Health inspection·October 21, 2024

F 0626 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure resident ' s rights were upheld for one of three residents (Resident 1) when Resident 1 was transferred to a General Acute Care Hospital (GACH) for evaluation of inappropriate sexual behaviors and cleared to return to the facility on [DATE]. This deficient practice resulted in Resident 1 being denied readmittance to a facility where he had resided for approximately 38 days. 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 schizophrenia (chronic mental illness that affects how person thinks, feels, and behaves), malignant neuroleptic syndrome (life-threatening condition that can occur as a side effect of certain antipsychotic[medication that affects the brain] medications) and diabetes mellitus type 2 (condition when the body cannot regulate blood sugar). During a review of Resident 1's History and Physical (H&P), dated 9/3/2024,the H&P indicated Resident 1 did not have awareness of place, location, and time. During a review of Resident 1's Minimum Data Set [(MDS), a federally mandated screening tool], dated 7/7/2024, the MDS indicated Resident 1 had impaired cognitive (ability to think, understand, learn, and remember) skills for daily decision making. The MDS indicated Resident 1 did not have any limitation in functional range of motion (range of motion required for a person to be as independent as possible). During a review of Resident 1's Bed Hold informed (process to ensure a resident has a continuous place of residence and can return to their facility after a hospital stay) consent , dated 8/31/2024, the consent indicated Resident 1 had been informed of his right to request the facility to hold his bed for seven days in the event of being transferred to an acute hospital, the form revealed a signature by Resident 1 ' s conservator (a person who is appointed by a judge to make decisions for someone who is unable to do so for themselves) on 8/31/2024. A note on the consent indicated a confirmation and bed hold provision was provided to Resident 1 ' s conservator on 10/9/2024. During a review of Resident 1's Change of Condition document ([COC]significant change in resident ' s status that requires intervention) dated 10/8/2024, the COC indicated Resident 1 had ' inappropriately touched ' Resident 2. Page 1 of 3 056283 056283 10/21/2024 Bixby Towers Post-Acute Rehab 3747 Atlantic Avenue Long Beach, CA 90807

F 0626 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of Resident 1's physician orders, dated 10/9/2024, the physician orders indicated, may transfer Resident 1 to the GACH for psychiatric evaluation. During a review of Resident 1's nurses notes, dated 10/9/2024, the nurse ' s notes indicated Resident 1 was transferred to GACH 2 on 10/9/2024 at 7:50 a.m., for psychiatric evaluation due to inappropriately touching another resident. During a review of the GACH ' s admission Record (Face Sheet), the facesheet indicated Resident 1 was admitted to the GACH on 10/9/2024 with a chief complaint of weakness and behavior concern. During a review of the GACH ' s Case Management Progress Note dated 10/9/2024, the note indicated Resident 1 was cleared to return to the facility on [DATE]. During a review of Resident 1 ' s GACH social worker evaluation note, dated 10/9/2024, the note indicated Resident 1 was admitted to the GACH on 10/9/2024 for a psychiatric evaluation. The note stated Resident 1 was cleared by the GACH's psychiatrist (a health practitioner that specializes in the diagnosis and treatment of mental illness) for return to the facility and the facility agreed to readmit Resident 1. During a review of Resident 1 ' s GACH ' s discharge planning note, dated 10/10/2024, the note indicated the GACH discharge care planner received a follow up call from the facility that stated the facility will not be readmitting Resident 1 due to Resident 1 being a threat to the facility ' s resident population. During an interview on 10/21/2024 at 11:00 a.m., the Director of Nursing (DON) stated Resident 1 ' s conservator was provided a bed hold notice informing her of Resident 1 ' s right to return to the facility in the event of a hospitalization during the time of Resident 1 ' s admission on [DATE] and when he was transferred to the hospital on [DATE]. During an interview on 10/21/2024 at 12:19 p.m., with the DON and the Administrator (ADM), the ADM stated the GACH called on 10/9/2024 and informed him that Resident 1 was ready for readmission to the facility. The ADM stated Resident 1 would not be admitted back to the facility due to his behaviors toward other residents, despite being cleared for discharge by the GACH 's psychiatrist. The DON stated our current residents ' safety would be at risk due to Resident 1 ' s sexually impulsive (acting or doing without considering the consequence) behaviors. The DON stated we do not want to take the chance of risking thefacility's residents safety by taking Resident 1 back into our facility. During an interview on 10/22/2024 at 2:15 p.m., with the GACH discharge case manager, the case manager stated the facility informed the GACH's discharging planning team of their refusal to take Resident 1 back after Resident 1 was cleared by the GACH's psychiatrist. The GACH case manager stated, Resident 1 was admitted to the GACH to be evaluated, which he was, and once Resident 1 was cleared, the facility refused to readmit him because he was a danger to their residents. The GACH case manager stated the facility did not have the resources to use a 1:1 sitter (intervention where a healthcare professional is continuously present with a resident)to ensure residents safety. A review of the facility ' s policy and procedure (P/P), titled Bed-Hold and Returns, revised 3/2017, the P/P indicated residents may return to and resume residence in the facility after hospitalization or therapeutic leave as outlined in the policy. 056283 Page 2 of 3 056283 10/21/2024 Bixby Towers Post-Acute Rehab 3747 Atlantic Avenue Long Beach, CA 90807

F 0626 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of the facility ' s P/P, titled transfer or discharge documentation , revised 1/2019, the P/P indicated should a resident be transferred or discharged the following information will be communicated to the receiving facility or provider, the basis for the transfer or discharge, if the resident is being transferred or discharged because his or her needs cannot be met at the facility, the documentation will include the specific residents needs that cannot be met, the facility ' s attempt to meet those needs, the receiving facility ' s services that are available to meet those needs. 056283 Page 3 of 3