Health inspection·April 25, 2025

F 0661 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure one of three sampled residents (Resident A) received a post-discharge plan of care, which contained the necessary information for the continuation of care after discharge. This failure resulted in Resident A ' s family calling the facility for advice and sending Resident A to the emergency room, within 24 hours of his discharge from the facility. Findings: On March 28, 2025, at 9:50 a.m., an unannounced visit to the facility was conducted to investigate quality of care concern and discharge rights. On March 28, 2025, at 1 p.m., an interview was conducted with the Social Service Assistant (SSA). The SSA stated the case managers and social service director are the ones who help the residents plan for discharge and follow up care. The SSA stated Resident A was discharged on March 18, 2025, and she called Resident A twice following his discharge, but she did not speak with Resident A. On March 28, 2025, at 1:10 p.m., an interview was conducted with the Case Manager (CM). The CM stated Resident A was discharged from the facility on March 18, 2025, she had ordered home health, a safety evaluation from physical therapy and occupational therapy, and wound care. The CM stated Resident A was receiving wound care when he was at the facility and the care should continue after he leaves. The CM stated a family member of Resident A ' s called about Resident A ' s leg being swollen and the CM told the family member if Resident A ' s leg was red and swollen, he may need to go to the hospital. The CM stated she called and spoke with the home health agency and asked when they would be out to evaluate Resident A. The CM stated she does provide discharge planning and speaks with the residents, and the nurse reviews all the information with the residents at the time of discharge and provides a handwritten discharge summary for their reference. On March 28, 2025, at 1:55 p.m., a review of Resident A ' s record was conducted. Resident A was admitted to the facility on [DATE], with diagnoses which included a left above the knee amputation, COPD (chronic obstructive pulmonary disease- a group of lung conditions that damage the airways and lungs), and cirrhosis of the liver (chronic damage leading to scarring and failure) with ascites (a complication of cirrhosis causing a buildup of fluid in the abdominal cavity). Resident A ' s order summary indicated: Page 1 of 4 055474 055474 04/25/2025 Woodcrest Post Acute & Rehabilitation 8133 Magnolia Avenue Riverside, CA 92504

F 0661 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few -Follow up with [name] Cardiology (focuses on the heart and blood vessels) in one week, ordered March 4, 2025. -Abdominal x-ray due to abdominal distention (bloating and swelling of the belly), ordered March 11, 2025. -Follow up with [name] gastroenterology/Hepatology (medical specialty focusing on the digestive system and the liver) clinic one week, ordered March 4, 2025. A review of Resident A ' s Wound Evaluation and Treatment, dated March 10, 2025, indicated .+2 edema (a moderate level of swelling, where an indentation remains after pressing the skin for a few seconds) RLE (right lower extremity) .Rec (recommend) artena [sic] (arterial); and venous doppler (a non-invasive imaging test that uses sound waves to visualize blood flow in the arteries and veins) RLE. Elevate RLE .Site 003 .right dorsal (the part of the foot that faces upwards while standing) foot .venous ulcer (a wound on the leg or ankle caused by damaged or abnormal vein function) with fat layer exposed .measurement (LxWxD) (length x width x depth): 11.0 x 8.0 x 0.1cm (centimeter-a unit of measurement) .100% epithelial (packed cells lining a body surface) tissue .treatment Plan: cleanse with sterile normal saline (a fluid with 0.9% sodium) pat dry apply betadine (a topical antiseptic) cover with roll gauze dressing change dressing daily and PRN (as needed) for loss of integrity/soiling . A review of Resident A ' s Case Management Notes: -dated March 5, 2025, at 10:29 a.m., indicated .he lives alone .DME (Durable Medical Equipment-medical supplies) at home include W/C (wheelchair), walker, shower chair, power chair, prosthesis (artificial replacement for a body part) .patient states his discharge plan is to return home under [insurance name] ( name of program of all-inclusive care for the elderly) Program . -dated March 18, 2025, indicated .Spoke with .[insurance name] regarding transport not arriving as arranged for scheduled discharge on [DATE] (March 18, 2025) .will reschedule transport .attempted to reach [family member] .message left regarding change in discharge date s .[insurance name] aware of HH (home health), PT (physical therapy)/OT (occupational therapy) as well as needed visit for primary, hepatology, and cardiology . -dated March 19, 2025, indicated .family member has concerns of patients [sic] leg ' being swollen ' .advise patient to go to ER for evaluation .call placed to [care coordinator at insurance] in order to expedite home health visit, as well as scheduling F/U [follow up] with primary MD as soon as possible . A review of Resident A ' s Discharge Summary indicated, .diagnosis (identified cause of a disease or injury) during stay: COPD . There was no documentation found for discharge diagnosis or prognosis (predication of how a disease, injury, or illness will progress over time). A review of Resident A ' s Post DC (discharge) Plan of Care, indicated no documentation found for responsible party, relationship to patient, or phone number, Resident A ' s activity levels, equipment/supplies, home health agency or phone number, home health referrals for rehabilitation, what treatments/ supplies are needed for wounds, state ombudsman information and phone number, follow up appointments with dates and times, as well as pharmacy information on form. 055474 Page 2 of 4 055474 04/25/2025 Woodcrest Post Acute & Rehabilitation 8133 Magnolia Avenue Riverside, CA 92504

