Other·August 14, 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 ammended findings of the California Department of Public Health during an abbreviated survey for the investigation of complaint #CA00627659. Representing the Department of Public Health: Health Facility Evaluator Nurse (HFEN): 38628 The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility.

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

F623 08/28/2019 §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 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: FKEH11 Facility ID: CA030000820 If continuation sheet 1 of 20 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: _______________ 555337 (X3) DATE SURVEY COMPLETED 08/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CITRUS HEIGHTS POST ACUTE 7807 Uplands Way Citrus Heights, CA 95610 (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 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. §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 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: FKEH11 Facility ID: CA030000820 If continuation sheet 2 of 20 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: _______________ 555337 (X3) DATE SURVEY COMPLETED 08/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CITRUS HEIGHTS POST ACUTE 7807 Uplands Way Citrus Heights, CA 95610 (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 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 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 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: FKEH11 Facility ID: CA030000820 If continuation sheet 3 of 20 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: _______________ 555337 (X3) DATE SURVEY COMPLETED 08/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CITRUS HEIGHTS POST ACUTE 7807 Uplands Way Citrus Heights, CA 95610 (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 by: This requirement is not met as evidenced by : Based on interview and record review, facility failed to assure that 1 of 3 sampled residents (Resident 1) was provided a notice of discharge to resident representative and the Office of the State Long-Term Care (Ombudsman), which indicated the reasons for discharge in writing as is required by regulation Failure to communicate this information placed the Resident 1at risk for more than minimal harm by increasing the risk of complications and adverse events during the transition and precluded the resident's appeal rights and access to long term car (Ombudsman). Findings: Resident 1 was admitted in 2019 into facility for rehabilitation after surgery for spinal stenosis (a condition, in which spinal canal narrows causing pain), low back pain, and bipolar disorder (mental disorder). Review of clinical record for Resident 1 included the following: 1. Review of a clinical document titled My Transition Home (MTH) last dated 3/6/19, a document prepared by facility when Resident 1 was discharged home. The document didn't include the written notification of discharge to Resident 1, resident representative, or Ombudsman. 2. The document MTH did not indicated: the reason for discharge, the effective date of discharge, the location to which the Resident 1 was to be discharged, a statement of the resident appeal rights, or the name, address, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: FKEH11 Facility ID: CA030000820 If continuation sheet 4 of 20 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: _______________ 555337 (X3) DATE SURVEY COMPLETED 08/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CITRUS HEIGHTS POST ACUTE 7807 Uplands Way Citrus Heights, CA 95610 (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 telephone number of the Ombudsman. 3. Review of Resident 1 Progress Notes dated 3/5/19 at 2:04 p.m. indicated the following: - The record indicated that the Business Office Manager (BOM) and Registered Nurse 1 (RN 1) talked to Resident 1 regarding order for discharge home. - The record indicated that the BOM told Resident 1 she did not meet the criteria to live in Skilled Nursing Facility (SNF) and Resident 1 needed to seek other housing arrangements. - The record indicated that the BOM told Resident 1 that Social Service 1(SS 1) would help her with placement and Resident 1 could reside in facility until everything it's worked out. 4. Review of Resident 1 Progress Notes dated 3/1/19 at 2:30 p.m., indicated that SS 1 informed Resident 1 regarding discharge and an agent from housing agency would help Resident 1 to find a place to live. 5. Review of Resident 1's Progress Notes, dated 3/6/19 at 5:14 p.m., indicated that Resident 1 was reluctant to leave the facility. 6. Review of Resident 1's Progress Notes dated 3/6/19 at 6 p.m. indicated Resident 1 left the facility at 5:45 p.m. 7. Clinical document titled Discharge Notification and Discharge Information, dated 1/24/19, indicated the Resident 1 was to be discharged on 1/28/19. No indication of the address where the resident would be discharged. