Health inspection·January 7, 2026

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge. Based on interview and record review, Facility 2 failed to document Resident 1's needs that could not be met by Facility 2 and the reasons why Resident 1's transfer or discharge was necessary. Facility 2 failed to appropriately communicate information concerning Resident 1's condition to Facility 1 prior to sending Resident 1 back to Facility 1. Facility 2 staff failed to properly admit Resident 1 to Facility 2 and then had Resident 1 transported back to Facility 1 from Facility 2, without properly discharging Resident 1 (from Facility 2) or having his medical needs assessed. This failure had the potential to result in a lapse in care when Resident 1 was sent back to Facility 1 from Facility 2 within a seven hour period on the same day.During a record review of Facility 1's document titled, Inpatient Medicine Discharge Summary, dated 7/11/25, the Inpatient Medicine Discharge Summary indicated Resident 1 had been admitted at Facility 1 from 6/12/2024 to 7/11/2025 with multiple diagnoses including dementia (a decline in mental ability severe enough to interfere with daily life) and altered mental status (a change in mental function). The Inpatient Medicine Discharge Summary also indicated Resident 1 was discharged on 7/11/25 at 10:30 a.m. from Facility 1. During an interview on 9/23/25 at 4:10 p.m. at Facility 2 with Registered Nurse 2 (RN2), RN2 stated when a new resident was going to be admitted , there will be a group text thread started on facility-issued phones so that they know when to expect the resident and can assign staff to care for them. During a concurrent interview and record review on 9/23/25 at 4:12 p.m. at Facility 2, text messages on RN2's facility-issued phone were reviewed. RN2 stated two text messages dated 7/10/25 sent from Registered Nurse 1 (RN1) indicated that Resident 1 was expected to arrive at Facility 2 around 10 a.m. on 7/11/25. During a concurrent interview and record review on 1/7/26 at 2:25 p.m. at Facility 2 with Assistant Director of Nursing (ADON), an Interfacility Transport Company's document titled, Receiving Facility Signature, dated 7/11/25 at 11:57 a.m., was reviewed. ADON stated the Receiving Facility Signature indicated that Resident 1 arrived at Facility 2 on 7/11/25 at 11:57 a.m. ADON also stated she signed the Receiving Facility Signature document because Resident 1 was unable to sign the document.During a concurrent phone interview and record review on 1/7/26 at 2:43 p.m. at Facility 2 with the Director of Nursing (DON), an email with the subject line, Male HMO Admission, dated 7/10/25 was reviewed. DON stated the Male HMO Admission email indicated Resident 1 was an expected admission and had approved insurance authorization. The Male HMO Admission email was sent on 7/10/25 at 4:29 p.m.During a follow-up phone interview on 1/7/26 at 2:45 p.m. at Facility 2 with DON, DON stated when Resident 1 arrived at Facility 2, it was determined that Resident 1 was not an appropriate fit for Facility 2. DON stated they offered Resident 1 food and then Resident 1 was sent back to Facility 1. DON stated there was no medical record created for Resident 1. DON stated Facility 2 did not document why Resident 1 was not appropriate for their facility [Facility 2]. DON also stated there was no nursing assessment done upon Resident 1's arrival to Facility 2. During a review of Facility 1's document titled, Medicine History and Physical, dated 7/11/25, the Medicine History Page 1 of 2 056389 056389 01/07/2026 Vale Healthcare Center 13484 San Pablo Avenue San Pablo, CA 94806

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and Physical indicated Resident 1 returned to Facility 1 on 7/11/25 at 5:22 p.m., after being gone approximately 7 hours. During a review of Facility 2's policy titled admission to the Facility, dated OP2 0203.00, the policy indicated, .The Medical Record Department logs the resident into the Admission/Discharge Register. The policy also indicated, .Nursing initiates clinical care. A. Take and record the resident's vital signs.During a review of Facility 2's policy titled Transfer and Discharge, dated OP 0209.00, the policy indicated, .the notices of transfer/discharge shall contain the following information: a. The reason for the transfer/discharge; b. The effective date of the transfer/discharge; c. The location to which the resident is being transferred or discharged . d. A statement of the resident's rights to appeal the transfer/discharge,. 056389 Page 2 of 2