Other·October 19, 2020

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 a complaint. Complaint number: CA00705379. Representing the Department: HFEN 40638. The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. One deficiency was written as a result of complaint CA00705379. See Tag 0626.

F626 SS=H Permitting Residents to Return to Facility CFR(s): 483.15(e)(1)(2)

F626 10/22/2020 §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 semiprivate 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. (ii) If the facility that determines that a 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: 865J11 Facility ID: CA020000026 If continuation sheet 1 of 8 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 10/15/2020 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 who was transferred with an expectation of returning to the facility, cannot return to the facility, the facility must comply with the requirements of paragraph (c) as they apply to discharges. §483.15(e)(2) Readmission to a composite distinct part. When the facility to which a resident returns is a composite distinct part (as defined in § 483.5), the resident must be permitted to return to an available bed in the particular location of the composite distinct part in which he or she resided previously. If a bed is not available in that location at the time of return, the resident must be given the option to return to that location upon the first availability of a bed there. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review the skilled nursing facility (SNF) failed to establish a policy and procedure that permits residents to return to the SNF after a stay in the acute care hospital (ACH). The SNF's policy stated it would discharge residents after 30 days. Resident 1 was not permitted to return to the SNF from the ACH when a bed became available. Resident 1 was ready to return to the facility on 9/14/20. Resident 1 has been in the ACH for over 30 days. This failure resulted in psychological harm and distress to Resident 1 who has lived in the SNF for over eight years and called it his home. Resident 1 made repeated phone calls to the State Agency upset and request information on when he would be returning to the SNF. Findings: The Department received a complaint on 9/16/20 regarding the SNF refusing to readmit FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 865J11 Facility ID: CA020000026 If continuation sheet 2 of 8 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 10/15/2020 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 Resident 1 from the ACH. Resident 1 called the Department on 9/18/20 stating he wanted to know when he could go back to his SNF. On 9/22/20 at 12:56 p.m. Resident 1 called again, he was upset and demanded to know when he could go back. Resident 1 called on 9/23/20 at 11:34 a.m. wanting to know dates when he was going back to the SNF. During a phone conversation with Resident 1 on 10/12/20 at 2:25 p.m. Resident 1 wanted to know what was happening with his appeal (Resident 1 requested a hearing with the State's appeal unit). A review of Resident 1's medical record, the Minimum Data Set, (MDS, an assessment tool), dated 7/30/20, indicated Resident 1 was originally admitted to the SNF 3/9/12. During a review of Section C 0500 of the MDS, it indicated Resident 1 has a Brief Interview for Mental Status (BIMS, a cognitive assessment tool) of 15, cognitively intact. Review of Sections D and E indicated Resident 1 did not exhibit mood or behavioral problems. According to Section I of the MDS, Resident 1 has diagnoses to include C5 spinal cord injury, pressure ulcer, and chronic pain. Review of Section G Functional Status of the MDS indicated Resident 1 is totally dependent needing two persons to assist to transfer, and one person assist for dressing, eating, toilet use, and personal hygiene. Resident 1 is able to independently move around with the use of a motorized wheelchair. During a review of the nurse's note dated 9/8/20, Resident 1 was transported to the ACH due to unresponsiveness and low blood pressure. During an interview with the Administrator FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 865J11 Facility ID: CA020000026 If continuation sheet 3 of 8 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 10/15/2020 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 (ADM), on 9/17/20 at 11:00 a.m., ADM stated there were no available beds for Resident 1. ADM stated the ACH had been advised and Resident 1 would be readmitted to the SNF on 9/22/20. During an interview with the DON on 9/17/20 at 11:05 a.m., DON stated the facility had not initiated a discharge and Resident 1 was eligible for a seven-day bed hold. DON stated Resident 1's admission had been greater that seven days so he would get the first available bed. During a review of Resident 1's Admission Agreement at the SNF dated 4/8/12, Resident 1 was eligible for a seven-day bed hold. The document indicated, " ...If you are away from out facility for more than seven days due to hospitalization or other medical treatment we will readmit you to the first available bed in a semi-private room if you need the care provided by our facility and wish to be readmitted ..." During a telephone interview with Resident 1 on 9/21/20 at 4:11 p.m., Resident 1 stated he had been told he was not going back to the facility on 9/22/20. During a telephone interview with DON on 9/21/20 at 4:20 p.m., DON stated they would take Resident 1 back on 9/25/20. During a telephone interview with DON on 9/28/20 at 10:53 a.m., DON stated Resident 1 had not returned to the facility. During an onsite visit and observation on 9/28/20 at 3:00 p.m., observed Room 101 was unoccupied with two beds available. Empty male beds were noted in rooms 103B, 105A, 108A, 112A, 114B, 115A, 305A and 305B. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 865J11 Facility ID: CA020000026 If continuation sheet 4 of 8 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 10/15/2020 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 interview with Resident 1 on 9/29/20 at 1:15 p.m., Resident 1 stated it has been very difficult for him not being home. Resident 1 stated he is unable to have visitors in the hospital and there is no one to even have a conversation with. Resident stated he felt very isolated. During an interview with ADM on 9/29/20 at 3:19 p.m., ADM stated Resident 1 had not returned to the facility because there was no bed. ADM stated, "It's a very complicated situation." During a review of the IDT Discharge Planning Notes dated 9/30/20 at 1:00 p.m., the Interdisciplinary Team (IDT) noted the SNF "has gone out of it's way to provide for all his needs despite his being verbally abusive, threatening behavior, and multiple complaints against staff members, but it appears it is never enough as he continues to call the state repeatedly with complaints and to complain about the care given by staff who have provided excellent care to our residents over the course of many years. The IDT expressed that his demands are beyond the capacity of any nursing home and the IDT believes that this facility cannot meet his needs and should not be readmitted to the facility." During a phone interview between the District Manager (DM) in the State Agency local office and the DON on 9/30/20 at 1:23 p.m., DON stated "We told ACH today that we will not readmit Resident 1 due to his non-compliance with our rules. His behavior is consistently threatening with the staff. He threatens to have their licenses taken away by the State." During an interview with Patient Care Coordinator (PCC), at ACH on 9/30/20 at 3:00 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 865J11 Facility ID: CA020000026 If continuation sheet 5 of 8 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 10/15/2020 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 p.m., PCC stated the SNF has continued to refuse to readmit Resident 1. PCC stated her staff has documented in his chart and she has made multiple phone calls herself. PCC attempted to call on the following dates and times: Friday 9/25/20: 10:30 AM Friday 9/25/20: 12:08 PM Friday 9/25/20: 12:21 PM Friday 9/25/20: 3:17 PM Monday 9/28/20: 8:37 AM Tuesday 9/29/20: 1:20 PM Wednesday 9/30/20: 2:21 PM PCC stated the ADM and DON have not returned her calls. During a review of the Discharge Planner notes from ACH dated 9/16/20, 9/18/20, 9/19/20, 9/20/20, 9/21/20, 9/23/20, 9/25/20, 9/26/20, 9/27/20, 9/28/20 and 9/30/20, the notes indicated Resident 1 is medically cleared with a discharge order since 9/14/20 and unable to return to the facility due to no available bed. During a review of the Acute Care Psychology consult dated 10/7/20, the Psychologist (PsyD) noted that Resident 1 was experiencing distress due to not previous facility not taking him back. PsyD discussed coping strategies and planned to follow up and continue to provide treatment for anxiety and stress. During an interview with Admissions Coordinator (AC) on 10/6/20 at 11:00 a.m., the AC stated the SNF issued a discharge notice dated 10/2/20 to Resident 1. The AC stated since Resident 1 is still in the ACH, it was mailed to him there. During a review of the discharge notice dated 10/2/20, it indicated Resident 1 was discharged because it was necessary for his welfare and his needs could not be met in the SNF; and the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 865J11 Facility ID: CA020000026 If continuation sheet 6 of 8 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 10/15/2020 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 safety of individuals in the SNF was endangered due to the clinical or behavioral status of Resident 1. During a review of the Readmission to the Facility Policy, dated 3/2017, the policy indicated, "A Medicaid resident whose hospitalization or therapeutic leave exceeds the bed hold period allowed by the state will be readmitted to the facility upon the first availability of a bed in a semi-private room if the resident: a. Requires the services provided by the facility; b. Meets the admission criteria as outlined in facility policy; c. Was not discharged for any reason outlined in the Transfer or Discharge Notice policy; and d. Is eligible for Medicaid nursing facility services." It further indicated that if "it is determined that a resident who was transferred with an expectation that he or she will return cannot return to the facility, he or she will be discharged according to the discharge policy." During a review of the Transfer or Discharge Notice Policy, dated 3/2017, the policy indicated that a resident will be given a 30-day advance notice of an impending transfer or discharge. It further indicated that "under the following circumstances, the notice will be given as soon as it is practicable but before the transfer or discharge: a. transfer 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; FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 865J11 Facility ID: CA020000026 If continuation sheet 7 of 8 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 10/15/2020 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 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; f. An immediate transfer or discharge is required by the resident's urgent medical needs; g. The resident has not resided in the facility for 30 days; and/or h. The facility ceases to operate. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 865J11 Facility ID: CA020000026 If continuation sheet 8 of 8