Health inspection·April 12, 2023

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the resident/resident representative and the Ombudsman for a facility-initiated transfer for one of 3 sampled residents (Resident 1). This failure resulted in Resident 1 being transferred without capacity to understand and make decisions, not being informed of his rights regarding transfer/discharge and the added protection of the Ombudsman (patient rights advocate who ensures residents are not inappropriately discharged ). Findings: An abbreviated survey was conducted on March 30, 2023, at 12:35 PM to investigate a complaint related to Admission, Transfer & Discharge Rights. During a review of Resident 1's admission Record (general demographics), the document indicated Resident 1 was admitted to the facility on [DATE], with diagnoses to include vascular dementia (caused by impaired blood supply to brain) hypertension (high blood pressure), cerebral infarction (disrupted blood flow to brain/stroke). During a concurrent interview and record review on March 30, 2023, at 1:21 PM, with Director of Nursing (DON), review of Resident 1's . 1. History and Physical form (assessment of the patient by the physician) dated September 10,2020, indicates, Does NOT have the capacity to understand and make decisions. 2. Discharge summary dated [DATE], at 00:13 indicates, Discharge to (admitting facility) March 04, 2023, at 08:00, resident needs higher level of care, SNF .17a. Only verbalizes a couple words. 18.needs help with all ADLS. 3. Physician Discharge Summary-V2 dated March 07, 2023, 12:42, indicates, admission January 26,2022, Discharge March 04, 2023, 9:15 .resident discharge, resident acknowledge understanding of discharge paperwork, resident discharged alert and oriented x1 (alert, awake and oriented to person). 4. Facility cannot provide documentation of Ombudsman notification and Integrated Discharge Team (multi-disciplinary team) IDT meeting regarding transfer to other facility with same level of care. DON states, Resident 1 was not supposed to have been transferred to (same level of care facility) based on the records we just reviewed. When asked, did the facility do an IDT meeting for this (continued on next page) 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. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 056024 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056024 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Palms Healthcare Center 7534 Palm Ave Highland, CA 92346 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)