Other·January 3, 2019

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 for the investigation of complaint #CA00607682. Representing the Department of Public Health: HFEN, 38970 The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility.

F626 SS=D Permitting Residents to Return to Facility CFR(s): 483.15(e)(1)(2)

F626 12/28/2018 §483.15(e)(1) Permitting residents to return to facility. A facility must establish and follow a written policy on permitting residents to return to the facility after they are hospitalized or placed on therapeutic leave. The policy must provide for the following. (i) A resident, whose hospitalization or therapeutic leave exceeds the bed-hold period under the State plan, returns to the facility to their previous room if available or immediately upon the first availability of a bed in a semiprivate room if the resident(A) Requires the services provided by the facility; and (B) Is eligible for Medicare skilled nursing facility services or Medicaid nursing facility services. (ii) If the facility that determines that a resident who was transferred with an expectation of returning to the facility, cannot return to the facility, the facility must comply with the requirements of paragraph (c) as they apply to discharges. 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: MCKV11 Facility ID: CA030000059 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: _______________ 056177 (X3) DATE SURVEY COMPLETED 12/04/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DOUBLE TREE POST ACUTE CARE CENTER 7400 24th Street Sacramento, CA 95822 (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 §483.15(e)(2) Readmission to a composite distinct part. When the facility to which a resident returns is a composite distinct part (as defined in § 483.5), the resident must be permitted to return to an available bed in the particular location of the composite distinct part in which he or she resided previously. If a bed is not available in that location at the time of return, the resident must be given the option to return to that location upon the first availability of a bed there. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to follow their policy on permitting a long-term care resident to return to the facility after a hospitalization when the facility did not offer one of three sampled residents (Resident 1) the first available bed. This failure resulted in Resident 1 remaining in the hospital 16 days past his date of discharge, and potentially causing the resident psychosocial harm. Findings: During a review of the clinical record for Resident 1, an Admission Record indicated the resident was admitted to the facility in March 2018 with diagnoses that included quadriplegia (unable to move from the neck down), and post-traumatic stress disorder. A Minimum Data Set (MDS, an assessment tool) dated 3/19/18, indicated Resident 1 was totally dependent on staff for mobility and activities of daily living (eating, toileting, bathing). A nurse progress note, dated 9/22/18, indicated Resident 1 was scheduled for a procedure at a hospital on 9/26/18 and would be arriving at the hospital the day before. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MCKV11 Facility ID: CA030000059 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: _______________ 056177 (X3) DATE SURVEY COMPLETED 12/04/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DOUBLE TREE POST ACUTE CARE CENTER 7400 24th Street Sacramento, CA 95822 (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 A review of the facility's admissions from 10/1/18 to 10/18/18 indicated the facility admitted 11 residents, three of which were male residents. During a review of the hospital medical record for Resident 1, the hospital Social Worker (SW) progress notes dated 10/3/18 to 10/18/18 indicated the SW contacted the facility on 10/3/18, 10/4/18, 10/5/18, 10/9/18, 10/12/18, and 10/15/18 and was told the facility had no beds available. During an interview with the SW on 10/17/18 at 3 p.m., the SW stated Resident 1 was still at the hospital. She stated the physician deemed him ready to return to the facility on 10/2/18. The SW stated the facility would not allow the resident to return due to no bed availability for long-term care residents. The SW spoke with the facility Administrator (ADM) who told her the resident was not paying for his stay prior to his transfer to the hospital, and the hospital would have to pay for his stay in order to allow his re-admission to the facility. The SW stated Resident 1 had a pending Medi-Cal (State funded health insurance) application to receive coverage benefits. The SW stated the resident did not receive a Notice of Discharge from the facility during his stay at the hospital. During an interview with the Admissions Coordinator (AC) on 10/18/18 at 11:25 a.m., the AC stated the first time the hospital SW called her to have Resident 1 re-admitted, the facility only had beds available for short-term residents. The AC told the SW the facility could not re-admit the resident at that time. The AC stated she does not like