Health inspection·July 7, 2023

F 0626 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure Resident 1 who was transferred to a General Acute Care Hospital (GACH) for a therapeutic leave was permitted to be readmitted back to the facility on the first available bed, in accordance with the facility's policy and procedure on readmission to the Facility for one of one sampled resident (Resident 1). Resident 1 1 who was transferred to the GACH from Skilled Nursing Facility (SNF)1 on 6/15/23 due to a change in condition and was medically stable to be discharged back to SNF 1 on 6/23/23, had to stay in the GACH setting for 14 days (from 6/23/23 to 7/7/23) when Resident 1 was transferred and admitted to SNF 2 due to SNF 1 refusing to readmit Resident 1 back. This deficient practice had the potential to cause psychosocial harm to Resident 1 and incurred unnecessary hospital days (14 days) at the GACH, from 6/23/23 to 7/7/23. Findings: A review of Resident 1's admission Record indicated the resident was initially admitted to the facility on [DATE] with the diagnosis of dementia (the impaired ability to remember, think, or make decisions that interferes with doing everyday activities), major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest) and Type 2 diabetes (a disease that occurs when your blood sugar is too high). A review of Resident 1's Minimum Data Set (MDS - a standardize assessment and care screening tool) dated 5/25/2023 indicated the resident had moderately impaired cognition (the ability or mental action or process of acquiring knowledge and understanding). A review of Resident 1's Change of Condition Form (COC) dated 6/15/2023 timed at 4:15 PM, indicated Resident 1 was transferred to the GACH for ALOC. A review of Resident 1's Notice of Proposed Transfer/discharge date d and signed by Resident 1's family member/responsible party (Family [FM]1) and facility administrator on 6/15/2023, indicated Resident 1 was transferred/discharge to the GACH for further evaluation and treatment, due to altered level of consciousness (ALOC - a change in one's mental state). A review of Resident 1's Notification of Bed Hold (a hold or reservation on the resident's bed while out of the facility for therapeutic services) dated 6/15/2023, indicated a bed hold would be maintained for Resident 1 (not to exceed seven [7] days) for the period of Bed hold start date 6/15/2023, Page 1 of 3 055135 055135 07/07/2023 Montrose Healthcare Center 2123 Verdugo Blvd. Montrose, CA 91020

F 0626 Bed hold stop date 6/21/2023. Level of Harm - Minimal harm or potential for actual harm A review of SNF 1's Social Service Note dated 6/15/2023 timed at 9:31 PM, indicated a verbal instruction from FM 1 that stated, Per FM 1, at this moment don't refer Resident 1 to other facility until I give written notice discharge to other SNF. Residents Affected - Few A review of Resident 1's GACH record titled Social Work Note dated 6/26/2023, timed at 4:57 PM, indicated that GACH Social Worker (SW) 1 contacted several other skilled nursing facilities to follow up regarding placement. A review of Resident 1's GACH record titled Social Work Note dated 6/27/2023 timed at 5:48 PM, indicated that GACH SW 1 informed FM 1 that there were no other facilities accepting Resident 1 at that time. A review of Resident 1's GACH record titled Social Work Note dated 7/3/2023, timed at 4:48 PM, indicated GACH SW 1 contacted SNF 1 and asked if SNF 1 would be accepting Resident 1 back to the facility. The note further indicated FM 1 also called SNF 1 and spoke with one of the facility staff and was informed SNF 1 declined Resident 1's readmission back to SNF 1. A review of Resident 1's GACH Final Report dated 7/3/2023 indicated Resident 1 had discharge orders to a SNF since 6/23/2023. The Report indicated Resident 1's status as Pending SNF placement and medically stable to be discharged when bed is available. During a telephone interview on 7/3/2023 at 11:56 AM, GACH SW 1 stated that SNF 1's Director of Nurses (DON) refused to readmit Resident 1 pending a legal matter. During an interview on 7/3/2023 at 1:30 PM, the DON acknowledged that SNF 1 had refused to readmit Patient 1 back to the facility according to the advice of SNF 1's corporate attorney due to the legal matter. The DON further stated that on 6/15/2023, SNF 1 planned to readmit Patient 1 back to the facility. However, on 6/17/23, the facility decided they would not readmit Resident 1 back to the facility. During an interview with the DON on 7/6/23 at 11:30 AM, the DON stated the facility still would not readmit Resident 1 back to SNF 1. During a review of an email communication dated 7/6/23 timed at 4:49 PM, sent by SNF 1's DON to FM 1 indicated a Written Involuntary discharge notification sent for Resident 1. The email attachment indicated a document titled Notice of Discharge. The Notice indicated The facility had determined the resident should be discharged on 6/19/2023 at the GACH. The Notice indicated under Advance Notice of Discharge that 30 days advance notice is not required because the resident is being discharged for one or more of the reasons checked under Section 4 (a - f), and notice was being provided as soon as practicable. The Notice indicated the reason for discharge under Section 4 d. indicated, The safety of individuals in the facility are endangered due to the clinical or behavioral status of the resident. During an interview with GACH SW 1 on 7/7/23 at 4:30 PM, GACH SW 1 stated that Resident 1 was 055135 Page 2 of 3 055135 07/07/2023 Montrose Healthcare Center 2123 Verdugo Blvd. Montrose, CA 91020

F 0626 transferred to another facility (SNF 2) on 7/7/23. Level of Harm - Minimal harm or potential for actual harm A review of the facility's policy titled, readmission to the Facility (undated) indicated, residents who have been discharged to the hospital or for therapeutic leave will be given priority in readmission to the facility. The policy indicated that a resident whose stay exceeded the bed hold period would be readmitted to the facility upon the first availability of a bed . Residents Affected - Few 055135 Page 3 of 3