The breakdown occurred with Resident 2, who was admitted in March 2025 with cognitive communication deficits, age-related cognitive decline, and epilepsy. The resident's brain disorders made communication difficult due to impaired memory, attention, and problem-solving abilities rather than speech problems.
The Long Term Care Ombudsman first emailed the facility's social worker requesting a care plan meeting with the resident's representative. Staff initially scheduled the meeting for October 28 at 10 a.m., but postponed it to November 3 because the resident was hospitalized.
The resident returned to the facility on October 30. The representative informed the social worker of the return on November 1. But no confirmation or discussion about the rescheduled meeting occurred.
For nearly two weeks, from October 30 to November 12, the resident remained at the facility without any care plan meeting. On November 12, the resident was hospitalized again.
The ombudsman told inspectors about multiple attempts to get the meeting scheduled. After the social worker didn't reply to the initial email, the ombudsman reached out again on November 3 asking if any meetings had been scheduled.
Two weeks later, on November 17, the resident's representative informed the ombudsman that no meeting had ever been scheduled. The facility was trying to discharge the resident, and the representative wanted updates on the discharge plan and process.
When inspectors interviewed the social worker on November 18, she couldn't show any documentation of a scheduled care plan meeting in the clinical record. She explained that receptionists typically call families to arrange meetings for newly admitted residents.
The social worker said the ombudsman had requested the meeting via email, and it was initially scheduled for October 28 but postponed due to the hospitalization. She acknowledged that although the representative informed her of the resident's return on November 1, no coordination occurred for setting up the rescheduled meeting.
The receptionist told inspectors that initial care conferences are scheduled for newly admitted residents. But for Resident 2, who was returning from the hospital rather than being newly admitted, it was the social worker's responsibility to schedule subsequent meetings.
No documentation existed anywhere in the clinical record of any coordination efforts to reschedule the meeting.
The facility's own policy, last revised in February 2021, states that residents and legal representatives are encouraged to attend and participate in developing person-centered care plans. The policy specifically notes that residents and representatives have the right to request meetings, and the facility must provide sufficient advance notice.
The ombudsman's involvement highlighted the urgency of the situation. Long Term Care Ombudsmen serve as advocates for nursing home residents, investigating complaints and ensuring facilities follow regulations. Their request for a care planning meeting typically signals serious concerns about a resident's care.
The resident's complex medical conditions made family involvement particularly important. Cognitive communication deficits affect how people process information and express their needs. Age-related cognitive decline can impact decision-making abilities. Epilepsy requires careful medication management and monitoring for seizures.
With the facility pursuing discharge, the representative needed current information about treatment plans, medications, and care requirements for the next placement. Care planning meetings serve as the primary forum for families to understand their loved one's condition and participate in decisions about treatment goals.
The social worker's failure to follow up after the resident's return from hospitalization left the family in limbo for weeks. Despite knowing the representative wanted the meeting and having been reminded by the ombudsman, no staff member took responsibility for rescheduling.
The breakdown revealed confusion about basic responsibilities within the facility. The receptionist believed scheduling was the social worker's job for returning residents. The social worker couldn't produce any documentation of scheduling efforts. Meanwhile, the resident's representative waited for information about someone they were legally responsible for protecting.
Federal regulations require nursing homes to ensure residents and their representatives can participate in care planning. The facility's failure to schedule the requested meeting violated the resident's right to be informed about treatment objectives and care plans.
The resident remained caught between hospitalizations and potential discharge, with family members unable to get basic information about care plans from the facility they trusted with their loved one's wellbeing.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for San Leandro Healthcare Center from 2025-11-26 including all violations, facility responses, and corrective action plans.
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