Health inspection·April 4, 2025

§483.15(e)(1) Permitting residents to return to facility. A facility must establish and follow a written policy on permitting residents to return to the facility after they are hospitalized or placed on therapeutic leave. The policy must provide for the following. (i) A resident, whose hospitalization or therapeutic leave exceeds the bed-hold period under the State plan, returns to the facility to their previous room if available or immediately upon the first availability of a bed in a semi-private room if the resident- (A) Requires the services provided by the facility; and (B) Is eligible for Medicare skilled nursing facility services or Medicaid nursing facility services. (ii) If the facility that determines that a resident who was transferred with an expectation of returning to the facility, cannot return to the facility, the facility must comply with the requirements of paragraph (c) as they apply to discharges. § 72523(a) Patient Care Policies and Procedures. (a)Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. On 2/18/2025, the California Department of Public Health (CDPH) received a complaint alleging the facility did not want to readmit a resident (Resident 1) to the facility. On 2/19/2025 the CDPH conducted an unannounced visit to the facility to investigate the complaint allegation. Upon investigation, CDPH determined Resident 1 was transferred to a General Acute Care Hospital (GACH) on 1/21/2025 due to shortness of breath (SOB) and was cleared by the GACH to return to the facility on 1/31/2025, but the facility refused to readmit Resident 1 because he owed the facility money. The facility failed to: 1. Ensure Resident 1 was readmitted to the facility when the GACH cleared him to return to the facility on 1/31/2025. 2. Ensure the facility followed its Policy and Procedure (P/P) titled, "Bed holds and Returns" which indicated prior to transfers and therapeutic leaves, residents or resident representatives will be informed in writing of the bed hold and return policy. The P/P indicated residents may return to and resume residence in the facility after hospitalization or therapeutic leave and shall apply to all residents in the facility. 3. Ensure the facility followed its P/P titled, "Transfer or Discharge Documentation" which indicated "each resident would be permitted to remain in the facility, and not to be transferred or discharged unless: residents and/or representatives are notified in writing, and in language and format they understand, at least 30 days prior to a transfer or discharge with the specific reason for transfer or discharge, effective date of discharge and the location to which the resident is being transferred or discharged." As a result of these deficient practices, Resident 1 remained at the GACH for 22 days beyond the date that the GACH attempted to transfer him back to the facility and kept the resident away from his home (facility) This deficient practice had the potential for Resident 1's continuity of care to be interrupted. A review of Resident 1's Admission Record (Face Sheet), indicated Resident 1, a 72-year-old male, was initially admitted to the facility on 1/5/2024 with diagnoses including heart failure (a life threatening condition that occurs when the heart suddenly can't pump enough blood not the body) and chronic respiratory failure (a serious condition that makes it difficult for a person to breathe on his/her own). A review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 1/10/2025, indicated Resident 1 was able to make decisions that were consistent and reasonable, and he required a one person assist to complete his activities of daily living ([ADLs] activities such as bathing, dressing and toileting a person performs daily). A review of Resident 1's Care Plan dated 5/3/2024, indicated Resident 1 wished to remain in the facility long term and/or under custodial care (facility providing with basic, non-medical assistance with everyday tasks such as bathing, dressing, eating, and getting around to people who need help due to age, disability, or illness, usually provided by a caregiver without formal medical training). The Care Plan indicated Resident 1 and his Responsible Party (RP) had no intentions of being discharged to any other location. The Care Plan's goal was for Resident 1 to stay in the facility long term and the interventions included meeting with Resident 1 and his representative to reassess discharge to the community at regular intervals. A review of Resident 1's Change of Condition Evaluation (COC) dated 1/21/2025 and timed at 9:20 a.m., indicated on 1/21/2025 at 8:10 a.m. Resident 1 was SOB and was transferred to a GACH at 8:38 a.m. A review of Resident 1's Order Summary (Physician's Order) dated 1/21/2025 and timed at 8:14 a.m., indicated to transfer Resident 1 to a GACH by paramedics because of SOB. The Physician's Order indicated there was no order to hold Resident 1's bed for 7 days. A review of Resident 1's Clinical Record indicated there was no Notice of Transfer Discharge available for review. A review of the GACH's Admission Record (Face sheet), indicated Resident 1 was admitted to the GACH on 1/21/2025 with diagnosis of hypoxia (a life threatening condition where the body doesn't have enough oxygen because of chronic heart and lung conditions) related to acute or chronic congestive heart failure (a life threatening condition that occurs when the heart suddenly can't pump enough