Health inspection·June 13, 2024

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 observation, interview, and record review, the facility failed to readmit one of one sampled resident (Resident 1) as indicated in the facility's policy and procedure titled readmission to Facility. This failure resulted in Resident 1 to remain in General Acute Care Hospital 1 (GACH 1) for two days from 6/10/2024 to 6/11/2024. Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 10/4/2023 and readmitted on [DATE] with diagnoses that included asthma (chronic lung disease that inflames and narrows the airways) with exacerbation (worsening) and dependence on renal dialysis (treatment for kidney failure [loss of kidney function] that removes unwanted toxins, waste products and excess fluids by filtering the blood). During a review of Resident 1's History and Physical (H&P) dated 11/3/2023, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care-screening tool) dated 4/10/2024, the MDS indicated Resident 1 had intact cognition (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 1 required supervision in toileting, shower, lower body dressing and putting on footwear. During a review of Resident 1's Physician Orders (PO) dated 5/30/2024, the PO indicated to transfer Resident 1 via 9-1-1 (emergency services) to GACH 1 for further evaluation of shortness of breath and altered level of consciousness (alertness). During a review of GACH 1's Internal Medicine Progress Notes (IMPN) dated 6/10/2024, the IMPN indicated Resident 1 was medically stable for transfer back to SNF once bed was available. During a review of Resident 1's GACH 1 Discharge Planning Progress Note (DPPN) dated 6/10/2024 and timed at 12:40 pm, the DPPN indicated GACH 1 Case Manager 1 (CM 1) spoke to Skilled Nursing Facility (an inpatient rehabilitation and medical treatment center) 1 (SNF1)'s Administrator (ADM) that Resident 1 wanted to return back to SNF 1. The DPPN indicated, Resident 1 stated I do not care if there was an ongoing Corona Virus 19 (COVID 19, a mild to severe respiratory illness that spread from person to person) outbreak at the facility (SNF 1). Page 1 of 3 555107 555107 06/13/2024 Victoria Care Center 3541 Puente Avenue Baldwin Park, CA 91706

F 0626 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of Resident 1's GACH 1 DPPN dated 6/10/2024 and timed at 2:15pm, the DPPN indicated GACH 1 CM 1 set up transportation for Resident 1 to be discharged to SNF 1. The DPPN indicated on 6/10/2024 at 2 pm, 3:15 pm and 3:25 pm, GACH 1 CM 1 was unable to reach SNF 1 ADM and GACH 1 CM 1 did not get a call back from SNF 1 ADM. During a review of Resident 1's GACH 1 DPPN dated 6/11/2024 and timed 4:02 pm, the DPPN indicated GACH 1 CM 2 received an endorsement from GACH 1 CM 3 that SNF 1's ADM was unable to accept to readmit Resident 1 back to SNF 1 today (6/11/2024) due to late acceptance and there was no Registered Nurse (RN) to readmit Resident 1 back to SNF 1. The DPPN indicated, SNF 1's ADM stated ADM was currently rearranging bed assignment and advised GACH 1 CM 3 to contact ADM on 6/12/2024. During a phone interview on 6/12/2024 at 10:31 am with GACH 1 Case Manager Director (CMD), GACH 1 CMD stated SNF 1's ADM answered the call yesterday (6/11/2024) and Resident 1 would be readmitted back to SNF 1 today (6/12/2024). GACH 1 CMD stated, Resident 1 stated Resident 1 wanted to return back to SNF 1. During an interview on 6/12/2024 at 10:39 am with SNF 1's admission Coordinator (AC), the AC stated she spoke to Resident 1 on 6/12/2024 and stated Resident 1 wanted to go back to SNF 1. The AC stated, it was confirmed on 6/10/2024 that we (SNF1) accepted Resident 1 to be readmitted . During a phone interview on 6/12/2024 at 10:51 am with Resident 1, Resident 1 stated, I just want to go back to the facility (SNF 1), that is my home. Resident 1 stated, her belongings were left in the facility. During an interview on 6/12/2024 at 11:39 am with SNF 1's Director of Nursing (DON), the DON stated, there was an available room at SNF 1 on 6/10/2024 and DON did not know the reason why Resident 1 was not readmitted back to SNF 1 on 6/10/2024. During an interview on 6/12/2024 at 12:49 pm with SNF 1's Director of Staff and Development (DSD), the DSD stated there was also no staffing issues on 6/11/2024 and licensed nurses could admit Resident 1 on 6/11/2024. The DSD stated she was not informed that Resident 1 will be readmitted back to SNF 1 on 6/11/2024. During an interview on 6/12/2024 at 1:31 pm with SNF 1's DON, the DON stated there were no staffing issues on 6/10/2024 and 6/11/2024. During an interview on 6/12/2024 at 1:36 pm with SNF 1's ADM, the ADM stated, GACH 1 called on 6/10/2024 and did not inform the ADM that Resident 1 was ready to come back to SNF 1. During a review of SNF 1's Daily Census dated 6/12/2024, the Daily Census indicated Resident 1 was readmitted back to SNF 1 on 6/12/2024. During a concurrent observation and interview on 6/13/2024 at 9:57 am with Resident 1 in Resident 1's room, Resident 1 was alert and sitting in bed. Resident 1 stated, This is my home, this is all I got. Resident 1 stated, I am very happy because I am back. During an interview on 6/13/2024 at 10:50 am with GACH 1 CM 3, GACH 1 CM 3 stated, Resident 1 wanted to go back to the facility. GACH 1 CM 3 stated, a conference call was done with SNF 1 ADM and Resident 1 on 6/11/2024 and Resident 1 stated she wanted to go back to SNF 1. GACH 1 CM 3 stated she 555107 Page 2 of 3 555107 06/13/2024 Victoria Care Center 3541 Puente Avenue Baldwin Park, CA 91706

F 0626 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few would be able to proceed the discharge of Resident 1 on 6/10/2024 once she secured the bed from SNF 1, but GACH 1 CM 3 did not hear back from SNF 1 on 6/10/2024. A review of the facility's Policy and Procedure (P&P) titled, readmission to Facility, revised on 12/19/2022, the P&P indicated the facility will readmit the resident to the first available bed in the particular location of the composite distinct part in which the resident resided previously. The P&P indicated if a bed was not available in that location at the time of readmission, the resident will be given an option to return to that location upon first availability of a bed there. The P&P indicated residents who seek to return to the facility after the expiration of the bed-hold period or when state law does not provide for bed-holds, are allowed to return to their previous room if available or immediately to the first available bed in a semi-private room provided. 555107 Page 3 of 3