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F0628
D

Failure to Notify Ombudsman Prior to Resident Discharge

Riverside, California Survey Completed on 06-23-2025

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 provide a copy of the Notice of Proposed Transfer/Discharge to the State Long-Term Care Ombudsman prior to the planned discharge dates for two residents. Both residents were scheduled for discharge to home, with one having diagnoses including pneumonia and sepsis, and the other with heart failure. The notices were given to the residents and acknowledged, but the copies intended for the Ombudsman were only sent after the residents had already been discharged from the facility. Interviews with facility staff, including the Social Services Director, Director of Nursing, and Administrator, confirmed that the required notifications to the Ombudsman were not made before the residents left. The facility's own policy required that such notices be sent to the Ombudsman in advance of discharge, but this procedure was not followed for the two residents in question.

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