Other·December 7, 2018

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following represents the finding of the California Department of Public Health during the investigation of a complaint. Intake number: CA00612625 Representing the Department: 34714, Health Facility Evaluator Nurse. The investigation was limited to the specific complaints and does not represent the findings of a full inspection of the facility. One deficiency was issued to complaint CA00612625.

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

F626 12/18/2018 §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 who was transferred with an expectation of 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: 7DTE11 Facility ID: CA020000123 If continuation sheet 1 of 4 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: _______________ 055338 (X3) DATE SURVEY COMPLETED 11/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SAGE POST ACUTE 1832 B Street Hayward, CA 94541 (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 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 interviews and record reviews, the facility failed to readmit one (Resident 1) of three residents discharged from the hospital who was ready to return to the facility. This failure resulted in Resident 1 requiring a longer hospitalization stay when medical care was not necessary and kept Resident 1 away from his home. Findings: A review of the Resident 1 admission record revealed that Resident 1 was admitted to the facility on 5/16/18 and had diagnoses to include Alzheimer's dementia (brain disorder that causes problems with memory, thinking and behavior). During a review of the nurse's notes, it indicated on 11/17/18 at 3:03 p.m., Resident 1 exhibited aggressive behavior, yelling, shouting, hitting a staff member, throwing objects to staff and threatening to hit other residents. Resident 1 refused to take routine FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7DTE11 Facility ID: CA020000123 If continuation sheet 2 of 4 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: _______________ 055338 (X3) DATE SURVEY COMPLETED 11/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SAGE POST ACUTE 1832 B Street Hayward, CA 94541 (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 medications despite several attempts to calm resident down. Police was called when aggressive behavior became threatening and dangerous to resident, staff and resident himself. Police attempted to calm Resident 1 with no resolution and Resident 1 was sent to hospital by an ambulance. Review of the hospital "Tele-psychiatry Consultation Note" dated 11/19/18 at 1411 indicated Resident 1 was admitted for "Agitation" with recommendation to restart on him on Depakote 500 milligrams (mg), a (mood stabilizer), Seroquel 50 mg twice a day and Ativan 1 to 2 mg by mouth/intramuscular every 4 hours as needed for agitation. Review of the hospital "Discharge Summary", dated 11/18/18 at 1352, the physician indicated Resident 1 was ready for transfer to skilled nursing. Review of the "Hospitalist Progress Note", dated 11/19/18 at 1135 indicated Resident 1 had "no episodes of aggression ..." It also indicated Resident 1 was "medically cleared to be discharged back to a SNF". During an interview on 11/21/18 at 9:40 a.m. the hospital Social Worker (MSW) stated she called and spoke with the facility SSD on Sunday, 11/18/18 about Resident 1 medically cleared to go back to the facility. The SSD informed MSW that Resident 1 could not go back to the facility due to his violent behavior. MSW stated it was best for Resident 1 to be back in his usual secured environment. During concurrent interview and document review with the Director of Nursing (DON) on 11/20/18, at 4:15 p.m., DON stated she spoke with a hospital staff on 11/18/18 regarding Resident 1's hospital discharge. The DON FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7DTE11 Facility ID: CA020000123 If continuation sheet 3 of 4 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: _______________ 055338 (X3) DATE SURVEY COMPLETED 11/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SAGE POST ACUTE 1832 B Street Hayward, CA 94541 (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 informed the hospital staff she could not accept Resident 1 back because the facility was not able to provide for his needs and wanted to speak with the conservator first to have an action plan for an appropriate placement for Resident 1. The DON stated she was instructed not to accept Resident 1 back to the facility. The DON stated she did not ask or receive information of Resident 1's medical reason for hospitalization or the type of treatment the hospital provided. During an interview on 11/27/18, at 10:45 a.m., the Conservator stated the facility was "a good place to be" for Resident 1 where his needs were met at the facility's secured unit since he wandered and it was the conservator's desire for Resident 1 to return to his home. The conservator hoped that the facility would take him back and put appropriate care measures in place for him. During interviews on 11/20/18, at 3:50 p.m., the Administrator stated she did not have a policy and procedure for discharging a resident. The administrator stated the facility followed Title 22, state regulations, for discharging Resident 2. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 7DTE11 Facility ID: CA020000123 If continuation sheet 4 of 4