Health inspection·September 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 interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was readmitted to the facility after Resident 1 was transferred and treated at the General Acute Care Hospital (GACH). This deficient practice resulted in Resident 1 remaining at the GACH for two additional days after Resident 1 was deemed appropriate for discharge back to the facility but was denied readmission by the facility. Findings: A review of Resident 1 ' s admission Record, the admission record indicated Resident 1 was admitted to the facility on [DATE] with a diagnosis of right hemiplegia (a condition caused by a brain injury, that results in a varying degree of weakness, stiffness, and lack of control in one side of the body) and chronic kidney (disease gradual loss of kidney function. Kidneys are unable to filter wastes and excess fluids from blood). A review of Resident 1 ' s History and Physical (H&P), dated 8/26/2024, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1 ' s Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 9/1/2024, the MDS indicated that Resident 1 ' s cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making was moderately impaired. During a review of Resident 1's Change of Condition (COC) dated 9/4/2024, the COC indicated Resident 1 was transferred to the GACH for symptoms of wheezing (a high-pitched, whistling sound that occurs during breathing when the airways in the lungs become narrowed or blocked) and shortness of breath. During a review of Resident 1's Nurse Progress Note dated 9/4/2024 and timed at 6:10 a.m., the Progress Note indicated Resident 1 was transferred to the GACH for further evaluation. During an interview on 9/13/2024 at 9:08 a.m. with Complainant 1, Complainant 1 stated the GACH called facility to request a bed for Resident 1 because she was medically cleared to return to the facility. Complainant 1 stated facility was informed Resident 1 had a history of multidrug-resistant organisms ([MDRO] Bacteria that resist treatment with more than one antibiotic) in 2021 and 2022. Complainant 1 stated the facility refused to accept Resident 1 because of history of MDRO. Complainant 1 Page 1 of 2 555128 555128 09/13/2024 Downey Community Health Center 8425 Iowa Street Downey, CA 90241

F 0626 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated facility was explained they did not have to put Resident 1 in isolation because MDRO was not active. Complainant 1 stated facility was called on 9/11/2024 and 9/12/2024 and for both times the facility refused to accept resident. During an interview on 9/13/2024 at 12:01 p.m. with admission Coordinator (AC), the AC stated the case manager from GACH called the facility on 9/11/2024, to inform her that Resident 1 was ready to return to the facility. The AC stated the Director of Nursing (DON) stated she could not accept Resident 1 back into the facility because she did not have any isolation beds (a bed that is used to isolate patients who are infected with a contagious or airborne disease, or who are susceptible to infection from others) available. The AC stated she informed the DON that Resident 1 had a history of MDRO and that she did not have active MDRO, and the DON still wanted an isolation bed for Resident 1. The AC stated she did not inform the DON about the available beds because the DON also had a copy of the census, and she was aware of the empty beds. The Adm Coord stated it was important for Resident 1 to return to the facility because the facility was her home. During an interview on 9/13/2024 at 1:41 p.m. with the DON, the DON stated the Adm Coord notified her GACH called the facility to notify Resident 1 was ready to return to facility on 9/11/2024. The DON stated she did not allow resident to return to the facility on 9/11/2024 because she did not have an isolation bed available. During a concurrent interview and record review on 9/13/2024 at 1:56 p.m. with DON, the facility ' s census dated 9/11/2024 and 9/12/2024 was reviewed. The census indicated Room A was empty on 9/11/2024 and 9/12/2024. The DON stated based on facility ' s census she did have a bed available on 9/11/2024 and 9/12/2024 for Resident 1. The DON stated it was important for Resident 1 to return to facility to start her healing. During a review of the facility's policy and procedure (P&P) titled readmission to the Facility, dated 4/2013, 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. During a review of the facility's P&P titled Discharge/Transfer of Resident, dated 12/2028, the P&P indicates the resident has the right to return to the facility after hospitalization or therapeutic leave if the facility can provide the services the resident requires consistent with federal and state guidelines. 555128 Page 2 of 2