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: FKEH11 Facility ID: CA030000820 If continuation sheet 5 of 20 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: _______________ 555337 (X3) DATE SURVEY COMPLETED 08/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CITRUS HEIGHTS POST ACUTE 7807 Uplands Way Citrus Heights, CA 95610 (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 Interviews: During an interview on 3/12/19 at 10:15 a.m., Complainant 1 stated that Resident 1 did not receive any notification regarding discharge, only Resident 1 was told that the doctor wrote an order to go home because the insurance did not pay for staying longer in facility. Complainant 1called Ombudsman agent 1, but did not get any information because the agency did not know anything about the case. During an interview on 3/13/19 at 9:30 a.m, Ombudsman agent 1 stated that Facility never informed the agency when Resident 1 was discharged home or into community. During a concurrent interview and record review on 3/13/19 at 11:15 a.m, Case Manager (CM) stated the Resident 1 was alert, oriented to place, person, time, and situation and made her needs known. CM stated the Resident 1 was informed verbally of the discharge plan. The Resident 1 indicated at admission time that she had a place to live. CM verified the discharge notice in Resident 1's medical record and could not be located. Regarding notification of Ombudsman about Resident 1 discharge, CM stated that the facility did not call Ombudsman to inform about discharge of resident. During a concurrent interview and record review on 3/13/19 at 12:05 p.m., SS 1 stated that Resident 1 was informed orally about the discharge home. SS 1did not know about the written notice of discharge to resident and resident representative. She stated the facility did not inform the Ombudsman about discharge Resident 1 home. SS 1 looked in the Resident 1 medical records and did not find any discharge notice to resident, resident representative, or Ombudsman. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: FKEH11 Facility ID: CA030000820 If continuation sheet 6 of 20 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: _______________ 555337 (X3) DATE SURVEY COMPLETED 08/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CITRUS HEIGHTS POST ACUTE 7807 Uplands Way Citrus Heights, CA 95610 (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 a concurrent interview and record review on 3/13/19 at 4:00 p.m., the facility's Administrator stated that the resident knew Resident 1 she was to go home. The Administrator stated that the facility talked to Resident 1 before and informed her that the insurance stopped paying for staying longer, because the Resident 1 was stable. The Administrator stated that the facility did not call the Ombudsman to inform them about Resident 1 disacharge because it is not in their policy. The Administrator looked in Resident 1's medical records and didn't find any discharge notice. The administrator went to the medical records office and brought some papers, but did not produce copy of Resident 1 discharge notice. Review the Policy titled "Discharge: Home or Non-Institutional Setting", dated 12/2009 indicated the instruction to follow up the procedure done on the day prior to discharge, and on the day of discharge. The policy did not reflect directions regarding the discharge notice to resident, resident representative, or Ombudsman.

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: FKEH11 08/28/2019 Facility ID: CA030000820 If continuation sheet 7 of 20 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: _______________ 555337 (X3) DATE SURVEY COMPLETED 08/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CITRUS HEIGHTS POST ACUTE 7807 Uplands Way Citrus Heights, CA 95610 (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 one of three sampled residents (Resident 1) when Resident 1 was discharged home. This failure placed Resident 1 at risk for more than minimal harm by increasing depression, anxiety level, and unsafe discharge from facility. Findings: Resident 1 was admitted in 2019 in facility for rehabilitation after surgery for spinal stenosis (a condition, in which spinal canal narrows and causing pain), low back pain, and bipolar disorder (mental disorder). Review included clinical records for Resident 1, dated 1/19/19, the following physician orders: 1. Occupational Therapy (OT) services, 2. Physical Therapy (PT) services, 3. Pain Medication regimen and to continue medication for bipolar disorder, and 4. Treatment for incision wound due to back surgery. Record Review: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: FKEH11 Facility ID: CA030000820 If continuation sheet 8 of 20 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: _______________ 555337 (X3) DATE SURVEY COMPLETED 08/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CITRUS HEIGHTS POST ACUTE 7807 Uplands Way Citrus Heights, CA 95610 (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 Review of a clinical document titled My Transition Home (MTH) last dated 3/6/19, a document prepared by facility when Resident 1 was discharged home. The document did not indicate that Resident 1 was prepared and oriented prior discharge home. The MTH document did not indicate that Resident 1 had a place to live, or where, she would be discharged. Review of Resident 1 Progress Notes, dated 3/1/19 at 2:30 p.m. indicated that Social Service 1 (SS 1), told Resident 1 that she was assigned to an agent from a housing agency who was going to help Resident 1 to find housing. Review of Resident 1 Progress Notes, dated 3/1/19 at 2:04 p.m. indicated Resident 1 told SS 1 that her husband was staying at the old place, in a shed. Review of Resident 1 Progress Notes, dated 3/5/19 at 2:04 p.m. regarding discharge, indicated the following: 1. The document indicated that RN 1 and the Business Office Manager (BOM) met with Resident 1 and informed Resident 1 that MD is going to write a discharge order. 