Health inspection·September 11, 2025

F 0627 Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to prepare and ensure a safe and appropriate discharge for one of three residents (Resident 1) when:1. Resident 1's fall risk level was not updated;2. Resident 1's discharge minimum data set (MDS, a clinical assessment tool) was not accurately coded;3. The facility did not provide discharge notice (a written notice in advance to the resident and the resident's representative in a language and manner they understand and an opportunity to appeal) to Resident 1 and/or her son (Resident 1's co-health care decision maker). Resident 1 also did not have a discharge care plan and did not have discharge notes on the day of her discharge; and4. The facility did not verify the license and the care capabilities of the discharge placement facility.These failures resulted in Resident 1 who had severe cognitive impairment (a significant decline in a person's ability to think, learn, remember, use judgement, and make decisions that can lead to a point where the individual is incapable of living independently because of the inability to plan and carry out activities of daily living [ADL, the tasks of everyday life] and apply judgment), poor recent memory, poor insight and judgment, mental illness, required a Preadmission Screening and Resident Review Level 2 (PASRR Level 2, a comprehensive, person-centered evaluation conducted for individuals identified by a Level 1 screening as having or potentially having a Serious Mental Illness [SMI], Intellectual Disability [ID, a condition that involves limitations on intelligence, learning and everyday abilities necessary to live independently], Developmental Disability [DD, a group of conditions due to an impairment in physical, learning, language, or behavior areas], or related condition), and required moderate to maximal assistance or dependent on the staff for ADL was discharged to an unlicensed Room and Board (Independent Living, living accommodations and dining services) on 5/22/25. Resident 1 fell at the discharge placement facility and was sent to acute care on 6/11/25. Findings:1. Review of Resident 1's admission Record indicated she was admitted to the facility on [DATE] with diagnoses including malignant neoplasm (cancer, an abnormal growth of cells) of left breast, diabetes (high blood sugar levels), protein-calorie malnutrition (an imbalance between the nutrients the body needs to function and the nutrients it gets), hyperlipidemia (high level of fats in the blood), hypertension (HTN, high blood pressure), reduced mobility (limitations in movement), muscle weakness, osteoporosis (a disease that weakens the bones; it makes the bones thinner and less dense than they should be), and depression (a persistent feeling of sadness and loss of interest and can interfere with the daily life).Review of Resident 1's clinical record indicated she did not have quarterly fall risk assessments from 8/22/24 to the day of her discharge on [DATE] (two quarterly assessments).During an interview with the director of nursing (DON) on 7/28/25, at 4:10 p.m., he reviewed Resident 1's clinical record and confirmed that Resident 1 did not have quarterly fall risk assessments from 8/22/24 to the day of her discharge on [DATE]. The DON stated the resident fall risk assessment should be done every quarter.2. During an interview with certified nursing assistant Page 1 of 4 055315 055315 09/11/2025 Camino Ridge Post-Acute 1949 Grant Road Mountain View, CA 94040

F 0627 Level of Harm - Actual harm Residents Affected - Few A (CNA A) on 7/30/25, at 1:40 p.m., CNA A stated before the discharge of Resident 1 was dependent on staff for shower and upper and lower body dressing and needed maximal assistance (the helper does more than half the effort) for personal hygiene.During an interview with certified nursing assistant B (CNA B) on 7/30/25, at 2 p.m., CNA B stated before the discharge Resident 1 was dependent on staff for shower, upper and lower body dressing, and personal hygiene.During an interview with certified nursing assistant C (CNA C) on 7/30/25, at 2:15 p.m., CNA C stated before the discharge Resident 1 was dependent on staff for shower and upper and lower body dressing and needed maximal assistance for personal hygiene.During an interview with certified nursing assistant D (CNA D) on 7/30/25, at 3:20 p.m., CNA D stated before the discharge Resident 1 needed moderate assistance (the helper does less than half the effort) for upper and lower body dressing and needed maximal assistance for shower and personal hygiene.During an interview with certified nursing assistant E (CNA E) on 7/30/25, at 3:50 p.m., CNA E stated before the discharge Resident 1 needed a lot of help; Resident 1 was dependent on staff for shower, upper and lower body dressing, and personal hygiene.Review of Resident 1's 5/2025 Document Survey Report V2 (Resident 1's Daily ADL status reported by the CNAs) indicated that for the last three days of her stay (from 5/20/25 to 5/22/25) at the facility she needed maximal assistance for bathing and needed moderate to maximal assistance for upper and lower body dressing and personal hygiene.However, review of Resident 1's discharge MDS on 5/22/25 indicated it was coded that Resident 1 needed moderate assistance for bathing and supervision for upper and lower body dressing and personal hygiene.During an interview with the MDS director (MDSD) on 7/30/25, at 2:45 p.m., she reviewed Resident 1's 5/2025 Document Survey Report V2 and discharge MDS dated [DATE] and confirmed that Resident 1's discharge MDS on 5/22/25 was not accurately coded.3. Review of Resident 1's clinical record indicated she did not have a discharge notice and discharge care plan before her discharge, and there were no discharge notes on the day of her discharge.During an interview with the social service director (SSD) on 7/30/25, at 4:10 p.m., she confirmed that Resident 1 did not have a discharge care plan. The SSD stated the discharge notice was for short-term residents. Resident 1 was a long-term resident, so she did not have discharge notice.During an interview with the director of nursing (DON) on 7/30/25, at 4:50 p.m., he reviewed Resident 1's clinical record and confirmed that there were no discharge notes on the day of her discharge. The DON stated when the residents were discharged , there should be notes on how the residents were, the residents discharged with whom and to where, and what had been done during discharge.4. Review of Resident 1's MDS, dated [DATE], indicated her cognition was severely impaired.Review of Resident 1's Che Behavioral Health Note (Che-Outside Consultant Note), dated 2/14/25, indicated her recent memory and her insight/judgment were poor.Review of Resident 1's result of PASRR Level 1 Screening (the initial screening tool), dated 7/23/23, indicated it was positive (requires Level 2 evaluation), and a PASRR Level 2 Screening was required for her.Review of Resident 1's admission Record indicated Resident 1 and her son, both were health care decision makers for her.Review of Resident 1's Social Services Notes, dated 5/6/25, indicated that Resident 1's son stated that he didn't remember having any conversation on wanting to move Resident 1 out of the facility.Review of Resident 1's Lease Agreement that the facility asked Resident 1 to sign and not her son on the day of her discharge, 5/22/25, indicated the discharge placement was to provide medication assistance to Resident 1 by medication reminder.Review of Resident 1's Physician's Orders Upon Discharge, dated 5/21/25, indicated her discharge medications were acetaminophen (for left knee pain) 325 milligrams (mg, a metric unit of mass) two tablets every 6 hours as needed, anastrozole (for breast cancer treatment) 1 mg one time day, aspirin (blood thinner) 81 mg one time a day, atorvastatin (for hyperlipidemia) 40 mg one time a day, docusate sodium (for bowel management) 055315 Page 2 of 4 055315 09/11/2025 Camino Ridge Post-Acute 1949 Grant Road Mountain View, CA 94040

