Health inspection·December 12, 2024

F 0620 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Not require residents to give up Medicare or Medicaid benefits, or pay privately as a condition of admission; and must tell residents what care they do not provide. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement their admission policy when one of three residents (Resident 1) was admitted to the facility without sufficient information to determine if appropriate care and services could be provided to the resident. As a result of this deficient practice, the facility sent Resident 1 back to the hospital which had the potential to cause the resident distress. Findings: A review of Resident 1's admission Record indicated the resident was admitted to the facility on [DATE] and was discharged on 6/19/24. On 11/14/24 at 4:24 P.M., a telephone interview was conducted with Resident 1. Resident 1 stated he met with the facility's admissions marketer (AM) while he was at the hospital. Resident 1 stated he had disclosed his parole status to the AM and that he wore an ankle monitor as a condition of his parole. Resident 1 stated he was admitted to the facility, given a room and bed, and was provided dinner. Resident 1 stated everything was fine until the next morning when an administrative staff member came into his room and asked about his parole status and ankle monitor. Resident 1 stated the administrative staff member told him, We can't have you here, and that he would have to go back to the hospital. Resident 1 stated, It wasn't right , but he did not want to cause trouble. Resident 1 stated, If I mess up in any way, I go back to prison Resident 1 stated a transport came and took him back to the hospital and he stayed overnight in the emergency room. Resident 1 stated he did not do anything inappropriate while at the facility. Resident 1 stated he did not have a medical need that required treatment at the hospital. Resident 1 stated, They just didn't want me there [at the facility]. On 11/15/24 at 9:15 A.M., an interview was conducted with the facility's admissions coordinator (AC). The AC stated he reviewed the hospital referrals and a potential resident's clinical record to see if the facility could meet their needs. The AC was asked what admission criteria the facility followed to determine who could be admitted at the facility. The AC stated, We don't have admission criteria. We want to say yes to everyone. The AC stated the facility did not screen potential residents for parole status or if they had a criminal background. The AC stated the facility had admitted a resident before with an ankle monitor and that there was communication between the facility and the resident's parole officer. The AC stated, We take residents with criminal backgrounds. They're no different than anyone else Page 1 of 4 055182 055182 12/12/2024 Lemon Grove Care and Rehabilitation Center 8351 Broadway Lemon Grove, CA 91945

F 0620 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of Resident 1's admission Note dated 6/18/24, indicated, the resident was admitted to the facility at 3:46 P.M., and that the resident was pleasant and cooperative. There was no mention of Resident 1's ankle monitor in the admission note. A review of Resident 1's Progress Note dated 6/19/24 at 9:35 A.M., indicated, Placed call to [nurse practitioner] regarding resident history and also informed about resident ankle monitor, [hospital] did not disclose this information and resident history, received new order to send out resident to hospital for further eval A review of Resident 1's Progress Note dated 6/19/24 at 10 A.M., indicated, .With ankle monitor. Noted new order from [physician] to send resident back to [hospital], re: no disclosure to resident's history. Resident has been picked up by [transport] at 11 A.M On 11/15/24 at 10:47 A.M., a joint interview and record review was conducted with licensed nurse (LN). LN 1 reviewed Resident 1's clinical record and stated there was no documentation the resident had presented as a danger to self or others while at the facility. LN 1 stated there was no documentation Resident 1 had a medical situation that required evaluation at the hospital. LN 1 stated, The only reason [Resident 1] was sent back was because the hospital didn't disclose the monitor. On 11/15/24 at 11:08 A.M., a joint interview and record review was conducted with the director of nursing (DON). The DON stated the facility did not have sufficient information about Resident 1 and that the hospital did not tell the facility about the resident's parole status. The DON stated Resident 1 had slipped through the facility's admission process and, We need to tighten our admission screening process. The DON reviewed the facility's admission criteria on an undated document titled Admissions Decision Tree. The DON stated there was no criteria on the document to screen for residents with criminal history or those on parole. The DON stated that should be included on the Admissions Decision Tree so the facility could adequately determine if a resident was appropriate for admission. The DON reviewed the facility's Facility Assessment (document that evaluated the facility's ability to provide care to residents and the resources that were needed to provide care/treatment) dated 8/2/24. The DON stated there was no mention of residents with criminal background or those on parole because, We aren't able to provide care to them. The DON acknowledged the facility had admitted Resident 1 and without properly screening the resident. The DON stated they were not comfortable providing care to him. A review of the facility's policy titled Admission, General revised 1/2024, indicated, .Assessment of Need .All aspects of an individual's care are carefully considered during admission .The decision to admit the resident is based on knowledge that the facility can meet the medical and psychosocial needs of the resident adequately. If the facility does not receive sufficient information to make an informed decision as to whether the facility can provide adequate care for the resident, the facility will not admit the resident 055182 Page 2 of 4 055182 12/12/2024 Lemon Grove Care and Rehabilitation Center 8351 Broadway Lemon Grove, CA 91945