2. The document indicated the BOM informed Resident 1 that the insurance stopped paying for her to stay in facility weeks ago because Resident 1 did not meet the criteria to live in a Skill Nursing Facility (SNF) any longer and Resident 1 had to seek other housing arrangements. 3. The document indicated the BOM informed Resident 1 that facility offered service through SS to assist with placement and informed her FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: FKEH11 Facility ID: CA030000820 If continuation sheet 9 of 20 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: _______________ 555337 (X3) DATE SURVEY COMPLETED 08/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CITRUS HEIGHTS POST ACUTE 7807 Uplands Way Citrus Heights, CA 95610 (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 that she could still remain at facility while it was worked out. Interviews: During an interview on 3/12/19 at 1:00 p.m. Complainant 1 stated that Resident 1 did not receive any instruction or information regarding her discharge into community and Resident 1 ended up living in a car. During a concurrent interview and record review on 3/13/19 at 12:05 p.m, SS 1 stated that Resident 1 received information and instructions prior to discharge home. SS 1 stated that Resident 1 was alert, oriented and able to make her needs known and orally informed about discharge. SS 1 was unable to locate the documented evidence of instruction regarding discharge of Resident 1. During a concurrent interview and record review on 3/13/19 at 4:00p.m. the facility's Administrator stated that Resident 1 when she went home received the information and instruction regarding discharge. Administrator was unable to locate documentation that Resident 1 was prepared for discharge. During an interview on 4/25/19 at 11:55 a.m. the Director of Nursing (DON) stated that SS 1 did Resident 1's discharge, and was responsible for the whole process of discharge. Review the Policy Discharge Home or NonInstitutional Setting, updated 12/2009, reflected the purpose of the policy: "To provide safe departure from center to home or noninstitutional setting." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: FKEH11 Facility ID: CA030000820 If continuation sheet 10 of 20 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: _______________ 555337 (X3) DATE SURVEY COMPLETED 08/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CITRUS HEIGHTS POST ACUTE 7807 Uplands Way Citrus Heights, CA 95610 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

F660 Discharge Planning Process CFR(s): 483.21(c)(1)(i)-(ix)

F660 SS=D PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 08/28/2019 §483.21(c)(1) Discharge Planning Process The facility must develop and implement an effective discharge planning process that focuses on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to postdischarge care, and the reduction of factors leading to preventable readmissions. The facility's discharge planning process must be consistent with the discharge rights set forth at 483.15(b) as applicable and(i) Ensure that the discharge needs of each resident are identified and result in the development of a discharge plan for each resident. (ii) Include regular re-evaluation of residents to identify changes that require modification of the discharge plan. The discharge plan must be updated, as needed, to reflect these changes. (iii) Involve the interdisciplinary team, as defined by §483.21(b)(2)(ii), in the ongoing process of developing the discharge plan. (iv) Consider caregiver/support person availability and the resident's or caregiver's/support person(s) capacity and capability to perform required care, as part of the identification of discharge needs. (v) Involve the resident and resident representative in the development of the discharge plan and inform the resident and resident representative of the final plan. (vi) Address the resident's goals of care and treatment preferences. (vii) Document that a resident has been asked about their interest in receiving information FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: FKEH11 Facility ID: CA030000820 If continuation sheet 11 of 20 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: _______________ 555337 (X3) DATE SURVEY COMPLETED 08/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CITRUS HEIGHTS POST ACUTE 7807 Uplands Way Citrus Heights, CA 95610 (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 