F 0627 Level of Harm - Actual harm Residents Affected - Few 250 mg two times a day, loratadine (for itching) 10 mg one time a day, melatonin (for supplement to maintain the natural 24-hour cycle) 3 mg at bedtime, metformin (for diabetes) 500 mg two times a day, optic-Vites with lutein (for eye health) one tablet one time a day.Review of Resident 1's Physician's Report (Resident 1's primary physician's report/notes for referral to the placement agency) for Residential Care Facilities for the Elderly (RCFE, a non-medical facility that provides housing, meals, supervision, and personal assistance with daily activities to seniors who need help but not 24-hour nursing care; these facilities, also known as assisted living or board and care homes, to help seniors maintain independence in a homelike setting, with services like help with bathing, dressing, and medication management), dated 2/17/25, the physician indicated that Resident 1 could not administer own prescription medications.During an interview with the SSD on 7/28/25, at 3 p.m., she stated she asked the placement agency (an organization that helps to find suitable residential care options for seniors, such as independent living, assisted living, memory care, or skilled nursing facilities) for the license of Resident 1's discharge placement, but she didn't receive it, and she did not verify it. The SSD stated she thought Resident 1's discharge placement was a Board and Care (a small, residential facility, that provides room, board, and assistance with daily living activities for individuals who need non-medical supervision but cannot live independently). She did not know Resident 1's discharge placement was a Room and Board (Independent Living, living accommodations and dining services) until Resident 1 was brought to acute care after her fall.During an interview with the SSD on 8/19/25, at 12:25 p.m., she stated the placement agency came to the facility, assessed Resident 1, and determined that they could provide care to her at their place. The SSD stated she would look for that document or request from the placement agency for that document.During an interview with the SSD on 9/11/25, at 11:45 a.m., she confirmed that she could not find the document on Resident 1's assessment by the placement agency. The SSD also confirmed that she requested it, but the placement agency didn't provide it for her.Review of Resident 1's Social Services Notes, dated 6/11/25, indicated on 5/29/25 Resident 1 had an unwitnessed fall in the bathroom at the discharge placement.Review of Resident 1's acute care History and Physical, dated 6/11/25, indicated Resident 1 was found on the floor sitting against her bed at the discharge placement and was brought into the acute care by ambulance. It also indicated that Resident 1's discharge placement was an unlicensed Room and Board (Independent Living).Review of Resident 1's acute care History and Physical, dated 6/11/25, indicated Resident 1's discharge placement refused to take her back. The acute care also determined that they didn't want to send Resident 1 back to her discharge placement, an unlicensed Room and Board (Independent Living), because it was not appropriate for Resident 1, and it would be liability on them if they sent her back there. The acute care determined that Resident 1 would be appropriate for skilled nursing home placement.Review of the facility's policy, Fall Prevention and Response, dated 8/2023, indicated . 1. Utilizing the Resident Assessment Instrument (RAI- a guide that facility staff use for coding and transmission) 3.0 User's Manual Version 1.19.1, dated October 2024) process, facility will identify and address potential for fall accidents, environmental factors, individual risk factors, need for supervision, care, and assistive devices.Review of the Long-Term Care Facility Resident Assessment Instrument (RAI), indicated, It is important to note that information obtained should be validated for accuracy, what the resident's actual status was during the observation period.Review of the facility's policy, Admissions, Transfer, Discharge and Bed-Holds, dated 12/2016, indicated . Transfer and discharge: . Before a resident is transferred or discharged , the facility will notify the resident and the resident's representative of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. Notice will be made at least 055315 Page 3 of 4 055315 09/11/2025 Camino Ridge Post-Acute 1949 Grant Road Mountain View, CA 94040

F 0627 Level of Harm - Actual harm 30-days prior to transfer or discharge, or as soon as practical . The facility will provide sufficient preparation and orientation to residents and resident representatives in order to ensure a safe and orderly discharge from the facility. Residents Affected - Few 055315 Page 4 of 4