Health inspection·April 3, 2025

The following reflects the findings of the California Department of Public Health during the investigation of two (2) complaints. Complaint Numbers: CA00944131 and CA00946606. Survey Event ID: EGUM11 2/4/25 State Citation B was written. F626 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, §483.15(c) Transfer and discharge- §483.15(c)(1) Facility requirements- (i) The facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless- (A) The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility; (B) The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility; (C) The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident; (D) The health of individuals in the facility would otherwise be endangered; (E) The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. Nonpayment applies if the resident does not submit the necessary paperwork for third party payment or after the third party, including Medicare or Medicaid, denies the claim and the resident refuses to pay for his or her stay. For a resident who becomes eligible for Medicaid after admission to a facility, the facility may charge a resident only allowable charges under Medicaid; or (F) The facility ceases to operate. 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 2/4/25, the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to investigate two complaints regarding a resident's transfer/discharge. The CDPH determined the facility failed to re-admit Resident 1, when Resident 1 was transferred to an acute care hospital on 1/9/25 and was medically cleared to return to the facility on 1/13/25. This failure resulted in a violation of Resident 1's right to return to the facility and had the potential to cause psychosocial harm due to not being able to return to the facility. Review of Resident 1's "ADMISSION RECORD," indicated Resident 1 was admitted to the facility in 2018 with diagnoses which included paraplegia (a condition where there is a loss or impairment of motor and sensory function in the lower half of body). During a phone interview on 2/4/25, at 9:33 a.m., with the Hospital Case Manager (HCM), the HCM stated Resident 1 was admitted to the hospital on 1/9/25 and was ready to be discharged on 1/13/25. The HCM further stated the hospital was calling the facility every day since 1/13/25 for bed availability, but the facility said they had no beds available. The HCM explained Resident 1 was still in the hospital waiting for placement. During a review of Resident 1's hospital record titled, "Physician Note," dated 1/13/25, the Assessment/ Plan section indicated, "...Patient [Resident 1] medically cleared for discharge, awaiting care facility authorization for return pending isolation precautions..." Further review of Resident 1's hospital record titled, "Physician Note," dated 1/14/25, under the Subjective section indicated, "...Patient [Resident 1]...Endorsed severe frustration at having to remain in the hospital...Endorses frustration with his SNF..." During a concurrent observation and interview on 2/4/25, at 12:15 p.m., with License Nurse (LN) 1, resident rooms were observed under the West Nurses' station. LN 1 confirmed there were multiple unoccupied beds available at the West Nurses' station. LN 1 confirmed there was a total of 9 residents on isolation precautions. LN 1 stated the residents were either on contact isolation precautions (a type of infection control precaution used to prevent the spread of infection that are transmitted through direct contact with an infected person or their contaminated environment), or on enhanced barrier precautions (EBP- a set of infection control measures that use gowns and gloves to reduce the spread of multidrug-resistant organisms during high contact care activities with residents who are colonized or infected by organism, or used with residents who have wounds or indwelling medical devices). LN 1 further stated Resident 1 was on a bed hold (ensures that a resident can return to their room or a comparable space if they're temporary absent such as a hospitalization) and the expectation was for the resident to return to facility after being discharged from the hospital. During a concurrent observation and interview on 2/4/25, at 12:30 p.m., with LN 2, resident rooms were observed under the East Nurses' station. LN 2 confirmed there was 1 unoccupied bed available, and 5 residents were on isolation precautions at the East Nurses' station. During a phone interview on 2/4/25, at 1:05 p.m., Resident 1 stated that he had been living at the facility for over 6 years. Resident 1 further stated he had been at the hospital for 3 weeks and he still wanted to come back to the facility. During a concurrent interview and record review on 2/4/25, at 1:30 p.m., with the Admission Coordinator (AC), the facility daily census reports were reviewed. The AC confirmed there were 3 unoccupied beds in the facility on 1/13/25, 2 unoccupied beds on 1/29/25, and 7 unoccupied beds were available on 2/4/25. The AC stated Resident 1 tested positive for Carbapenem Resistant Enterobacteriaceae CRE (group of bacteria that are resistant to carbapenems, a class of powerful antibiotics) and the facility did not expect Resident 1 to return because there was no isolation room available at the facility. The AC further stated that the facility had capability of taking care of any resident, and residents with the same infection could share rooms. During an interview on 2/4/25, at 2:36 p.m., with the Infection Prevention Nurse (IP), the IP stated currently there were 3 residents on contact isolation precautions. The IP further stated Resident 1 tested positive for CRE and required contact isolation. The IP stated the facility had not followed up with the hospital regarding Resident 1's source of infection, if it was active or colonized (bacteria present without causing illness or symptoms), and/ or what kind of antibiotics Resident 1 was on. The IP further stated the facility did not accommodate CRE regardless of the source of infection. The IP confirmed there were no communications between her and the hospital related to concerns about Resident 1's CRE infection and Resident 1 being non-compliant with isolation precautions. The IP stated they could not accept Resident 1 back to the facility. The IP further stated the facility could not accept residents with CRE infections. During a concurrent interview and record review on 2/4/25, at 3:23 p.m., with the Director of Nursing (DON), Resident 1's electronic health record (EHR) and the facility census report for 2/4/25 and 1/13/25 were reviewed. The DON confirmed there were 3 residents in the facility on contact precautions as of 2/4/25. The DON further confirmed there was no documentation in Resident 1's EHR by facility staff discussing about Resident 1's CRE infection or the risk of spreading CRE due to Resident 1's history of noncompliance. The DON stated the facility had not attempted to cohort other residents to re-admit Resident 1. The DON further stated due to Resident 1's CRE infection, the facility could not accept him. The DON stated it was not about the resident; it was about the positive CRE infection. The DON further stated she had no communication with the hospital so she was unaware of Resident 1's CRE source of infection or if it was active. The DON explained it was the IP's responsibility to reach out to the local public health department for guidance on CRE. The DON stated Resident 1 had lived at the facility for almost 7 years and might feel sad for not returning to the facility. Review of an online document by the California Department of Public Health (CDPH) titled, "Recommendations for Infection Control for Residents with CRE in Long-Term Care Facilities," dated 1/21/16, indicated, "...The CDC [Centers for Disease Control and Prevention] has developed guidance to help facilities and regions control spread of CRE...Recommendations: Admission or readmission to a long-term care facility should not be denied based on known colonization or infection with any multidrug-resistant organism (MDRO), including CRE..." (https://www.cdph.ca.gov/Programs/CID/DCDC/CDPH%20Document%20Library/CareofCREinLongTermCareFacilities.pdf) Therefore, the Department determined the facility failed to re-admit Resident 1, when Resident 1 was transferred to an acute care hospital on 1/9/25 and was medically cleared to return to the facility on 1/13/25. This failure resulted in a violation of Resident 1's right to return to the facility and had the potential to cause psychosocial harm due to not being able to return to the facility. This violation had a direct or immediate relationship to the health, safety, or security of Resident 1.