regarding returning to the community. (A) If the resident indicates an interest in returning to the community, the facility must document any referrals to local contact agencies or other appropriate entities made for this purpose. (B) Facilities must update a resident's comprehensive care plan and discharge plan, as appropriate, in response to information received from referrals to local contact agencies or other appropriate entities. (C) If discharge to the community is determined to not be feasible, the facility must document who made the determination and why. (viii) For residents who are transferred to another SNF or who are discharged to a HHA, IRF, or LTCH, assist residents and their resident representatives in selecting a postacute care provider by using data that includes, but is not limited to SNF, HHA, IRF, or LTCH standardized patient assessment data, data on quality measures, and data on resource use to the extent the data is available. The facility must ensure that the post-acute care standardized patient assessment data, data on quality measures, and data on resource use is relevant and applicable to the resident's goals of care and treatment preferences. (ix) Document, complete on a timely basis based on the resident's needs, and include in the clinical record, the evaluation of the resident's discharge needs and discharge plan. The results of the evaluation must be discussed with the resident or resident's representative. All relevant resident information must be incorporated into the discharge plan to facilitate its implementation and to avoid unnecessary delays in the resident's discharge or transfer. This REQUIREMENT is not met as evidenced by: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: FKEH11 Facility ID: CA030000820 If continuation sheet 12 of 20 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: _______________ 555337 (X3) DATE SURVEY COMPLETED 08/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CITRUS HEIGHTS POST ACUTE 7807 Uplands Way Citrus Heights, CA 95610 (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 Based on interview and record review, the facility failed to develop and implement an effective discharge planning process that focused on resident discharge goals and needs and referrals to local contact agencies for one of three sampled residents (Resident 1). This failure placed Resident 1 at risk for more than minimal harm by increasing the risk of complications and adverse events during the resident transition. Findings: Resident 1 was admitted in 2019 into the facility for rehabilitation after surgery for spinal stenosis (a condition, in which spinal canal narrows and causing pain), low back pain, and bipolar disorder (mental disorder). Review of clinical records for Resident 1, dated on 1/19/19, indicated the following physician orders: 1. Occupational Therapy (OT) services, 2. Physical Therapy (PT) services, 3. Pain medication regimen, 4. Continue medication for bipolar disorder, and 5. Treatment for incision wound due to back surgery. Review a document titled My Transition Home (MTH), last dated on 3/6/19. MTH was a document prepared by facility when Resident 1 discharged home. The MTH form indicated the following: 1. Discharge instructions for nursing, dated 3/6/19, indicated the treatment of wound care of lower back surgical incision: "Lower back surgical site cleanse with normal saline, pat FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: FKEH11 Facility ID: CA030000820 If continuation sheet 13 of 20 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: _______________ 555337 (X3) DATE SURVEY COMPLETED 08/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CITRUS HEIGHTS POST ACUTE 7807 Uplands Way Citrus Heights, CA 95610 (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 dry, leave it open to air." 2. Discharge instructions for therapy, dated 3/6/19, indicated Resident 1 was recommended a shower chair and PT services 5x/week to increase functional independence. 3. Discharge instructions for Social Services 1 (SS 1), dated 1/25/19, indicated Resident 1 would be discharged when therapy goals met. The discharge instructions indicated that Resident 1 to be followed by home health and SS 1 wrote: " May discharge home on 1/28/19. Follow up with PCP at Molina clinic within 7-10 days of discharge. No equipment needed upon discharge. May send medication with current orders with upon discharge." 4. Medication reconciliation document was blank, dated 1/28/19. 5. Discharge instructions for equipment, dated 3/6/19, when Resident 1 discharged home indicated front wheeled walker (FWW). No indication that Resident 1 received the FWW or the shower chair, as recommended in the earlier note. 6. Discharge instructions for appointments, dated 1/25/19 indicated Resident 1 "will schedule follow up appointment" with primary care physician (PCP) at Molina Clinic." 