Health inspection·September 10, 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 Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. On 7/29/2025, the California Department of Public Health (CDPH) received a complaint alleging a resident (Resident 1), who was transferred to a General Acute Care Hospital (GACH), was refused readmission to the Skilled Nursing Facility (SNF), where the resident was transferred from. On 7/30/2025, CDPH conducted an unannounced visit to the facility to investigate the complaint allegation. Upon investigation CDPH determined the facility failed to: 1. Re-admit Resident 1 back to the facility after Resident 1 was evaluated and cleared (by the GACH) to return to the facility on 7/23/2025. 2. Ensure the facility followed its policy and procedure (P&P) titled, “Bed Holds” which indicated “if the resident’s hospitalization or therapeutic leave exceeds the bed-hold period of (7) days, the resident may return to the facility to their previous room, if available, or immediately upon the first availability of a bed, if the resident requires the services provided by the facility.” These deficient practices resulted in Resident 1 being unable to return to the facility that has been considered their home, for about 12 months after being deemed appropriate for transfer to the SNF. As a result, Resident 1 was transferred to another SNF, and both Resident 1 and Family Member (FM) 1 experienced psychosocial harm, including emotional distress and dissatisfaction. A review of Resident 1’s Admission Record indicated Resident 1 a 68-year-old male, was admitted to the facility on 7/24/2024 with diagnoses including psychotic disorder with hallucinations and major depressive disorder.   A review of Resident 1’s “History and Physical Examination” (H&P), dated 7/26/2024, indicated Resident 1 had the capacity to understand and make decisions.   A review of Resident 1’s Minimum Data Set (MDS- a resident assessment tool), dated 4/28/2025 indicated Resident 1’s cognitive function was intact. The MDS indicated Resident 1 required setup assistance with eating, oral hygiene, moderate assistance with toileting hygiene, personal hygiene, maximal assistance with showering, and dressing.   A review of Resident 1’s Physician’s Order Summary Report, dated 7/15/2025 indicated an order to transfer Resident 1 to a GACH for psychological evaluation and to have the resident’s bed on hold for seven days.   A review of Resident 1’s Notice of Transfer/Discharge, dated 7/15/2025 indicated the facility transferred Resident 1 to the GACH.   A review of Resident 1’s Nursing Life Progress Note from the GACH, dated 7/23/2025, indicated the physician at the GACH ordered to discharge Resident 1 back to the facility on 7/23/2025. A review of Resident 1’s Discharge Planning note from the GACH, dated 7/23/2025, at 3:07 p.m. indicated the Director of Community Liaison (DCL) 1 at the facility  informed Discharge Care Planner (DCP) 1 at the GACH that the facility did not have a bed available for the resident t but they will refer to a sister facility who can accommodate Resident 1 until a bed becomes available. The Discharge Planning note indicated, DCP1 spoke to Resident 1’s family member (FM) 1 and FM 1 did not want Resident 1 moved to a new facility, stating Resident 1 had been there for about a year. DCP 1 informed the facility that the patient needs to be discharged back to the facility. A review of Resident 1’s Nursing Progress Notes, dated 7/24/2025 at 10:46 p.m., indicated the Director of Staff Development (DSD) informed FM1 that the facility had no available beds to accept Resident 1 from the GACH.   A review of Resident 1’s GACH’s Discharge Summary, dated 7/25/2025 at 3:05 p.m., indicated the GACH discharged Resident 1 to another facility.   During an interview on 7/30/2025 at 1:52 p.m., Resident 1 stated the facility told FM1 the facility could not accept Resident 1 back to the facility because there was no bed available. Resident 1 stated when FM 1 visited the facility to pick up Resident 1’s belongings on 7/26/2025, FM 1 saw empty beds in the facility.  Resident 1 stated that made him and FM 1 upset.   During a concurrent interview and record review on 7/30/2025 at 3:56 p.m. with the Director of Nursing (DON), the Facility Census’, dated 7/23/2025 ,7/24/2025, 7/25/2025, 7/26/2025, 7/27/2025, and 7/28/2025 were reviewed. The DON stated there were open beds available on 7/24/25, and the information given by the DSD to FM 1 on 7/24/2025 was not accurate. The DON stated if Resident 1 wished to return to the facility, he could have been readmitted. The DON stated there were empty beds available on the following dates: On 7/23/25, there were total 3 female and 1 male empty bed available. On 7/24/25, there were total 3 female and 1 male empty bed available. On 7/25/25, there were total 3 female and 1 male empty bed available. On 7/26/25, there were total 4 female and 1 male empty bed available. On 7/27/25, there were total 4 female and 1 male empty bed available. On 7/28/25, there were total 4 female beds 2 male empty bed available.   During an interview on 7/31/2025 at 1:56 p.m., the DON stated residents have the right to return to the facility, even after the seven-day bed hold period ends, if the resident wishes to return to the facility.  During an interview on 7/13/2025 at 3:41p.m., the Administrator (ADM) stated the facility was considered as the residents' home. The ADM stated if a resident’s seven-day bed hold had expired the facility should have accepted the resident back to the facility if there was a bed available. The ADM stated if the resident was refused reentry, they may have felt unwanted by the facility, which could have caused the resident anxiety and distress.   A review of the facility’s policy and procedure (P&P) titled, “Bed hold”, revised 12/2023, the P&P indicated “If the resident’s hospitalization or therapeutic leave exceeds the bed-hold period of (7) days, the resident may return to the facility to their previous room, if available, or immediately upon the first availability of a bed, if the resident requires the services provided by the facility.”   The facility failed to: 1. Re-admit Resident 1 back to the facility after Resident 1 was evaluated and cleared (by the GACH) to return to the facility on 7/23/2025. 2. Ensure the facility followed its policy and procedure (P&P) titled, “Bed Holds” which indicated “if the resident’s hospitalization or therapeutic leave exceeds the bed-hold period of (7) days, the resident may return to the facility to their previous room, if available, or immediately upon the first availability of a bed, if the resident requires the services provided by the facility.” These deficient practices resulted in Resident 1 being unable to return to the facility that has been considered their home, for about 12 months after being deemed appropriate for transfer to the SNF. As a result, Resident 1 was transferred to another SNF, and both Resident 1 and FM 1 experienced psychosocial harm, including emotional distress and dissatisfaction. These violations, jointly, separately or in any combination, had a direct or immediate relationship to the health, safety, or security of Resident 1.