F 0661 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On March 28, 2025, at 3:00 p.m., and interview was conducted with the Licensed Vocational Nurse (LVN). The LVN stated she was the nurse who went over Resident A ' s discharge instructions. The LVN stated his discharge summary was reviewed, the resident had expressed an understanding, a copy was given to resident at discharge. On April 9, 2025, at 3:30 p.m., an interview was conducted with the CM. The CM stated Resident A had orders for follow up appointments with cardiology and GI/hepatology, Resident A has [insurance name] and their process is to contact them, they arrange the approval for follow up appointments and transportation. The CM stated she spoke with the Care Coordinator [name], on March 5, 2025, and gave them Resident A ' s follow up appointment orders, and called again, on March 7, 2025, to follow up. The CM stated she did not speak with Care Coordinator [name] again until March 18, 2025, when arranging Resident A ' s discharge from the facility, and again on March 19, 2025, when Resident A ' s family had called with a concern. The CM stated she did not make the follow up appointments for Resident A per the orders, nor discussed the possibility of applying for Medi Cal to receive additional services and resources, Resident A may not be receiving with only Medi Care services. On April 10, 2025, at 11:40 a.m., an interview was conducted with the CM. The CM stated she spoke with the Social Services Director (SSD), the SSD stated she did not speak with Resident A about applying for additional services and resources through Medi Cal. The CM stated she had spoke with Resident A ' s Care Coordinator at [name] multiple times, and no appointments had been made while Resident A was in the facility. On April 10, 2025, at 11:55 a.m., an interview was conducted with the Care Coordinator (CC) for Resident A ' s insurance. The CC stated Resident A was in the skilled nursing facility (SNF) from March 4th until March 18, 2025, Resident A has no follow up appointments pending at this time. The CC stated she had received orders for Resident A on March 7, 2025, from the SNF, the orders were sent to Resident A ' s primary doctor for approval. The CC stated she was notified by the SNF on March 12, 2025, that Resident A would need home health and wound care services upon discharge. The CC stated Resident A had wound care follow up appointments on March 24, and March 26, 2025, but Resident A was admitted to the hospital, and the appointments were cancelled. On April 10, 2025, at 12:10 p.m., an interview was conducted with the Registered Nurse Supervisor (RNS) at [name]. The RNS stated Resident A was sent to the emergency room and admitted to the hospital on [DATE]. The RNS stated while Resident A was in the SNF receiving care, the SNF has control over the care, makes the decisions when assisting the resident, and is responsible for all follow up appointments, and additional care needs ordered. The RNS stated our program can assist by providing transportation if requested. The RNS stated the program will resume care once the resident is released from the SNF. On April 10, 2025, at 12:25 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated she was made aware Resident A had missing information on his discharge summary and Plan of Care, which should have been in the documents. A review of the facility ' s job descriptions for Case Manager indicated .is responsible for communicating care requirements to the facility care team and coordinating healthcare benefits for patients .ensures that the care needs of patients and residents within the facility are met in a competent, safe, and consistent manner and in accordance with current federal, state and local regulations .participates in patient/resident care plan meetings and follows-up as directed .educates patients/residents and their families of their benefits as needed .continuing communication with the 055474 Page 3 of 4 055474 04/25/2025 Woodcrest Post Acute & Rehabilitation 8133 Magnolia Avenue Riverside, CA 92504

F 0661 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few interdisciplinary team and insurance providers .acts as a liaison/coordinator with insurance and other alternative .providers .participates in regular meetings for management of Medi Care/managed care patients and residents as needed . A review of the facility ' s policy titled Transfer or Discharge, Preparing a Resident for, dated December 2023, indicated .When a resident is scheduled for transfer or discharge, the business office will notify nursing services of the transfer or discharge so that appropriate procedure can be implemented .a post-discharge plan is developed for each resident prior to .transfer or discharge .Nursing services is responsible for .preparing the discharge summary and post-discharge plan .providing the resident or representative (sponsor) with required documents . 055474 Page 4 of 4