Other·May 25, 2017

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 represents the findings of the California Department of Public HealthLicensing and Certification during an Abbreviated Survey for an Entity Reported Incident (ERI) CA00518850. Representing the California Department of Public Health-Licensing and Certification by Federal ID 36476, RN HFEN. The Abbreviated Survey was limited to the specific incident investigated and does not represent the findings of a full inspection of the facility. ERI CA00518850: One deficiency was issued.

F204 SS=G PREPARATION FOR SAFE/ORDERLY TRANSFER/DISCHRG CFR(s): 483.15(c)(7)

F204 06/18/2017 (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 sufficient preparation for a safe and orderly discharge for one of three sampled Residents (Resident 1), when 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: MJXP11 Facility ID: CA030000088 If continuation sheet 1 of 11 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: _______________ 055084 (X3) DATE SURVEY COMPLETED 05/18/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERBANK POST-ACUTE 2649 Topeka St Riverbank, CA 95367 (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, who was known by the facility to have serious mental illness, inability to care for herself and an unhealed right foot wound that required treatment was permitted to plan her own discharge. Resident 1 was discharged to the care of a taxi driver and traveled by taxi and bus to a city 70 miles away from the facility with no arranged wound care, personal care or housing in place upon arrival. This failure placed Resident 1 at risk for serious physical harm from an untreated wound and lack of ability to meet her own need for food and shelter. Findings: Resident 1's clinical record titled, "Admission Record," indicated Resident 1 was admitted to the facility on 12/4/16 with diagnoses that included; Anxiety Disorder (disorder characterized by feelings of uneasiness, apprehension and dread), Psychotic Disorder (disorder characterized by impaired thinking and loss of contact with reality), Stage 4 Pressure Ulcer of the Right Heel (full thickness tissue loss with exposed bone, tendon or muscle), Difficulty in Walking, Chronic Pain Syndrome, Neuropathy (disorder causing nerve pain, numbness and tingling of the extremities), Hypertension (high blood pressure) and Noncompliance with Medical Treatment and Regimen (failure to follow medical recommendations and treatments). Review of Resident 1's clinical record from the Acute Care Hospital (ACH) 1 titled, "Diagnostic Impression for [ACH 1]. Mental Health Exam [of Resident 1] dated 12/14/16, indicated "... Insight - poor; Judgment- poor; Impulse control - poor ... Very limited coping techniques ..." Resident 1's Care Plan dated initiated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MJXP11 Facility ID: CA030000088 If continuation sheet 2 of 11 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: _______________ 055084 (X3) DATE SURVEY COMPLETED 05/18/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERBANK POST-ACUTE 2649 Topeka St Riverbank, CA 95367 (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 12/15/16, indicated "Focus: Resident has multiple behavior/mood issues such as verbal and physical aggression, uses foul language, paranoid (thinks everyone is trying to hurt her or steal from her), constant talking to self and others not present (frequently tells imaginary person to "get off me"), very frequent refusals of care including meds [medications] and wound care, can be very delusional[beliefs that are firmly held, contrary to reality]/flight of thoughts, very poor reality awareness, nonsensical conversations ..." Review of Resident 1's clinical record titled, "Minimum Data Set (MDS) (a resident assessment tool used to plan care) assessment, dated 1/18/17, indicated Resident 1 had not walked in the hallway during the 7 days prior to the assessment and required extensive assistance of two staff members for personal hygiene. The MDS indicated Resident 1 had delusions and verbal behavioral symptoms directed toward others such as threatening, screaming and cursing. Review of Resident 1's clinical record titled, "Wound Care Specialist Initial Evaluation," dated 12/9/16, indicated, "... Stage 4 pressure wound of the right heel...on my examination I noted an exposed bone in the wound bed [on the right heel] ... There is moderate serous exudate [clear drainage]." Resident 1's Physician's order dated 12/19/17, indicated, "Cleanse stage 4 [stage 4 pressure ulcer on the right heel] with normal saline [a sterile salt water solution], pat dry. Apply calcium alginate with silver [type of wound dressing that absorbs drainage, protects against bacteria and reduces odor] dressing and cover with dry dressing every day." Review of Resident 1's clinical record titled, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MJXP11 Facility ID: CA030000088 If continuation sheet 3 of 11 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: _______________ 055084 (X3) DATE SURVEY COMPLETED 05/18/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERBANK POST-ACUTE 2649 Topeka St Riverbank, CA 95367 (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 "Wound Care Specialist Progress Note," dated 1/6/17, indicated "... Assessment & Plan: Stage 4 pressure wound of the right heel - no change ..." On 2/2/17 at 11:15 a.m., during an interview, Social Services Director (SSD) 1 stated Resident 1 was discharged from the facility on 1/18/17. SSD 1 stated Resident 1 had been talking about going to a women's center in (a city 70 miles from the facility) and to a women's shelter two blocks from the women's center. SSD 1 stated, "[Resident 1] said there was a women's shelter 2 blocks away from the center and that she had stayed there before several times. I didn't get the name [of the shelter]. She [Resident 1] did not share any information about the shelter ..." SSD 1 stated the facility's Interdisciplinary Team (IDT, a team of facility healthcare professionals who meet to plan resident care) did not meet before Resident 1's discharge on 1/18/17 to plan Resident 1's possible discharge to the women's center. SSD 1 stated she communicated with the facility Administrator (Admin) and Resident 1's Medical Doctor (MD) 1 regarding the discharge. SSD 1 stated she asked the facility nurses to contact MD 1 for a discharge order for Resident 1. SSD 1 stated she wrote MD 1 a letter regarding Resident 1's discharge from the facility. SSD 1 stated a taxi ride from the facility to the bus station was set-up the day before Resident 1's discharge on 1/18/17. The SSD stated a bus voucher and a wheelchair were purchased for Resident 1. The SSD stated the taxi took Resident 1 to the bus station and Resident 1 took the bus to (city 70 miles away from the facility). SSD 1 stated she called a taxi company in (the city 70 miles away from the facility) to arrange for a taxi to meet Resident 1 at the bus station and transport Resident 1 from the bus station to the women's center. SSD 1 stated she purchased two backpacks for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MJXP11 Facility ID: CA030000088 If continuation sheet 4 of 11 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: _______________ 055084 (X3) DATE SURVEY COMPLETED 05/18/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERBANK POST-ACUTE 2649 Topeka St Riverbank, CA 95367 (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 to take with her upon discharge. One backpack contained wound care supplies and the second backpack contained clothes and personal care supplies. SSD 1 stated the facility gave Resident 1 $30.00 in cash, two packs of cigarettes and a $25.00 gift card upon discharge. On 2/2/17 at 12:39 p.m., during an interview, Licensed Nurse (LN) 3 stated Resident 1 had a stage 4 pressure ulcer on her right heel that required treatment while she was in the facility. LN 3 stated, "I don't think she is capable of taking care of herself because of this schizophrenic [severe mental illness causing loss of contact with reality] personality that she has, plus her wound. She won't have proper care ...lots of potential problems." On 2/2/17 at 12:58 a.m., during an interview, Licensed Nurse (LN) 1 stated, "It was about one to two days before discharge that I did her wound care last. The wound had maceration [moist white tissue] around the edges ...0.3 cm [centimeter, a linear measurement] deep, three inches by five inches around on the right heel. Yes it was a stage 4 sore. She [Resident 1] refused teaching about her wound care ...She has the mental capacity to take care of the wound if she tries. The question would be ...would she do it?" On 2/2/17 at 1:26 p.m., during an interview, LN 2 stated, "Most of the time she [Resident 1] is in her own world; talking away; soft to loud to yelling. It don't know if it was safe to discharge her [Resident 1 on 1/18/17]. I am scared for her." On 2/3/17 at 10:50 a.m., during an interview, the Admin stated the facility IDT normally met to discuss and plan resident discharges but the IDT did not meet to plan Resident 1's discharge FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MJXP11 Facility ID: CA030000088 If continuation sheet 5 of 11 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: _______________ 055084 (X3) DATE SURVEY COMPLETED 05/18/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERBANK POST-ACUTE 2649 Topeka St Riverbank, CA 95367 (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 on 1/18/17. The Admin stated Resident 1 left against medical advice (AMA, leaving despite physician recommendations to stay in the facility and continue treatment) and the IDT did not meet if the discharge was AMA. The Admin stated there was no psychiatric evaluation of Resident 1's condition prior to discharge on 1/18/17 because Resident 1 left the facility AMA. Review of Resident 1's clinical record titled, "Social Service Progress Note" dated 1/5/17 at 11:26 a.m., indicated, "Resident [Resident 1] has been stating that she wants to leave this facility. Social Services has called the shelter and they only have breakfast from 8-11 [a.m.] and then everybody leaves. It [the women's center] is not a shelter. They do not have rooms. They are a hospitality place. Resident will not be discharging to [women's center]." The progress note was signed by SSD 2. Review of facility document, untitled, dated 1/9/17, indicated "[MD] 1, Can you please reevaluate [Resident 1's] orders for capacity [mental capacity]? Please re-evaluate and update so we can have appropriate orders ..." The document was signed by SSD 1. MD 1's response indicated, " ...She [Resident 1] clearly understand what she want and not want and decide what she want and not want clearly. But she has mental issues which need psych eval [evaluation by psychiatrist] and treatment." Review of facility document, untitled, dated 1/11/17, indicated "[MD 1] [Resident 1] is requesting to be discharged to a women's center in [city]. She wants to take a taxi to the bus station, a bus to [city], and then a taxi to the women's center. We have called and verified that the women's center assists with food, clothing, shelter, etc. At this time [Resident 1] continues to have the open wound FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MJXP11 Facility ID: CA030000088 If continuation sheet 6 of 11 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: _______________ 055084 (X3) DATE SURVEY COMPLETED 05/18/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERBANK POST-ACUTE 2649 Topeka St Riverbank, CA 95367 (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 on her foot which she seldom allows us to treat. [Resident 1] states that she would allow HH [home health] RN [registered nurse] to come to the women's center and provide wound care. We have contacted [HH] and they go to the center. I have contacted the Ombudsman [name] and she has spoken to [Resident 1]. She agrees that [Resident 1] has the right to go. So our question is, can we get a Discharge order such as: Discharge to Shelter of choice, Follow up with local clinic for wound care. Continue current meds as ordered. Or ...AMA?" The document was signed by SSD 1. Review of MD 1's response indicated, "Had a detail discussion with my NP [nurse practitioner] about patient care and DC [discharge plan]. Both of us agree that patient need more care than at woman shelter with home health for wound care. She refuses care at SNF. We cannot hold pt [patient] against her will. She can be discharged at AMA. We still can try to arrange what she needs. But will be AMA discharge." The response was signed by MD 1. Review of facility document titled, "[MD 1] Discharge Instructions" dated 1/11/17, indicated "1) Check list for discharge if: Vital signs stable and wound improved/stabilized ...Cleared by Physical Therapy. Home safety evaluation done, and home health care set up as indicated." The document was signed by MD 1. Review of Resident 1's clinical record titled, "Progress Notes" dated 1/18/17 at 5:17 a.m., indicated, "Pt [patient ] was assisted into taxi cab, seatbelt fastened, at 0430 hours [ 4:30 a.m.], leaving facility AMA. Pt refused all care when preparing to leave, including shower, clean clothes, dressing change to foot wound, clean socks and protective booties ...Pt was offered oral medications, but refused, stating, "I FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MJXP11 Facility ID: CA030000088 If continuation sheet 7 of 11 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: _______________ 055084 (X3) DATE SURVEY COMPLETED 05/18/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERBANK POST-ACUTE 2649 Topeka St Riverbank, CA 95367 (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 will see my own doctor when I get there" ...Pt was asked to sign the AMA statement, she refused ..." On 2/2/17 at 2:28 p.m., during an interview, Licensed Social Worker (LSW) from the acute care hospital (ACH) 1 in (city) stated Resident 1 arrived in the ACH 1 Emergency Department (ED) on 1/18/17 at about 8 p.m. and spent the night in the ED. The LSW stated Resident 1 told her the skilled nursing facility gave her a bus voucher earlier that day and she had come to the ER from the bus depot which was about two blocks from ACH 1. The LSW stated ACH 1 found a board and care placement for Resident 1 and Resident 1 was transferred to the board and care on 1/19/17. The LSW stated Resident 1 was "kicked out" of the board and care the next day for aggressive behavior. The LSW stated the board and care owner had called 911 (emergency response number) to take Resident 1 to ACH 2. Review of ACH 1 record, titled, "Clinical Social Work Progress Note," dated 1/19/17, indicated placement for Resident 1 was initially made at a motel with referral to a senior placement organization to follow up. The note indicated, "This writer witnessed pt [Resident 1] outside attempting to get into cab; pt unable to transfer self. Pt soiled her clothes. This writer and SW [ACH 1 LSW] went out to assess situation. Pt is currently unable to transfer self or toilet self at this time. Pt does not have a way to care for self or obtain food while staying in hotel for 3 days; this discharge plan deemed unsafe ...new plan in process ...needs higher level of care ...Approval granted for 1 month of board and care as well as case mgmt. [management] services ..." Review of ACH 1 progress notes dated 1/20/17 and signed by ACH 1 LSW indicated Adult FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MJXP11 Facility ID: CA030000088 If continuation sheet 8 of 11 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: _______________ 055084 (X3) DATE SURVEY COMPLETED 05/18/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERBANK POST-ACUTE 2649 Topeka St Riverbank, CA 95367 (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 Protective Services (APS) had been notified of Resident 1's situation regarding removal from the board and care facility. The progress note indicated, "APS worker reported that she has contacted all [hospitals] in the surrounding area however have not been able to locate pt [Resident 1]. As of the time of this writing pt [Resident 1] has not returned to [ACH 1]." Review of Resident 1's clinical record from ACH 1 indicated an admission date of 1/18/17 and a discharge date of 1/19/17. The clinical record titled "ED Progress Notes" section "Medical Decision Making" indicated "... this is a 79 year old female who has dementia (cognitive deficits and memory loss) ...She is clearly unable to care for herself ..." On 2/13/17 at 3 pm during a telephone interview, SSD 1 stated she had not verified services offered at the women's center prior to Resident 1's discharge on 1/18/17. SSD 1 stated she understood SSD 2 had verified services were offered at the center. SSD 1 stated no arrangements were made with the women's center and the women's center was not notified by the facility regarding Resident 1's pending arrival on 1/18/17. On 2/13/17 at 6:12 p.m., during an interview, the Social Worker (SW) from the woman's center stated she had been in front of the women center about 1:30 p.m. on 1/18/17. The SW stated as she was leaving the center a taxi pulled up with Resident 1 inside. The SW stated Resident 1, upon arrival, was disheveled, very confused and agitated. The SW stated, "Somebody did this person wrong. It was the worst scenario ever. I could not believe that a facility would have sent this person to us that way. I have never known a facility to do that. It was pouring rain. This woman came to the center in a taxi. I went out FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MJXP11 Facility ID: CA030000088 If continuation sheet 9 of 11 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: _______________ 055084 (X3) DATE SURVEY COMPLETED 05/18/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERBANK POST-ACUTE 2649 Topeka St Riverbank, CA 95367 (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 and told the taxi driver and the woman to not even get out of the taxi. I told the taxi driver to take her to the Emergency Room." The SW stated, "We are open only from 7:30 a.m. to 11:30 a.m. Why would a facility send a patient to here in a bus without any arrangement of any kind? There's no available shelter in [city]. I have many, many people waiting for a shelter. If the facility would have asked for me, I would have told them not to send anybody up this way because there is no available placement up here. That woman [Resident 1] was in no form to take care of herself. It really bothered me that a facility would trust that person's judgement." Review of facility policy titled, "Transfer and Discharge" dated 7/1/16, indicated "II. Compliance Guidelines 1. Complete and accurate patient information, in sufficient detail to provide for continuity of care shall be transferred with the resident at the time of transfer...5. Refusal of treatment does not constitute grounds for transfer, unless the needs of the resident cannot be met or the health and safety of others is endangered...12 d. Orienting caregivers at the receiving site to the resident's daily patterns and psychosocial needs identified by the resident's assessment and care plan...14. For an anticipated discharge (not an emergency or not due to the resident's death), a discharge summary is prepared that includes: a. A recapitulation of the resident's stay; b. A final summary of the resident's status for all MDS items at the time of discharge; and c. A post-discharge plan of care developed in conjunction with the resident and his or her family." Review of facility policy titled, "Discharge Against Medical Advice" dated 7/1/16, indicated "I. Purpose: To delineate the procedure when a resident chooses to leave FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MJXP11 Facility ID: CA030000088 If continuation sheet 10 of 11 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: _______________ 055084 (X3) DATE SURVEY COMPLETED 05/18/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVERBANK POST-ACUTE 2649 Topeka St Riverbank, CA 95367 (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 facility against medical advice. II. Policy: ...B. The charge nurse and/or the Skilled Nursing Director, Director of Nursing as to the necessity of continued treatment as ordered by the physician, the social worker or other members of the staff who have developed positive relations with the patient may be asked to assist. C. If the resident insists on leaving against medical advice, a report will be made to Adult Protective Services if determined necessary because of anticipated harm to the resident...E. The facility will provide discharge information necessary for the continuity of care..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MJXP11 Facility ID: CA030000088 If continuation sheet 11 of 11