Health inspection·May 27, 2025

REGULATION VIOLATION(S) §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. (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. §483.15(e)(2) Readmission to a composite distinct part. When the facility to which a resident returns is a composite distinct part (as defined in § 483.5), the resident must be permitted to return to an available bed in the particular location of the composite distinct part in which he or she resided previously. If a bed is not available in that location at the time of return, the resident must be given the option to return to that location upon the first availability of a bed there. The facility failed to follow its policy for permitting residents to return to the facility after hospitalization, when facility staff did not readmit one resident (Resident 1) following her transfer to the hospital for emergency care and services. This failure resulted in Resident 1's temporary loss of residence and a negative psychosocial outcome, as evidenced by vocalizations of sadness and anger. During a telephone interview on 3/20/21 at 9:15 a.m., the facility Administrator (ADM) stated Resident 1 would not be re-admitted back in the facility from the Emergency Room because of her severe mental illness and very abusive behavior towards staff. The ADM stated staff endured emotional trauma due to mental and verbal abuse by Resident 1. The ADM stated 17 nursing staff had resigned from the facility due to Resident 1, and more CNAs had recently submitted resignation letters. The ADM stated he would not allow more nursing staff to resign from this facility because of Resident 1. The ADM stated he would take the consequences and responsibility for not re-admitting Resident 1 rather than losing all his nursing staff. The ADM stated he called the Ombudsman (An ombudsman is a legal representative, often appointed by a government or organization to investigate complaints made by individuals in the interest of the citizens or employees) to inform them he would not re-admit Resident 1 in the facility from the Emergency Room. During an interview on 3/20/21 at 10 a.m., in his room, Resident 4 stated a resident frequently yelled very loud (referring to Resident 1) as he pointed at Resident 1's room. During an interview on 3/20/21 at 10:08 a.m., the Director of Nursing (DON) stated Resident 1's behavior was disruptive, and she yelled constantly. The DON stated Resident 1 would call 911 from her room, to report a CNA who allegedly abused her when she did not get her way. The DON stated the Medical Doctor (MD), Resident 1's attending physician, was aware of the increased disruptive and abusive behavior, so he increased the dose of the medication called Seroquel (Seroquel is used to treat bipolar disorder in adults). The DON stated there was no change in Resident 1's behavior after the increased dose of Seroquel. The DON stated, on 3/8/21, Resident 1 demanded to get a Magnetic Resonance Imaging (MRI -- A diagnostic study to assess the health of organs and structures inside the body) of her bladder. The DON stated she informed the MD, but the MD did not agree with Resident 1's request. The DON stated Resident 1 became very angry and yelled when the MD did not order an MRI of her bladder. Staff B stated she called the MD again, and the MD ordered to transfer Resident 1 to the Emergency Room for the reason Resident 1 had dark urine and left flank pain (left back pain). Staff B stated she did not fill out the consent for bed hold and readmission form. During an interview on 3/20/21 at 10:50 a.m., Resident 5 stated one resident was very demanding, and she complained and yelled a lot (referring to Resident 1) as she pointed at Resident 1's room. During a telephone interview with Resident 1's daughter on 3/20/21 at 11:15 a.m., the daughter stated the ADM informed her he would not re-admit Resident 1 due to Resident 1's worsening psychiatric behavior. The daughter stated Resident 1 cried and exhibited anger after the hospital Social Worker told her the facility would not re-admit her from the hospital's Emergency Room. The daughter stated she was aware how difficult it was to care for Resident 1 due to her psychiatric condition. The daughter stated her mother felt nobody wanted her. During an interview on 3/20/21 at 12 p.m., License Nurse E (LN E) stated she felt nervous when she cared for Resident 1. LN E stated Resident 1 made her feel inferior, screamed, yelled and called her offensive names. LN E stated Resident 1 was her own Responsible Party, she was very controlling and refused to take her psychiatry medications. During an interview on 3/20/21 at 12:25 p.m., Certified Nursing Assistant F (CNA F) stated Resident 1 would call her, "stupid" and behaved abusively towards staff. CNA F stated Resident 1 called other residents names and acted bossy toward other residents. CNA F stated Resident 1 had instigated an argument with a previous roommate, who had since been discharged. During an interview on 3/20/21 at 2 p.m., the ADM stated he did not ask Resident 1 to sign the bed hold consent/form because the facility would not re-admit her. A review of the Policy & Procedure (P&P) titled, "Transfer or Discharge Documentation," revised 12/2016, indicated the following: "The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident. ... The health of individuals in the facility would otherwise be endangered." A review of the P&P titled, "Bed holds and Readmission," dated 5/11, indicated: "If you must be transferred to an acute hospital for seven days or less, we will notify you or your representative that we are willing to hold your bed. You and your representative have 24 hours after receiving this notice to let us know whether you want us to hold your bed for you." A review of the form titled, "Bed Hold Informed Consent," revealed the facility did not fill out the Bed Hold Informed Consent. A record review titled, "Before the State of California, Department of Health Care Services, Office of Administrative Hearings and Appeals, In the Matter of the Refusal to Readmitted," dated 4/19/21, the Court determination the facility's decision to discharge Resident 1 did not comply with regulations, and the facility should re-admit Resident 1 from the hospital Emergency Department. Therefore, the facility failed to readmit Resident 1 following her transfer to the hospital resulting in an automatic B violation. The violation of the regulation had a direct relationship to the health, safety, or security of residents.