Health inspection·February 26, 2026

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 ensure the resident's right to return to the facility was protected for one of three sampled residents (Resident 1), when Resident 1 was transferred to the hospital and was not allowed to return to the facility on [DATE].This failure placed Resident 1 at risk for psychosocial harm (mental and emotional suffering) due to separation from the resident's home and familiar environment. Findings:Review of Resident 1's admission RECORD, indicated Resident 1 was admitted to the facility in [DATE] with diagnoses including non-ST elevation myocardial infarction ( a type of heart attack), type 2 diabetes mellitus (a condition that causes high blood sugar), Alzheimer's disease ( a disease that caused memory loss and affects thinking and behavior), hypothyroidism (an underactive thyroid gland that slows the body's metabolism), difficulty in walking, muscle weakness, hypertension, anxiety disorder.Review of Resident 1's MINIMUM DATA SET (MDS [resident assessment tool]) RESIDENT ASSESSMENT AND CARE SCREENING Nursing Home Discharge (ND) Item Set dated [DATE], in section A . Entry/discharge reporting indicated, Resident 1 was discharge with return anticipated to the facility.Review of Resident 1's General Notes Report dated [DATE] indicated that Resident 1 was sent out to hospital on [DATE] due to unwitnessed fall and was admitted to the hospital. The notes indicated Resident 1's representative stated she would like Resident 1 to return to the facility.Review of Resident 1's referral communication record dated [DATE] at 10:41 AM, indicated the facility's Director of Marketing (DM) sent a message to the hospital stating Resident 1 required a higher level of care and the facility could not provide the level of care needed. Review of Resident 1's hospital record, Physician Progress Note, dated [DATE] indicated Resident 1 was admitted to the hospital after an unwitnessed ground-level fall and was diagnosed with syncope (fainting), left frontal hematoma (a collection of blood under the skin on the forehead), status post fall, Alzheimer's disease, diabetes mellitus, and hypothyroidism. The notes indicated physical therapy evaluated Resident 1 and recommended physical therapy five times per week. During concurrent interview and record review on [DATE] at 3:16 PM with the Director of Nursing (DON), the DON stated the facility had a bed capacity of 99 with a confirmed facility census of 94 and one bed hold. The DON stated the facility could not accept Resident 1 back to the facility despite of bed availability because Resident 1 required a higher level of care due to safety concerns such as aggressiveness, wandering, and risk for falls. The DON stated a non-clinical facility staff member checked Resident 1's status at the hospital on [DATE] and there was no nurse-to-nurse communication between the hospital and the facility for a nursing assessment. Resident 1's care plan initiated on [DATE] in the section titled Focus indicated The resident [Resident 1] is risk for unavoidable falls r/t confusion,.poor safety awareness., the care plan initiated on [DATE] in the section titled Focus indicated, Resident has episodes of aggressive behaviors. and the care plan initiated on [DATE] in the section titled Focus indicated Resident exhibits wandering behaviors. which were reviewed with the DON. The Page 1 of 2 055917 055917 02/26/2026 Harvest Crossing Post Acute 469 East North Street Manteca, CA 95336

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few DON stated that Resident 1's behaviors including risk for falls, aggression and wandering were present before Resident 1 was transferred to the hospital and stated if the facility had known Resident 1 had these behaviors, the facility would not have admitted Resident 1. The DON stated Resident 1 was a long-term care resident in the facility and the facility was Resident 1's home. The DON further stated residents who could not return to their home were at risk of emotional distress. During a concurrent interview and record review on [DATE] at 4:15 PM, with the Social Services Director (SSD), Resident 1's care plan initiated on [DATE] in the section titled Focus indicated Resident [Resident 1] is long term with no plans for discharge. was reviewed. The SSD stated that there was no discharge plan in place for Resident 1. The SSD stated Resident 1 was a long-term resident and considered the facility as Resident 1's home. The SSD stated Resident 1 staying in the hospital for longer periods could cause sadness, confusion, and depression and made the hospital a less suitable placement for Resident 1. During an interview on [DATE] at 4:23 PM with the Administrator (Adm), the Adm stated if a resident was a long-term resident and could not return to her home, it could disrupt the resident's regular routine and could have negative emotional and psychosocial impacts (effects on mental and emotional well-being).During an interview on [DATE] at 9:53 AM with the hospital's Social Worker (SW), the SW stated Resident 1 remained in the hospital as of [DATE] and had no aggressive or behavioral issues but remained confused due to Alzheimer's.Review of Resident 1's Psychiatric Follow-up Visit note dated [DATE], indicated Resident 1 did not have physical or verbal aggressive behavior, did not have behaviors of auditory or visual hallucinations (hearing or seeing things that are not there), homicidal ideation (thoughts of harming others), or suicidal ideation (thoughts of harming oneself). Further review of the note indicated Resident 1 had low to moderate level of anxiety and the provider increased buspirone (an anti-anxiety medication) to 15 milligrams (mg - a unit of measure) twice daily and recommended non-pharmacological interventions such as staff provide empathetic listening, positive reinforcement, and redirection, and encourage Resident 1 to participate in pleasant activities.Review of Resident 1's PASRR (Preadmission Screening and Resident Review-screening to determine mental health needs before or after nursing admission) notice of attempted evaluation dated [DATE], indicated Resident 1 had no serious mental illness (SMI) requiring specialized mental health services.Review of facility's policy and procedure (P&P) titled Bed-Holds and Returns revised on 10/2022, the P&P indicated .The requirement that residents be permitted to return to the facility following hospitalization or therapeutic leave applies to all residents.Residents who seek to return to the facility after the state bed-hold period has expired.are allowed to return to their previous room if available or immediately to the first available bed.provided that the resident.still requires services provided by the facility, and.is eligible for Medicare skilled nursing facility or Medicaid nursing facility services. 055917 Page 2 of 2