Health inspection·July 9, 2025

CFR §483.15(d)(1) - (e)(1)-(2) Bed Hold and Permitting Residents to Return Facilities must develop and implement policies for bed-hold and permitting residents to return following hospitalization or therapeutic leave. These policies apply to all residents, regardless of their payment source. The facility policies must provide that residents who seek to return to the facility within the bed-hold period defined in the State plan are allowed to return to their previous room, if available. Additionally, 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 that the resident: • Still requires the services provided by the facility; and • Is eligible for Medicare skilled nursing facility or Medicaid nursing facility services. The policies must also provide that if the facility determines that a resident cannot return, the facility must comply with the requirements at 42 CFR 483.15(c). Medicaid-eligible residents must be permitted to return to the first available bed even if the residents have outstanding Medicaid balances. CFR §483.15 Transfer and discharge (c)(1) Facility requirements¬ (i) The facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless- (A) The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility. (B) The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility. (C) The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident. (D) The health of individuals in the facility would otherwise be endangered. (E) The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. Nonpayment applies if the resident does not submit the necessary paperwork for third party payment or after the third party, including Medicare or Medicaid, denies the claim and the resident refuses to pay for his or her stay. For a resident who becomes eligible for Medicaid after admission to a facility, the facility may charge a resident only allowable charges under Medicaid; or (F) The facility ceases to operate. CFR §483.15(c)(2) Documentation. When the facility transfers or discharges a resident under any of the circumstances specified in paragraphs (c)(1)(i)(A) through (F) of this section, the facility must ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institution or provider. (i) Documentation in the resident's medical record must include: (A) The basis for the transfer per paragraph (c)(1)(i) of this section. (B) In the case of paragraph (c)(1)(i)(A) of this section, the specific resident need(s) that cannot be met, facility attempts to meet the resident needs, and the service available at the receiving facility to meet the need(s). (ii) The documentation required by paragraph (c)(2)(i) of this section must be made by (A) The resident's physician when transfer or discharge is necessary under paragraph (c) (1) (A) or (B) of this section; and (B) A physician when transfer or discharge is necessary under paragraph (c)(1)(i)(C) or (D) of this section. CCR § 72520 Bed Hold. (a) If a patient of a skilled nursing facility is transferred to a general acute care hospital as defined in Section 1250(a) of the Health and Safety Code, the skilled nursing facility shall afford the patient a bed hold of seven (7) days, which may be exercised by the patient or the patient's representative. (1) Upon transfer to a general acute care hospital, the patient or the patient's representative shall notify the skilled nursing facility within twenty-four (24) hours after being informed of the right to have the bed held, if the patient desires the bed hold. (b) Upon admission of the patient to the skilled nursing facility and upon transfer of the patient of a skilled nursing facility to a general acute care hospital, the skilled nursing facility shall inform the patient, or the patient's representative, in writing of the right to exercise this bed hold provision. No later than June 1, 1985, every skilled nursing facility shall inform each current patient or patient's representative in writing of the right to exercise the bed hold provision. Each notice shall include information that a non-Medi-Cal eligible patient will be liable for the cost of the bed hold days, and that insurance may or may not cover such costs. (c) A licensee who fails to meet these requirements shall offer to the patient the next available bed appropriate for the patient's needs. This requirement shall be in addition to any other remedies provided by law. CCR § 72523 Patient Care Policies and Procedures. (a) Written patient care policies and procedures shall be implemented to ensure that patient related goals and facility objectives are achieved. On 5/27/2025 at 2:44 p.m., the California Department of Public Health (CDPH) received a complaint indicating that the complainant was told by the facility on 4/29/2025, the same day when Resident 1 went to a general acute care hospital (GACH) for a procedure, that the facility was full and Resident 1's bed was given to another resident waiting to be admitted, so Resident 1 could not return to the facility. On 5/28/2025, the CDPH conducted an unannounced visit to the facility to investigate the allegation. The facility failed to: 1). Implement its policy and procedure (P&P) titled, "Bed-Holds (when a nursing home holds [reserve] a bed for seven (7) days) when the resident goes to the hospital) and Returns," which indicated residents who seek to return to the facility within the bed-hold period must be allowed back to their room, if available, regardless of payor source or outstanding debt. 2). Hold Resident 1's sub-acute bed (specialized unit of the facility providing care and services to residents with tracheostomy [surgical opening in the neck area for breathing]) for 7 days (4/28/2025 to 5/5/2025), while Resident 1 was at GACH 1 for a procedure. 