Health inspection·May 24, 2024

F 0626 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few arrangements for Resident 1 to go to a different facility from the GACH. The ADM stated those arrangements eventually did not happen as the other facility could not accept Resident 1. The ADM stated the facility did have an empty room at the time the GACH was ready to send Resident 1 back to the facility but that the facility was concerned the C. Auris would spread in the facility. During a concurrent interview and record review on 5/24/2024 at 9:55 AM with the Admissions Coordinator (AC), the facility's Daily Census for 5/19/2024 and 5/25/23/2024 were reviewed. The Daily Census, dated 5/19/2024 indicated room A had an empty bed. The Daily Census, dated 5/23/2024 indicated Resident 2 was moved from Room B to Room A and that Resident 1 was admitted to Room B. The AC stated the facility moved Resident 2 to accommodate the readmission of Resident 1 to the facility. The AC stated Resident 1 was transferred to the GACH on 5/7/2024. The AC stated the Case Manager (CM) at the GACH notified AC on 5/13/2024 that Resident 1 was ready to be discharged from the GACH and would need to return to the facility. The AC stated the facility could not readmit Resident 1 to the facility because Resident 2 required an isolation room. The AC stated the facility could have accommodated the admission of Resident 1 on 5/19/2024 if the facility had made the same room changes that were done on 5/23/2024. During a telephone interview on 5/24/2024 at 10:01 AM with the CM, the CM stated Resident 1 had a discharge order from the GACH on 5/13/2024. The CM stated Resident 1 was stable and ready to return to the facility. The CM stated Resident 1 tested positive for C. Auris while at the GACH. The CM stated the AC told her that the facility did not have an isolation room for Resident 1. The CM stated the facility is required to take residents back even if the resident has an isolation need. The CM stated because the facility did not receive Resident 1 back Resident 1 overstayed at GACH for 10 days. During an interview on 5/24/2024 at 10:31 AM with the Infection Preventionist (IP), the IP stated Resident 1 was the fifth resident at the facility with C. Auris. During a review of the facility's P&P titled, readmission to the Facility, revised March 2017, the P&P indicated, Residents who have been discharged to the hospital or for therapeutic leave will be given priority in readmission to the facility. The P&P indicated, A Medicaid resident whose hospitalization or therapeutic leave exceeds the bed hold period allowed by the state will be readmitted to the facility upon the first availability of a bed in a semi-private room if the resident: a. Requires the services provided by the facility. b. Meets the admission criteria as outlined in facility policy. c. Was not discharged for any reason outlined in the transfer or discharge notice policy. d. Is eligible for Medicaid nursing facility services. During a review of the facility's P&P titled, Bed-Holds and Returns, revised October 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 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. Residents who seek to return to the facility after the state bed-hold period has expired (or when state law does not provide for bed-holds) are allowed to return to their previous room if available or immediately to the first available bed in a semi-private room provided that the resident: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056291 If continuation sheet Page 2 of 3 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056291 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Casa Bonita Convalescent Hospital 535 E Bonita Avenue San Dimas, CA 91773 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0626 a. Still requires the services provided by the facility; and Level of Harm - Minimal harm or potential for actual harm b. Is eligible for Medicare skilled nursing facility or Medicaid nursing facility services. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056291 If continuation sheet Page 3 of 3