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F0627
D

Failure to Admit Resident to Available Bed Following Hospitalization

Pasadena, California Survey Completed on 12-26-2025

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 admit a resident to the first available bed following a hospital stay, despite the resident meeting all criteria for readmission and an available bed being present. The resident, who had severe cognitive impairment and was dependent on staff for all activities of daily living, required contact isolation due to a positive test for Candida auris. The resident's discharge from the hospital was delayed from 12/18/2025 to 12/24/2025 because the facility did not facilitate timely readmission. Record review and interviews revealed that the hospital's case manager repeatedly contacted the facility's Admissions Coordinator (AC) regarding bed availability for the resident, but the AC consistently reported no available isolation bed. The AC did not communicate with the Director of Nursing (DON) or the Infection Preventionist Nurse (IPN) about the need for an isolation bed or the resident's readiness for discharge. Both the DON and IPN stated they were unaware of the situation and indicated that they could have arranged for an isolation bed by moving other residents if they had been informed. Further review of the facility's daily census reports confirmed that there were open beds available in a four-bed room during the relevant period. The facility's policy required priority readmission for residents returning from the hospital, and the job description for the AC included maintaining updated bed availability and communicating with nursing leadership. The failure to coordinate and communicate internally resulted in the resident remaining unnecessarily in the hospital despite the facility's ability to accommodate the resident's needs.

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