Health inspection·September 25, 2024

F 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure Notice of Medicare Non-Coverage (NOMNC, a form given by the facility to all Medicare beneficiaries before the end of a Medicare covered Part A stay or when all of Part B therapies are ending) was not given in a timely manner to one of two sample residents (Resident 1). Residents Affected - Few This failure resulted in Resident 1 not being able to make an appeal. Findings: During an interview over the phone on 9/19/24 at 8:53 a.m. with Resident 1's relative (RR), it was stated that RR saw a voicemail from the facility on 9/11/24. RR also stated she wanted to make an appeal and called the facility on 9/11/24 regarding the NOMNC. RR stated that facility informed RR that they will call back with the information. RR stated that facility did not call back. A review of Resident 1's admission record indicated, Resident one was admitted on [DATE]. A review of Resident 1's Minimum Data Set (MDS, a federally mandated assessment tool) dated 8/14/24 indicated a Brief Interview for Mental Status (BIMS, an assessment tool used by facilities to screen and identify memory, orientation and judgement status of the resident) score of 5 (a score of 13 to 15 suggests the resident is mentally intact, 8 to 12 suggests moderately impaired and 0 to 7 suggests severe impairment). A review of facility provided document titled Notice of Medicare Non-Coverage for Resident 1, NOMNC indicated, The effective date coverage of your Skilled Nursing Services Will End: 9/10/24. NOMNC also indicated, Your request for an immediate appeal should be made as soon as possible, but no later than noon of the day before the effective date indicated above. A handwritten note under additional information indicated, Patient family member/Responsible Party did not answer. Voicemail left and copy left in pt room. NOMNC was signed by two Case Managers dated 9/9/24 at 6:33 p.m. During a concurrent interview and record review on 9/25/24 at 1:18 p.m. with Social Services Director (SSD), SSD confirmed NOMNC for Resident 1 was signed and dated by two case managers on 9/9/24 at 6:33 p.m. SSD stated Business Office sends the NOMNC to the case managers and we notify residents at least 72 hours. During a concurrent interview and record review on 9/25/24 at 2:47 p.m. with the Administrator (ADM), ADM confirmed NOMNC was dated given on 9/9/24 at 6:33 p.m. via voicemail. ADM also confirmed Page 1 of 4 056116 056116 09/25/2024 Los Altos Post-Acute 809 Fremont Avenue Los Altos, CA 94024

F 0582 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few there was no indication on the NOMNC document that the information was understood and received by Resident 1's responsible party. ADM also stated, NOMC should have been given three days prior to end of Medicare coverage. During a concurrent interview and record review on 9/25/24 at 3:00 p.m. with the Director of Nursing (DON), DON stated I did not know what the NOMNC was. DON also confirmed the NOMNC was signed and dated 9/9/24 and timed 6:33 p.m. by two facility Case Managers. DON confirmed there was no signature from Resident 1 or a responsible party. A review of facility's policy and procedure (P&P) titled Transfer and Discharge (including AMA) revised 7/20/23, the P&P indicated, The facility's transfer/discharge notice will be provided to the resident and the resident's representative in a language and manner in which they can understand. The notice will include all of the following at the time it is provided: .d. An explanation of the right to appeal the transfer or discharge to the State .f. Information on how to obtain an appeal form According to Title 42 of the Code of Federal Regulations, § 405.1200 Notifying beneficiaries of provider service terminations, Timing of notice. A provider must notify the beneficiary of the decision to terminate covered services no later than 2 days before the proposed end of the services. 056116 Page 2 of 4 056116 09/25/2024 Los Altos Post-Acute 809 Fremont Avenue Los Altos, CA 94024

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 ensure that resident representative was notified prior to discharge for one (Resident 1) of two sampled residents. This failure had the potential to result in psychosocial distress for Resident 1 when Resident 1's relative (RR) was not able to communicate with Resident 1 before, during and right after Resident 1's discharge to another facility. Findings: During an interview over the phone on 9/19/24 at 8:53 a.m. with Resident 1's relative (RR), RR stated that facility did not communicate the discharge of Resident 1. RR stated she saw a voicemail on 9/10/24 from the facility regarding discharge and called the facility on 9/10/24 to make an appeal. RR stated she was told she will receive a call back with the information. RR stated that facility did not call back. RR also stated discharge date was not provided by the facility and there was no written notice of discharge given. RR also stated, she went to the facility on 9/13/24 and was informed that Resident 1 was already discharged . A review of Resident 1's medical record indicated, Resident one was admitted on [DATE] and was discharged on 9/11/24 at 11:59 a.m. A review of Resident 1's Minimum Data Set (MDS, a federally mandated assessment tool) dated 8/14/24 indicated a Brief Interview for Mental Status (BIMS, an assessment tool used by facilities to screen and identify memory, orientation and judgement status of the resident) score of 5 (a score of 13 to 15 suggests the resident is mentally intact, 8 to 12 suggests moderately impaired and 0 to 7 suggests severe impairment). A review of Resident 1's Order Summary indicated, MD determines that Resident does NOT have the mental capacity to make healthcare decisions as per History and Physical with order date 8/9/24. A review of facility provided document titled Advance Health Care Directive, signed by Resident 1 and dated 1/14/16. The document indicated that RR was designated and appointed by Resident 1 as agent to make healthcare decisions . During an interview on 9/25/24 at 11:22 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated that social services communicate with the residents' family about the discharge process. During a concurrent interview and record review on 9/25/24 at 1:18 p.m. with Social Services Director (SSD), SSD stated he did not call RR to notify about discharge. RR stated it was the Case Manager who must call the family to notify about the discharge. RR also stated case manager should have waited for the call back from RR before proceeding to discharge Resident 1. During a concurrent interview and record review on 9/25/24 at 2:47 p.m. with the Administrator (ADM), ADM confirmed Resident 1's Advance Directive indicated RR as agent to make health care decisions. The ADM stated we should have not discharged Resident 1 without speaking with RR. 056116 Page 3 of 4 056116 09/25/2024 Los Altos Post-Acute 809 Fremont Avenue Los Altos, CA 94024

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a concurrent interview and record review on 9/25/24 at 3:00 p.m. with the Director of Nursing (DON), DON confirmed Resident 1's Advance Directive indicated RR as agent to make health care decisions. The DON stated we should not discharge the resident home without speaking with the responsible party. A review of facility's policy and procedure (P&P) titled Transfer and Discharge (including AMA) revised 7/20/23, the P&P indicated, The facility's transfer/discharge notice will be provided to the resident and the resident's representative in a language and manner in which they can understand. The notice will include all of the following at the time it is provided: b. The effective date of transfer of discharge. 056116 Page 4 of 4