F 0622 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of three residents (Resident 1) was permitted to remain in the facility when the resident was discharged to the hospital without a valid clinical reason. This deficient practice had to potential to cause Resident 1 to experience psychosocial and emotional distress. Findings: A review of Resident 1's admission Record indicated the resident was admitted to the facility on [DATE] and was discharged on 6/19/24. On 11/14/24 at 4:24 P.M., a telephone interview was conducted with Resident 1. Resident 1 stated he met with the facility's admissions marketer (AM) while he was at the hospital. Resident 1 stated he had disclosed his parole status to the AM and that he wore an ankle monitor as a condition of his parole. Resident 1 stated he was admitted to the facility, given a room and bed, and was provided dinner. Resident 1 stated everything was fine until the next morning when an administrative staff member came into his room and asked about his parole status and ankle monitor. Resident 1 stated the administrative staff member told him, We can't have you here, and that he would have to go back to the hospital. Resident 1 stated, It wasn't right , but he did not want to cause trouble. Resident 1 stated, If I mess up in any way, I go back to prison Resident 1 stated a transport came and took him back to the hospital and he stayed overnight in the emergency room. Resident 1 stated he did not do anything inappropriate while at the facility. Resident 1 stated he did not have a medical need that required treatment at the hospital. Resident 1 stated, They just didn't want me there [at the facility]. On 11/15/24 at 9:15 A.M., an interview was conducted with the facility's admissions coordinator (AC). The AC stated once the facility admitted a resident they're ours. The AC stated the facility, Can't send [residents] back to the hospital if we change our minds. It doesn't work like that. The AC further stated, We take residents with criminal backgrounds. They're no different than anyone else .everyone deserves the same respect and treatment A review of Resident 1's admission Note dated 6/18/24, indicated, the resident was admitted to the facility at 3:46 P.M., and that the resident was pleasant and cooperative. There was no mention of Resident 1's ankle monitor in the admission note. A review of Resident 1's Progress Note dated 6/19/24 at 9:35 A.M., indicated, Placed call to [nurse practitioner] regarding resident history and also informed about resident ankle monitor, [hospital] did not disclose this information and resident history, received new order to send out resident to hospital for further eval A review of Resident 1's Progress Note dated 6/19/24 at 10 A.M., indicated, .With ankle monitor. Noted new order from [physician] to send resident back to [hospital], re: no disclosure to resident's history. Resident has been picked up by [transport] at 11 A.M On 11/15/24 at 10:47 A.M., a joint interview and record review was conducted with licensed nurse 055182 Page 3 of 4 055182 12/12/2024 Lemon Grove Care and Rehabilitation Center 8351 Broadway Lemon Grove, CA 91945

F 0622 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few (LN). LN 1 reviewed Resident 1's clinical record and stated there was no documentation the resident had presented as a danger to self or others while at the facility. LN 1 stated there was no documentation Resident 1 had a medical situation that required evaluation at the hospital. LN 1 stated, The only reason [Resident 1] was sent back was because the hospital didn't disclose the monitor. LN 1 further stated, We can't send [residents] back to the hospital because we don't want them. LN 1 stated there was a reason Resident 1 was admitted and it was the resident's right to stay until it was appropriate to discharge to a lower level of care (home). On 11/15/24 at 11:08 A.M., a joint interview and record review was conducted with the director of nursing (DON). The DON was asked about a resident's right to remain in the facility until it was appropriate to discharge to a lower level of care. The DON stated, Yes, they're ours once we take them. He [Resident 1] slipped through, and we need to tighten our admission screening process. The DON reviewed Resident 1's clinical record and stated there was no documentation the resident had any behavior that endangered self or others and had no medical need that required hospital care and/or evaluation. The DON acknowledged the facility had admitted Resident 1 and without properly screening the resident. The DON stated they were not comfortable providing care to him and sent the resident back to the hospital. A review of the facility's policy titled Admission, General revised 1/2024, indicated, .This facility shall not transfer or discharge the resident from the facility unless: Transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility. Transfer or discharge is appropriate because the resident's health has sufficiently improved and the resident no longer needs the services provided by the facility. The safety of individuals in the facility are endangered . The health of individuals in the facility would otherwise be endangered 055182 Page 4 of 4