Health inspection·February 25, 2026

F627 §483.15(e)(1) Permitting patients to return to facility. A facility must establish and follow a written policy on permitting patients 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. § 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. § 72521. Administrative Policies and Procedures (C) Each facility shall establish at least the following: (2) Policies and procedures for patient admission, leave of absence, transfer, pass and discharge, categories of patient accepted and retained, rates of charge for services included in the basic rate, type of services offered, changes for extra services, limitations of services, cause for termination of services and refund policies applying to termination of services. (3) Policies and procedures for admission or discharge of a patient which state that a patient shall not be admitted or discharged based on race, color, religion, ancestry, national origin, sexual orientation, disability, medical condition, marital status, or registered domestic partner status, except: An unannounced visit was conducted by California Department of Public Health on 12/22/2025 at 9 AM to investigate a complaint and a facility reported incident regarding resident- to- resident altercation. The facility (Facility 1) failed to ensure Resident 1 was admitted to the resident’s previous bed (Bed AA) that was on bed hold (holding or reserving a resident’s bed while the resident is absent from the facility for therapeutic leave or hospitalization) on 1/14/2026. This failure resulted in discharge of Resident 1 from general acute care hospital (GACH) to another Skilled Nursing Facility (SNF) 2 on 1/14/2025 and violates the right of Resident 1 to return to his previous bed that was reserved for the resident. A review of Resident 1’s Admission Record, the Admission Record indicated the resident is a 70- year- old- male resident who was initially admitted to the facility on 3/6/2023 and readmitted 6/6/2025 with diagnoses of dementia (a progressive state of decline in mental abilities) and polyneuropathies (a condition involving widespread damage to many peripheral nerves – those outside the brain and spinal cord). A review of Resident 1’S Minimum Data Set (MDS – a resident assessment tool), dated 12/14/2025, the MDS indicated the resident was severely impaired (never/rarely made decisions) with cognitive skills for daily decision making. The MDS also indicated Resident 1 needed partial/moderate assistance (helper does less than half the effort) with chair/bed-to-chair transfers, upper and lower body dressing, putting on/taking off footwear and personal hygiene. In addition, it indicated Resident 1 needed supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with rolling left and right in bed and going from lying down to sitting on the side of the bed. A review of Resident 1’s Physician (MD) Order from 1/10/2026 at 6:53 PM, Resident 1’s MD Order indicated to transfer Resident 1 to GACH for escalating (the worsening of symptoms) dementia. During an interview on 1/23/2026 at 2:15 PM with the Administrator (ADM), ADM stated Resident 1 was transferred from GACH to SNF 2. ADM stated he had asked if they could find alternative placement for Resident 1 due to an isolated incident of sexual abuse (non-consensual [without the person’s permission] sexual contact of any type with a resident who does not wish to engage in sexual activity or may not have the capacity to consent) that happened involving Resident 1 on 1/10/2026. ADM further stated he did not want the incident to happen again and that SNF 2 was more appropriate to care for Resident 1 than they were. During an interview on 1/23/2026 at 3:26 PM with ADM, ADM stated he does not believe the skilled nursing facility (SNF 2) Resident 1 was transferred to is a locked facility. During an interview on 1/23/2026 at 3:35 PM with the Admissions Director (AD) of SNF 2 (current SNF Resident 1 is residing at), AD stated SNF 2 is not a locked facility and that the inquiry for Resident 1 to be transferred over to them came from Resident 1’s previous SNF (Facility 1) and coordinated by the Facility 1’s Marketer (MK). AD stated they were not given a reason why Resident 1 was being transferred over to them but stated Facility 1 had just asked if SNF 2 could take the resident for now and stated that Resident 1 was transferred to them from GACH on 1/14/2026. During an interview on 1/23/2026 at 3:39 PM with GACH’s Case Manager (CM), CM stated the request for Resident 1’s to be transferred to SNF 2 was not a request from the resident nor Resident 1’s