Mountain View Conv Hosp: Discharge Notice Failures - CA
The inspection at Mountain View Convalescent Hospital, completed August 12, found that the signed Notice of Transfer or Discharge for Resident 1 listed one assisted living facility as the discharge destination. The resident was sent to a different one entirely.
Nobody updated the form.
The Director of Nursing reviewed the notice with inspectors and acknowledged it outright: the facility had not provided Resident 1 with a Notice of Transfer or Discharge for the new facility. There was no documented evidence that any changes had been made to the paperwork before the resident left the building.
The Director of Nursing described how the discharge process is supposed to work. A registered nurse provides the notice, reviews medications, confirms follow-up visits and home health arrangements, and then both the resident and the RN sign the form. The specific location where the resident is going is supposed to be on that form. The facility's own policy, last reviewed in September 2024, states the resident and their representative must be notified in writing of the specific location, including the name of the new provider or its address.
None of that happened for Resident 1.
What the Director of Nursing said next is the part that matters most. Because the signed notice listed the wrong facility, home health services may not have known where Resident 1 actually went. The Director of Nursing said there is "a potential with home health to not be aware of Resident 1 going to AL 2, potentially resulting in Resident 1 missing on services."
That is the Director of Nursing's own words, describing what happens when a discharge notice lists the wrong address: a resident arrives somewhere, and the nurses and aides scheduled to provide follow-up care at home show up somewhere else, or don't show up at all, because no one told them the plan changed.
The inspection also cited the facility's documentation policy, which was last reviewed in September 2024 and states that entries in the medical record must be objective, complete, and accurate. The signed Notice of Transfer or Discharge for Resident 1 was none of those things. The Director of Nursing confirmed the notice "is not accurate because there is a potential to not have accurate records," a statement that could serve as its own summary of what went wrong.
The violation was classified as causing minimal harm or the potential for actual harm, and it affected a small number of residents.
The classification of "minimal harm" reflects the regulatory framework's threshold, not necessarily what Resident 1 experienced after discharge. Whether home health services reached Resident 1 at the correct location, whether any follow-up care was delayed or missed entirely, is not something the inspection report answers. The record documents what the facility failed to do. What happened to Resident 1 afterward is not in the file.
What is in the file is a Director of Nursing who, when shown the paperwork, confirmed it was wrong, confirmed the facility knew it was wrong, and explained in plain language exactly how a resident could go without services as a result. The facility's own policies required accurate records. The facility's own process required the correct destination on the form. The form was signed, filed, and left unchanged.
Resident 1 was discharged to an address that was not written down anywhere in the official record of where she was going.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Mountain View Conv Hosp from 2025-08-12 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
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Last verified: November 3, 2026 · Our methodology
MOUNTAIN VIEW CONV HOSP in SYLMAR, CA was cited for violations during a health inspection on August 12, 2025.
The resident was sent to a different one entirely.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.