Health inspection·January 5, 2024

F 0622 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to readmit Resident 1 after he transferred to an acute care hospital and was ready to return to the facility. This failure resulted in a violation of Resident 1's right to return to the facility and had the potential to cause psychosocial harm due to not being able to return to the facility. Findings: Resident 1 was admitted to the facility in July of 2023 with diagnoses which included unspecified cirrhosis of the liver (a disorder in which the liver is scarred or permanently damaged) and chronic pain syndrome. During a telephone interview on 1/5/24, at 8:03 AM, the Ombudsman (OMB) stated there had been a conflict between Resident 1 and the facility. The OMB further stated the facility contacted law enforcement, and Resident 1 was sent to an acute care hospital. The OMB stated hospital staff talked to the Administrator (ADM) and the social services department and they refused to accept Resident 1 back. During a telephone interview on 1/5/24, at 11:10 AM, the hospital Case Manager (CM), stated Resident 1 was transferred to the hospital on [DATE]. The CM further stated the facility reported Resident 1 was throwing food at them and they were sending him out. The CM stated the facility was told the transfer was inappropriate, but they would not take him back. The CM further stated, .they dumped him . The CM stated Resident 1 remained at the hospital until they could find him alternate placement which occured on 11/15/23. During an interview on 1/10/24, at 9:28 AM, the OMB stated Resident 1 had been upset because he still had belongings at the facility and the facility did not want him back. During an interview on 1/12/24, at 12:31 PM, the OMB stated during a visit with Resident 1 on 1/10/24, he stated he had wanted to return to the facility after his hospital stay to be closer to his family and because he liked the atmosphere there. A review of Resident 1's electronic health record (EHR), in the section titled, Progress Notes from the period of 11/10/23 through 11/14/23 indicated: 11/10/23 at 1:32 PM, .Social Services Note .Administrator came in to speak with the patient, I stayed at the door. The administrator told the patient that he needs to stop being abusive to the staff, Page 1 of 3 555245 555245 01/05/2024 North Park Post-Acute 2586 Buthmann Ave Tracy, CA 95376

F 0622 Level of Harm - Minimal harm or potential for actual harm he continues to curse, throw, and threaten staff. Today he had food piled behind the door, he throws his food on the floor daily and he opens ranch packets and spills the ranch all over 11/10/23 at 1:34 PM, .Social Services note .Patient continues abusive behavior, I called the police department to speak with the resident and take the appropriate steps Residents Affected - Few 11/10/23 at 4:29 PM, .Social Services note .Incident report number # [xxxxx] for todays call to the police department 11/14/23 at 10:38 AM, .Nurses Notes .Resident discharged on 11/10/23 There were no further entries documented in Resident 1's progress notes. During a concurrent interview and record review on 1/5/24, at 11:28 AM, the Social Services Director (SSD), stated Resident 1 requested to be sent to the hospital, he said he was in pain, and we were not providing him care. The SSD further stated they had been discussing his behaviors and decided to call the police. The SSD stated the police called the fire department because Resident 1 was in pain. The SSD confirmed there was no documentation in Resident 1's EHR regarding the transfer or discharge. The SSD further stated they did not accept Resident 1 back to the facility because he was not appropriate, he was rude to his roommate and his behaviors put other residents at risk. The SSD confirmed there was no documentation of referrals for psychiatric services or of IDT (interdisciplinary team, group of health care professionals from different disciplines who assess and coordinate care) meetings regarding his behaviors. The SSD stated Resident 1's belongings were brought to the hospital on [DATE]. The SSD confirmed Resident 1 did not sign the inventory list confirming receipt of his belongings. During an interview on 1/5/24, at 12:18 PM, Licensed Nurse (LN) 1, stated during her shift on 11/10/23, Resident 1 had asked for pain medication. LN 1 further stated she administered the medication and then after 30 minutes Resident 1 was screaming and talking to social services. LN 1 stated the Administrator (ADM) went in Resident 1's room and then the police were called. LN 1 stated she did not see Resident 1 after that. During a concurrent interview and record review on 1/5/24, at 12:42 PM, LN 2 stated Resident 1 did not want to go with the police he wanted to go to the hospital instead. LN 2 confirmed Resident 1's EHR did not have a physician order for transfer/discharge to the hospital. LN 2 further confirmed there was no documentation in Resident 1's EHR regarding his transfer to the hospital. During an interview on 1/5/24, at 1:09 PM, the ADM stated the hospital was upset that they transferred Resident 1 to them. The ADM further stated Resident 1 had been hostile and verbally aggressive which prompted them to call the police. The ADM stated they had every indication that Resident 1 would leave with the police but Resident 1 demanded to go to the hospital. The ADM confirmed there was no documentation regarding Resident 1's transfer to the hospital. A review of Resident 1's admission document titled, California Standard admission Agreement for Skilled Nursing Facilities and Intermediate Care Facilities, dated July 5, 2023, indicated, .Bed holds and readmission .If you must be transferred to an acute hospital for seven days or less, we will notify you or on July 5, 2023. 555245 Page 2 of 3 555245 01/05/2024 North Park Post-Acute 2586 Buthmann Ave Tracy, CA 95376

F 0622 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of Resident 1's document titled, BED HOLD NOTIFICATION, dated 11/10/23 indicated, .confirmation of transfer & bed hold provision .transferred to [line was blank] .on 11/10/23 at 1:45 . the form indicated Resident 1's daughter was notified on 11/10/23 at 2 PM by the ADM of the bed hold notification. During a concurrent interview and record review with the ADM on 1/5/24, at 2:04 PM, the ADM confirmed the facility's daily census report dated 11/10/23, indicated, Resident 1's name was listed in the column titled Discharges/send outs. The census dated 11/12/23, 11/13/23 and 11/14/23 did not have Resident 1's name listed. The census did list on 11/12/23-11/14/23 another resident's name with the letters BH (bed hold) next to his name in red. The ADM confirmed the letters BH stood for bed hold and further confirmed the census did not designate Resident 1 as on a bed hold for those dates. Resident 1's room remained empty until 11/14/23, when another resident's name was listed in Resident 1's previous room, per the census report. The ADM was unable to provide a Bed hold policy upon request. A review of a facility policy and procedure (P&P) titled, Transfer or Discharge Documentation, revised December 2016, indicated, .When a resident is transferred or discharged , details of the transfer or discharge will be documented in the medical record .Each resident will be permitted to remain in the facility, and not be transferred or discharged unless .the transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility .When a resident is transferred .the following information will be documented in the medical record .The basis for transfer or discharge .the specific resident needs that cannot be met .the facility's attempt to meet those needs .the receiving facility's service(s) that are available to meet those needs .the date and time of the transfer or discharge .the new location of the resident .the mode of transportation .A summary of the resident's overall medical, physical and mental condition .Disposition of personal effects . 555245 Page 3 of 3