Health inspection·July 31, 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:1. Re-admit one of three sampled residents (Resident 1) to the facility after Resident 1 was evaluated and cleared by the General Acute Care Hospital (GACH) to return to the facility.2. Ensure the facility followed its policy and procedure (P&P), titled Bed Holds which indicated if the resident's hospitalization or therapeutic leave exceeds the bed-hold period of (7) days, the resident may return to the facility to their previous room, if available, or immediately upon the first availability of a bed, if the resident requires the services provided by the facility.This deficient practice resulted in Resident 1 being unable to return to the skilled nursing facility (SNF) that has been considered their home, for about 12 months after being deemed appropriate for transfer to the SNF. As a result, Resident 1 was transferred to another SNF, and both the Resident 1 and Family Member (FM) 1 experienced unnecessarily psychosocial harm, including emotional distress and dissatisfaction.Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on [DATE] with diagnoses including psychotic disorder (severe mental illnesses where people lose touch with reality) with hallucinations ( a sensory experience that feels real but is not based on an external stimulus) and major depressive disorder( a serious mental health condition characterized by persistent feelings of sadness, loss of interest in activities, and a lack of energy that significantly impact daily life). During a review of Resident 1's History and Physical Examination (H&P), dated [DATE], the H&P indicated, Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated [DATE], the MDS indicated Resident 1's cognitive (functions your brain uses to think, pay attention, process information, and remember things) was intact. The MDS indicated Resident 1 required setup assistance (helper sets up or cleans up) with eating, oral hygiene, moderate assistance (helper does less than half the effort to complete the task) with toileting hygiene, personal hygiene, maximal assistance (helper does more than half the effort to complete task) with showering, and dressing. During a review of Resident 1's Order Summary Report, dated [DATE], the Order Summary Report indicated the facility may transfer Resident 1 to a GACH for psych evaluation and bed-hold for seven days. During a review of Resident 1's Notice of Transfer/Discharge, dated [DATE], the Notice of Transfer indicated the facility transferred Resident 1 to the GACH. During a review of Resident 1's Nursing Life Cyle (NLC) at the GACH, dated [DATE], the NLC indicated the physician at the GACH ordered to discharge Resident 1 back to the facility on [DATE]. During a review of Resident 1's Discharge Planning note at the GACH, dated [DATE], at 3:07 p.m., the Discharge Planning note indicated, Director of Community Liaison (DCL) 1 at the facility informed the Discharge Care Planner (DCP) 1 at GACH that the facility did not have a bed available for the patient but they will refer to a sister facility who can accommodate Resident 1 until a bed becomes available. The Discharge Planning note indicated, DCP1 spoke to Resident 1's family Page 1 of 3 055387 055387 07/31/2025 Edgewater Skilled Nursing Center 2625 East Fourth Street Long Beach, CA 90814

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few member (FM) 1 and FM 1 did not want Resident 1 moved to a new facility, stating Resident 1 had been there for about a year. DCP 1 informed the facility that the patient needs to be discharged back to the facility. During a review of Resident 1's Discharge Planning note at the GACH, dated [DATE], at 3:28 p.m., the Discharge Planning note indicated FM 1 had not spoken to anyone at the facility regarding placement and stated she was very upset. The Discharge Planning note indicated DCP 1 reached out to the facility and informed Resident 1's medical Power of Attorney (POA) was waiting for someone at the facility to reach out to her. The Discharge Planning note indicated, DCP 1 was awaiting a response. During a review of Resident 1's Nursing Progress Notes, dated [DATE] at 10:46 p.m., the Nursing Progress Notes indicated the Director of Staff Development (DSD) informed FM1 that the facility had no empty beds to accept Resident 1 from the GACH. During a review of Resident 1's Discharge Planning note at the GACH, dated [DATE] at 1:50 p.m., the Discharge Planning indicated FM1 expressed her frustration with the facility to DCP1. During a review of Resident 1's Discharge Summary at the GACH, dated [DATE] at 3:05 p.m., the Discharge Summary indicated the GACH discharged Resident 1 to another facility. During an interview on [DATE] at 1:52 p.m. with Resident 1, Resident 1 stated the facility told FM1 the facility could not accept Resident 1 back to the facility because there was no bed available. Resident 1 stated when FM 1 visited the facility to pick up Resident 1's belongings on [DATE], FM 1 saw empty beds in the facility. Resident 1 stated that made him and FM 1 upset. During a concurrent interview and record review on [DATE] at 3:56 p.m. with the Director of Nursing (DON), the Facility Census, dated [DATE] ,[DATE], [DATE], [DATE], [DATE], and [DATE] were reviewed. The DON stated there were open beds available on [DATE], and the information given by the DSD to FM 1 on [DATE] was not accurate. The DON stated if Resident 1 wished to return to the facility, he could have been readmitted . The DON stated there were empty beds available on the following dates: [DATE], there were total 3 female and 1 male empty beds available. [DATE], there were total 3 female and 1 male empty beds available. [DATE], there were total 3 female and 1 male empty beds available. [DATE], there were total 4 female and 1 male empty beds available. [DATE], there were total 4 female and 1 male empty beds available. [DATE], there were total 4 female beds 2 male empty beds available. During an interview on [DATE] at 1:56 p.m. with the DON, the DON stated residents have the right to return to the facility, even after seven-day bed hold period ends, if the resident wishes to return to the facility. During an interview on [DATE] at 3:41p.m. with the Administrator (ADM), the ADM stated this facility was considered as the residents' home. The ADM stated if a resident's seven-day bed hold had expired the facility should have accepted the resident back to the facility if there was bed available. The ADM stated if the resident was refused reentry, they may have felt unwanted by the facility, which could have caused anxiety and distress. During a review of the facility's policy and procedure (P&P) titled, Bed hold, revised 12/2023, the P&P indicated If the resident's hospitalization or therapeutic leave exceeds the bed-hold period of (7)days, the resident may return to the facility to their previous room, if available, or immediately upon the first availability of a bed, if the resident requires the services provided by the facility. 055387 Page 2 of 3 055387 07/31/2025 Edgewater Skilled Nursing Center 2625 East Fourth Street Long Beach, CA 90814

F 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. Based on interview and record review, the facility failed to provide a completed written Bed Hold notification to one of one sampled resident (Resident 1) upon transfer on 7/15/2025 to the General Acute Care Hospital (GACH). This failure had the potential to result in a resident and/or their representative being unaware of their right to return to the facility within the designated bed-hold period, potentially leading to unnecessary displacement.Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 7/24/2024 with diagnoses including psychotic disorder (severe mental illnesses where people lose touch with reality) with hallucinations ( a sensory experience that feels real but is not based on an external stimulus) and major depressive disorder( a serious mental health condition characterized by persistent feelings of sadness, loss of interest in activities, and a lack of energy that significantly impact daily life). During a review of Resident 1's History and Physical Examination (H&P), dated 7/26/2024, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 4/28/2025, indicated Resident 1's cognitive (functions your brain uses to think, pay attention, process information, and remember things) was intact. The MDS indicated Resident 1 required setup assistance (helper sets up or cleans up) with eating, oral hygiene, moderate assistance (helper does less than half the effort to complete the task) with toileting hygiene, personal hygiene, maximal assistance (helper does more than half the effort to complete task) with showering, and dressing. During a review of Resident 1's Order Summary Report, dated 7/15/2025, the Order Summary Report indicated the facility may transfer Resident 1 to a GACH for psychological evaluation and bed-hold for seven days. During a review of Resident 1's Notice of Transfer/Discharge, dated 7/15/2025, the Notice of Transfer indicated the facility transferred Resident 1 to the GACH. During a review of Resident 1's Bed Hold Notification, dated 7/15/2025, the Bed Hold Notification indicated the section for the resident or resident representative's response was left blank, including the resident's desire for bed hold, date and time of notification, and the facility representative's signature. During a concurrent interview and record review on 7/31/2025 at 4:35 p.m. with the Director of Nursing (DON), Resident 1's Bed Hold Notification, dated 7/15/2025, was reviewed. The DON stated facility staff did not notify Resident 1 of the Bed Hold notification upon transfer. The DON stated the Bed Hold Notification lacked documentation of Resident 1's desire for bed hold, the resident or representative's documentation indicating Resident 1 refused to sign the form. The DON stated providing bed hold notification upon transfer is essential to ensure the residents are informed of their right to seven-day bed hold. During a review of the facility's policy and procedure (P&P) titled, Bed hold, revised 12/2023, the P&P indicated the resident, or the resident's representative shall be informed in writing of their right to exercise the bed hold provision in the event of a transfer from the facility to a general acute care hospital or at the start of a resident's therapeutic leave. 055387 Page 3 of 3