Failure to Support Resident Choice for Transfer to Another Facility
Penalty
Summary
The facility failed to promote and support a resident's choice to transfer to another skilled nursing facility. The resident, who was cognitively intact with a BIMS score of 15 on an MDS dated 2/2/26, had been admitted on an earlier date and later expressed dissatisfaction with remaining at the facility. An IDT conference note dated 1/15/26 documented that the resident preferred to reside in a skilled nursing facility located in Solano County to be closer to his son and sister. During an interview on 3/5/26, the resident stated he had informed the Administrator and the IDT of his desire to transfer approximately two months earlier but had not received any updates regarding efforts to locate another placement and reported feeling sad and stuck at the current facility. During a concurrent record review and interview on 3/5/26, the SSD acknowledged awareness of the resident's request to transfer and stated she had contacted two skilled nursing facilities regarding possible placement. However, when asked, the SSD was unable to provide any documentation—such as records, notes, referral forms, emails, or other written evidence—showing that outreach had been made to facilitate the transfer. The facility's undated Resident Rights policy indicated that residents are guaranteed certain basic rights under federal and state law, including being informed about their rights and responsibilities and being entitled to exercise their rights and privileges to the fullest extent possible. Despite this policy, there was no documented evidence that the facility actively assisted the resident in locating an alternative placement after the transfer request.
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