complaint·March 10, 2026

Interview with the Facility Manager revealed that the facility believed R1 required a higher level of care due to a diagnosis of incomplete quadriplegia and frequent hospital visits for disimpaction. The Facility Manager stated that R1 required extensive care and acknowledged that a re-appraisal had not been completed. The Facility Manager also reported that prior to the 02/27/2026 hospital transfer, R1 had expressed interest in relocating to a Skilled Nursing Facility (SNF), and that R1’s provider and the Long-Term Care Ombudsman (LTCO) agreed that a higher level of care was appropriate. The Facility Manager further stated that R1’s provider informed the hospital that R1’s safety would be at risk if discharged back to the facility. R1 was later transferred to a second hospital, which also contacted the facility to arrange R1’s return; the facility again refused readmission. Interview with the Administrator revealed that the facility believed R1’s disruptive behaviors, need for a two (2) person assist, and assistance with smoking were beyond what the facility could provide. The Facility Manager and Administrator stated that the facility attempted to relocate R1 to other licensed facilities and SNFs but was unsuccessful. Record review confirmed that the facility did not document a change of condition, did not complete a re-appraisal, and did not provide evidence that R1’s needs exceeded the facility’s licensed capacity. Information provided by the hospital indicated that R1 was medically cleared for discharge back to the facility and that R1 was in agreement with returning. Based on interviews and record review, the facility initiated the refusal of readmission despite the hospitals’ attempts to discharge R1 and R1’s expressed desire to return. The preponderance of evidence standard has been met; therefore, the allegation is deemed SUBSTANTIATED at this time. Pursuant to Title 22 CA Code of Regulations and/or the Health and Safety Code, the following deficiency was cited (Refer to LIC 9099-D). Exit interview conducted. A copy of the appeal rights and report was reviewed and provided.