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F0628
D

Failure to Notify Ombudsman Prior to Resident Discharge

Upland, California Survey Completed on 05-09-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to notify the Office of the State Long-Term Care (LTC) Ombudsman prior to the discharge of a resident who had been admitted for orthopedic aftercare following a left below-the-knee amputation. The resident was determined to have the capacity to understand and make decisions. According to the facility's own policy and federal requirements, the Ombudsman should be notified at least 30 days before a resident is transferred or discharged, or as soon as practicable before the event. Record review and staff interviews revealed that the Notice of Proposed Transfer/Discharge for the resident was faxed to the Ombudsman's office after the resident had already been discharged. The Director of Social Services confirmed the late notification, and both the Director of Nursing and the Administrator acknowledged that the required notification timeframe was not met. The facility's policy was reviewed and found to be consistent with the regulatory requirement for advance notification.

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