Other·January 31, 2019

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 an abbreviated survey for the investigation of two complaints: CA00613394 and CA00613498 . Representing the Department: HFEN 39555. For Complaint Number CA00613394, one deficiency was issued. For Complaint Number CA00613498, one deficiency was issued.

F622 SS=D Transfer and Discharge Requirements CFR(s): 483.15(c)(1)(i)(ii)(2)(i)-(iii)

F622 02/25/2019 §483.15(c) Transfer and discharge§483.15(c)(1) Facility requirements(i) The facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless(A) The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility; (B) The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility; (C) The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident; (D) The health of individuals in the facility would otherwise be endangered; (E) The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. Nonpayment applies if the resident 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: 2ZJ511 Facility ID: CA020000026 If continuation sheet 1 of 5 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: _______________ 056348 (X3) DATE SURVEY COMPLETED 02/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BAY VIEW REHABILITATION HOSPITAL, LLC 516 Willow Street Alameda, CA 94501 (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 does not submit the necessary paperwork for third party payment or after the third party, including Medicare or Medicaid, denies the claim and the resident refuses to pay for his or her stay. For a resident who becomes eligible for Medicaid after admission to a facility, the facility may charge a resident only allowable charges under Medicaid; or (F) The facility ceases to operate. (ii) The facility may not transfer or discharge the resident while the appeal is pending, pursuant to § 431.230 of this chapter, when a resident exercises his or her right to appeal a transfer or discharge notice from the facility pursuant to § 431.220(a)(3) of this chapter, unless the failure to discharge or transfer would endanger the health or safety of the resident or other individuals in the facility. The facility must document the danger that failure to transfer or discharge would pose. §483.15(c)(2) Documentation. When the facility transfers or discharges a resident under any of the circumstances specified in paragraphs (c)(1)(i)(A) through (F) of this section, the facility must ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institution or provider. (i) Documentation in the resident's medical record must include: (A) The basis for the transfer per paragraph (c) (1)(i) of this section. (B) In the case of paragraph (c)(1)(i)(A) of this section, the specific resident need(s) that cannot be met, facility attempts to meet the resident needs, and the service available at the receiving facility to meet the need(s). (ii) The documentation required by paragraph (c)(2)(i) of this section must be made by(A) The resident's physician when transfer or discharge is necessary under paragraph (c) (1) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2ZJ511 Facility ID: CA020000026 If continuation sheet 2 of 5 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: _______________ 056348 (X3) DATE SURVEY COMPLETED 02/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BAY VIEW REHABILITATION HOSPITAL, LLC 516 Willow Street Alameda, CA 94501 (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 (A) or (B) of this section; and (B) A physician when transfer or discharge is necessary under paragraph (c)(1)(i)(C) or (D) of this section. (iii) Information provided to the receiving provider must include a minimum of the following: (A) Contact information of the practitioner responsible for the care of the resident. (B) Resident representative information including contact information (C) Advance Directive information (D) All special instructions or precautions for ongoing care, as appropriate. (E) Comprehensive care plan goals; (F) All other necessary information, including a copy of the resident's discharge summary, consistent with §483.21(c)(2) as applicable, and any other documentation, as applicable, to ensure a safe and effective transition of care. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to ensure that one (Resident 1) of three sampled residents was readmitted to the facility in a timely manner after hospitalization. This failure resulted in Resident 1 being displaced from his home. Findings: A review of the facility document titled "Situation, Background, Assessment, Recommendations," dated 11/16/18 and timed at 2:30 p.m., showed that a normally alert and oriented Resident 1 was noted to have an episode of confusion on 11/16/18. He was unable to name the staff that he had known and was unusually sleepy. A review of the facility Nurse Notes, dated 11/16/18 at 2:45 p.m., showed that the resident was confused and a call was placed to the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2ZJ511 Facility ID: CA020000026 If continuation sheet 3 of 5 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: _______________ 056348 (X3) DATE SURVEY COMPLETED 02/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BAY VIEW REHABILITATION HOSPITAL, LLC 516 Willow Street Alameda, CA 94501 (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 primary care physician for instructions. Further review of the same note showed that the resident was transferred to a local area hospital (Hospital 1) at 4 p.m. The facility was informed at 11:50 p.m. that Resident 1 was going to be admitted to the Hospital 1 for a bladder infection. During a telephone interview on 11/27/18 at 1:56 p.m., the hospital Social Worker (SW) stated Resident 1 was admitted to the Hospital 1 on 11/16/18 and had been ready to go back to the facility on 11/20/18. SW stated when she contacted the facility on 11/20/18 to notify them of Resident 1's readiness to return, the Director of Staff Development (DSD) told her the facility was not able to take him back. SW further stated Resident had not developed any new medical conditions during his current hospital stay which would make it inappropriate for him to be transferred back to his facility and that his bladder infection was treated. During a telephone interview with Resident 1 on 11/27/18 at 9 a.m., Resident 1 stated when he was a patient at a Hospital 1, he found out from SW that his facility was refusing to readmit him. Resident 1 stated he lived in that facility for six years and he considered it his home. In another telephone interview on 11/29/18 at 3:30 p.m., Resident 1 stated he was worried and anxious about the possibility of not being able to return to the facility. A review of Hospital 1's Discharge Summary dated 12/14/18 indicated Resident 1 was admitted on 11/16/18 for principal diagnosis of septic shock (a widespread infection causing organ failure and dangerously low blood pressure) from a bladder infection. According to the Discharge Summary, Resident 1's condition was stable and ready to be discharged back to his skilled nursing facility on 11/20/18. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2ZJ511 Facility ID: CA020000026 If continuation sheet 4 of 5 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: _______________ 056348 (X3) DATE SURVEY COMPLETED 02/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BAY VIEW REHABILITATION HOSPITAL, LLC 516 Willow Street Alameda, CA 94501 (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 During an observation of the facility on 11/27/18 at 12:10 p.m. Resident 1 was not at the facility and his Room was occupied by another resident. During a review of the Facility Census form dated 11/26/18 indicated there were three open male beds. During an interview on 11/27/18 at 2:45 p.m. the DSD stated the facility did refuse to take Resident 1 back. Review of the facility's "Bed-Holds Returns" Policy, revised March 2017, "The resident will be permitted to return to an available bed in the location of the facility that he or she previously resided." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2ZJ511 Facility ID: CA020000026 If continuation sheet 5 of 5