Health inspection·April 16, 2024

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Based on interview, and record review, the facility failed to provide notice of a facility-initiated discharge to the appropriate parties and provide all the required information on the 30-Day Notice of Transfer or Discharge, (a document given by the facility to the resident indicating an upcoming transfer or discharge from the current facility to another facility/home) that was given to Resident 1 when: 1. The facility did not inform the Office of the State Long-Term Care (LTC) Ombudsman (a government appointed person who actively supports the rights of the residents) on the same day the facility served Resident 1 with a 30-Day Notice of Transfer or Discharge form, 2. The location that Resident 1 was transferred to was not listed on the 30-Day Notice of Transfer or Discharge form; and, 3. The appeal (an application to the courts for a decision to be reversed) rights information was not correct on the 30-Day Notice of Transfer or Discharge form. These failures could have resulted in Resident 1 not having access to an advocate (a person appointed to look out for the best interests of the resident) to inform Resident 1 of her options for an appeal and/or Resident 1 could have had an inappropriate transfer or discharge. Findings: 1. During a review of Resident 1's clinical record titled, admission Record, indicated, Resident 1's diagnosis included difficulty walking and muscle weakness. During a review of Resident 1's clinical record titled, 30 DAY NOTICE OF TRANSFER OR DISCHARGE, dated 2/21/24, signed by the Administrator (Admin) and Resident 1, indicated, .This is to inform you, [Resident 1], will be transferred/discharged on or before March 21, 2024, for the following reason(s): Refusal of payment of you Share of Cost [portion of money owed by the resident] . During a concurrent interview and record review on 4/16/24, at 10:30 a.m., with the Director of Nursing (DON), the document titled, Cover Sheet [fax cover sheet], dated 2/26/24, by the Admin, was reviewed. The document indicated the facility faxed Resident 1's 30-Day Notice of Transfer or Discharge Notice form to the Ombudsman on 2/26/24 and the DON stated the Ombudsman was not notified the same day the notice was given to Resident 1. During a joint interview on 4/16/24, at 12:55 p.m., with the Admin and DON, the Admin stated Page 1 of 3 055917 055917 04/16/2024 Harvest Crossing Post Acute 469 East North Street Manteca, CA 95336

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident 1 was given the 30-Day Notice of Transfer or Discharge form on 2/21/24 and the facility notified the Ombudsman on 2/26/24. The Admin stated he was unaware the Ombudsman was supposed to be notified the same day Resident 1 was given the 30-Day Notice of Transfer or Discharge form until he was informed by the DON. The DON stated it was important to notify the Ombudsman immediately upon serving Resident 1 with the 30-Day Notice of Transfer or Discharge form because the Ombudsman would act as an advocate for Resident 1 and could have assisted with the appeal process. During a phone interview on 4/18/24, at 8:30 a.m., with the Ombudsman (OMB), stated she visited Resident 1 on 3/27/24 and Resident 1 expressed feelings of not wanting to leave the facility because she had friends at the facility and participated in a lot of activities. OMB stated because the Notice of 30-Day Transfer or Discharge form was not faxed the same day to the Ombudsman's office, Resident 1 did not get a chance to meet with an Ombudsman to file another appeal with the court to remain in the facility. During a concurrent interview and record review on 4/16/24, at 3 p.m., with the DON, the Policy and Procedure (P&P) titled, Transfer or Discharge Documentation, dated April 2021, was reviewed. The P&P indicated, When a resident is transferred or discharged , details of the transfer to discharge will be documented in the medical record and appropriate information will be communicated to the receiving health care facility or provider . The DON acknowledged the P&P was not followed when the Ombudsman was not notified the same day Resident 1 was served with the 30 Day Notice of Transfer or Discharge and acknowledged the 30 Day Notice of Transfer or Discharge was not completed accurately. 2. During a phone interview on 4/18/24, at 8:30 a.m., with the OMB, OMB stated the destination address was not listed on Resident 1's 30 Day Notice of Transfer or Discharge. The OMB stated the address was important information for Resident 1 and their responsible party (RP, the person who was designated responsibility for the resident) to know for peace of mind and ability to alert others of the new residence. During a review of Resident 1's clinical record titled, 30 DAY NOTICE OF TRANSFER OR DISCHARGE, dated 2/21/24, signed by the Admin and Resident 1, indicated the notice did not include the address of the new board and care facility. During a concurrent interview and record review on 4/16/24, at 3 p.m., with the DON, the P&P titled, Transfer or Discharge Documentation, dated April 2021, was reviewed. The P&P indicated, When a resident is transferred or discharged , details of the transfer to discharge will be documented in the medical record and appropriate information will be communicated to the receiving health care facility or provider . The DON acknowledged the P&P was not followed. 3. During a review of Resident 1's clinical record titled, 30 DAY NOTICE OF TRANSFER OR DISCHARGE, dated 2/21/24, signed by the Admin and Resident 1, indicated, .This is to inform you, [Resident 1], will be transferred/discharged on or before March 21, 2024, for the following reason(s): Refusal of payment of you Share of Cost [portion of money owed by the resident] .If you believe that the proposed transfer/discharge is inappropriate in your case, you have the right to file an appeal. An appeal can be filed by writing to or calling the following: [ADDRESS and PHONE NUMBER provided]. During an interview on 4/16/24, at 10:50 a.m., with the Admin, stated a 30-Day Notice of Transfer or Discharge form was given by the facility to Resident 1 on 2/21/24. An appeal was filed on 3/12/24 to stop the 30-Day Notice of Transfer or Discharge form and a court hearing was set for 3/27/24 to decide the case. The Admin stated the [STATE AGENCY] instructed him that the appeal information on 055917 Page 2 of 3 055917 04/16/2024 Harvest Crossing Post Acute 469 East North Street Manteca, CA 95336

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the 30-Day Notice of Transfer or Discharge was incorrect. The Admin stated he should have ensured the correct information for an appeal was filled out on the 30-Day Notice of Transfer or Discharge form and he should have communicated with Resident 1's RP that an appeal had been filed. During a phone interview on 4/18/24, at 8:30 a.m., with the OMB, OMB stated Resident 1's 30-Day Notice of Transfer or Discharge did not have the correct appeal information listed (name of department, address, phone number, fax number). OMB stated Resident 1 and the RP should have been given the correct information on the 30-Day Notice of Transfer or Discharge and a copy of the appeal letter notice of hearing. During a concurrent interview and record review on 4/16/24 at 3 p.m., with the DON, the P&P titled, Transfer or Discharge Documentation, dated April 2021, was reviewed. The P&P indicated, When a resident is transferred or discharged , details of the transfer to discharge will be documented in the medical record and appropriate information will be communicated to the receiving health care facility or provider . The DON acknowledged the P&P was not followed when the ombudsman was not notified the same day Resident 1 was served with the 30 Day Notice of Transfer or Discharge and acknowledged the 30 Day Notice of Transfer or Discharge was not filled out accurately. 055917 Page 3 of 3