Other·May 8, 2026

§483.15(e)(1) Permitting residents to return to facility. A facility must establish and follow a written policy on permitting residents to return to the facility after they are hospitalized or placed on therapeutic leave. The policy must provide for the following. §72520 (c) A licensee who fails to meet these requirements shall offer to the patient the next available bed appropriate for the patient's needs. This requirement shall be in addition to any other remedies provided by law. On 4/9/26 at 11:47 A.M., an unannounced visit to the facility was conducted regarding a complaint of not accepting the resident back to the facility from hospitalization. The facility failed to permit Resident 1 to return to the facility following hospitalization. As a result, Resident 1 had an extended stay in the hospital while waiting for alternate placement. Resident 1 was admitted to the facility on 1/3/26 with diagnoses which included paraplegia (inability to move lower limbs) and was discharged to a General Acute Care Hospital (GACH) on 3/28/26, according to the facility's Admission Record. A review of the SBAR (Situation, Background, Assessment, Recommendation- is a structured, standardized communication to ensure concise and accurate information exchange) report dated 3/28/26 at 10:59 A.M., Resident 1 demonstrated severe agitation starting at 8 A.M.and failed to calm down despite multiple interventions. Attempts to communicate or interact with the resident only worsened the situation. The resident's behavior showed no improvement, including continued violence towards staff and residents, verbally abusive, and threatening gestures. Resident 1 was transferred to GACH on a 5150 (72-hour hold) for being a danger to themselves or others. A review of the GACH's Case Manager Interdisciplinary Note, dated 3/30/26 (two days after being admitted to the GACH) at 11:39 A.M. Resident 1 was calm and cooperative, and was medically cleared for discharge back to his skilled nursing facility. Resident 1 stated that he wanted to return to the skilled nursing facility. Although Resident 1 had an active bed hold at the skilled nursing facility, they were not accepting him back. A review of the GACH's Nursing Note, dated 4/3/26 at 6:46 P.M., indicated Resident 1 discharged to a different skilled nursing facility on 4/3/26 (Four days after he was initially cleared for discharge back to his initial skilled nursing facility). On 4/9/26 at 12:08 P.M., an interview was conducted with the Admissions Director (AD). The AD stated, the GACH attempted to send Resident 1 back to the facility, but the facility made the decision not to readmit him. On 4/14/26 at 2:52 P.M., a telephone interview was conducted with the Administrator. The Administrator stated, the facility decided not to readmit Resident 1 from the GACH. A review of the facility's policy titled, "Bed-Holds and Returns," revised October 2022, indicated, "5. The requirement that residents be permitted to return to the facility following hospitalization...6. Residents who seek to return to the facility within the bed-hold period...are allowed to return to their previous room...11. Following a hospitalization, residents whom staff are concerned about permitting to return due to their clinical/behavioral condition at the time of transfer are evaluated based on their current condition, not their condition when originally transferred." The facility failed to permit Resident 1 to return to the facility following hospitalization. As a result, Resident 1 had an extended stay in the hospital while waiting for alternate placement. This violation(s) caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to a patient.