Other·July 5, 2018

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during the investigation of complaint CA00580409. The investigation was limited to the complaint and does not reflect the findings of a full inspection of the facility. Representing the Department: Health Facilities Evaluator Nurse #37797. Complaint CA00580409 was substantiated with deficiencies related to transfer and discharge requirements for residents.

F623 SS=D Notice Requirements Before Transfer/Discharge CFR(s): 483.15(c)(3)-(6)(8)

F623 07/09/2018 §483.15(c)(3) Notice before transfer. Before a facility transfers or discharges a resident, the facility must(i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State LongTerm Care Ombudsman. (ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and (iii) Include in the notice the items described in paragraph (c)(5) of this section. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QSWF11 Facility ID: CA010000034 If continuation sheet 1 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055268 (X3) DATE SURVEY COMPLETED 06/06/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SONOMA POST ACUTE 678 2nd St W Sonoma, CA 95476 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.15(c)(4) Timing of the notice. (i) Except as specified in paragraphs (c)(4)(ii) and (c)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged. (ii) Notice must be made as soon as practicable before transfer or discharge when(A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section; (B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section; (C) The resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(i)(B) of this section; (D) An immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (c)(1)(i)(A) of this section; or (E) A resident has not resided in the facility for 30 days. §483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following: (i) The reason for transfer or discharge; (ii) The effective date of transfer or discharge; (iii) The location to which the resident is transferred or discharged; (iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request; (v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman; (vi) For nursing facility residents with FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QSWF11 Facility ID: CA010000034 If continuation sheet 2 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055268 (X3) DATE SURVEY COMPLETED 06/06/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SONOMA POST ACUTE 678 2nd St W Sonoma, CA 95476 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and (vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act. §483.15(c)(6) Changes to the notice. If the information in the notice changes prior to effecting the transfer or discharge, the facility must update the recipients of the notice as soon as practicable once the updated information becomes available. §483.15(c)(8) Notice in advance of facility closure In the case of facility closure, the individual who is the administrator of the facility must provide written notification prior to the impending closure to the State Survey Agency, the Office of the State Long-Term Care Ombudsman, residents of the facility, and the resident representatives, as well as the plan for the transfer and adequate relocation of the residents, as required at § 483.70(l). This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to provide written notice of transfer to the responsible party of one of two residents (Resident 1) and to the Office of the State Long-Term Care Ombudsman (Ombudsman) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QSWF11 Facility ID: CA010000034 If continuation sheet 3 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055268 (X3) DATE SURVEY COMPLETED 06/06/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SONOMA POST ACUTE 678 2nd St W Sonoma, CA 95476 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE prior to non-emergently transferring Resident 1 to another facility. This failure caused emotional distress to Resident 1's responsible party and prevented her from participating in Resident 1's transfer. This failure also prevented the Ombudsman from advocating for Resident 1. Findings: Resident 1's "Admission Record" indicated he was 75 years old, was a veteran, and had been admitted to the facility on 11/24/17 with diagnoses of dementia with behavioral