Health inspection·November 20, 2025

T22 DIV5 CH3 ART5-72519(a) Patient Transfer (a) The licensee shall maintain written transfer agreements with other nearby health facilities to make the services of those facilities accessible and to facilitate the transfer of patients. Complete and accurate patient information, in sufficient detail to provide for continuity of care shall be transferred with the patient at time of transfer. T22 DIV5 CH3 ART5-72519(b) Patient Transfer (b) When a patient is transferred to another facility, the following shall be entered in the patient health record: T22 DIV5 CH3 ART5-72520(b) Bed Hold (b) Upon admission of the patient to the skilled nursing facility and upon transfer of the patient of a skilled nursing facility to a general acute care hospital, the skilled nursing facility shall inform the patient, or the patient's representative, in writing of the right to exercise this bed hold provision. No later than June 1, 1985, every skilled nursing facility shall inform each current patient or patient's representative in writing of the right to exercise the bed hold provision. Each notice shall include information that a non-Medi-Cal eligible patient will be liable for the cost of the bed hold days, and that insurance may or may not cover such costs. T22 DIV5 CH3 ART5-72520(c) Bed Hold (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. T22 DIV5 CH3 ART5-72521(a) Administrative Policies and Procedures (a) Written administrative, management and personnel policies shall be established and implemented to govern the administration and management of the facility. T22 DIV5 CH3 ART5-72521(c) Administrative Policies and Procedures (c) Each facility shall establish at least the following: T22 DIV5 CH3 ART5-72527(a)(6) 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. This Statute is not met as evidenced by: On 10/21/2025 at 12:35 PM, an unannounced visit was conducted at the facility to investigate a complaint regarding: Patient 1 was transferred to Hospital A for concerns related to suicidal ideation, and the need for higher level psychiatric intervention. Patient 1 stabilized in the hospital, medically cleared to discharge, and verbalized a desire to return to the facility. The facility stated it was unable to provide the necessary level of care to Patient 1 and resulted in Patient 1 being denied readmission to the facility. The facility failed to adhere to bed-hold readmission requirements, provide orderly/discharge notice, implement readmission policies as written, and ensure continuing of care during transfer, including but not limited to: 1. Denying Patient 1 readmission to the next available appropriate bed. 2. Not providing written bed-hold notice to Patient 1 during time of transfer. 3. Follow facility’s policy and procedure regarding bed-holds and readmission. Patient 1 was admitted to the facility on 7/10/2025. Diagnoses included: Major Depressive Disorder, Muscle Weakness, and Chronic right-hand weakness. Review of Patient 1’s Hospital Discharge Summary, dated 7/1/2025, Patient 1 has decision making capabilities and was baseline bedbound. Findings: A review of Patient 1’s medical records on 10/21/25 at 1:40p.m., the records did not contain written transfer/discharge notice, reason, destination, or appeal rights and Ombudsman information. No Interdisciplinary Team (IDT) or care-planning note documenting that the facility was unable to meet Patient 1’s needs after the hospital determined the resident was stable. The record did not indicate that a “next available bed” was offered to Patient 1. During an interview on 11/04/2025 at 3:45 PM with Patient 1 at his bedside in Hospital A, Patient 1 stated, “Yes, I never wanted to leave, they don’t like me but I feel safe there” when asked if he wanted to return to the facility. Patient 1 stated, “They tricked me into leaving no one gave me anything in writing”. When asked if anyone explained bed-hold or right to have the next available bed, Patient 1 stated, “No, never, they wanted me out”. When asked if he received a written transfer/discharge notice with appeal and Ombudsman information, Patient 1 stated, “The hospital told me they tried calling the facility, but they don’t like me there and they did not answer”. He further stated, “Hospital A said they called the facility several times and left voicemails asking about my return back to the facility, but no one called back and I never got any letter saying they were discharging me or refusing to take me back”. During an observation on 11/05/2025 at 2:50 PM in the Director of Nursing (DON)’s office, the daily census board indicated no bed or room assignment or staff preparation for Patient 1. During an interview on 11/05/2025 at 3:00 p.m. with DON, DON stated they were unable to locate a written bed-hold notice or 30-day transfer/discharge notice for Patient 1 in the facility record. The DON also stated, there was no designated log or process to track hospital calls and emails specifically for readmissions outside of routine business hours and they could not identify who, if anyone, had responded to the hospital’s requests regarding Patient 1. A concurrent review and interview with the DON on 11/5/25 at 3:50 p.m. of the facility’s policy and procedure (P&P), titled, “Hospital Transfer and Bed-Hold,” (undated), was reviewed. The P&P indicated, the patient would receive written bed-hold information at the time of transfer, the facility would monitor bed-hold status and offer the next available appropriate bed when residents return from the hospital, and staff would to hospital and family inquiries and document transfers and readmissions in the medical record to ensure continuity of care and continuity of services. The P&P further indicated that communication with hospitals and responsible parties was required to coordinate safe discharge and readmission planning. The DON stated that the facility did not have a copy of a signed bed-hold notice for Patient 1 and was unable to show documentation that a next available bed had been offered or that a formal written refusal with appeal rights and Ombudsman information had been issued. During a phone interview on 11/13/2025 at 1:30 p.m. with the hospital Case Manager (CM), the CM stated, multiple phone calls and emails were made to the facility on 10/19/25 and after 10/30/2025 to arrange Patient 1’s readmission after the hospital physician determined Patient 1 was medically stable for SNF-level care. The CM stated, “We left several voicemails and sent emails with the discharge summary and orders attached. We did not receive any return call or written response from the facility about whether they would accept the patient back or offer the next available bed.” The CM further stated, “There was no written refusal with appeal rights or Ombudsman information, we were just told verbally at one point that they weren’t taking Patient 1 back, and no written response received from SNF.” During a review of Patient 1’s hospital record dated 10/19/2025, the discharge summary and physician’s orders indicated, Patient 1 is medically stable for SNF-level care, no order for 1:1 sitter or services beyond the scope of a SNF. The physician further documented that Patient 1 could safely return to the prior SNF with routine precautions typically provided in SNF settings. In violation of the above cited standards, the facility failed to adhere to bed-hold readmission requirements, provide orderly/discharge notice, implement readmission policies as written, and ensure continuity of care during transfer, including but not limited to: 1. Denying Patient 1 readmission to the next available appropriate bed. 2. Not providing written bed-hold notice to Patient 1 during time of transfer. 3. Follow facility’s policy and procedure regarding bed-holds and readmission.