blood not the body). A review of the GACH's Case Manager/Social Work Notes, dated 1/31/2025 and timed at 1:02 p.m., indicated the Administrator (ADM) did not want to readmit Resident 1 to the facility because Resident 1 owed the facility more than $14,500. A subsequent note by the GACH's Case Manager dated 2/6/2025 and timed at 3 p.m., indicated a follow up call to the facility's ADM and a subsequent note by the GACH's Case Manager dated 2/11/2025 and timed at 3:27 p.m., indicated Resident 1 was medically stable to be discharged from the GACH for transfer to a skilled nursing facility that day (2/11/2025). During a telephone interview on 2/19/2025 at 4:46 p.m., Resident 1's RP stated she received a call from the facility's business office staff on the day Resident 1 was transferred to the hospital (1/21/2025) informing her that Resident 1 would be evicted from the facility because he owed the facility money. The RP stated she was not given a bed hold or discharge notice prior to or when Resident 1 was transferred to the GACH or before she was informed Resident 1 would not be readmitted to the facility. The RP stated she was worried that Resident 1 would become homeless. During an interview on 2/20/2025 at 9:49 a.m., and a subsequent interview on 2/21/2025 at 1:49 p.m., the Director of Nursing Services (DON) stated Resident 1 should have been allowed to come back to the facility for continuity of his care and to prevent him from feeling abandoned. The DON stated Resident 1 was not provided a bed hold when he was transferred to the GACH or a notice of transfer discharge 30 days prior to being transferred to the GACH because Resident 1's transfer was not anticipated. During an interview on 2/20/2025 at 12:02 p.m., the ADM confirmed there was no Bed Hold or Notice of Discharge Transfer provided to Resident 1 or his RP. The ADM stated the facility would readmit Resident 1 to the facility, if Resident 1 and his family paid the money owed to the facility. The ADM acknowledged Resident 1's quality of life would be affected if his (Resident 1's) care was discontinued. A review of the facility's undated Policy and Procedure (P/P) titled, "Transfer or Discharge Documentation" indicated each resident would be permitted to remain in the facility, and not to be transferred or discharged unless: a. The transfer or discharge was necessary for the resident's welfare and the resident's needs could not be met in the facility b. The transfer or discharge was appropriate because the resident's health had improved sufficiently so the resident no longer needed the services provided by the facility c. The safety of individuals were endangered due to the clinical or behavioral status of the resident d. The health of the other individuals in the facility would be otherwise endangered e. The resident failed after reasonable and appropriate notice, to pay for (or have paid under Medicare or Medicaid) a stay at the facility f. The facility ceased to operate. The resident and his or her representative are given a 30 day advance written notice of an impending transfer or discharge from the facility. A review of the facility's undated P/P titled, "Bed holds and Returns" indicated prior to transfers and therapeutic leaves, residents or resident representatives will be informed in writing of the bed hold and return policy. The P/P indicated residents may return to and resume residence in the facility after hospitalization or therapeutic leave and shall apply to all Medicaid residents in the facility. A review of the facility's undated P/P titled, "Transfer or Discharge Notice" indicated residents and/or representatives are notified in writing, and in language and format they understand, at least 30 days prior to a transfer or discharge with the specific reason for transfer or discharge, effective date of discharge and the location to which the resident is being transferred or discharged. The facility failed to: 1. Ensure Resident 1 was readmitted to the facility when the GACH cleared him to return to the facility on 1/31/2025. 2. Ensure the facility followed its Policy and Procedure (P/P) titled, "Bed holds and Returns" which indicated prior to transfers and therapeutic leaves, residents or resident representatives will be informed in writing of the bed hold and return policy. The P/P indicated residents may return to and resume residence in the facility after hospitalization or therapeutic leave and shall apply to all residents in the facility. 3. Ensure the facility followed its P/P titled, "Transfer or Discharge Documentation" which indicated "each resident would be permitted to remain in the facility, and not to be transferred or discharged unless: residents and/or representatives are notified in writing, and in language and format they understand, at least 30 days prior to a transfer or discharge with the specific reason for transfer or discharge, effective date of discharge and the location to which the resident is being transferred or discharged." As a result of these deficient practices, Resident 1 remained at the GACH for 22 days beyond the date that the GACH attempted to transfer him back to the facility and kept the resident away from his home (facility) This deficient practice had the potential for Resident 1's continuity of care to be interrupted. These violations, jointly, separately or in any combination, had direct or immediate relationship to the health, safety, or security and welfare of Resident 1.