disturbance, post-traumatic stress disorder and need for assistance with personal care. The "Admission Record" indicated Resident 1's family member was his responsible party (the person who made decisions on his behalf) and listed her complete contact information. A review of Resident 1's physician orders revealed an order dated 11/24/17 indicating Resident 1 did not have the capacity to make health care decisions and his decision maker was Resident 1's family member. A review of the facility's "Admit/Discharge Report", dated 3/16/18, indicated Resident 1 was transferred on 3/16/18 to the Veterans Affairs Hospital in San Francisco (VA Hospital), 45 miles away. During interviews on 4/12/18, starting at 3:35 p.m., the Administrator stated Resident 1 had dementia and needed 24 hour supervision by a sitter (a person who stays with the resident during all times). The Administrator stated the Veterans Affairs Administration had not been reimbursing the facility for the cost of the sitter and the facility could no longer absorb the expenses. The Administrator stated this was the reason the facility transferred Resident 1 to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QSWF11 Facility ID: CA010000034 If continuation sheet 4 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055268 (X3) DATE SURVEY COMPLETED 06/06/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SONOMA POST ACUTE 678 2nd St W Sonoma, CA 95476 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE the VA Hospital. The Administrator confirmed Resident 1 was transferred non-emergently to the VA Hospital on 3/16/18. The Administrator was asked if a written notice of the transfer was provided to Resident 1's family member. The Administrator stated no written notice of the transfer was provided to Resident 1's family member. The Administrator stated the transfer was coordinated by the facility's Business Manager (BM). During an interview on 4/12/18, at 3:55 p.m., the BM stated he was the facility staff who coordinated Resident 1's transfer to the VA Hospital but all arrangements were made by VA Hospital staff. The BM stated Resident 1 was transferred because the facility could no longer afford to incur the costs of paying for a sitter for him. He stated the facility had a contract with the Veterans Affairs Administration which stipulated that if the facility was no longer able to provide care for Resident 1 he would be transferred to the VA Hospital. The BM stated he talked to Resident 1's family member a few days before the transfer about the transfer to the VA Hospital. The BM was asked if he had any written records or notes of his conversations with Resident 1's family member about the transfer. The BM stated he did not keep any notes or records of conversations with family members. The BM was asked if he notified the Ombudsman of the transfer and he said no. During an interview on 6/7/18, at 9:35 a.m., the State Ombudsman for Sonoma County stated her office was not informed and did not receive any notice of the transfer of Resident 1. During an interview on 6/6/18, at 3:30 p.m., Resident 1's family member stated she was not consulted about the transfer of Resident 1 to the VA Hospital. She stated she did not receive FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QSWF11 Facility ID: CA010000034 If continuation sheet 5 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055268 (X3) DATE SURVEY COMPLETED 06/06/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SONOMA POST ACUTE 678 2nd St W Sonoma, CA 95476 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE any verbal or written notice from the facility that Resident 1 was going to be transferred to the VA Hospital on 3/16/18. Resident 1's family member stated she only became aware of the transfer when, on 3/16/18, at 10 p.m., she received a telephone call from the VA Hospital informing her that Resident 1 had arrived there. In tears, Resident 1's family member described how she wished she could have been with Resident 1 during the transfer, how she wished she could have prepared him for the transfer and how she wished she had the opportunity to ensure the VA Hospital would be able to care for Resident 1's needs before he was sent there. Facility policy titled "Discharging the Resident", dated 2001, indicated: "The resident should be consulted about the discharge."