family representative. CM stated Facility 1’s MK had informed CM that the building was undergoing remodeling due to water damage from the rain so the facility cannot admit Resident 1 and the resident needed to be transferred to another facility short term due to Resident 1’s room needing to undergo remodeling. CM stated according to Facility 1’s MK, Resident 1’s family representative was notified and aware of the transfer. A review of Resident 1’s GACH Interdisciplinary Note dated 1/14/2026 at 3:47 PM, Resident 1’s GACH Interdisciplinary Note indicated according to Facility 1 there is a problem at the facility and Resident 1 will be sent to Facility 1’s sister facility which is SNF 2 temporarily and per MK Resident 1’s family was made aware of the transfer and that the transfer will be temporary due to building under construction due to rain damage. During an observation on 1/23/2026 at 3:56 PM in Room 207, there was no observation of any remodeling or maintenance being done in the room. During an interview on 1/23/2026 at 3:58 with Maintenance Supervisor (MS), MS stated the only current work that needs to be done for the building is for rooms 201 and 223 where they are changing the drywall due to leak damage and that there is no work that needs to be done in Room 207. During an interview on 1/23/2026 at 4:10 PM with MK, MK stated she was told by her management director to send a referral for Resident 1 to go to their sister facility SNF 2 due to Resident 1 exhibiting some sort of behavior (not identified). MK stated she was not sure if the transfer was temporary or not and that she does know if Facility 1 is having some type of remodeling but is not sure if it is happening in Resident 1’s previous room or not. During an interview on 1/23/2026 at 4:16 PM with Facility 1’s Director of Nursing (DON), the DON stated Resident 1 was on a 7 day bed hold and if Resident 1 was able to return to the facility within 7 days, it would be his right to come back. The DON further stated that she was not made aware of the reason why Resident 1 was transferred to another SNF. During an interview on 1/23/2026 at 4:45 PM with the DON, the DON stated it is Resident 1’s right to return to the facility because it is Resident 1’s home and stated Resident 1 was previously in room 207. The DON stated she only knows that Rooms 201 and 223 are currently undergoing work. The DON also stated she was not aware that Facility 2, where Resident 1 was transferred, was not a locked facility, and stated SNF 2 should have also been made aware by MK of Resident 1’s behavior prior to accepting the resident. The DON further stated on 1/14/2026, when Resident 1 was transferred to SNF 2, she was not notified and therefore could not confirm whether a bed was available for Resident 1 to be admitted back to Facility 1. During an interview on 1/23/2026 at 5:03 PM with the DON, the DON stated Resident 1 being discharged from GACH on 1/14/2026 would have been within Resident 1’s bed hold and should have been able to come back to the facility on that day in the same room (Room 207) and bed (Bed AA) the resident was previously residing in. The DON stated she is not sure if the transfer to SNF 2 is temporary but stated if Resident 1 returned to Facility 1, she would have placed him back on 1:1 monitoring if there had been no other room available other than Resident 1’s previous room. During an interview with the DON on 2/10/2026 at 12:55 PM, the DON stated Facility 1 admitted Resident 1 back at the facility today (2/10/2026). A review of the facility’s policy and procedure titled “Bed-Holds and Returns,”, review date on 6/2/2025, the policy indicated the resident who seek to return to the facility within the bed hold period defined in the state plan are allowed to return to the resident’s previous room, if available. The policy also indicated, following a hospitalization, reisdent whom staff are concerned about permitting to return to the facility due to the resident’s clinical/ behavioral condition at the time of transfer are evaluated based on the resident’s current condition, not the resident’s condition when originally transferred. The facility (Facility 1) failed to ensure Resident 1 was admitted to the resident’s previous bed (Bed AA) that was on bed hold from 1/10/2026 to 1/14/2026. This failure resulted in discharge of Resident 1 from GACH to another SNF 2 on 1/14/2025 and violates the right of Resident 1 to return to his previous bed that was reserved for the resident. The above violation had a direct or immediate relationship to the health, safety, or security of Resident 1.