Health inspection·March 10, 2025

The following reflects the findings of the California Department of Public Health during the investigation of complaint number CA00943628. A Class "B" Citation was written. REGULATORY VIOLATIONS: Title 42 Code of Federal Regulations: §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. §483.15(e)(2) Readmission to a composite distinct part. When the facility to which a resident return 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. Title 22 California Code of Regulations: § 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 1/31/2025, the California Department of Public Health (State Survey Agency [SSA]) made an unannounced visit to the facility to investigate a complaint related to refusal to readmit a resident. The facility failed to implement its' policy and procedures (P&P) titled "permitting Resident to Return To Facility" by failing to permit Resident 1 to return to the facility following a hospitalization on 11/16/2024, 11/24/2024, and 2/3/2025. Resident 1 was transferred to general acute care hospital (GACH) on 8/24/2024. As a result, there is a potential for psychosocial harm to Resident 1, and had caused emotional distress and confusion for Resident 1's decision maker family member (FM). During a review of Resident 1's "Admission Records," dated 1/31/2025, the admission record indicated, Resident 1, a 59 year-old female was initially admitted to the facility on 8/30/2024 and readmitted on 10/23/2024 with a diagnosis including chronic respiratory failure (a condition in which your blood doesn't have enough oxygen causing shortness of breath and difficulty breathing, often caused by a disease or injury) dysphagia (difficulty swallowing) generalized muscle weakness (reduced strength in one or more muscles) type 2 diabetes (A long-term condition in which the body has trouble controlling blood sugar and using it for energy). Resident 1's face sheet indicated FM was the emergency contact family member. During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 9/5/2024, indicated Resident 1 had severely impaired cognitive skills (mental action or process of acquiring knowledge and understanding) to make daily decision on self-care activities, dependent for mobility to turn left and right (Helper does all of the effort, Resident does none of the effort to complete the activity). During a review of Resident 1's History and Physical (H&P) dated 9/30/2024, the H&P indicated Resident 1 has encephalopathy (a disease damaged the functions of the brain), type 2 diabetes (A long-term condition in which the body has trouble controlling blood sugar and using it for energy), cerebrovascular accident (CVA- stroke, loss of blood flow to a part of the brain) with paraplegia (loss of movement and/or sensation, to some degree, of the legs). During a review of Resident 1's Census list dated 1/31/2025 indicated, Resident 1 was transferred to GACH on 9/16/2024, 10/14/2024, and 10/28/2024. A review of facility's census indicted; the facility has a subacute unit (a medical facility that provides short-term, intensive care for patients who need more care than an assisted living facility but less than a hospital). The census indicated the following: 1/31/2025 capacity of 24 beds with census 18, one female isolation vacant bed. 1/30/2025 capacity 24 beds with census 19, one female isolation vacant bed. 1/29/2025 capacity 24 beds with census 19, one female vacant bed. 1/28/2025 capacity 24 beds with census 19, one female isolation vacant bed and one female vacant bed. 1/27/2025 capacity 24 beds census 21, one female isolation vacant bed. 1/26/2025 capacity 24 beds census 20, one female isolation vacant bed. 1/25/2025 capacity 24 beds census 20, one female isolation vacant bed. 1/24/2025 capacity 24 beds census 21, one female isolation vacant bed. During an interview on 1/31/2025 at 10:26 AM, with the Director of Admissions (DAD), the DAD stated, admissions are referred to the director of nursing (DON), hospital administrator (ADM), and infection prevention nurse (IP) for review and recommendations. Clinical staff makes the final decision for admissions. Stated, I am familiar with Resident 1 and have spoken to many people from GACH. Resident 1 is not admitted back to the facility because the resident requires isolation room, cannot be cohorted with other residents. The plan is to admit Resident 1 when a single isolation room is available. During an interview on 1/31/2025 at 11:34 AM, the facility's admissions marketing (MKTG) stated, I am involved in decision makings for admissions collaborating with clinical staff and ADM. The MKTG stated, I am familiar with Resident 1, has spoken with GACH staff and Resident 1's FM. The MKTG stated the last conversation with GACH and FM was on 1/30/2025. MKTG stated, the facility was unable to provide