Health inspection·September 26, 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 9/9/2025, 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 9/10/2025 at 7:45 a.m., the CDPH conducted an unannounced investigation at the facility. The facility failed to: 1. Follow its policy and procedure (P&P) titled "Bed Hold," which indicated "When the resident or his/her representative provides notice within 24 hours of transfer that the resident elects his/her right to hold the bed, the Facility keeps that bed available for seven (7) days." 2. Follow its P&P titled, "Readmission," which indicated "The Facility will allow residents who were previously residents of the Facility to be readmitted to the Facility." 3. Ensure Resident 1 who was transferred to a General Acute Care Hospital (GACH) on 9/2/2025 due to persistent cough was readmitted to the facility when the GACH cleared him to return to the facility on 9/6/2025. As a result, Resident 1 remained in the hospital for four days beyond the initial date of discharge. Resident 1 was a 64-year-old male initially admitted to the facility on 5/8/2024 and readmitted on 8/27/2025. Resident 1's diagnoses included metabolic encephalopathy (a condition where the brain's metabolism is disrupted, leading to altered brain function), pneumonia (an infection/inflammation in the lungs), type 2 diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing) and schizophrenia (a mental illness that is characterized by disturbances in thought). A review of Resident 1's history and physical (H&P), dated 8/28/2025, indicated Resident 1 did not have the capacity to make decisions and was unable to make his needs known. A review of Resident 1's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 9/2/2025, indicated Resident 1 was cognitive (thinking) skills were severely impaired. The MDS also indicated Resident 1 was dependent on staff members with 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 Change of Condition (COC) form, dated 9/2/2025, indicated Resident 1 was transferred to the GACH due to persistent (existing for a long or longer than usual time or continuously) cough, increased secretions (mucus) despite receiving intravenous (IV) antibiotic treatment for pneumonia. A review of the facility's census dated 9/3/2025 indicated Resident 1's bed was occupied by another resident due to a room change. During a telephone interview, on 9/10/2025 at 8:15 a.m., with the GACH Social Worker (GACHSW), the GACHSW stated the facility's Regional Marketer (RM) informed her that Resident 1 was not coming back to the facility. The GACHSW stated the RM also stated the facility will not honor Resident 1's bedhold (a policy that lets a resident keep their bed in a care facility when on a temporary leave with the expectation that they will return). The GACHSW stated Resident 1 had GACH discharge orders for 9/6/2025 and the facility stopped answering the phone. The GACHSW stated, "If we can get him back to the facility, then that will be fine. " During an interview, on 9/10/2025, at 9:03 a.m., with the Admission Coordinator (AC), the AC stated he was responsible for facilitating a residents' return to the facility after a hospitalization. The AC stated all residents who were transferred to a hospital were required to have a 7-day bedhold. The AC stated Resident 1 was transferred to the GACH on 9/2/2025. The AC stated he was informed by the facility's RM that Resident 1's Public Guardian (PG) did not want Resident 1 to return to the facility. The AC stated the risk of not readmitting a resident could result in a resident not being able to return to what was considered their home. During an interview, on 9/10/2025 at 9:46 a.m., with the Regional Marketer (RM), the RM stated all residents required a bedhold for up to 7 days if transferred to a GACH. The RM stated a case manager at the GACH called and informed her that Resident 1 would not be returning to the facility per Resident 1's PG's request due to being unhappy with the care at the facility. The RM stated she called Resident 1's PG and Resident 1's PG stated she did not say that. The RM stated the GACH's discharge planner called the facility on 9/8/2025 stating Resident 1 was able to return to the facility. The RM stated she informed the GACH's discharge planner that she spoke with the GACH's case manager who stated Resident 1 was not returning to the facility. During an interview, on 9/10/2025 at 10:23 a.m., with the Director of Nursing (DON), the DON stated the protocol for readmitting a resident required her (the DON) to be notified if a resident was to be readmitted to the facility by the AC and RM. The DON stated she was not aware of Resident 1 being denied readmission to the facility. The DON stated the risk of not readmitting a resident could result in a resident's rights issue. During an interview, on 9/10/2025 at 11:33 a.m., with Resident 1's PG, Resident 1's PG stated she was informed by GACHSW that Resident 1 could not return to the facility. Resident 1's PG stated the GACH SW informed her that the facility stated she did not want Resident 1 to return. Resident 1's PG stated she hadn't spoken to anyone at the facility. Resident 1's PG stated the facility had given Resident 1's bed away. Resident 1's PG stated she called the RM and told her she never said Resident 1 could not return to the facility. Resident 1's PG stated the facility did not honor Resident 1's bedhold. 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 to the Facility." A review of the facility's policy and procedures (P&P), titled "Bedhold", revised 7/2027, indicated "When the resident or his/her representative provides notice within 24 hours of transfer that the resident elects his/her right to hold the bed, the Facility keeps that bed available for seven (7) days." The facility failed to: 1. Follow its (P&P) titled "Bed Hold," which indicated "When the resident or his/her representative provides notice within 24 hours of transfer that the resident elects his/her right to hold the bed, the Facility keeps that bed available for seven (7) days." 2. Follow its P&P titled, "Readmission," which indicated "The Facility will allow residents who were previously residents of the Facility to be readmitted to the Facility." 3. Ensure Resident 1 who was transferred to a GACH on 9/2/2025 due to persistent cough was readmitted to the facility when the GACH cleared him to return to the facility on 9/6/2025. As a result, Resident 1 remained in the hospital for four days beyond the initial date of discharge. This violation had a direct or immediate relationship to the health, safety, or security of Resident 1 and other residents in the facility.