7. Discharge instructions for Resident 1, dated 3/6/19, regarding concerns for next physician visit indicated a review of medication, but no medication review, the document was blank also. Review Resident 1 Progress Notes, dated 3/1/19 at 2:30 p.m. regarding discharge, indicated Resident 1 was assigned to an agent from a housing agency who was going to help FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: FKEH11 Facility ID: CA030000820 If continuation sheet 14 of 20 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: _______________ 555337 (X3) DATE SURVEY COMPLETED 08/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CITRUS HEIGHTS POST ACUTE 7807 Uplands Way Citrus Heights, CA 95610 (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 find housing. The Progress Notes indicated that Resident 1's husband was staying at the old place, in a shed. Resident 1 Progress Notes, dated 3/2/19 at 9:58 p.m, indicated a physician referral for recommendation of a pain specialist for pain management related to spinal stenosis and chronic pain. The medical records did not reflect if the referral was done. Resident 1 Progress Notes dated 3/5/19 at 2:04 p.m. regarding Discharge Planning, indicated the following: 1. The record noted RN 1 and the Business Office Manager (BOM) met with Resident 1 and informed Resident 1 that Medical Doctor (MD) is going to write a discharge order. 2. The record noted the BOM informed Resident 1 that the insurance stopped paying for her to stay in facility weeks ago because Resident 1 did not meet the criteria to live in a Skill Nursing Facility (SNF) any longer and Resident 1 had to seek other housing arrangements. 3. The record noted that the BOM informed Resident 1 that the facility offered service through Social Service to assist with placement and informed her that she could still remain at facility while it was worked out. Resident 1 Progress Notes, dated 3/6/19 at 5:14 p.m. regarding discharge, indicated that Resident 1 was reluctant to leave the facility. The Progress notes indicated that SS 1 told Resident 1 she had a higher level of functioning and not qualified to live in Skill Nursing Facility (SNF), and also SS 1 did not indicate if a place for living was found for Resident 1 or that discharge instructions were given to Resident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: FKEH11 Facility ID: CA030000820 If continuation sheet 15 of 20 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: _______________ 555337 (X3) DATE SURVEY COMPLETED 08/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CITRUS HEIGHTS POST ACUTE 7807 Uplands Way Citrus Heights, CA 95610 (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 1. Resident 1 Progress Notes dated 3/6/19 at 6 p.m. indicated that Resident 1 left the facility with her personal property and pain medication. Interviews: During interview on 3/12/19 at 1:00 p.m. the Complainant 1 stated that Resident 1 did not receive any instruction or information regarding her discharge into the community. Resident 1 ended up living in a car. During an interview on 3/13/19 at 9:30 p.m. with the Ombudsman 1, who stated he did not know anything about Resident 1's status related to housing because the facility did not notify him. During a concurrent interview and record review on 3/13/19 at 12:05 p.m. SS 1 stated that Resident 1 received information regarding Discharge Planning. Resident 1 was alert, oriented, and able to make her needs known and was told about discharge planning on 3/5/19. SS 1 stated that Resident 1 received notification regarding discharge, and discharge summary, and care plan post discharge. The SS 1 looked into Resident 1 medical records to find the documents of discharge. She was unable to locate the evidence of discharge plan of Resident 1. During a concurrent interview and record review on 3/13/19 at 4:00p.m. the facility's Administrator stated that Resident 1 when she went home received the information regarding discharge process including a copy of Discharge Planning form. The Administrator stated that Resident 1 received instruction FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: FKEH11 Facility ID: CA030000820 If continuation sheet 16 of 20 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: _______________ 555337 (X3) DATE SURVEY COMPLETED 08/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CITRUS HEIGHTS POST ACUTE 7807 Uplands Way Citrus Heights, CA 95610 (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 regarding activity of daily living (ADL), medication reconciliation, information regarding home health agency (HHA), information regarding MD appointments or other contacts. The administrator stated that all forms could be found in My Transition Home Document. The Administrator looked into Resident 1's medical record and did not find any discharge forms. The Administrator went to medical record office, but did not produce the discharge forms for Resident 1. During an interview on 4/25/19 at 11:55 a.m. the Director of Nursing (DON) stated that "SS who did Resident 1's discharge had to follow the policy for discharge titled: Discharge Home or Non-Institutional Setting." Review the policy Discharge Home or NonInstitutional Setting, updated 12/2009, did not include information or instruction regarding development and implementation of an effective discharge plan that focussed on the resident's discharge goals. . .