to mix short-term residents with long-term residents stating it would impact their quality of life. The AC stated the facility did not have a policy on reserving FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MCKV11 Facility ID: CA030000059 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: _______________ 056177 (X3) DATE SURVEY COMPLETED 12/04/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DOUBLE TREE POST ACUTE CARE CENTER 7400 24th Street Sacramento, CA 95822 (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 beds for short-term residents. She stated she made the decision to not re-admit based on how she would feel as a long-term resident sharing a room with a short-term resident. During a concurrent interview with the Director of Nursing (DON) on 10/18/18 at 11:25 a.m., he stated the resident was not considered discharged from the facility because the facility expected him to return once a bed became available. During an interview with the Director of Admissions (DA) on 10/18/18 at 12:05 p.m., the DA stated a miscommunication occurred between the AC and the hospital SW the day prior, when the AC told the SW she was expecting a bed to become available the next day and would contact her when one became available. When the SW called the next day to send the resident back to the facility, the DA informed her there were no long-term beds available. During an interview with the Social Services Director (SSD) on 10/26/18 at 1 p.m., the SSD stated she assisted Resident 1 with his MediCal application in May 2018, and the application was still pending when the resident transferred to the hospital. During a review of Resident 1's hospital medical record, a document titled "Discharge Summaries" dated 10/18/18 and written by the physician indicated, "Admitted 9/25/18 for [surgical procedure] in the OR [operation room] on 9/26/18. Postoperatively developed low grade temperature [an oral temperature above 99.5 degrees Fahrenheit] and tachycardia [a heart rhythm above 100 beats per minute] till 10/2/18. By that time his [Resident 1's] bed in the nursing home had been assigned to someone else. [Name of hospital SW] worked FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MCKV11 Facility ID: CA030000059 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: _______________ 056177 (X3) DATE SURVEY COMPLETED 12/04/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DOUBLE TREE POST ACUTE CARE CENTER 7400 24th Street Sacramento, CA 95822 (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 nursing home and SW there to get a bed for him there again as his belongings were there." The SW progress note dated 10/18/18, indicated the SW spoke with the facility ADM on 10/16/18. The progress note indicated, "[The ADM] noted [the hospital] hasn't been paying. Medi-Cal is pending and Medicare stopped paying for his care. [ADM] was open to taking [Resident 1] if [the hospital] could pay for a temporary contract...." The note indicated the SW was able to approve a 30-day contract to pay for the resident's stay at the facility. The SW spoke with the DA on 10/17/18 who accepted the resident's return to the facility on 10/18/18. A facility policy and procedure titled "Readmission to the Facility" dated March 2017, indicated, "Residents who have been discharged to the hospital...will be given priority in readmission to the facility," and "Residents who are not receiving Medicaid [State funded health insurance] benefits will be readmitted to the facility upon the first availability of a bed if the resident: a. Needs care and medical treatment that can be provided by the facility; b. Was not discharged for non-payment of services..." Review of an undated facility Admission Packet indicated resident rights, which included, "...if our Facility participates in Medi-Cal and you [resident] are eligible for Medi-Cal, if you are away from our Facility for more than seven days due to hospitalization or other medical treatment, we will readmit you to the first available bed in a semi-private room if you need the care provided by our Facility and wish to be readmitted," and "If a resident of a longterm health care facility has been hospitalized in an acute care hospital and asserts his or her FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MCKV11 Facility ID: CA030000059 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: _______________ 056177 (X3) DATE SURVEY COMPLETED 12/04/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DOUBLE TREE POST ACUTE CARE CENTER 7400 24th Street Sacramento, CA 95822 (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 rights to readmission...and the facility refuses to readmit him or her, the resident may appeal the facility's refusal...If the resident appeals...and the resident is eligible under the Medi-Cal program, the resident shall remain in the hospital and the hospital may be reimbursed at the administrative day rate, pending the final determination of the hearing officer...." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MCKV11 Facility ID: CA030000059 If continuation sheet 6 of 6