Health inspection·May 29, 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 ensure one of one sampled residents (Resident 1) who resided at the facility and was transferred to General Acute care hospital (GACH) was readmitted to the facility after Resident 1 was cleared by GACH to return to the facility on [DATE]. This deficient practice resulted in Resident 1 remaining at the GACH after Resident 1 was deemed appropriate for discharge back to the facility but was denied readmission by the facility. Resident 1 did not return to the facility. This deficient practice resulted in Resident 1 ' s temporary loss of residence and had negative psychosocial outcome, as evidenced by vocalizations of depression (feeling of sadness and loss of interest), sadness and anxiety. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including cerebral infarction (damage to the brain from interruption of its blood supply), and atrial fibrillation (irregular heartbeat). During a review of Resident 1 ' s History and Physical (H&P), dated [DATE], the H&P indicated, Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1 ' s Minimum Data Set ([MDS], resident assessment tool), dated [DATE], the MDS indicated, Resident 1 required partial/moderate assistance (helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort) for toileting, shower/bath self. During a concurrent interview and record review on [DATE] at 9:00 a.m. with Registered Nurse Supervisor (RNS), the Facility ' s Census (the number of inpatients present in a healthcare facility at a specific time) dated [DATE] was reviewed. The Facility ' s Census indicated, the facility had nine open beds, which included two female beds. RNS stated that the facility had open beds available on [DATE]. RNS stated the facility ' s process when residents were transferred to the hospital, residents ' bed was placed on bed hold for seven days, however even if the bed hold goes beyond seven days the residents may return back to the facility if there was a room available or the next available bed. RNS stated residents should be able to return to the facility because it was the residents ' home. RNS stated residents could become depressed and feel unwanted if they were not able to return to their home/facility. During an interview on [DATE] at 10:20 a.m. with the admission Coordinator (AC), AC stated Page 1 of 3 055918 055918 05/29/2025 Villa Del Sol Post Acute 16910 Woodruff Ave. Bellflower, CA 90706

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few residents should be able to return to the facility once they were discharged from the hospital. AC stated even if the residents bed hold had expired and there was a bed available the residents have the right to be able to return to the facility. AC stated Resident 1 should have been able to return to the facility, because the facility was Resident 1 ' s home. AC stated Resident 1 probably felt sad, and worried about where she would live. AC stated she does not remember why Resident 1 was not accepted back to the facility, but she does remember Resident 1 had a share of cost (refers to the portion of healthcare costs that the insured individual pays) that she needed to pay. AC stated Resident 1 should have been able to return to the facility even though she had a share of cost balance. AC stated she had spoken to Resident 1 prior to her transfer to the hospital regarding her share of cost and Resident 1 informed her that she could not afford to pay it. AC stated she did not attempt to assist Resident 1 regarding her inability to pay the share of cost. AC stated she does not know why she did not assist Resident 1, but she should have referred her to social service. During a review of Resident 1 ' s Order Summary, dated [DATE], the Order Summary indicated to transfer Resident 1 to GACH due to desaturation (a decrease in the oxygen saturation (SpO2) of the blood) and altered mental status (a change in a person's cognitive [ability to think, understand, learn, and remember] function, including alertness, attention, orientation, and memory ). The Order Summary indicated seven days bed hold. During an interview on [DATE] at 8:45 a.m. with Resident 1, Resident 1 stated she had been living at the facility for three years. Resident 1 stated she was transferred to the hospital due to difficulty breathing. Resident 1 stated she did not have any concerns with the staff during her stay at the facility and was looking forward to returning after her discharge from GACH. Resident 1 stated she was informed by the staff at the hospital that the facility would not accept her back at the facility. Resident 1 stated she was informed the facility could not take her back because her bed hold had expired. Resident 1 began to cry during our conversation and stated she became extremely fearful because she did not know where she would go. Resident 1 stated that she considered the facility to be her home. Resident 1 stated she became anxious and was worried about her belongings that were left at the facility. Resident 1 stated the facility began to constantly call her son to pick up her belongings from the facility and that also made her anxious and depressed. Resident 1 stated she currently does not want to return to the facility because she feels like they did not want her and she does not want the staff to be the ones responsible for caring for her, because she does not trust them. During a review of Resident 1 ' s GACH Discharge Plan Update, dated [DATE], the Discharge Plan Update indicated, per facility admission Coordinator (AC), Resident 1 was off bed hold and facility were not able to accept Resident 1 back to the facility. During a concurrent interview and record review on [DATE] at 9:50 a.m. with the Director of Nursing (DON), the Facility ' s Census dated [DATE], the Facility Census indicated Resident 1 ' s room prior to discharge to GACH was unoccupied. The DON stated Resident 1 ' s room was empty, and Resident 1 should have been accepted back to the facility. The DON stated even though Resident 1 ' s bed hold had expired the facility should had accepted her back to the facility. The DON stated it was the responsibility of the facility to ensure that the residents return to the facility because it was considered the residents ' home. The DON stated Resident 1 probably felt unwanted by the facility and could have caused her to become anxious and depressed which could have had a negative impact on her health. During an interview on [DATE] at 10:15 a.m. with the Administrator (ADM), the ADM stated Resident 1 should had been accepted back to the facility. ADM stated that he does not know why she was not 055918 Page 2 of 3 055918 05/29/2025 Villa Del Sol Post Acute 16910 Woodruff Ave. Bellflower, CA 90706

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few accepted back to the facility. The ADM stated Resident 1 had a share of cost balance and she was not able to pay. The ADM stated Resident 1 did not want to return to the facility. The ADM stated if the facility told Resident 1 initially that he could not return to the facility and then told Resident 1 he could return, Resident 1 would not want to return to the facility because he would not trust the staff. During a review of the facility ' s policy and procedure (P&P) titled, Transfer and Discharge (including AMA), dated 2022, the P&P indicated The resident will be permitted to return to the facility upon discharge from the acute care setting. 055918 Page 3 of 3