Health inspection·January 21, 2026

§483.15(e)(2) Permitting residents to return to facility. Readmission to a composite distinct part. When the facility to which a resident returns is a composite distinct part (as defined in § 483.5), the resident must be permitted to return to an available bed in the particular location of the composite distinct part in which he or she resided previously. If a bed is not available in that location at the time of return, the resident must be given the option to return to that location upon the first availability of a bed there. §483.15(e)(1)(i)(A)(B) 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 §72523(a) 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 12/5/2025, the California Department of Public Health (CDPH) received a complaint alleging a resident (Resident 1) was dumped after being transferred to a General Acute Care Hospital (GACH) on 10/30/2025 for evaluation following behaviors of singing too loud and on 11/2/2025 when she was cleared to return to the facility, the resident was not allowed readmission. Resident 1 remained at the GACH until 11/28/2025 when she was transferred to a different facility. On 12/5/2025, the CDPH conducted an unannounced visit to investigate the complaint allegations. The facility failed to: 1. Readmit Resident 1, who was transferred to a GACH on 10/30/2025, for behaviors of uncontrollable singing, when she was cleared by the GACH on 11/7/2025. 2. Follow their undated Policy and Procedure, (P/P), titled "Notification of Bed Hold" which indicated if a resident was transferred to a GACH the facility shall afford the resident a bed hold of seven days. 3. Follow their P/P titled, "Bed-Holds and Returns" revised 10/2022 which indicated after the bed hold period expired residents were allowed to return to their previous room if available or immediately to the first available bed. These deficient practices resulted in Resident 1 remaining in the GACH from 11/7/2025 to 11/28/2025 a total of 21 days, after attempts to transfer Resident 1 back to the facility were made by the GACH on 11/7/2025. These deficient practices placed Resident 1 at risk for disruption in her routine, anxiety and non-continuity of care. Resident 1, a 86-year-old-female, was admitted to the facility on 2/20/2021with diagnoses including Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), and dementia (a progressive state of decline in mental abilities). A review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool), dated 10/15/2025 indicated Resident 1 had severe cognitive (the ability to think and reason) impairment. The MDS indicated Resident 1 required substantial/maximal assistance to complete most of her activities of daily living ([ADLs] activities such as bathing, dressing and toileting a person performs daily) A review of Resident 1's SBAR [(situation, background, assessment, recommendation] a communication tool used by healthcare workers when there is a change of condition among the residents) dated 10/30/2025 indicated Resident 1 had uncontrollable singing of unknown words creating a disturbance amongst her roommates, and refusal to have her activities of daily living ([ADLs] activities such as bathing, dressing and toileting a person performs daily) completed by staff. A review of Resident 1's Physician's Order, dated 10/30/2025 indicated to transfer Resident 1 to a GACH for further evaluation and intervention related to dementia. A review of Resident 1's Bed Hold Notice, dated 10/30/2025 indicated the Bed Hold Notice start date was 10/30/2025 and the Bed Hold notice stop date was 11/5/2025 (six days). The Bed Hold Notice indicated if a resident was transferred to a GACH the facility shall afford the resident a bed hold of seven days which may be exercised by the resident or the resident's representative. A review of Resident 1's Notice of Proposed Transfer and Discharge dated 10/30/2025 (the same day Resident 1 was transferred to the GACH) indicated Resident 1's discharge was necessary for Resident 1's welfare and her needs could not be met in the facility. The Notice of Proposed Transfer and Discharge was not signed by Resident 1 or Resident 1's FM, instead there was a printed name in the space designated for a signature. The Notice of Proposed Transfer and Discharge did not indicate how far in advance the notice should be given to the resident and/or the resident's representative. A review of Resident 1's Licensed Nursing Note, dated 10/30/2025, and timed at 6:38 p.m., indicated Resident 1 was transferred to a GACH emergency room for treatment and evaluation by ambulance at 6:30 p.m. A review of the Facility's Census dated 11/2/2025 indicated one female bed was available and a bed was held for Resident 1. A review of the Facility's Census dated 11/28/2025 indicated four female beds were available. A review of the GACH's Emergency Department (ED) Record dated 10/30/2025 indicated Resident 1 arrived to the ED on 10/30/2025 at 6:58 p.m. A review of the GACH's Progress Note, dated 11/7/2025 indicated on 11/7/2025 the Social Worker (SW) received a call from the facility's Admissions Coordinator (AC) informing her the facility would not be accepting Resident 1 back to the facility after she was stabilized. The Progress Note indicated the facility's psychiatrist informed her (SW) that the facility did not want Resident 1 to return to the