Health inspection·October 1, 2025

§483.15(d)(1) – (e)(1)-(2) 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 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. §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 §483.15(e)(1)(ii) Not Permitting Residents to Return Not permitting a resident to return following hospitalization or therapeutic leave constitutes a discharge and requires a facility to meet the requirements as outlined in §483.15(c)(1)(ii). Because the facility was able to care for the resident prior to hospitalization or therapeutic leave, documentation related to the basis for discharge must clearly show why the facility can no longer care for the resident. § 72520. Bed Hold. (a) If a patient of a skilled nursing facility is transferred to a general acute care hospital as defined in Section 1250(a) of the Health and Safety Code, the skilled nursing facility shall afford the patient a bed hold of seven (7) days, which may be exercised by the patient or the patient's representative. (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. An unannounced visit was conducted by California Department of Public Health on 9/11/2025 to investigate a complaint on Admission, Transfer and Discharge Rights. The facility failed to follow its Bed Hold (holding or reserving a resident’s bed while the resident is absent from the facility for therapeutic leave or hospitalization) policy by failing to hold Resident 1’s bed for up to seven (7) days while the resident was transferred to the General Acute Care Hospital (GACH) on 9/2/2025.  This deficient practice resulted in Resident 1 not being readmitted back when the resident was ready to return to the facility from GACH on 9/6/2025. This had the potential to cause psychosocial harm from displacement and incurred unnecessary hospital days (12 days) at the GACH (from 9/6/2025 to 9/18/2025).   A review of Resident 1's Admission Record indicated Resident 1, a 23 year old female, was initially admitted to the facility on 4/19/2025 with diagnosis which included respiratory failure (condition where there's not enough oxygen or too much carbon dioxide in your body) , dependence on respirator /ventilator (patient cannot breathe sufficiently on their own and requires mechanical assistance for daily respiration ), and persistent vegetative state (individual with severe brain damage appears to be awake but shows no evidence of awareness of their surroundings).     A review of Resident 1's “Bed Hold Consent,” dated 8/14/2025, indicated Resident 1 has the option of requesting a 7- day bed hold to keep a bed vacant and available for return to the facility. The Bed Hold Consent was signed by Resident 1’s Responsible Party on 8/14/2025. The Bed Hold Consent also indicated confirmation of Resident 1’s bed hold provision and GACH transfer on 9/2/2025 at 10:30PM.   A review of Resident 1's Order Summary Report, dated 9/3/2025, indicated to transfer Resident 1 to GACH via 911 (the number to call to contact the emergency services) due to tachycardia (a rapid heart rate), and hypertension (high blood pressure) for further evaluation and treatment. The Order Summary Report also indicated “Bed hold x (for) 7days.”     A review of Resident 1's Progress Notes, initiated 9/2/2025, and timed at 10:55 PM, indicated Resident 1’s heart rate increased to 180 beats per minute (BPM) to 190 BPM and Resident 1’s blood pressure was 150/80 millimeters of mercury (mmHg, a unit of pressure). The paramedics (medical professional who specializes in emergency treatment) arrived at the facility on 9/2/2025 at 10:25 PM and transferred Resident 1 to GACH.   During a concurrent record review of the facility’s census from 9/1/2025 to 9/10/2025 and interview with Licensed Vocational Nurse 1 (LVN 1) on 9/11/2025 at 9:55 AM, LVN 1 stated that according to the census, Resident 1 was occupying a facility bed on 9/1/2025. LVN 1 added that from 9/2/2025 to 9/4/2025, the census indicated Resident 1 was on bed hold. LVN 1 stated Resident 1’s bed was occupied by a new resident on 9/5/2025.  LVN 1 stated there was no available bed for Resident 1 on 9/6/2025.   During an interview on 9/11/2025 at 10:29 AM with the facility’s Marketing Admission Staff (MA), MA stated she received a call from the GACH coordinator on 9/6/2025 stating that Resident 1 was ready to return to the facility. MA stated there was no available bed for Resident 1 since another resident is now occupying Resident 1’s previous bed.     During an interview on 9/11/2025 at 11:33 PM, the GACH Social Worker (GSW) stated Resident 1 was ready for discharge on 9/6/2025. GSW stated GACH Case Manager called the facility on 9/6/2025 and informed the MA that Resident 1 was ready to return to the facility on 9/6/2025 but was made aware that the facility does not have an available bed for Resident 1.      During a concurrent record review of the facility form titled, “Admission / Discharge to/ from Report,” from 9/1/2025 to 9/10/2025 and interview with Registered Nurse (RN1) on 9/11/2025 at 1:39 PM, RN 1 stated the “Admission / Discharge to/ from Report” indicated Resident 1 was discharged to GACH on 9/2/2025. RN1 also stated the facility did not follow the physician’s order for 7-day bed hold because the facility had admitted a new resident in Resident 1’s bed. RN 1 stated this was the reason Resident 1 was still in GACH and could not be readmitted back to the facility.    During an interview on 9/11/2025 at 2 PM with the Administrator (ADM), the ADM stated the bed reserved for Resident 1 was no longer available because it was given to a new resident on 9/5/2025. ADM also stated that Resident 1’s bed should have been reserved for Resident 1 for 7 days, which was from 9/3/2025 to 9/9/2025.  The ADM also stated the purpose of the bed hold was to reserve the same bed for 7 days to ensure the residents would have a homelike environment when ready to return to the facility anytime within that period. The ADM further stated if the facility had saved Resident 1’s bed, Resident 1 would have gone back to the same room on the day the resident was ready to return to the facility.   A record review of the facility’s Policy & Procedure (P&P) titled, “Bed Hold,” revised 9/1/2023, upon admission, the facility advises residents/ resident’s representative in writing that the facility has a bed hold policy and will hold the resident’s bed for up to 7 days if the resident is transferred to a general acute hospital.   The facility failed to follow its Bed Hold (holding or reserving a resident’s bed while the resident is absent from the facility for therapeutic leave or hospitalization) policy by failing to hold Resident 1’s bed for up to 7 days while the resident was transferred to GACH on 9/2/2025.  This deficient practice resulted in Resident 1 not being readmitted back when the resident was ready to return to the facility from GACH on 9/8/2025. This had the potential to cause psychosocial harm from displacement and incurred unnecessary hospital days (12 days) at the GACH (from 9/6/2025 to 9/18/2025). The above violation had a direct or immediate relationship to the health, safety, or security of Resident 1.