Health inspection·December 19, 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 11/4/2025, 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) and then transferred to Long-Term Acute Care (LTAC), was refused readmission back to the Skilled Nursing Facility (SNF). On 11/5/2025, CDPH conducted an unannounced visit to the facility to investigate the complaint allegation. Upon investigation, CDPH determined the facility failed to: 1. Readmit Resident 1 back to the facility after Resident 1 was evaluated and cleared by the LTAC to return to the facility on 10/7/2025. 2. Implement facility's policy and procedure (P&P) titled, "Bed Hold" which indicated the facility shall provide the resident with the first available bed if the bed-hold period has expired. These deficient practices resulted in Resident 1 being denied returning to the facility that has been the resident's home for two years and had the potential for Resident 1 to experience psychosocial harm. Resident 1 was not readmitted to the facility until 11/7/2025. A review of Resident 1's Admission Record, indicated Resident 1 was admitted to the facility on 8/12/2023 with diagnoses including anoxic brain injury, chronic respiratory failure and atrial fibrillation. A review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 7/16/2025, indicated Resident 1 was severely impaired and was dependent on staff with activities of daily living (ADL). A review of Resident 1's Nursing Health Status Note dated 7/16/2025 at 9:37 a.m., indicated Resident 1 was transferred to GACH for generalized body swelling on 7/16/2025. A review of the LTAC treatment team communication note dated 10/7/2025 indicated the LTAC informed the facility's Admission Coordinator (AC) that Resident 1 had a discharge order to return to the facility dated 10/7/2025. During an interview on 11/5/2025 at 8:23 a.m., LTAC Case Manager (CM), stated Resident 1 had a discharge order on 10/7/2025. The CM stated she reached out to the facility's AC on 10/7/2025 and was told there were no beds available for Resident 1. During a telephone interview on 11/5/2025 at 1:19 p.m., the Director of Business Development (DOBD), stated he had been communicating with the LTAC CM regarding Resident 1's re-admission but on the day the request was made to readmit Resident, there were no open beds. During an interview on 11/5/2025 at 1:54 p.m. the Administrator (ADM), indicated he was only made aware of the request for Resident 1's readmission one to two weeks (no specific date recalled) ago and it was not clear why this was not communicated to him. The ADM stated Resident 1 should have been readmitted back to the facility when there was a female bed available unless there was another admission assigned to the open bed. During a concurrent interview and record review on 11/5/2025 at 3:19 p.m. with the Director of Nursing (DON), the Facility Census' dated 10/17/2025, 10/18/2025, 10/19/2025, and 10/23/2025 were reviewed. The DON stated there were open female beds available on 10/17/2025, 10/18/2025, 10/19/2025, and 10/23/2025 but was unable to state why Resident 1 was not readmitted on one of these days. During a concurrent interview and record review on 11/5/2025 at 3:32 p.m. with the ADM, the Facility Census' dated 10/17/2025, 10/18/2025, 10/19/2025, and 10/23/2025 were reviewed. The ADM stated there were open female beds on each of the dates. The Administrator stated he will investigate why Resident 1 was not offered readmission each of the days when female beds were available. During a telephone interview on 11/6/2025 at 12:23 p.m., the DOBD stated he could not explain why Resident 1 was not readmitted to the facility and would not comment on the availability of female beds in October. A review of the facility's policy and procedure (P&P) titled, "Bed Hold," dated 7/2017, the P&P indicated, "If the bed-hold period expires and the resident does not elect to pay to hold the bed, but wishes to return to the facility, the facility will provide the resident with the first available bed." The facility failed to: 1. Readmit Resident 1 back to the facility after Resident 1 was evaluated and cleared by the LTAC to return to the facility on 10/7/2025. 2. Implement facility's policy and procedure (P&P) titled, "Bed Hold" which indicated the facility shall provide the resident with the first available bed if the bed-hold period has expired. These deficient practices resulted in Resident 1 being denied returning to the facility that has been the resident's home for two years and had the potential for Resident 1 to experience psychosocial harm. Resident 1 was not readmitted to the facility until 11/7/2025. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of patients or residents.