3). Re-admit Resident 1 to the facility within the 7-day bed-hold period. As a result, Resident 1 was not able to return to the facility within the 7-day bed-hold period (4/28/2025 to 5/5/2025) and remained at another facility as of 6/2/2025. Resident 1 was 62-year-old female, admitted to the facility in Room A, Sub-acute unit on 12/31/2024. Resident 1's diagnoses included tracheostomy ([trache] a surgical opening in the neck for breathing), gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), and recurrent major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). Resident 1's Admission Record indicated Resident 1 had a responsible party. The Admission Record indicated Resident 1 was discharged to GACH 1 on 4/28/2025. A review of Resident 1's physician's order dated 12/31/2024, indicated to connect Resident 1's trache to a T-Bar (T- shaped tubing connected to the trache and oxygen) with oxygen at 2 liters per minute. The physician's orders indicated to suction tracheal secretions and tracheostomy care every shift. A review of Resident 1's "Bed Hold Notification, Informed Consent" on admission dated 12/31/2024, the Confirmation of Transfer and Bed Hold Provision section indicated on 4/28/2025, Resident 1's family representative (FM) 1 was informed of the right to request a 7-day bed-hold should the resident be transferred to a GACH. A review of Resident 1's History and Physical (H&P), dated 1/1/2025, indicated Resident 1 did not have the ability to make medical decisions. A review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 1/7/2025, indicated Resident 1 was unable speak and had severe cognitive impairment. The MDS indicated Resident 1 was dependent (helper does all the effort) with oral and toileting hygiene, personal hygiene, shower/bathing self, upper and lower body dressing, putting on/ taking off footwear, tub/shower transfer, the ability to roll from lying on back to left and right side and return to lying on back on the bed, sit to lying and in lying to sitting on the side of bed. A review of Resident 1's Progress Notes, dated 4/22/2025, indicated Resident 1 had a planned transfer to GACH 1 on 4/28/2025 for a cardiology clearance (an assessment of the cardiovascular system [heart, blood vessels, and circulatory system] to identify any potential issues that could complicate [undesirable outcome] a surgery). A review of Resident 1's Progress Notes, dated 4/28/2025 at 3:35 p.m., indicated Resident 1 was admitted to GACH 1 for cardiology clearance. A review of Resident 1's Physician Order, dated 4/28/2025 at 3:29 p.m., the order indicated bed-hold for 7 days for Resident 1. A review of the facility's daily census dated 4/28/2025, indicated Resident 1 was discharged from the facility on 4/28/2025 and Resident 1 was transferred from Room A (sub-acute) to Room B (Skilled Nursing unit, where residents without trache is admitted). A review of the facility's daily census from 4/28/2025 through 5/4/2025, indicated Resident 1 was in Room B. A review of GACH 1's Care Coordination form (notes) dated 5/2/2025 at 4:37 p.m., by the GACH 1 Registered Nurse (RN) Case Manager (CM) indicated, per the GACH physician, Resident 1 was ready to go back to the facility on Sunday 5/4/2025. The notes indicated GACH 1 CM called the facility on 5/2/2025, but no one picked up the call. The notes indicated on 5/2/2025 at 4:42 p.m., the facility's Admission Director (AD) called GACH 1 CM back and stated he would pull Resident 1's information from the computer system and get in contact with GACH 1 CM or the GACH 1 nurse. A review of GACH 1 CM's notes dated 5/5/2025 at 9:04 a.m., indicated the facility's AD was notified Resident 1 was ready to return to the facility on 5/5/2025. The notes indicated the facility's AD notified GACH 1 CM that the facility was full and could not move patients to accommodate Resident 1. The notes indicated GACH 1 CM asked the facility's AD if Resident 1 was on bed-hold. The notes indicated the facility's AD notified GACH 1 CM that Resident 1 was on bed-hold, but there was no available bed for Resident 1. The notes indicated the facility's AD was unable to let the GACH 1 CM know if there will be a bed open for Resident 1. A review of GACH 1 CM's notes dated 5/7/2025 at 11:13 a.m., indicated the facility's AD had notified Resident 1's family member that the facility had no bed for Resident 1. The notes indicated GACH 1 CM