Other·May 3, 2018

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during an abbreviated survey regarding a complaint investigation conducted on 4/16/18 through 4/18/18. For Complaint CA00581835 regarding Resident/Patient/Client Rights, the Department did not substantiate a violation of federal or state regulations. For Complaint CA00581804 regarding Admission, Transfer, and Discharge Rights, a federal deficiency was identified (see F622). In addition a Class "B" citation was issued. Inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. Representing the California Department of Public Health: 38087, Health Facilities Evaluator Nurse.

F622 SS=D Transfer and Discharge Requirements CFR(s): 483.15(c)(1)(i)(ii)(2)(i)-(iii)

F622 05/14/2018 §483.15(c) Transfer and discharge§483.15(c)(1) Facility requirements(i) The facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless(A) The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility; (B) The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE 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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: XDDL11 Facility ID: CA070000031 If continuation sheet 1 of 6 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555838 (X3) DATE SURVEY COMPLETED 04/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CAMDEN POSTACUTE CARE, INC. 1331 Camden Ave Campbell, CA 95008 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE services provided by the facility; (C) The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident; (D) The health of individuals in the facility would otherwise be endangered; (E) The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. Nonpayment applies if the resident does not submit the necessary paperwork for third party payment or after the third party, including Medicare or Medicaid, denies the claim and the resident refuses to pay for his or her stay. For a resident who becomes eligible for Medicaid after admission to a facility, the facility may charge a resident only allowable charges under Medicaid; or (F) The facility ceases to operate. (ii) The facility may not transfer or discharge the resident while the appeal is pending, pursuant to § 431.230 of this chapter, when a resident exercises his or her right to appeal a transfer or discharge notice from the facility pursuant to § 431.220(a)(3) of this chapter, unless the failure to discharge or transfer would endanger the health or safety of the resident or other individuals in the facility. The facility must document the danger that failure to transfer or discharge would pose. §483.15(c)(2) Documentation. When the facility transfers or discharges a resident under any of the circumstances specified in paragraphs (c)(1)(i)(A) through (F) of this section, the facility must ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institution or provider. (i) Documentation in the resident's medical record must include: (A) The basis for the transfer per paragraph (c) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: XDDL11 Facility ID: CA070000031 If continuation sheet 2 of 6 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555838 (X3) DATE SURVEY COMPLETED 04/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CAMDEN POSTACUTE CARE, INC. 1331 Camden Ave Campbell, CA 95008 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (1)(i) of this section. (B) In the case of paragraph (c)(1)(i)(A) of this section, the specific resident need(s) that cannot be met, facility attempts to meet the resident needs, and the service available at the receiving facility to meet the need(s). (ii) The documentation required by paragraph (c)(2)(i) of this section must be made by(A) The resident's physician when transfer or discharge is necessary under paragraph (c) (1) (A) or (B) of this section; and (B) A physician when transfer or discharge is necessary under paragraph (c)(1)(i)(C) or (D) of this section. (iii) Information provided to the receiving provider must include a minimum of the following: (A) Contact information of the practitioner responsible for the care of the resident. (B) Resident representative information including contact information (C) Advance Directive information (D) All special instructions or precautions for ongoing care, as appropriate. (E) Comprehensive care plan goals; (F) All other necessary information, including a copy of the resident's discharge summary, consistent with §483.21(c)(2) as applicable, and any other documentation, as applicable, to ensure a safe and effective transition of care. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility refused to take Resident 1 back from out on pass. This resulted in the facility discharging Resident 1 against medical advice without a physician's order and without Resident 1's consent. This failure had the potential to compromise Resident 1's health and wellbeing. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: XDDL11 Facility ID: CA070000031 If continuation sheet 3 of 6 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555838 (X3) DATE SURVEY COMPLETED 04/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CAMDEN POSTACUTE CARE, INC. 1331 Camden Ave Campbell, CA 95008 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Findings: Review of Resident 1's clinical record indicated he was admitted on 2/5/2018 with diagnoses including: altered mental state, paraplegia, chronic pain syndrome and pressure ulcers of left heel and sacral region. During a phone interview on 4/16/18 at 9:30 a.m. with complainant, she indicated Resident 1 was ready for discharge from Acute Hospital. She stated Resident 1 requested to return to the skilled nursing facility. Complainant stated the administrator (ADM) of the skilled nursing facility would not accept Resident 1 back into the facility. ADM informed the complainant Resident 1 had been discharged AMA (against medical advice: resident chooses to leave a healthcare facility before the treating physician recommends discharge) from the skilled nursing facility. The complainant stated the ADM refused to take Resident 1 back "under any circumstances" During a subsequent interview with complainant on 4/18/18 at 9:10 a.m., she stated she had contacted ADM on 4/17/18 and ADM refused to readmit Resident 1. During an interview on 4/16/18 at 3:05 p.m. with licensed vocational nurse A (LVN A) she stated Resident 1 signed himself out on pass at 10:00 a.m. on 4/3/18. She stated Resident 1 indicated he was going to the store. LVN A stated Resident 1 had not returned to facility by 3:00 p.m. so she contacted Resident 1 on his cell phone. LVN stated she advised Resident 1 " he is only allowed for 4 hours out on pass, and if it is more than 24 hours then he will be AMA". During an interview on 4/16/18 at 3:30 p.m. with registered nurse B (RN B) she stated she FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: XDDL11 Facility ID: CA070000031 If continuation sheet 4 of 6 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555838 (X3) DATE SURVEY COMPLETED 04/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CAMDEN POSTACUTE CARE, INC. 1331 Camden Ave Campbell, CA 95008 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE spoke to Resident 1 at 11:30 p.m. on 4/3/18. Resident 1 indicated he could not return to the facility because he had no bus transportation. RN B stated Resident 1 indicated he would call the facility in the morning. During an interview with social worker (SW) on 4/17/18 at 11:45 a.m., she stated she had a phone conversation with Resident 1 on 4/4/18, with no specific time identified. SW indicated Resident 1 requested to return to the skilled nursing facility. SW stated she was notified by ADM on 4/5/18 at 11:00 a.m. that Resident 1 had been discharged AMA on 4/3/18. During an interview with ADM on 4/17/18 at 8:55 a.m., he stated he discharged Resident 1 at 12:00 midnight on 4/5/18 AMA because he did not return from out on pass. During a review of Resident 1's hospital emergency department records dated 4/9/18, indicated Resident 1 was admitted with diagnoses including spinal cord injury, paraplegia (loss of the ability to move both lower limbs due to spinal disease or injury), contracture of multiple joints, pressure ulcer of left foot, left heel and coccyx (small bone at the base of the spine), chronic pain syndrome, osteomyelitis and osteoarthritis. Review of Resident 1's clinical record on 4/17/18 at 10:00 a.m., indicated Resident 1 signed out on pass on 4/3/18 and left the facility at 10:00 a.m. No documentation to indicate resident signed an AMA form or documented refusal to sign AMA form was noted on Resident 1's clinical record. Further review indicated no physician order to discharge Resident 1 AMA. Review of facility policy dated April 2005 titled "Discharge Against Medical Advice (AMA)", FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: XDDL11 Facility ID: CA070000031 If continuation sheet 5 of 6 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555838 (X3) DATE SURVEY COMPLETED 04/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CAMDEN POSTACUTE CARE, INC. 1331 Camden Ave Campbell, CA 95008 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE indicates "when a resident or family member demands discharge against medical advice, notify the physician immediately. If an order for a discharge is obtained, it must be signed and dated by a physician". FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: XDDL11 Facility ID: CA070000031 If continuation sheet 6 of 6