) on the scalp and was admitted to a general acute care hospital (GACH 1) for evaluation and treatment from 3/30/2025 to 4/10/2025 (a total of 11 days). Resident 1 was discharged back to B&C 1 on 4/10/2025 and on 4/12/2025, Owner 1 transferred Resident 1 to B&C 2, and on 4/13/2025, Resident 1 eloped, was found confused and wandering on the street by the law enforcement (Police) and transported to GACH 2 on 4/13/2025. Resident 1 was admitted to GACH 2 from 4/14/2025 to 4/27/2025 and discharged to another facility (facility 2). Resident 1 was at risk of exposure to worsening medical and psychiatric conditions (mental illness), adverse reaction from medication overdose, and elevated risk for serious injuries, elopement (a situation in which a resident leaves the premises or a safe area without the facility's knowledge and supervision), seizures and death. Resident 1 was a 67-year-old male, admitted to the facility on 10/2/2024, with diagnoses of epilepsy (recurrent seizures), encephalopathy (group of conditions that cause brain dysfunction), anxiety disorder (excessive and persistent worry, fear, and unease), and schizophrenia (a mental illness that is characterized by disturbances in thought). A review of Resident 1's History and Physical (H&P), dated 10/3/2024, indicated Resident 1 had fluctuating capacity to make medical decisions. A review of Resident 1's Fall Risk Assessment, dated 1/9/2025, indicated Resident 1 was at risk for falls due to intermittent confusion, incontinence (no control of bowel and bladder elimination), pre-disposing diseases (risk factors), use of assistive devices (mobility aids), instability while making turns, and medications. A review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 1/9/2025, indicated Resident 1 was unable to express ideas and wants, and unable to understand others. The MDS indicated Resident 1 required set-up or clean-up assistance with eating and oral hygiene, required partial/ moderate assistance (helper does more than half the effort) with toileting hygiene and with shower/ bathing self. The MDS indicated Resident 2 required supervision or touching assistance (helper provides verbal cues and/or touching/ steadying and/or contact guard assistance as resident completes activity, throughout or intermittently) with personal hygiene. The MDS indicated Resident 1 required supervision or touching assistance with sit to stand, chair/bed-to-chair transfer, toilet transfer, tub/shower transfer and walking 50 feet with two turns. The MDS indicated Resident 1 required setup or clean-up assistance walking 10 feet and 150 feet. A review of Resident 1's physician orders, dated 3/2025, indicated: 1. Seroquel oral tablet 200 mg (milligrams- metric unit of measurement, used for medication dosage and/or amount) by mouth at bedtime for schizophrenia m/b (manifested by) disorganized speech (talking off topic). 2. Depakote oral tablet 750 mg by mouth two times a day for seizures 3. Klonopin oral tablet 1 mg by mouth two times a day, for anxiety m/b inability to relax 4. Zonisamide 100 mg capsule, 1 capsule by mouth, one time a day for epilepsy A review of Resident 1's care plan, titled "Resident wishes to move to lower level of care such as Board and Care facility," dated 3/21/2025, indicated to coordinate Resident 1's discharge goals with rehabilitative therapies, follow up with resident to assure understanding of plan and make arrangements with required community resources to support independence post-discharge with home health ([HH] medical services provided in a patient's home), Registered Nurse (RN) and physical therapy (PT) services and durable medical equipment (DME - medical devices). A review of Resident 1's physician orders, dated 3/24/2025, indicated Resident 1 may be discharged to Board and Care (B&C 1) with HH services for RN/PT treatment and evaluation and a standard wheelchair on 3/24/2025. A review of Resident 1's physician report for the Residential Care Facilities for the Elderly (RCFE) Report, dated 3/24/2025, indicated Resident 1 was confused and disoriented at times and required medication management due to mild cognitive impairment. The report indicated Resident 1 was unable to store or administer his own medications. A review of Resident 1's Paramedic Report Sheet, dated 3/30/2025, indicated paramedics were dispatched to B&C 1 on 3/30/2025, at 3:40 p.m., after Resident 1 fell, hit his head, and sustained a 0.5-inch (unit of measurement) laceration on the top of his head. The report sheet indicated Resident 1 was confused, slow to respond to questions, and had unequal pupils (pupils of the two eyes are not the same size). The report sheet indicated Resident 1 arrived at GACH 1 on 3/30/2025 at 4:05 p.m. A review of Resident 1's GACH 1 Emergency Department (ED) provider notes, dated 3/30/2025, indicated Resident 1 was taken into the ED by paramedics. The ED note indicated Resident 1 had a right parietal (top or side of the head) laceration with surrounding hematoma (a collection of blood outside of a blood vessel caused by a broken blood vessel) and anisocoria (unequal pupil size that can indicate brain damage). The ED note indicated Resident 1 was admitted to the GACH for alteration of mental status and blunt head trauma evaluation and treatment, following a fall. A review of Resident 1's GACH 1 Discharge Planning Note, dated 4/10/2025, indicated Resident 1 was discharged to B&C 1 on 4/10/2025. A review of Resident 1's GACH 1 Discharge Summary Note, dated 4/18/2025, indicated Resident 1 had a computerized tomography (CT- diagnostic test) scan of his head which indicated some lymphadenopathy (lymph node enlargement) and no acute (sudden onset) intracranial (within the skull) hemorrhage (excessive bleeding). The discharge summary indicated Resident 1 had a magnetic resonance imaging ([MRI] a noninvasive medical imaging test that produces detailed images of almost every internal structure in the