Health inspection·July 10, 2025

CFR §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. CCR 72515. Admission of Patients. The licensee shall: (a) Admit a patient only on physician's orders. (b) Accept and retain only those patients for whom it can provide adequate care. CCR 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 5/27/2025, 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 05/28/2025, CDPH conducted an unannounced visit at the facility to investigate the complaint allegation. During the investigation CDPH determined that on 3/13/2025, Resident 1 was transferred to a GACH due to desaturation (a decrease in the oxygen saturation (SpO2) of the blood) and altered mental status (a change in a person's cognitive [ability to think, understand, learn, and remember] function, including alertness, attention, orientation, and memory). The GACH cleared Resident 1 to return to the facility on 3/31/2025, but the facility refused to readmit Resident 1. The facility failed to: 1. Re-admit Resident 1 to the facility on 3/31/2025 after the resident was evaluated, treated, and cleared by the GACH to return to the facility. 2. Ensure the facility followed its policy and procedure (P&P) titled, "Transfer and Discharge (including AMA)," dated 2022, which indicated "The resident will be permitted to return to the facility upon discharge from the acute care setting." These deficient practices resulted in Resident 1 remaining at the GACH after Resident 1 was deemed appropriate for discharge and return to the facility on 3/31/2025 but was denied re-admission by the facility. Resident 1 did not return to the facility. These deficient practices resulted in Resident 1's temporary loss of residence and negative psychosocial outcome evidenced by Resident 1's verbalization of feeling fearful and anxious. As of 5/28/2025 Resident 1 was still at the GACH. A review of Resident 1's Admission Record, indicated Resident 1 was admitted to the facility on 8/24/2022, with diagnoses including cerebral infarction (damage to the brain from interruption of its blood supply), and atrial fibrillation (irregular heartbeat). A review of Resident 1's History and Physical (H&P), dated 8/7/2024, indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set ([MDS], resident assessment tool), dated 3/6/2025, indicated, Resident 1 required partial/moderate assistance (helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort) for toileting, shower/bath self. During a concurrent interview and record review on 5/28/2025 at 9:00 a.m. with Registered Nurse Supervisor (RNS), the Facility's Census (the number of inpatients present in a healthcare facility at a specific time) dated 5/27/2025 was reviewed. The Facility's Census indicated, the facility had nine open beds, which included two female beds. RNS confirmed that the facility had available beds on 5/27/2025. RNS stated the facility's process was to hold a bed for seven-day when a resident transferred to the hospital. RNS stated even if the resident's bed hold goes beyond seven days, the residents may return to the facility if the bed was still available or to the next available bed. RNS stated residents should be able to return to the facility because it was the residents' home. RNS stated residents could become depressed and feel unwanted if they were not able to return to their home/facility. During an interview on 5/28/2025 at 10:20 a.m. the Admission Coordinator (AC), stated residents should be able to return to the facility once they were discharged from the hospital. AC stated that even if the residents' seven-day bed hold had expired and there was another bed available, the residents have the right to be able to return to the facility. AC stated Resident 1 should have been able to return to the facility, because the facility was Resident 1's home. AC stated Resident 1 probably felt sad and worried about where she would live. AC stated she does not remember why Resident 1 was not accepted back to the facility. A review of Resident 1's Physician's Order Summary, dated 3/13/2025, indicated an order to transfer Resident 1 to GACH due to desaturation and altered mental status. The Physician's Order Summary indicated having a seven-day bed hold. During a phone interview on 5/29/2025 at 8:45 a.m. with Resident 1, Resident 1 stated she had been living at the facility for three years. Resident 1 stated she was transferred to the hospital due to difficulty breathing. Resident 1 stated she did not have any concerns with the staff during her stay at the facility and was looking forward to returning after her discharge from GACH. Resident 1 stated she was informed by the staff (unknown) at the hospital that the facility would not accept her back at the facility. Resident 1 stated she was informed the facility could not take her back because her seven-day bed hold had expired. Resident 1 began to cry during our conversation and stated she became extremely fearful because she did not know where she would go. Resident 1 stated that she considered the facility to be her home. Resident 1 stated she became anxious and was worried about her belongings that were left at the facility. Resident 1 stated the facility began to constantly call her son to pick up her belongings from the facility and that also made her anxious and depressed. Resident 1 stated she currently does not want to return to the facility because she feels like they did not want her. A review of Resident 1's GACH's Discharge Plan Update, dated 3/31/2025, with Admission Coordinator (AC) indicated Resident 1's seven-day bed hold had expired and the facility was not able to accept Resident 1 back. During a concurrent interview and record review on 5/29/2025 at 9:50 a.m. with the Director of Nursing (DON), the Facility's Census dated 3/31/2025 was reviewed. The Facility Census indicated Resident 1's room prior to discharge from the GACH was unoccupied. The DON stated Resident 1's room was empty, and Resident 1 should have been accepted back to the facility. The DON stated that even though Resident 1's seven-day bed hold had expired the facility should have accepted her back to the facility. The DON stated it was the responsibility of the facility to ensure the resident returned to the facility because it was considered the residents' home. The DON stated Resident 1 probably felt unwanted by the facility and could have caused her to become anxious and depressed which could have had a negative impact on her health. During an interview on 5/29/2025 at 10:15 a.m. the Administrator (ADM), stated Resident 1 should have been accepted back to the facility. The ADM stated that he does not know why she was not accepted back to the facility. The ADM stated Resident 1 had a share of cost balance and she was not able to pay. The ADM stated Resident 1 did not want to return to the facility. The ADM stated if the facility told Resident 1 initially that he could not return to the facility and then told Resident 1 he could return, Resident 1 would not want to return to the facility because he would not trust the staff. A review of the facility's P&P titled, "Transfer and Discharge (including AMA)," dated 2022, indicated "The resident will be permitted to return to the facility upon discharge from the acute care setting." The facility failed to: 1. Re-admit Resident 1 to the facility on 3/31/2025 after the resident was evaluated, treated, and cleared by the GACH to return to the facility. 2. Ensure the facility followed its P&P titled, "Transfer and Discharge (including AMA)," dated 2022, the P&P indicated "The resident will be permitted to return to the facility upon discharge from the acute care setting." These deficient practices resulted in Resident 1 remaining at the GACH after Resident 1 was deemed appropriate for discharge back to the facility on 3/31/2025 but was denied re-admission by the facility. Resident 1 did not return to the facility. These deficient practices resulted in Resident 1's temporary loss of residence and negative psychosocial outcome evidenced by Resident 1's verbalization of feeling fearful and anxious. As of 5/28/2025 Resident 1 was still at the GACH. This violation had a direct relationship to the health, safety, or security of the residents.