Health inspection·March 5, 2025

The following reflects the findings of the California Department of Public Health during the investigation of complaint number 940672. The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. A deficiency was written for Complaint #940672 at F-tag 626/D. F626 Permitting Residents to Return to Facility §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. On 1/16/25, an unannounced visit was conducted at the facility to investigate a complaint regarding a resident not allowed to readmit to the facility from the acute hospital. Based on interview and record review, the facility failed to readmit one of three sampled residents (Resident 1) after hospitalization. This failure resulted in violation of resident's rights to return to the facility and had the potential to negatively affect Resident 1's well-being. Resident 1 was a 79-year-old male who was admitted to the facility on 12/26/2024 and has a diagnosis history of fracture (break in bone) of right femur (hip), acute myocardial infarction (heart attack), and unspecified atrial fibrillation (irregular heartbeat). During a review of Resident 1's "Admission Record (AR), " dated 1/16/25, the AR indicated, Resident 1 was admitted to the facility on 12/26/24, with diagnoses including history of fracture of the right femur and respiratory disorders in diseases classified elsewhere. During an interview on 1/16/25 at 12:27 p.m. with the Facility Marketing Director (FMD), FMD stated Resident 1 was discharged from the facility to the acute hospital on 1/2/25. During an interview on 1/16/25 at 1:11 p.m. with acute hospital Case Manager (CM), CM stated Resident 1 was ready for discharge from the acute hospital to the facility on 1/13/25. CM stated she called and spoke with FMD on 1/13/25 at approximately 1:55 p.m. regarding Resident 1's discharge back to the facility. CM stated FMD told her Resident 1 would not be accepted back to the facility due to refusing care. During a concurrent interview and record review on 1/16/25 at 1:21 p.m. with Administrator, Resident 1's Ensocare History (ENS -a tool used to communicate between the facility and acute hospital) dated 1/2025 was reviewed. The ENS indicated on 1/14/25 at 3:01 p.m. the facility refused to readmit Resident 1 due to, "Too low functioning." Administrator stated, "We (facility) should have taken him (Resident 1) back. " During a review of the facility's policy and procedure (P&P) titled, "Readmission to the Facility," dated 3/2017, 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. . . Readmission procedures apply equally to all residents regardless of race, color, creed, national origin, or payment source. . . Inquiries concerning our readmission policies should be referred to the administrator and/or the director of nursing services. " ` This violation had a direct or immediate relationship to the health, safety, or security of patients or residents and constitutes a class "B" citation.