Health inspection·June 17, 2025

§483.15 (e)(1) 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. 22CCR §72520. Bed Hold (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. 22CCR §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 5/28/2025, the California Department of Public Health (CDPH) received a complaint indicating a resident (Resident 1) was denied readmission to the facility after being hospitalized. On 5/29/2025 at 7:40 a.m., the CDPH conducted an unannounced investigation at the facility. The facility failed to: 1. Ensure Resident 1 was readmitted to the facility after being hospitalized. This deficient practice resulted in an unnecessary 30-days hospital stay for Resident 1. Findings: Resident 1 was a 76-year-old female admitted to the facility on 2/19/2025 with diagnoses which included metabolic encephalopathy (a brain dysfunction resulting from problems with the body's metabolism or chemical imbalances), spinal stenosis (a condition where the spinal canal narrows, potentially compressing the spinal cord and nerves), type 2 diabetes (a disorder characterized by difficulty in blood sugar control and poor wound healing) and chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing). A review of Resident 1's Minimum Data Set (MDS- a federally mandated resident assessment tool) dated 4/8/2025, indicated Resident 1 was cognitive (thinking) skills were intact. The MDS indicated Resident 1 required total assistance with bathing, dressing and toileting a person performs daily to care for themselves). A review of Resident 1's progress note dated 4/8/2025, indicated Resident 1 was transferred to the general acute care hospital (GACH) due to increased confusion and per family's request. A review of the facility's April 2025 census indicated there was one female bed available from 4/8/2025 to 4/20/2025. A review of the facility's May 2025 census indicated there was one female bed available on 5/2/2025 and 5/28/2025. A review of the facility's census on 5/29/2025 indicated Resident 1 remained out of the facility. During an interview, on 5/29/2025, at 9:15 a.m., the Admission Coordinator (AC) stated he was responsible for facilitating a resident's return to the facility after a hospitalization. The AC stated Resident 1 was transferred to the General Acute Care Hospital (GACH) on 4/8/2025. The AC stated he could not recall if he spoke to a case manager at the GACH where Resident 1 was admitted. The AC stated Resident 1 was denied readmission to the facility by the regional marketer due to a change in Resident 1's insurance. The AC stated the risk of denying readmission to a resident could result in a residents' rights violated. During an interview, on 5/29/2025, at 10:10 a.m., the Director of Nursing (DON), the DON stated the protocol for readmitting a resident required her (the DON) to be informed if a resident was to be readmitted to the facility by the Admission Coordinator. The DON stated she was not aware Resident 1 was denied readmission to the facility. The DON stated, "I did not know the hospital called to return the resident to the facility." The DON stated the facility's regional marketer did not have the authority to deny a resident's return to the facility. The DON stated the risk of not denying a resident's return to the facility could result in a placement issue as the resident wouldn't be able to return to their home which is the facility. A review of the facility's policy and procedures (P&P), titled "Readmission", revised 10/2013, indicated "The Facility will allow residents who were previously residents of the Facility to be readmitted." The facility failed to: 1. Ensure Resident 1 was readmitted to the facility after being hospitalized. This deficient practice resulted in an unnecessary 30-days hospital stay for Resident 1. This violation had a direct or immediate relationship to the health, safety, or security of Resident 1 and other residents in the facility.