notified the family member sub-acute referrals were sent to other areas and was awaiting replies/acceptance. During an interview on 5/28/2025 at 9:55 a.m., with Registered Nurse (RN 1), RN 1 stated Resident 1 had a right to a 7-day bed-hold. RN 1 stated Resident 1 had the potential to cognitively deteriorate and become anxious and withdrawn if she could not return to the facility. During an interview on 5/28/2025 at 10:45 a.m., with the facility's AD, the AD stated she was never contacted by GACH 1 or the GACH 1 CM. The AD stated the Long-Term Acute Care (LTAC) facility attempted to send Resident 1 back after the bed-hold (date not specified), but the facility had no sub-acute bed available. During an interview on 5/28/2025 at 1:05 p.m., with the LTAC CM, the LTAC CM stated on 5/21/2025, he (LTAC CM) called and notified the facility's AD that Resident 1 was clinically ready since the previous week (date not specified) to return to the facility but was told by the facility's AD that the facility still has no bed available and was full. During an interview on 5/28/2025 at 2 p.m. with GACH 1 CM, the GACH 1 CM stated on 5/2/2025 at 4:42 p.m., she first spoke with the facility's AD to coordinate Resident 1's transfer and the AD stated she would pull Resident 1's information from the chart. GACH 1 CM stated on 5/5/2025 at 9:04 a.m., Resident 1 was ready to be discharged back to the facility. GACH 1 CM stated the facility AD stated though Resident 1 was on bed-hold, the facility could not accommodate the resident's needs. The GACH 1 CM stated Resident 1's clinical information was never sent to the facility because the facility's AD told her that the facility will not have any bed available for two (2) weeks. The GACH 1 CM stated Resident 1 was transferred to the LTAC on 5/15/2025. During a concurrent interview and record review on 5/28/2025 at 3:45 p.m., with the Director of Nursing (DON), Resident 1's Nurses Notes dated 4/22/2025, Bed Hold Notification dated 12/31/2024, the facility's Daily Census dated 4/28/2025, the facility's P&P titled "Bed-Holds and Returns" dated 10/2022, and the P&P titled "Transfer/Discharge Documentation," dated 10/2022, were reviewed. The DON stated the Nurses Notes indicated Resident 1's transfer to GACH 1 on 4/28/2025 was planned on 4/22/2025. The DON stated Resident 1 was transferred to GACH 1 on 4/28/2025 at 7:30 a.m. and FM 1 signed the bed hold notice on 4/28/2025. The DON stated a sub-acute bed should have been held until 5/5/2025 so that Resident 1 could be readmitted to the facility. The DON stated Room B where Resident 1's name was placed, was at the skilled nursing side. The DON stated Resident 1, who had a tracheostomy, was not readmitted back to the facility because the bed held was on the skilled nursing side and could not accommodate the resident's medical needs. The DON stated Resident 1 was not provided with an appropriate bed-hold. The DON stated the Daily Census indicated Resident 1's bed-hold was transferred from the sub-acute side of the facility (Room A) to the basic skilled nursing side (Room B). The DON stated Resident 1's bed should not have been moved to Room B. During an interview on 6/2/2025 at 10:25 a.m. with FM 1, FM 1 stated Resident 1 was still at the LTAC. FM 1 stated he spoke to the facility's AD and was told the facility had no beds available for Resident 1. A review of the facility's P&P titled, "Bed-Holds and Returns," dated 10/2022, indicated the requirement that residents be permitted to return to the facility following hospitalization applies to all residents regardless of payer source. The P&P indicated, if the facility determines that a resident cannot return, the facility must comply with the requirements for facility-initiated discharges (a discharge when the facility decided and that did not originate from a resident's request). The P&P indicated residents are not discharged unless: a. the discharge or transfer is necessary for the resident's welfare, and the facility cannot meet the resident's needs. b. the resident's health bas improved sufficiently so that the resident no longer needs the services of the facility. c. the resident's clinical or behavioral status endangers the safety of individuals in the facility. d. the resident's clinical or behavioral status endangers the health of individuals in the facility; and/or e. the resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) his or her stay at the facility which applies if: (1) the resident does not submit the necessary paperwork for third party payment; or (2) the third party, including Medicare or Medicaid, denies the claim and the resident refuses to pay for his or her stay; or f. the facility ceases to operate. The facility failed to: 1). Implement its P&P titled, "Bed-Holds and Returns," which indicated residents who seek to return to the facility within the bed-hold period must be allowed back to their room, if available, regardless of payor source or outstanding debt. 2). Hold Resident 1's sub-acute bed for 7 days (4/28/2025 to 5/5/2025), while Resident 1 was at