Health inspection·January 18, 2025

F 0626 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to allow and readmit one of four sampled resident (Resident 1) to return to the facility following hospitalization at General Acute Care Hospital 1 (GACH 1) on 1/6/2025 according to the facility's policy and procedure (P&P) titled, Bed Hold Notice Upon Transfer. This deficient practice resulted in Resident 1 remaining in GACH 1 and was not allowed to be readmitted timely to her original facility where she had resided. Findings: A review of Resident 1's admission Record indicated resident was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy (a chemical imbalance in the blood affecting the brain), chronic embolism (a condition where a blood clot remains lodged in a blood vessel for an extended period, typically more than three months) and thrombosis (a condition where a blood clot (thrombus) forms within a blood vessel, obstructing blood flow) of deep vein (large veins located deep within the body, typically beneath the muscles) of left lower extremity and muscle weakness. A review of the Minimum Data Set (MDS - resident assessment tool) dated 9/9/2024, indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions was moderately impaired. The MDS indicated Resident 1 required maximal assistance from staffs for Activities of Daily Living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). A review of Resident 1's Progress Notes dated 12/22/2024 indicated, Medical Doctor (MD) ordered resident (1) to transfer to GACH 1 for further evaluation. A review of Resident 1's GACH 1 referral sent to the facility on [DATE], indicated, Resident 1 was to be discharged from the hospital back to the facility after 12/31/2024. A review of the facility's census indicated the following: i. On 1/6/2025, census was 42 with five empty beds. ii. On 1/7/2025, census was 41 with six empty beds. iii. On 1/8/2025, census was 41 with six empty beds. Page 1 of 2 555054 555054 01/18/2025 Pacific Post Acute 1323 17th Street Santa Monica, CA 90404

F 0626 iv. On 1/9/2025, census was 43 with four empty beds. Level of Harm - Minimal harm or potential for actual harm v. On 1/10/2025, census was 44 with three empty beds. vi. On 1/11/2025, census was 42 with four empty beds. Residents Affected - Few vii. On 1/17/2025, census was 44 with three empty beds. During an interview with admission / Business Development (AD/BD) on 1/18/2025 at 11:26 a.m., AD/BD stated, they received GACH 1's referral for Resident 1 on 12/31/2024 for readmission after hospitalization. AD/BD stated, he received a call from the Case Manager 1 (CM 1) from GACH 1 but he was out of town, so he referred them to the management head at the facility. AB/DB stated, he came back from vacation but was never able to follow-up on the referral for readmission. During an interview with the Director of Nursing (DON) on 1/18/2025 at 1:08 p.m., DON stated, she was not aware that Resident 1 was still at the hospital. DON stated, the AD/BD should have followed up on the referral and she was told that he will take care of it even if he was out of town. DON further stated, she talked to CM 1 and they notified her that they did not have a bed available when Resident 1 was ready to be discharge so she told them to call them back to follow-up. DON stated, she never called CM 1 to follow-up when they had a bed available. A review of the facility's P&P titled, Bed Hold Notice Upon Transfer, dated 9/18/2024, the P&P indicated, 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 for under Medicare or Medicaid) a stay at the facility. Non-payment applies if the resident does not submit the necessary paperwork for third party payment or after the third party, including if 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 only allowable charges under Medicaid. f. The facility ceases to operate. 555054 Page 2 of 2