Health inspection·May 17, 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 readmit one (1) of two (2) sampled residents (Resident 1) back to the facility on 5/17/2025 after Resident 1 was discharged from General Acute Care Hospital (GACH) back to the facility in accordance with the facility's policy and procedure (P&P) titled Bed Holds and Returns. This deficient practice had the potential to violate the rights of Resident 1 and lengthen unnecessary stay in GACH. Findings: During a review of Resident 1's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that including but not limit to spondylosis (gradual breakdown of the spine and related structures), anxiety disorder (persistent and excessive worry that interferes with daily activities), depression (a common mental health condition characterized by a persistent low mood, loss of interest or pleasure in activities, and other symptoms that can significantly interfere with daily life) and borderline personality disorder (a personality disorder characterized by severe mood swings, impulsive behavior, and difficulty forming stable personal relationships). During a review of Resident 1's Minimum Data Set (MDS, resident assessment screening tool), dated 2/1/2025, indicated the resident had no impairment of cognitive (capable of remembering, learning new things, concentrating, or making decisions that affect everyday life) skills for daily decision making. Resident 1 required supervision (helper provides verbal cues or touching assistance) for upper and lower body dressing and putting on/taking off footwear. Resident 1 required set up or clean up assistance (helper sets up or cleans up) for eating, oral hygiene and personal hygiene. During a review of Resident 1's Physician Order Sheet (POS) for 5/2025, indicated Resident 1 had an order to be transferred to GACH on 5/12/2025, due to danger to herself. During a review of Resident 1's Progress Notes dated 5/12/2025 at 9:36 AM, Progress Notes indicated Resident 1 was transferred to GACH on 5/12/2025 for further evaluation. During a review of Resident 1's Progress Notes dated 5/16/2025 at 6:04 PM, Progress Notes indicated GACH called facility to ask if facility could readmit Resident 1 but facility will not readmit Resident 1. During a review of Resident 1's GACH Discharge Orders dated 5/17/2025 at 11:49 AM, Discharge Orders Page 1 of 2 055341 055341 05/17/2025 Pasadena Palace Tcu 716 South Fair Oaks Ave Pasadena, CA 91105

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few indicated Resident 1 is in stable condition and may be transferred back to facility but unable to return to facility. During an interview and record review on 5/19/2025 at 10:04 AM with the Director of Admissions (DOA) the facility's census for 5/15/25 was reviewed. The census indicated there were beds available to admit residents. DOA stated that GACH called on 5/16/25 to ask if Resident 1 can be readmitted . DOA stated that the facility will not admit Resident 1 back to the facility by order of the Administrator (ADM). During a concurrent interview and record review on 5/19/2025 at 10:21 AM with the ADM, the facility's P&P titled Bed Holds and Returns, revised 1/2001 was reviewed. The P&P indicated: The requirement that residents be permitted to return to the facility following hospitalization or therapeutic leave applies to all residents regardless of payer source. Residents who seek to return to the facility within the bed hold period defined in the state plan are allowed to return to their previous room, if available. DON stated, the policy states the resident is allowed to return to the facility but Resident 1 was not allowed to return. I don't want to accept her back because she had a dog that required a private room and she caused a lot of problems for the facility. 055341 Page 2 of 2