F661 Discharge Summary FORM CMS-2567(02-99) Previous Versions Obsolete

F661 Event ID: FKEH11 08/28/2019 Facility ID: CA030000820 If continuation sheet 17 of 20 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: _______________ 555337 (X3) DATE SURVEY COMPLETED 08/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CITRUS HEIGHTS POST ACUTE 7807 Uplands Way Citrus Heights, CA 95610 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) SS=D CFR(s): 483.21(c)(2)(i)-(iv) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.21(c)(2) Discharge Summary When the facility anticipates discharge, a resident must have a discharge summary that includes, but is not limited to, the following: (i) A recapitulation of the resident's stay that includes, but is not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results. (ii) A final summary of the resident's status to include items in paragraph (b)(1) of §483.20, at the time of the discharge that is available for release to authorized persons and agencies, with the consent of the resident or resident's representative. (iii) Reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over-thecounter). (iv) A post-discharge plan of care that is developed with the participation of the resident and, with the resident's consent, the resident representative(s), which will assist the resident to adjust to his or her new living environment. The post-discharge plan of care must indicate where the individual plans to reside, any arrangements that have been made for the resident's follow up care and any postdischarge medical and non-medical services. This REQUIREMENT is not met as evidenced by: Based on interview and record review, facility failed to develop a discharge summary which included: - identification and address of place to live; - a recapitulation of the resident 's stay, - a final summary of the resident's status, and - reconciliation of all pre- and post discharge FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: FKEH11 Facility ID: CA030000820 If continuation sheet 18 of 20 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: _______________ 555337 (X3) DATE SURVEY COMPLETED 08/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CITRUS HEIGHTS POST ACUTE 7807 Uplands Way Citrus Heights, CA 95610 (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 medication for one of three sampled residents (Resident 1) when Resident 1 was discharged home. This failure to provide the discharge summary, the facility placed Resident 1 at risk for more than minimal harm due to the potential for inaccuracies in medication and other orders during the transition of care. Resident 1 was admitted in 2019 to facility for rehabilitation after surgery for Spinal Stenosis (a condition, in which spinal canal narrows and causing pain), low back pain, and bipolar disorder (mental disorder). Review of clinical records for Resident 1, dated 1/19/19, indicated the following physician order: 1. Occupational Therapy (OT) services, 2. Physical Therapy (PT) services, 3. Pain medication regimen, 4. Continue medication for bipolar disorder, and 5. Surgical incision care. Findings: Clinical Record Review of Resident 1 indicated the following: A document titled Discharge Summary part B, dated 3/6/19, indicated: 1. The diagnosis of admission of Resident 1 into facility: lumbar radiculopathy, spinal stenosis (a condition, in which spinal canal narrows and causing pain), low back pain, and bipolar disorder (mental disorder). 2. The paragraph of recapitulation of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: FKEH11 Facility ID: CA030000820 If continuation sheet 19 of 20 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: _______________ 555337 (X3) DATE SURVEY COMPLETED 08/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CITRUS HEIGHTS POST ACUTE 7807 Uplands Way Citrus Heights, CA 95610 (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 stay/changes in medical status was blank. 3. The paragraph for prognosis was blank. 4. The paragraph for final diagnosis was blank. 5. Final disease or condition paragraph was blank. 6. Paragraph for physician signature was blank. Interviews: During an interview and concurrent record review on 3/13/19 at 12:05 p.m, Social Services 1(SS 1) stated that Resident 1 received documents of discharge: PostDischarge Plan of Care. The SS 1 looked into Resident 1 medical record and she was unable to locate the notes which indicated that Resident 1 received post-discharge plan of care document During a concurrent interview and record review on 3/13/19 at 4 p.m. the facility's Administrator stated the all discharge instructions could be found in My Transition Home document. The Administrator looked in Resident 1's medical record and was unable to locate any discharge summary. Review of policy for Discharge Home or NonInstitutional Setting updated on 12/2009 indicated that a discharge summary needed to be done and placed in medical records. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: FKEH11 Facility ID: CA030000820 If continuation sheet 20 of 20