human body, including the organs, bones, muscles and blood vessels) scan of the brain which indicated no acute changes. The summary note indicated Resident 1 was evaluated for neurologic and malignancy (cancer-related) illnesses during his admission at GACH 1. A review of Resident 1's GACH 2 Discharge Summary, dated 4/27/2025, indicated Resident 1 was admitted to GACH 2 from 4/14/2025 to 4/27/2025. The Discharge Summary indicated Resident 1 eloped from B&C 2 on 4/13/2025, had two Code Gold (behavioral issues, where a patient's violent or self-destructive behavior poses a threat to their own safety or the safety of others) episodes in the ED, were evaluated, and admitted to GACH 2 for observation and placement. The report indicated B&C 2 was unable to care for Resident 1's high level of needs and was not an appropriate facility for Resident 1. The summary indicated Resident 1 had no capacity to make informed decisions and required long-term skilled nursing facility placement. During an interview on 4/28/2025 at 8:35 a.m., with a Social Worker from GACH 2 (SW), GACH 2 SW stated Resident 1 was discharged from the facility on 3/24/2025 and transferred to B&C 1. GACH 2 SW stated Resident 1 was admitted to GACH 1 on 3/30/2025 from B&C 1 and discharged back to B&C 1 on 4/10/2025. GACH 2 SW stated B&C 1 transferred Resident 1 to B&C 2 on 4/12/2025 because the resident's needs could not be met at B&C 1. GACH 2 SW stated Resident 1 eloped from B&C 2 on 4/13/2025 and was found by the Police wandering in the street. GACH 2 SW stated the Police transported Resident 1 to GACH 2 on 4/14/2025 where he was admitted and was discharged on 4/27/2025 to another facility, where his needs could be met. GACH 2 SW stated Resident 1 was not awake or alert when he arrived at GACH 2 on 4/14/2025 and required long-term care due to his behavioral and medical needs. During an interview on 4/28/2025 at 9:21 a.m., with the owner of B&C 2 (Owner 2), Owner 2 stated Owner 1 called a Psychiatric Emergency Team (PET- a mobile team that provides mental health crisis intervention and assessment) on 4/12/2025 who referred Resident 1 to B&C 2 on 4/12/2025. Owner 2 stated within hours of arrival on 4/12/2025, Resident 1 eloped from B&C 2, walked into the street, and had a psychotic episode (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality). Owner 2 stated Resident 1 required a higher level of care than a B&C could provide due to his high level of medical and psychological needs. During a concurrent interview and record review on 4/28/2025 at 12:20 p.m., with the SSD, Resident 1's Discharge Planning Review Form, dated 4/24/2025 was reviewed. The SSD stated the form was initiated prior to Resident 1's discharge from the facility on 3/24/2025 but was incompletely filled. The SSD stated she did not tour (go onsite) the B&C 1 or verify the B&C 1's license prior to discharging Resident 1. The SSD stated she had no documentation about the services B&C 1 provided. During an interview on 4/30/2025 at 10:28 a.m., with the Director of Nursing (DON), the DON stated he was not present at Resident 1's IDT meeting on 3/21/2025 and was not notified of Resident 1's discharge plan or discharge. The DON stated he must be present for every IDT meeting. The DON stated he discovered that Resident 1 was discharged on 3/25/2025, the day after Resident 1 had left the facility on 3/24/2025. During an interview on 4/30/2025 at 10:35 a.m., with Owner 1, Owner 1 stated B&C 1 was not a licensed B&C and could not provide ambulation (walking) assistance, epilepsy management and response, or assistance with medication administration and storage. Owner 1 stated the staff from the facility did not inform B&C 1 of Resident 1's medical diagnoses, behavior, and care needs on 3/24/2025. Owner 1 stated Resident 1 was not appropriate for B&C 1 because Resident 1 required more services than B&C 1 could provide. Owner 1 stated B&C 1 did not receive any written or verbal report about Resident 1, prior to his arrival at B&C 1 on 3/24/2025. Owner 1 stated Resident 1 exhibited continuous screaming, sexually inappropriate behavior, and agitation and could not be redirected. Owner 1 stated she observed Resident 1 on the floor, with a head injury and blood dripping from the injured site (scalp) on 3/30/2025. Owner 1 stated she called 911 and Resident 1 was transferred to GACH 1 for evaluation and treatment. Owner 1 stated Resident 1 was at GACH 1 from 3/30/25 to 4/10/2025 and was discharged back to B&C 1. Owner 1 stated Resident 1's high level of needs was not appropriate for B&C 1, but GACH 1 forced her to take Resident 1 back on 4/10/2025. Owner 1 stated she called an emergency PET intervention on 4/12/2025 for Resident 1's uncontrollable behaviors. Owner 1 stated she and the PET transferred Resident 1 to B&C 2, which had more services needed by Resident 1. Owner 1 stated the facility's staff did not call B&C 1 to follow-up on Resident 1, after the resident was discharged from the facility. During a concurrent interview and record review on 4/30/2025 at 1:00 p.m., with the facility RN 1, Resident 1's RCFE report dated 3/24/2025, Progress Notes dated 3/24/2025, and Discharge Planning Review Form dated 4/24/2025, were reviewed. The facility RN 1 stated the RCFE report indicated Resident 1 required assistance in storing and administering medications. The facility RN 1 stated the Discharge Planning Review Form indicated Resident 1's medication reconciliation (medication review and comparison), discharge education, and self-care evaluation were not performed and not completed. Facility RN 1 stated the SSD was responsible for completing and documenting the Discharge Planning Review Form. The facility RN 1 stated she was not informed of what B&C 1's services were, did not provide hand-off report to B&C 1, and she would not have discharged Resident 1 if she knew B&C 1 was not equipped to provide the services Resident 1 required. Facil