Transfer and discharge · Resident Rights Deficiencies
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
F622 in California. Pick another state for the same tag.
Against expectation — 2025
California cites F622 more often than its own record predicts
Versus expected share1.20×
1.20 times the share F622 takes of citations nationally.
Share of California citations0.14%
Of every deficiency written in California in 2025, this is the portion that was F622.
California0.14%
National0.12%
Share of all citations that were F622.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What California surveyors wrote
F622 findings written in California, one from each severity band recorded here, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
J · Immediate jeopardy, isolatedApril 11, 2025
Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) who had severe cognitive impairment, was safely discharged when the facility failed to:
1. Ensure an Interdisciplinary Meeting ([IDT] gathering where healthcare professionals from different disciplines collaborate to discuss a patient's care, develop shared understandings, and coordinate treatment plans) for discharge planning was conducted for Resident 1.
2. Ensure Resident 1 ' s discharge location (house) could meet the resident ' s needs.
3. Follow up with Resident 1 after his discharge from the facility to the house, to ensure Resident 1 was safe and comfortably settled.
4. …
Based on interview and record review, the facility (Facility A) failed to permit five of 21 sampled residents (Resident 1, Resident 2, Resident 3, Resident 4, and Resident 5) to remain at the facility and not transfer to another facility without appropriate reason/s for discharge when:
1. Resident 1 was transferred to Facility B by a facility-initiated discharge (a transfer or discharge which the resident objects to or did not originate through a resident's verbal or written request) without an appropriate reason for discharge in accordance with CFR 483.15(c)(regulation with specific criteria for discharge/transfer of residents).
2. Resident 2 was transferred to Facility B by a facility- initiated discharge without an appropriate reason for discharge in accordance with CFR 483.15(c).
3. …
D · No harm, potential for more than minimal, isolatedApril 30, 2025
Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was provided with a detailed discharge summary. This failure had the potential for Resident 1 to be unaware of how to care for his wounds and the potential for the wounds to worsen.
Findings:
During a review of Resident 1's Order Summary Report (OSR-physicians orders) dated 12/1/24, the OSR indicated, L (left) back of heel diabetic ulcer (open sores or wounds on the feet of people with diabetes [high blood sugar]) 1.3 cm (centimeters-a unit of measurement) x 1.1 cm cleanse with wound cleaner, pay [sic] dry and swab with betadine.start date 8/21/24.unstageable pressure injury (pressure ulcer [injury to skin and underlying tissue resulting from prolonged pressure on the skin] where… …
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