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F0627
D

Failure to Assess Resident for Return Following Hospitalization

San Bernardino, California Survey Completed on 09-10-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to conduct an assessment to evaluate a resident's status and needs at the time of a proposed return from the hospital. The resident, who had a history of quadriplegia, schizoaffective disorder, and cannabis dependence, was sent to the hospital for behavioral evaluation due to being a danger to others. After being cleared for discharge by a psychiatrist, attempts were made by the hospital to return the resident to the facility. However, the facility declined to accept the resident back, citing her history of attempting to harm others, without performing a documented assessment of her current condition as required by facility policy. Record reviews and staff interviews confirmed that there was no documentation of an evaluation to determine if the resident was appropriate for transfer back to the facility. The facility's own policies require that residents returning from hospitalization be evaluated based on their current condition at the time of return, not their condition at the time of transfer. Despite this, the Director of Community Relations and the DON acknowledged that no such assessment was completed, and the facility's policies and procedures were not followed in this instance.

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