Other·March 23, 2020

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 a standard abbreviated survey regarding investigation of a complaint investigation conducted on 3/17/2020. For Complaints CA00680089 and CA00680352, regarding Admission, Transfer and Discharge Rights, a federal deficiency was identified (see F624). A Class "B" citation was also 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: 39238, Health Facilities Evaluator Nurse,

F624 SS=D Preparation for Safe/Orderly Transfer/Dschrg CFR(s): 483.15(c)(7)

F624 §483.15(c)(7) Orientation for transfer or discharge. A facility must provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility. This orientation must be provided in a form and manner that the resident can understand. This REQUIREMENT is not met as evidenced by: Based on interview and record review, 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: LCPY11 Facility ID: CA070000078 If continuation sheet 1 of 5 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: _______________ 055356 (X3) DATE SURVEY COMPLETED 03/17/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OCEANVIEW POST ACUTE 200 Lighthouse Ave Pacific Grove, CA 93950 (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 facility failed to provide a safe and orderly discharge for one of two residents (Resident 1) when: Resident 1's discharge placement did not accept him and he was dropped off outside a police station. This failure put Resident 1's health and safety at risk when he stayed outside the police station cold and shivering. Findings: Review of Resident 1's clinical record indicated, he was admitted to the facility on 2/10/2020 with diagnoses including cellulitis of left lower limb (painful bacterial infection), muscle weakness, unspecified open left thigh wound, unsteadiness on feet. Review of Resident 1's IDT (Interdisciplinary Team, a group of healthcare professionals) care conference dated, 2/11/2020 indicated he wanted to be discharged to a motel. During an interview on 3/11/2020 at 11:15 a.m., with the social services designee (SSD), she stated a discharge plan was to have Resident 1 return to a motel but he was not accepted because he did not have a valid identification card (ID). During a telephone interview on 3/12/2020 at 10:38 a.m. with the SSD, she stated Resident 1 was driven to his preferred motel (motel #1) but there was no available room and Resident 1 was driven to motel #2 but was not accepted because he did not have a valid ID. The SSD stated she was not aware of the motel requirements to have a valid ID. During a review of motels #1 and #2's website indicated "At the time of check-in, all guests must present valid, government issued identification ..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LCPY11 Facility ID: CA070000078 If continuation sheet 2 of 5 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: _______________ 055356 (X3) DATE SURVEY COMPLETED 03/17/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OCEANVIEW POST ACUTE 200 Lighthouse Ave Pacific Grove, CA 93950 (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 During a telephone interview on 3/14/2020 at 1:37 p.m. with Resident 1, he stated the facility's van driver (FVD) drove him to different hotels but his veteran ID was not accepted, the FVD drove him to a homeless shelter but he was denied because he was not mobile. Resident 1 further stated he paid his co-pay for the whole month of March. Resident 1 confirmed he requested to be dropped off to a police station and stayed outside for six hours shivering. Review of Resident 1's minimum data set (MDS, an assessment tool) dated 2/15/2020, indicated his cognition was intact. Further review of the MDS, indicated his balance was not steady. During a telephone interview on 3/16/2020 at 11:45 a.m. with the FVD, he stated Resident 1 was "originally planned to discharge to motel #2" but he was not accepted because he did not have a valid ID. He further stated, he drove Resident 1 to a shelter because that was the discharge plan but Resident 1 refused to stay. The FVD confirmed he dropped off Resident 1 outside a police station but did not notify the facility. The FVD stated he notified the SSD after he dropped off Resident 1. During an interview on 3/17/2020 at 11:05 a.m., with the Director of Rehab (DOR), she stated Resident 1 refused to be assessed for walking. The DOR further stated Resident 1's discharge plan was to stay in the facility. Review of Resident 1's physical therapy progress and discharge summary dated 3/5/2020, indicated discharge plan and instructions was to discharge to long term care at the facility. During an interview on 3/17/2020 at 11:21 a.m. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LCPY11 Facility ID: CA070000078 If continuation sheet 3 of 5 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: _______________ 055356 (X3) DATE SURVEY COMPLETED 03/17/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OCEANVIEW POST ACUTE 200 Lighthouse Ave Pacific Grove, CA 93950 (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 with the SSD, she stated she was aware of Resident 1's payment for his stay in the facility. The SSD stated Resident 1 had not lived in a shelter. The SSD added, "My administrator told us he could not stay longer in the facility". During an interview on 3/17/2020 at 11:37 a.m., with the business office manager (BOM), she confirmed the co-pay Resident 1 had paid was for his stay for the whole month of March. The BOM confirmed Resident 1 did not get a refund upon discharge. The BOM further added it was the ADM's decision to discharge Resident 1. Review of Resident 1's IDT discharge summary dated 2/28/2020, indicated his discharge date was 3/6/2020 and the reason for discharge was "appropriate to d/c (discharge)". The discharge summary did not indicate Resident 1 discharge's location. Review of Resident 1's discharge plan canceled on 3/8/2020, indicated the resident wanted to return to live in a motel. The discharge plan did not indicate a homeless shelter. Review of the notice of proposed transfer discharge dated 2/29/2020, sent to the Ombudsman (a public advocate), indicated "disposition/location: returning to prior living arrangements". The notice did not indicate discharge location address. Review of the facility's policy, "Discharge Summary and Plan" dated April 2009, indicated "discharge summary and post-discharge plan will be developed to assist the resident to adjust to his/her new living environment." Review of the facility's policy, "Notice of a Transfer and/or Discharge," dated December FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LCPY11 Facility ID: CA070000078 If continuation sheet 4 of 5 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: _______________ 055356 (X3) DATE SURVEY COMPLETED 03/17/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE OCEANVIEW POST ACUTE 200 Lighthouse Ave Pacific Grove, CA 93950 (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 2008, indicated the written notice should have the location to which the resident is being discharged. Review of the facility's policy "Orienting Residents to Transfers and Discharges" dated December 2009, indicated "The purpose of the orientation is to provide the resident and family with sufficient preparation and to ensure a safe and orderly transfer or discharge from the facility." Review of Resident 1's acute care hospital history and physical dated 3/9/2020, indicated he was admitted to an acute care hospital on 3/10/2020 due to a ground level fall. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: LCPY11 Facility ID: CA070000078 If continuation sheet 5 of 5