Health inspection·January 14, 2025

§483.15(e)(1) Permitting residents to return to the 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. §72527. Patients' Rights. (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. §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 12/17/2024, the California Department of Public Health (CDPH) received a complaint alleging a resident (Resident 3) was taken into police custody after a verbal argument and was not allowed to return to the facility. On 12/17/2024, the CDPH made an unannounced visit to the facility to investigate the complaint. The facility failed to: 1. Implement its policy and procedure (P&P) titled "Readmission", which indicated the facility will readmit residents who required skilled nursing care at the facility and allow residents who were previously at the facility to be readmitted. This resulted in denial of Resident 3's right to return to the facility. Resident 3 was a 66-year-old male, originally admitted to the facility on 6/24/2024 and readmitted on 10/1/2024 with diagnoses including schizophrenia (a mental illness that can affect thoughts, mood, and behavior), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), and hypertension (HTN-high blood pressure). A review of Resident 3's Minimum Data Set ([MDS] a resident assessment tool), dated 10/8/2024, indicated Resident 3's cognitive (the ability to think and process information) skills for daily decision making was moderately impaired. The MDS indicated Resident 3 required setup or clean-up assistance (helper sets up or cleans up; resident completes activity) from staff for 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 3's progress note, dated 12/14/2024 at 9:27 a.m., indicated Resident 3 had a resident-to-resident altercation with another resident (Resident 2) and law enforcement (Police Officer) was contacted. The progress note indicated the police officer arrested Resident 3. During a telephone interview on 12/17/2024 at 7:45 a.m., Licensed Vocational Nurse (LVN 1) stated on 12/14/2024 at approximately 6:30 a.m., Resident 3 walked toward Resident 2 and hit her (Resident 2) on the chest. LVN 1 stated both residents were separated. LVN 1 stated she called and reported the incident to the police. LVN 1 stated police arrived at the facility and arrested Resident 3. LVN 1 stated Resident 3 was arrested taken into police custody. During an interview on 12/17/2024 at 11:45 a.m., the Director of Nursing (DON) stated the facility received a phone call from a Police Officer and was informed that Resident 3 will be released from jail and sent back to the facility. The DON stated the facility told the Police Officer they will no longer provide care and services to Resident 3. The DON stated the facility would not readmit Resident 3. During an interview on 12/17/2024 at 12:10 p.m., the Administrator (ADM) stated the facility would not readmit Resident 3 back to the facility because he was arrested and taken to jail. During a telephone interview on 12/18/2024 at 10:19 a.m., Police Officer (PO 1) stated on the morning of 12/14/2024 (did not remember exact time) he (PO 1), received a report for a resident-to-resident altercation at the facility. PO 1 stated he arrived at the facility on 12/14/2024 at 6:30 a.m. and met with LVN 1 and Resident 3 in Resident 3's room. PO 1 stated LVN 1 reported Resident 3 hit Resident 2 and she (LVN 1) wanted Resident 3 to be arrested for assault (physical contact) and battery (knowingly causing bodily harm). PO 1 stated he advised LVN 1 to have Resident 3 psychiatrically evaluated (a mental health assessment that evaluates a person's emotional, behavioral, and psychological well-being) at the facility and transported to the hospital if necessary. PO 1 stated LVN 1 called the DON, and both (LVN 1, and DON) demanded Resident 3 be arrested. PO 1 stated he provided LVN 1 a document titled "Private Person's Arrest Statement Form", ([PPASF] a document signed by someone requesting for an arrest) PO 1 stated, LVN 1 signed the PPASF to have Resident 3 taken into custody. PO 1 stated Resident 3 was transported to the police station for battery charges. PO 1 stated on the evening of 12/14/2024 at 7:30 p.m., he received a phone call and was informed that Resident 3 would be released from jail and sent back to the facility. PO 1 stated the facility told him Resident 3 could not return to the facility and would not be provided with care and services. PO 1 transported Resident 3 from jail to a general acute care hospital (GACH) on 12/14/2024. A review of the facility's P&P titled "Readmission ", revised 10/1/2013, indicated the facility will provide readmission of the residents who required skilled nursing care at the facility. The P&P indicated the facility will allow residents who were previously residents at the facility to be readmitted. The facility failed to: 1. Implement its P&P titled "Readmission", which indicated the facility would provide readmission of the residents who require skilled nursing care at the facility and allow residents who were previously at the facility to be readmitted. This resulted in denial of Resident 3's right to return to the facility. This violation caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to Resident 3.