facility. A review of the GACH's Progress Note, dated 11/28/2025 and timed at 12:19 p.m., indicated the SW informed Resident 1's FM that another facility accepted Resident 1 for admission, but the FM requested that the SW contact the facility where Resident 1 was transferred from (10/30/2025) to see if they would accept Resident 1 back. The Progress Note indicated the SW spoke to the facility's AC and the AC stated, per the facility's Administrator (ADM), they were not going to accept Resident 1 back because they felt she needed a placement at a facility that could handle her behaviors. The Progress Note indicated the facility "did not give the patient a chance to improve before making that decision." A review of the GACH's Discharge Orders dated 11/28/2025 indicated Resident 1 was transferred to another skilled nursing facility on 11/28/2025 (21 days after Resident 1 was ready for transfer back to the facility). During an interview on 12/8/2025 at 11:13 a.m., the GACH's SW stated on 11/7/2025 she called the facility to make sure they were going to readmit Resident 1. The SW stated she spoke to the facility's AC, who told her they were not going to readmit Resident 1 back because she needed a more behavioral focused facility. The SW stated the facility did not give Resident 1 a chance to improve before deciding to send her to another facility. The SW stated she spoke to the facility's psychiatrist (date unknown) who told her the facility did not want to take Resident 1 back, so she (SW) began looking for new placement. The SW stated on 11/28/2025, per the FM's request, she called the facility again to inquire if they would take Resident 1 back, but the AC stated they would not readmit Resident 1 because she needed a facility that was more behavioral focused. During an interview on 12/8/2025 at 11:27 a.m., the AC stated she did not document the day or time, but she spoke to a female (SW) from the GACH who asked her about transferring Resident 1 back to the facility. The AC stated they declined Resident 1's readmittance because their psychiatrist wanted to send her to a facility with a behavioral unit. During an interview on 12/8/2025 at 11:34 a.m., the DON stated due to Resident 1's increased agitation and increased behavioral concerns, she spoke to their psychiatrist on 11/28/2025 and requested that Resident 1 be sent to a facility better suited for her behavioral concerns and the psychiatrist agreed. A review of the facility's undated P/P titled "Notification of Bed Hold" indicated if a resident was transferred to a GACH the facility shall afford the resident a bed hold of seven days, which may be exercised by the resident or the resident's representative. A review of facility's P&P titled "Bed-Holds and Returns" revised 10/2022 indicated residents who seek to return to the facility within the bed-hold period were allowed to return to their previous room, if available. Residents who seek to return to the facility after the stated bed-hold period had expired (or when state law did not provide for bed-holds) were allowed to return to their previous room if available or immediately to the first available bed in a semi-private room provided the resident still required the services provided by the facility; and was eligible for Medicare skilled nursing facility or Medicaid nursing facility services A review of Resident 1's Notice of Proposed Transfer and Discharge dated 10/30/2025 and timed at 6:41 pm., indicated the following criteria for discharge: 1. The discharge is necessary for your welfare, and the needs cannot be met in the facility. 2. The discharge is appropriate because your health has improved sufficiently so that you no longer require services provided by this facility. 3. The safety of individuals in the Facility is endangered by your presence. 4. The health of individuals in the Facility is endangered by your presence. 5. You have failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medi-Cal) a stay at the facility. If you become eligible for Medi-Cal after admission to the facility, the Facility may only charge you allowable charges under Medi-Cal. Also, if you are admitted as Medicare eligible in the Facility, the Facility may charge you only allowable charges under Medicare. 6. The facility is ceasing to operate The facility failed to: 1. Readmit Resident 1, who was transferred to a GACH on 10/30/2025, for behaviors of uncontrollable singing, when she was cleared by the GACH on 11/7/2025. 2. Follow their undated P/P titled "Notification of Bed Hold" which indicated if a resident was transferred to a GACH the facility shall afford the resident a bed hold of seven days. 3. Follow their P/P titled, "Bed-Holds and Returns" revised 10/2022 which indicated after the bed hold period expired residents were allowed to return to their previous room if available or immediately to the first available bed. These deficient practices resulted in Resident 1 remaining in the GACH from 11/7/2025 to 11/28/2025 a total of 21 days, after attempts to transfer Resident 1 back to the facility were made by the GACH on 11/7/2025. These deficient practices placed Resident 1 at risk for disruption in her routine, anxiety and non-continuity of care. These violations, jointly, separately or in any combination, had direct or immediate relationship to the health, safety, or security and welfare of Resident 1.