Health inspection·April 10, 2025

The following reflets the findings of the California Department of Public Health during an abbreviated survey for the investigation of three (3) complaints: CA00949409, CA00949469, and CA00951174. The Department substantiated complaints CA00949409 and CA00951174, and the findings were written under tags F622, F623, and F626. Event ID: GRY411 Exit Date 3/4/25 State B citation was written Cal. Code Regs. Tit. 22, § 72527 - Patients' Rights (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (6) To be transferred or discharged only for medical reasons, or the patient's welfare or that of other patients or for nonpayment for his or her stay and to be given reasonable advance notice to ensure orderly transfer or discharge. Such actions shall be documented in the patient's health record. Code of Federal Regulations, Title 42, Section §483.15(e)(1) (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. (i) A resident, whose hospitalization or therapeutic leave exceeds the bed-hold period under the State plan, returns to the facility to their previous room if available or immediately upon the first availability of a bed in a semi-private room if the resident (A) Requires the services provided by the facility; and (B) Is eligible for Medicare skilled nursing facility services or Medicaid nursing facility services. (ii) If the facility that determines that a resident who was transferred with an expectation of returning to the facility cannot return to the facility, the facility must comply with the requirements of paragraph (c) as they apply to discharges. On 3/4/25, an unannounced visit was conducted at the facility to investigate three complaints regarding transfer and discharge. The department determined the facility failed to ensure the right to return to the facility was protected when Resident 1 was sent to the hospital on 2/20/25 and was not allowed to return to the facility on 3/3/25, when the hospital was ready to discharge Resident 1 back to the facility. This failure placed Resident 1 at risk for emotional distress, depression, and anxiety. Review of Case Management Progress Note (from Acute Care Hospital 1), dated 3/2/25, indicated Resident 1 had diagnoses including: Stenosis of cervical spine with myelopathy (spinal canal in the neck narrows, compressing the spinal cord, leading to neurological symptoms like weakness, numbness, and difficulty walking), Quadriplegia (complete loss of movement and sensation in all four limbs) and Quadriparesis (muscle weakness in all four limbs), myelomalacia of cervical cord (a softening or degeneration of the spinal cord in the neck region). Resident 1 had spinal surgeries on 2/25/25 and 2/26/25 and required maximal assistance of two persons. During an interview with the Administrator (ADM) on 3/4/25 at 12:22 PM, the ADM stated that Resident 1 had been living at the facility since Spring of 2024 and left the facility on 2/20/25 to go to a scheduled appointment. The ADM further stated Resident 1 was admitted directly from the appointment to a hospital due to a needed surgery. The ADM explained on 2/20/25 a seven-day bed hold (a residents right to have their own bed held for seven days while they are in the hospital) was initiated. During a concurrent interview and record review on 3/4/25 at 12:46 PM with the ADM and the Director of Nursing (DON), the ADM stated that the hospital where Resident 1 had his surgery faxed a request packet for re-admission on 3/2/25. On 3/3/25 the "NOTICE OF TRANSFER OR DISCHARGE" paperwork was completed by the Social Services Director (SSD) and the DON. The DON stated she and the SSD served the notice to Resident 1's responsible party (RP) on 3/3/2025. The DON stated the reason listed for discharge was because Resident 1's needs could not be met at the facility. The ADM stated the facility served the paperwork only as a formality, since the seven-day bed hold had already expired. The ADM explained the facility was unable to meet Resident 1's needs because the facility was unable to make him happy or to care for Resident 1 "per his wishes." The ADM further stated the current census of the facility was 94 but was licensed to hold 176 residents. The ADM also stated Resident 1's bed in his previous room was still available. During an observation on 3/4/25 at 1:54 PM of room 116 bed D, Resident 1's name was still labeled on the placard outside of the room. Inside the room, bed "D" which was assigned to Resident 1 still had Resident 1's personal belongings on the bedside table and nightstand, a personal blanket was draped on the bed, personal pictures hung near the head of the bed. During a concurrent observation and interview on 3/4/25 at 2:54 PM with Certified Nursing Assistant (CNA) 1, CNA 1 confirmed that Resident 1's room 116 bed "D" still contained Resident 1's personal belongings. A review of the facility policy titled, "Bed-Holds and Returns," revised October 2022, indicated, " ...7. 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 ..." Therefore, the department determined the facility failed to ensure the right to return to the facility was protected when Resident 1 was sent to the hospital on 2/20/25 and was not allowed to return to the facility on 3/3/25, when the hospital was ready to discharge Resident 1 back to the facility. This failure placed Resident 1 at risk for emotional distress, depression, and anxiety. This violation caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to Resident 1.