a specific date for admissions because Resident 1 requires a single isolation room. The facility does not have a waiting list, admission is based on first come first serve and based on clinical accommodation needs. During an interview on 1/31/2025 at 11:50 AM with the facility administrator (ADM), ADM stated, I am familiar with Resident 1 and involved with DON, IP, and admissions department to make admission decisions. Stated the facility is licensed for 180 beds with 179 bed capacity. The Sub Acute unit has a capacity for 26 beds, 24 beds occupied regularly. Stated, Resident 1 used to stay in a single isolation room, we did not want to compromise other residents and cannot cohort Resident 1. Resident 1's old room was occupied by another resident; we are waiting for available single isolation room to admit Resident 1. A review of Resident 1's GACH "Discharge Planning Needs" dated 2/1/2025 indicated, Resident 1 anticipate discharge from GACH to Skilled Nursing Facility (SNF) on 11/16/2024. The Social Worker (SW)'s notes indicated GACH Case Manger (CM) spoke with the SNF facility's admission coordinator on 11/15/2024, SNF facility admission coordinator informed GACH CM that the facility does not have isolation bed at this time. The same Discharge Planning Needs indicated, GACH CM called and spoke to Resident 1's family member, family member agreeable for Resident 1 to go back to the facility. GACH attempted to discharge Resident 1 to the SNF on 11/16/2024, 11/24/2024, and 2/3/2025. A review of Resident 1's "Discharge Planning Needs" dated 2/1/2025 indicated, Resident 1 anticipated discharge date from GACH to SNF 11/24/2024. GACH received a call from the facilities marketer (MKTG) on 11/20/2024, MKTG indicated the facility could not accept Resident 1 due to isolation. A review of Resident 1's "Discharge Planning Needs" dated 2/1/2025 indicated, Resident 1 anticipated discharge date from GACH to SNF 1/14/2025. The Discharge Planning Needs 1/10/2025 notes indicated; no isolation bed today as stated by the facility's admissions intake to GACH discharge planner. A review of Resident 1's "Discharge Planning Needs" dated 2/1/2025 indicated, Resident 1 anticipated discharge date from GACH to SNF 2/3/2025. Communication notes on 1/30/2025, between GACH discharge coordinator and the facility's Marketing person, indicated, there is no isolation bed available at this time, Resident 1 is on waiting list number 2. During a telephone interview on 2/1/2025 at 12:02 PM with GACH Social Worker (SW), SW stated, we have attempted several times to transfer Resident 1 back to the SNF facility where Resident used to stay. We have an alternate facility booked for the resident but Resident 1's family/decision maker does not want Resident 1 to go to another facility. SW further stated Resident 1's FM has been informed by SNF admission staff named MKTG that Resident 1 cannot return to the facility because FM has filed a complaint against the facility in the past. During an interview on 2/3/2025 at 4:40 PM with Resident 1's FM, FM stated, Resident 1 has been in GACH for three and half months. Has been trying to go back the SNF, but the facility did not accept Resident 1. FM further stated, "the whole process was stressful and confusing, I can't even keep up with the back and forth between GACH and SNF, I wish I could record the conversations." FM stated when Resident 1 feels better and ready to transfer, I prefer Resident 1 go back to the same facility. During a review of the facility's policy and procedure (P&P) titled "permitting Resident to Return To Facility" reviewed November 2024, the P&P indicated, "The facility permits residents to return to the facility after they are hospitalized or placed on therapeutic leave. When a resident returns to the facility from a hospitalization or therapeutic leave, the resident must be permitted to return to return to their previous room, if available; or must be permitted to return to an available bed in the location in which he or she previously resided." The P&P further indicated, ...5. 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 provided that the resident: • Still requires the services provided by the facility; and • Is eligible for Medicare skilled nursing facility or Medicaid nursing facility services. The facility failed to implement its' P&P titled "permitting Resident to Return To Facility" by failing to permit Resident 1 to return to the facility following a hospitalization on 11/16/2024, 11/24/2024, and 2/3/2025. Resident 1 was transferred to general acute the GACH on 8/24/2024. As a result, there is a potential for psychosocial harm to Resident 1, and had caused emotional distress and confusion for Resident 1's decision maker FM. The above violation had a direct relationship to the health, safety, and security of Resident 1.