Health inspection·September 26, 2025

§483.15 (e)(1) Bed Hold and Permitting Residents to Return Facilities must develop and implement policies for bed-hold and permitting residents to return following hospitalization or therapeutic leave. These policies apply to all residents, regardless of their payment source. The facility policies must provide that residents who seek to return to the facility within the bed-hold period defined in the State plan are allowed to return to their previous room, if available. Additionally, residents who seek to return to the facility after the expiration of the bed-hold period or when state law does not provide for bed-holds are allowed to return to their previous room if available or immediately to the first available bed in a semi-private room. 22CCR §72520. Bed Hold (c) A licensee who fails to meet these requirements shall offer to the patient the next available bed appropriate for the patient's needs. This requirement shall be in addition to any other remedies provided by law. 22CCR §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 9/11/2025, the California Department of Public Health (CDPH) received a complaint indicating a resident (Resident 1) was denied readmission to the facility after being hospitalized. On 9/12/2025 at 7:22 a.m., the CDPH conducted an unannounced visit to the facility to investigate the allegation. The facility failed to: 1. Follow its policy and procedure (P&P) titled "Bed Hold," which indicated "in the event that the resident is in the hospital for more than seven (7) days, meet the standards for skilled nursing care, and is Medi-Cal/Medicaid eligible, the facility will readmit the resident to his/her previous room or the first available bed in a semi-private room." 2. Follow its P&P titled, "Readmission," which indicated "the facility will allow residents who were previously residents of the facility to be readmitted to the facility". 3.Ensure Resident 1 who was transferred to a General Acute Care Hospital (GACH) on 8/15/2025 due to altered mental status ([AMS] - a significant change in a person's awareness, consciousness, and cognitive function, such as confusion, disorientation, drowsiness, or unresponsiveness) was readmitted to the facility when the GACH cleared him to return to the facility on 8/29/2025. As a result, Resident 1 remained in the hospital for 14 days beyond the initial date of discharge. Findings: Resident 1 was a 63-year-old male initially admitted to the facility on 8/16/2024 and readmitted on 7/6/2025. Resident 1's diagnoses included liver cirrhosis (a chronic liver disease characterized by the formation of scar tissue in the liver), chronic obstructive pulmonary disease ([COPD] - a chronic lung disease causing difficulty in breathing), and bipolar disorder (mood swings that range from the lows of depression to elevated periods of emotional highs). A review of Resident 1's History and Physical (H&P), dated 7/7/2025, indicated Resident 1 could make needs known but could not make medical decisions. A review of Resident 1's Social Services Assessment, dated 7/28/2025, indicated Resident 1 had no active discharge plan to return to the community and to remain as long-term care resident. A review of Resident 1's Minimum Data Set ([MDS] - a resident assessment tool), dated 8/15/2025, indicated Resident 1 had modified independence in cognitive skills (problems with ability to think, use judgment, and reason) for daily decision making. The MDS also indicated Resident 1 was independent (resident completes the activity with no assistance from a helper) with eating, oral hygiene, and personal hygiene. A review of Resident 1's Progress Notes, dated 8/15/2025 at 4:20 p.m., indicated Resident 1 was transferred to the GACH for AMS. A review of Resident 1's GACH Discharge Planning Progress Note, dated 8/29/2025, /31/2025, 9/2/2025, 9/3/2025, 9/5/2025, and 9/8/2025 indicated Resident 1 had a discharge order to returned to the facility however, the facility's Admission Director (AD) denied to readmit Resident 1 to the facility because there was no male bed available. During a concurrent interview and record review on 9/12/2025 at 10:00 a.m. with the AD, the facility's Daily Census Report dated 8/29/2025 to 9/11/2025, were reviewed. The AD stated one male bed was available from 8/29/2025 through 9/11/2025. The AD stated she received a call from the GACH's discharge planner multiple times inquiring of Resident 1's male bed availability. The AD stated the Administrator (ADM) denied Resident's readmission to the facility. The AD stated she did not have any answer why Resident 1 was denied by the ADM for readmission to the facility. The AD stated Resident 1 was still not readmitted to on 9/11/2025. During an interview on 9/12/2025 at 10:41 a.m., with the Director of Nursing (DON), the DON stated Resident 1 was transferred to the GACH on 8/15/2025 and Resident 1's last day of bed hold (a resident's right to keep a bed vacant and available for seven days after their transfer to the hospital in anticipation of their return to the facility) was 8/21/2025. The DON stated Resident 1 should have been allowed to come back to the facility even after the seven-day bed hold for continuity of care and to prevent Resident 1 from feeling abandoned. The DON stated the facility could meet the needs of Resident 1 and there was no reason to deny Resident 1's readmission to the facility. During an interview on 9/12/2025 at 11:15 a.m., with the ADM, the ADM stated she accepted responsibility of not allowing Resident 1's return to the facility. The ADM stated the risk of denying readmission to a resident could result in a violation of resident's rights. A review of the facility's P&P titled, "Readmission," dated 10/1/2023, indicated "the facility will allow residents who were previously residents of the facility to be readmitted to the facility". A review of the facility's P&P titled, "Bed Hold," dated 7/2017, indicated "in the event that the resident is in the hospital for more than seven (7) days, meets the standards for skilled nursing care, and is Medi-Cal/Medicaid eligible, the facility will readmit the resident to his/her previous room or the first available bed in a semi-private room". The facility failed to: 1. Follow its P&P titled "Bed Hold," which indicated "in the event that the resident is in the hospital for more than seven (7) days, meets the standards for skilled nursing care, and is Medi-Cal/Medicaid eligible, the facility will readmit the resident to his/her previous room or the first available bed in a semi-private room." 2. Follow its policy and procedure (P&P) titled, "Readmission," which indicated "the facility will allow residents who were previously residents of the facility to be readmitted to the facility". 3.Ensure Resident 1 who was transferred to a General Acute Care Hospital (GACH) on 8/15/2025 due to altered mental status ([AMS] - a significant change in a person's awareness, consciousness, and cognitive function, such as confusion, disorientation, drowsiness, or unresponsiveness) was readmitted to the facility when the GACH cleared him to return to the facility on 8/29/2025. This deficient practice resulted in Resident 1 remaining in the hospital for 14 days beyond the initial date of discharge. This violation had a direct or immediate relationship to the health, safety, or security of Resident 1 and other residents in the facility.