Health inspection·April 10, 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 readmit one of two sampled residents (Resident 1) to the first available bed at the Skilled Nursing Facility (SNF) as indicated in the facility policy. This deficient practice resulted in the violation of Resident 1's rights to resume residency at the facility. Findings: During a review of the admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] with the diagnoses that included Parkinson's Disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), hyperlipidemia (elevated level of lipids-like cholesterol and triglycerides in blood). During a review of Resident 1's History and Present Illness (H&P- the most formal and complete assessment of the patient and the problem), dated 3/25/2023, the H&P indicated Resident 1 does not have decision making capacities. During a review of the Minimum Data Set (MDS- a comprehensive standardized assessment and screening tool), dated 3/1/2024, the MDS indicated Resident 1's brief interview for mental status (BIMS- standard cognitive assessment scores 00-15) score of 7 indicated Resident 1 had severe cognitive impairment (ability to understand and process information). During a review of Resident 1's Physician Order, dated 4/2/2024, at 8:19 p.m., the Order Details indicated Transfer to General Acute Care Hospital (GACH) for further evaluation d/t (due to) resident's refusal of all oral intake. During a review of the progress notes dated 4/2/2024 at 8:27 p.m., the progress notes indicated ambulance seen picking up Resident 1. During a review of Resident 1's GACH Care Manager (GCM) Notes, dated 4/5/2024, at 3:43 p.m., the multiple access transponder (MAT) health care information system (HCIS) indicated the GCM placed a call to the SNF, and spoke to the facility case manager (FCM) who stated Resident 1 will not be accepted back to the SNF. During an interview on 4/10/2024 at 11:45 a.m., with the Administrator, the Administrator stated on 4/5/2024 Resident 1 was ready to return to the facility from the GACH and our FCM did not accept (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 555832 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555832 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clara Baldwin Stocker Home for Women 527 S Valinda Avenue West Covina, CA 91790 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)