F624 SS=D Preparation for Safe/Orderly Transfer/Dschrg CFR(s): 483.15(c)(7) FORM CMS-2567(02-99) Previous Versions Obsolete

F624 Event ID: QSWF11 07/09/2018 Facility ID: CA010000034 If continuation sheet 6 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055268 (X3) DATE SURVEY COMPLETED 06/06/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SONOMA POST ACUTE 678 2nd St W Sonoma, CA 95476 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.15(c)(7) Orientation for transfer or discharge. A facility must provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility. This orientation must be provided in a form and manner that the resident can understand. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to provide and document sufficient preparation and orientation to ensure safe and orderly transfer to one of two residents (Resident 1) when the facility transferred Resident 1 to another facility without communicating and consulting with Resident 1's family member, without involving the facility's social services department in the transfer and without properly documenting the transfer process. This failure placed Resident 1's health and safety at risk. Findings: Resident 1's "Admission Record" indicated he was 75 years old, was a veteran, and had been admitted to the facility on 11/24/17 with diagnoses of dementia with behavioral disturbance, post-traumatic stress disorder and need for assistance with personal care. The "Admission Record" indicated Resident 1's family member was his responsible party (the person who made decisions on his behalf) and listed and listed her complete contact information. A review of Resident 1's physician orders revealed an order dated 11/24/17 indicating Resident did not have the capacity to make health care decisions and his decision maker FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QSWF11 Facility ID: CA010000034 If continuation sheet 7 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055268 (X3) DATE SURVEY COMPLETED 06/06/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SONOMA POST ACUTE 678 2nd St W Sonoma, CA 95476 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE was Resident 1's family member. A review of the facility's "Admit/Discharge Report" dated 3/16/18, indicated Resident 1 was transferred on 3/16/18 to the Veterans Affairs Hospital in San Francisco (VA Hospital), 45 miles away. During interviews on 4/12/18, starting at 3:35 p.m., the Administrator stated Resident 1 had dementia and needed 24 hour supervision by a sitter (a person who stays with the resident during all times). The Administrator stated the Veterans Affairs Administration was not reimbursing the facility for the cost of the sitter and the facility could no longer absorb the expenses. The Administrator stated for this reason the facility decided to transfer Resident 1 to the VA Hospital. The Administrator confirmed Resident 1 was transferred nonemergently to the VA Hospital on 3/16/18. The Administrator was asked if a written notice of the transfer was provided to the responsible party. The Administrator stated stated no written notice of the transfer was provided to Resident 1's family member. The Administrator was asked for documentation of the transfer process in Resident 1's medical records but none was provided other than a physician's order authorizing the transfer. The Administrator stated the transfer was coordinated by the facility's Business Manager (BM). During an interview on 4/12/18, at 3:55 p.m., the BM stated he was the facility staff who coordinated Resident 1's transfer to the VA Hospital but all arrangements were made by VA Hospital staff. The BM stated he communicated to Resident 1's family member several times about the transfer to the VA Hospital. The BM was asked if he had any written records or notes of his conversations FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QSWF11 Facility ID: CA010000034 If continuation sheet 8 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055268 (X3) DATE SURVEY COMPLETED 06/06/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SONOMA POST ACUTE 678 2nd St W Sonoma, CA 95476 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE with Resident 1's family member about the transfer and stated he did not document communications with resident family members. During an interview on 4/12/18, at 4:55 p.m., the facility's Social Services Director (SSD), stated she was responsible for coordinating resident transfers and discharges. The SSD stated the transfer/discharge process takes weeks to complete as it involves setting up services and communicating with all parties involves. The SSD stated she was at the facility the day Resident 1 was transferred but was not involved in the transfer of Resident 1. The SSD stated not until the afternoon of 3/16/18 she became aware Resident 1 was being transferred to the VA Hospital. During an interview on 6/6/18, at 3:30 p.m., Resident 1's family member stated she was not consulted about the transfer of Resident 1 to the VA Hospital. She stated she did not receive any verbal or written notice from the facility that Resident 1 was going to be transferred to the VA Hospital on 3/16/18. Resident 1's family member stated she only became aware of the transfer when, on 3/16/18, at 10 p.m., she received a telephone call from the VA Hospital informing her that Resident 1 had arrived there. In tears, Resident 1's family member described how she wished she could have been with Resident 1 during the transfer, how she wished she could have prepared him for the transfer and how she wished she had the opportunity to ensure the VA Hospital would be able to care for Resident 1's needs before he was sent there. Facility policy titled "Discharging the Resident", dated 2001, indicated: "The resident should be consulted about the discharge." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QSWF11 Facility ID: CA010000034 If continuation sheet 9 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055268 (X3) DATE SURVEY COMPLETED 06/06/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SONOMA POST ACUTE 678 2nd St W Sonoma, CA 95476 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE "If the resident is being discharged to a hospital or another facility, ensure that a transfer summary is completed..." Facility policy titled "Job Description: Social Services Director", dated March 2017, indicated the Social Services Director "Assist[s] in discharge planning with appropriate agencies, entities or individuals to include agency services, equipment and agency referrals. Coordinates with interdisciplinary team." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QSWF11 Facility ID: CA010000034 If continuation sheet 10 of 10