Health inspection·February 10, 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 12/24/2025 at 3:00 PM to investigate a complaint regarding facility refusing to readmit Resident 1 to the facility from GACH. The facility failed to admit one Resident 1 to the facility's first available bed from 12/18/2025 to 12/24/2025. This deficient practice has the potential to result in Resident 1 and his family to physical and emotional distress (an unpleasant emotional, psychological, or physical reaction to a difficult experience or ongoing stress that interferes with one's ability to cope with daily life) due to unnecessary stay in the hospital. A review of Resident 1 's Admission Record indicated Resident 1 is a 63- year-old- male resident who was admitted to the facility on 4/27/2022 and readmitted on 4/16/2025, with diagnoses that included chronic respiratory failure unspecified whether with hypoxia or hypercapnia (a patient has long-term trouble getting enough oxygen into their blood [hypoxia/hypoxemia] or removing carbon dioxide from their blood, but the specific type of gas exchange), paroxysmal atrial fibrillation ( a type of irregular heartbeat where episodes start and stop suddenly, usually within 7 days, either on their own or with treatment, returning the heart to a normal rhythm), and essential hypertension ( high blood pressure that develops gradually without a single identifiable cause). A review of the Minimum Data Set (MDS- a resident assessment tool) dated 10/30/2025, it indicated Resident 1 severely impaired cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS indicated Resident 1 is dependent (helper does all of the effort) with oral hygiene, toileting hygiene, personal hygiene, shower, bathe self, upper and lower body dressing, putting on/ taking off footwear, change of position, and transfer. A review of Resident 1's Physician Order (PO) dated 10/2/2025, PO indicated Resident 1 was transferred to General Acute Care Hospital (GACH) 2 for further care due to medical emergency. A review of GACH's CM discharge plan notes dated from 11/11/2025 to 12/24/2025, it indicated the following: 1. On 11/11/2025 - Still no available bed from the facility. 2. On 11/14/2025- GACH's CM followed up with the facility's Admission Coordinator (AC) and per AC there is no isolation bed to admit Resident 1. 3. On 11/20/2025- GACH's CM spoke with Resident 1's Representative (RR) and RR questioned why Resident 1 has not returned to the facility. 4. On 12/11/2025- GACH's CM followed up with AC and AC stated, the facility still does not have an available for Resident 1. 5. On 12/24/2025- GACH's CM followed up with AC and AC stated, "they (the facility) still do not currently have an available to accept Resident 1 back". During an interview on 12/24/2025 at 3:25 PM with the Director of Nursing (DON), the DON stated she did not know Resident 1 needs an isolation room for the resident was positive for Candita Auris (C. Auris- merging fungus that can cause severe, often multidrug-resistant, infections. It spreads easily among patients in healthcare facilities-, and use of contact precautions [gowns, gloves, dedicated equipment] is needed to stop its spread). The DON stated she was not aware that GACH CM has been speaking with the facility's Admission Coordinator (AC) since November 2025 (not sure of exact date) that Resident 1 was ready to be discharged to the facility with contact isolation precaution. The DON stated she could have moved residents around/ made some room changes to make a bed/isolation room available for Resident 1 so they could admit the resident back to the facility. The DON also stated Resident 1 met the criteria of admission/ readmission to the facility and there was no reason for the facility not to admit Resident 1 back since the facility had an available bed for Resident 1 since 12/18/2025. During an interview on 12/24/2025 at 3:29 PM with Infection Preventionist Nurse (IPN), IPN stated she did not know that GACH's CM spoke with AC that Resident was cleared to be discharge back to the facility with contact isolation precaution. IPN stated if only she knew, she could have moved residents around and made a bed available for Resident 1 so Resident 1 can be admitted back at the facility since 12/18/2025. IPN stated Resident 1 met the facility's readmission criteria and the facility can admit Resident 1 back to the facility from 12/18/2025 to 12/24/2025. During an interview on 12/24/2025 at 3:55 PM with AC, AC stated "I did not know why I did not ask the DON and IPN for any opening bed for resident with c. auris." AC stated, AC did not inquire with the DON nor IPN about room availability to admit Resident 1 to the facility when GACH CM's has been asking and/ or waiting for a bed available for Resident 1 since 12/18/2025. AC stated she told GACH CM that there was no isolation bed available, and the facility cannot admit Resident 1 back to the facility since 11/4/2025 and until 12/23/2025. AC stated she should have inquired and relayed the information to the DON and IPN regarding Resident 1 is for admission to the facility in isolation precaution. During a concurrent interview and record review on 12/24/2025 at 4:35 PM with the DON, the facility's Daily Census Report dated 12/18/2025 to 12/24/2025 were reviewed. The reports indicated starting from 12/18/2025 to 12/24/2025, there were three open beds inside Room A which is a room with four bed capacity. The DON stated she could have made some room changes and move the resident in Room A to another room to be able to admit Resident 1 in Room A from 12/18/2025. During an interview on 12/26/2025 at 10:44 AM with the DON, the DON stated she called GACH and spoke with GACH Registered Nurse (RN) to confirm if Resident 1 is still in GACH on 12/24/2025 in the late evening but she did not inform GACH RN that the facility has a bed available to admit Resident 1. The DON stated she should have let GACH RN know about the opening bed for Resident 1 to facilitate timely admission of Resident 1. During a telephone interview on 12/29/2025 at 4:36 PM with GACH CM, GACH CM stated he started his inquiry about readmission of Resident 1 to the facility on 11/5/2025 with AC. GACH CM stated AC has been telling GACH CM that there was no bed available until 12/23/2025. A review of the facility's Job Description titled, "Admissions Coordinator", undated, indicated the admissions coordinator is responsible for managing the community inquiry and admission process and providing customers with community-related information via facility tours, personal visits/assessments, conversations, and follow-up. Essential Functions: • Manages the admission process by maintaining updated bed availability and community services information at all time. • Manages the inquiry process professionally, timely, and with the appropriate follow-up. Effectively manages occupancy levels and census/premium mix enhancement. • Maintains close working relationships with the Director of Nursing Services (DNS/ DON) and the Revenue Cycle Manager (RCM) to ensure appropriate and efficient decisions about prospective admissions. • Communicates special needs of newly admitted residents to staff to ensure a smooth transition A review of the facility's policy and procedures (P&P) titled, "Readmission to the Facility," revised 3/2017, the P&P indicated, Residents who have been discharged to the hospital or for therapeutic leave will be given priority in readmission to the facility. The P&P also indicated a Medicaid resident whose hospitalization or therapeutic leave exceeds the bed hold period allowed by the state will be readmitted to the facility upon the first availability of a bed in a semi-private room if the resident: a. requires the services provided by the facility. b. meets the admission criteria as outlined in facility policy. The P&P also indicated readmission procedures apply equally to all residents regardless of race, color, creed, national origin, or payment source. The facility failed to admit Resident 1 to the facility's first available bed from 12/18/2025 to 12/24/2025. This deficient practice has the potential to result in increased Resident 1 and his family for physical and emotional distress due to unnecessary stay in the hospital. The above violation had a direct or immediate relationship to the health, safety, or security of Resident 1.