Health inspection·February 26, 2025

The following reflects the findings of the California Department of Public Health during the investigation of complaint number CA00941143. A Class "B" Citation was written. REGULATORY VIOLATIONS: Title 42 Code of Federal Regulations: §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. §483.15(e)(2) Readmission to a composite distinct part. When the facility to which a resident return is a composite distinct part (as defined in § 483.5), the resident must be permitted to return to an available bed in the particular location of the composite distinct part in which he or she resided previously. If a bed is not available in that location at the time of return, the resident must be given the option to return to that location upon the first availability of a bed there. Title 22 California Code of Regulations: § 72523. 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 1/18/2025, the California Department of Public Health (State Survey Agency [SSA]) made an unannounced visit to the facility to investigate a complaint related to admission, transfer, and discharge rights of a resident. The facility failed to allow and readmit Resident 1 to return to the facility following hospitalization at General Acute Care Hospital 1 (GACH 1) on 1/6/2025 according to the facility's policy and procedure (P&P) titled, "Bed Hold Notice Upon Transfer". As a result, Resident 1 remained in GACH 1 and was not allowed to be readmitted timely to her original facility where she had resided. A review of Resident 1's Admission Record indicated Resident 1, a 81 year-old female was admitted to the facility on 9/3/2024 with diagnoses including metabolic encephalopathy (a chemical imbalance in the blood affecting the brain), chronic embolism (a condition where a blood clot remains lodged in a blood vessel for an extended period, typically more than three months) and thrombosis (a condition where a blood clot (thrombus) forms within a blood vessel, obstructing blood flow) of deep vein (large veins located deep within the body, typically beneath the muscles) of left lower extremity and muscle weakness. A review of the Minimum Data Set (MDS - resident assessment tool) dated 9/9/2024, indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions was moderately impaired. The MDS indicated Resident 1 required maximal assistance from staffs for Activities of Daily Living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). A review of Resident 1's Progress Notes dated 12/22/2024 indicated, "Medical Doctor (MD) ordered resident (1) to transfer to GACH 1 for further evaluation." A review of Resident 1's GACH 1 referral sent to the facility on 12/31/2024, indicated, Resident 1 was to be discharged from the hospital back to the facility after 12/31/2024. A review of the facility's census indicated the following: On 1/6/2025, census was 42 with five female empty beds. On 1/7/2025, census was 41 with six empty beds (five female empty beds, one male empty bed). On 1/8/2025, census was 41 with six empty beds (five female empty beds, one male empty bed). On 1/9/2025, census was 43 with four empty beds (with two female empty beds, two male empty beds). On 1/10/2025, census was 44 with three female empty beds. On 1/11/2025, census was 42 with four empty beds (with three female empty beds and one male empty bed). On 1/17/2025, census was 44 with three empty beds (with two female empty beds and one male empty bed). During an interview with Admission / Business Development (AD/BD) on 1/18/2025 at 11:26 a.m., AD/BD stated, they received GACH 1's referral for Resident 1 on 12/31/2024 for readmission after hospitalization. AD/BD stated, he received a call from the Case Manager 1 (CM 1) from GACH 1 but he was out of town, so he referred them to the management head at the facility. AB/DB stated, he came back from vacation but was never able to follow-up on the referral for readmission. During an interview with the Director of Nursing (DON) on 1/18/2025 at 1:08 p.m., DON stated, she was not aware that Resident 1 was still at the hospital. DON stated, the AD/BD should have followed up on the referral and she was told that he will take care of it even if he was out of town. DON further stated, she talked to CM 1, and they notified her that they did not have a bed available when Resident 1 was ready to be discharge so she told them to call them back to follow-up. DON stated, she never called CM 1 to follow-up when they had a bed available. A review of the facility's P&P titled, "Bed Hold Notice Upon Transfer", dated 9/18/2024, the P&P indicated, "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 for under Medicare or Medicaid) a stay at the facility. Non-payment applies if the resident does not submit the necessary paperwork for third party payment or after the third party, including if 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 only allowable charges under Medicaid. f. The facility ceases to operate." The facility failed to allow and readmit Resident 1 to return to the facility following hospitalization at GACH 1 on 1/6/2025 according to the facility's P&P titled, "Bed Hold Notice Upon Transfer". As a result, Resident 1 remained in GACH 1 and was not allowed to be readmitted timely to her original facility where she had resided. This violation had a direct or immediate relationship to the health, safety, or security of Resident 1.