Health inspection·January 2, 2025

F 0626 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to protect one of eight sampled residents (Resident 8) right to return to the facility following hospitalization. This failure resulted in Resident 8 facing an unanticipated discharge from the facility. Findings: Resident 8 was admitted to the facility on Fall of 2024 with diagnoses that included long-term kidney disease and breathing problems. Resident 8's Power of Attorney (POA) was her daughter. During a review of the Resident 8's Minimum Data Set (MDS, an assessment tool), dated 12/20/24, the MDS indicated Resident 8 had an acute change in mental status and altered level of consciousness on 12/20/24. Review of the record, titled, Residents 8's Order Summer Report (OSR), dated 11/11/24, the OSR indicated, Resident has capacity to make her decisions, however, POA demands all decisions for healthcare and financial go thru [through] her . During a review of Resident 8's Nurse Practitioner Note (NPN), dated 12/30/24 at 5 p.m., the NPN indicated, [Resident 8's name] was recently discharged to the hospital due to change in mental status .12/20 [Resident 8's name] was sent out overnight about midnight due to extreme lethargy and her blood sugar was 61. Nurse reported pt [patient] was not following commands. Patient was sent to [Hospital's name]. During a review of the Resident 8's NN by the Director of Nursing (DON), dated 12/20/24 at 7:32 p.m., the NN indicated, .notice proposed discharge was given to POA and explain where she can appeal if she wishes. POA stated this is illegal since I did not receive it before my mother was discharge. Certified copy was mailed to POA today. During a review of Resident 8's NN, dated 12/20/24 at 10:50 a.m., the NN indicated Completed Notice of Proposed Discharge and faxed to the Ombudsman with confirmation of receipt attached and scanned into resident documents in her electronic chart. Prepared certified to be sent to her POA . During an interview on 1/2/25 at 12:26 p.m. with the Social Services Director (SSD), the SSD confirmed Resident 8 was discharged on the same day. The facility sent Resident 8 to the hospital on [DATE] and that the facility was aware that Resident 8 would not be readmitted due to her daughters' Page 1 of 2 055776 055776 01/02/2025 Westview Healthcare Center 12225 Shale Ridge Lane Auburn, CA 95602

F 0626 harassment. Level of Harm - Minimal harm or potential for actual harm During a review of the facility's policy and procedure (P&P) titled, Bed-holds and Returns , Revised 10/22, the P&P indicated, The requirement that residents be permitted to return to the facility following hospitalization or therapeutic leave applies to all residents .6. Residents who seek to return to the facility within the bed-hold period defined in state plan are allowed to return to their previous room, if available .9. If the facility determines that a resident cannot return, the facility must comply with the requirements for facility-initiated discharges. Residents Affected - Few During an interview on 1/2/25 at 11:04 a.m. with the Administrator (ADM), the ADM indicated that the patient's daughter was significantly hindering the medical staff's ability to provide care. The ADM stated the daughter prevented staff from performing necessary procedures and threatened to file complaints of neglect and abuse, causing staff and physicians to be apprehensive. The ADM stated, It is so much that the doctors said we are not providing care, so that when we sent her to the hospital, we are not having her back. The ADM stated that Resident 8 was transferred to the hospital on [DATE] and was discharged as soon as she went to the ER, we discharged her right away on that same day, we did not even take any bed-hold money. The ADM confirmed that Resident 8 was discharged due to the daughters' interference with patient care. During an interview on 1/2/25 at 12:36 p.m. with the DON, the DON stated that although Resident 8 had capacity, the resident deferred to her daughter, the POA, for all needs. This required all matters to go through the daughter who frequently withheld consent that resulted in delaying care. The DON stated that the daughter also interfered with the nurse practitioner and MD's plan of care, hindering the facility's ability to provide necessary treatment. The DON confirmed that the daughter's interruptions were the reason for Resident 8 was discharged . 055776 Page 2 of 2