Health inspection·November 5, 2025

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to re-admit one of one resident (Resident 1) back to the facility after Resident 1 was evaluated and cleared by the Long-Term Acute Care ([LTAC] a hospital that provides specialized, extended care for critically ill patients) facility to return on 10/7/2025.This deficient practice resulted in Resident 1 being denied returning to the facility that has been their home for two years and had the potential for psychosocial harm.Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including anoxic brain injury (when the brain receives no oxygen at all), chronic respiratory failure (not enough oxygen passes from your lungs to your blood), and atrial fibrillation (irregular heartbeat).During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 7/16/2025, the MDS indicated Resident 1 cognition (ability to think, understand, learn, and remember) is severely impaired and was dependent (helper does all the effort) with activities of daily living (ADLs- activities such as bathing, dressing, and toileting a person performs daily).During a review of Resident 1's Nursing Health Status Note dated 7/16/2025 at 9:37 a.m., the Nursing Health Status Note indicated Resident 1 was transferred to the General Acute Care Hospital (GACH) for generalized body swelling on 7/16/2025.During a review of the LTAC treatment team communication note dated 10/7/2025, the treatment team communication note indicated the LTAC informed the facility's admission Coordinator (AC) that Resident 1 had a discharge order to return to the facility dated 10/7/2025.During an interview on 11/5/2025 at 8:23 a.m., with LTAC Case Manager (CM), the CM indicated Resident 1 had a discharge order on 10/7/2025. The CM stated she reached out to the facility's AC on 10/7/2025 and was told there were no beds available for Resident 1.During a telephone interview on 11/5/2025 at 1:19 p.m., with the Director of Business Development (DOBD), the DOBD indicated he had been communicating with the LTAC CM regarding Resident 1's re-admission but the day the request was made to readmit Resident, there were open beds.During an interview on 11/5/2025 at 1:54 p.m. with the Administrator (ADM), the ADM indicated he was only made aware of the request for Resident 1's readmission on e to two weeks (no specific date recalled) ago and it is not clear why this was not communicated to him. The ADM stated Resident 1 should have been readmitted back to the facility when there was a female bed available unless there was another admission assigned to the open bed.During a concurrent interview and record review on 11/5/2025 at 3:19 p.m. with the Director of Nursing (DON), the Facility Census' dated 10/17/2025, 10/18/2025, 10/19/2025, and 10/23/2025 were reviewed. The DON stated there were open female beds available on 10/17/2025, 10/18/2025, 10/19/2025, and 10/23/2025 but was unable to state why Resident 1 was not readmitted on e of these days.During a concurrent interview and record review on 11/5/2025 at 3:32 p.m. with the ADM, the Facility Census' dated 10/17/2025, 10/18/2025, 10/19/2025, and 10/23/2025 were reviewed. The ADM stated there were open female beds on each of these dates. The ADM stated he will investigate why Page 1 of 2 055077 055077 11/05/2025 Coral Cove Post Acute 1730 Grand Ave Long Beach, CA 90804

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident 1 was not readmitted on each of these days with open female beds.During a telephone interview on 11/6/2025 at 12:23 p.m., with the DOBD, the DOBD stated he could not say why Resident 1 was not readmitted back to the facility but would not answer when asked about the days in October when there were open female beds. During a review of the facility's policy and procedure (P&P) titled, Bed Hold, dated 7/2017, the P&P indicated, If the bed-hold period expires and the resident does not elect to pay to hold the bed, but wishes to return to the facility, the facility will provide the resident with the first available bed. 055077 Page 2 of 2