Other·October 19, 2017

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 complaints #CA00531892, CA00538219, and CA00541837. Representing the Department of Public Health: HFEN, 17332 The inspection was limited to the specific complaints investigated and does not represent the findings of a full inspection of the facility.

F205 SS=D NOTICE OF BED-HOLD POLICY BEFORE/UPON TRANSFR CFR(s): 483.15(d)(1)(i)-(iv)(2)

F205 10/02/2017 (d) Notice of bed-hold policy and return(1) Notice before transfer. Before a nursing facility transfers a resident to a hospital or the resident goes on therapeutic leave, the nursing facility must provide written information to the resident or resident representative that specifies(i) The duration of the state bed-hold policy, if any, during which the resident is permitted to return and resume residence in the nursing facility; (ii) The reserve bed payment policy in the state plan, under § 447.40 of this chapter, if any; (iii) The nursing facility’s policies regarding bedLABORATORY 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: GYVJ11 Facility ID: CA030000084 If continuation sheet 1 of 3 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: _______________ 555542 (X3) DATE SURVEY COMPLETED 09/13/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PIONEER HOUSE 415 P Street Sacramento, CA 95814 (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 hold periods, which must be consistent with paragraph (c)(5) of this section, permitting a resident to return; and (iv) The information specified in paragraph (c) (5) of this section. (2) Bed-hold notice upon transfer. At the time of transfer of a resident for hospitalization or therapeutic leave, a nursing facility must provide to the resident and the resident representative written notice which specifies the duration of the bed-hold policy described in paragraph (e)(1) of this section. This REQUIREMENT is not met as evidenced by: Based on staff interview and clinical record review, the facility failed to ensure a bed hold notice was issued timely for Resident 1. This failure increased the potential for the Resident's representative to be uninformed regarding bed hold rights. Findings: Resident 1 was admitted to the facility on 11/17/16, with diagnoses including early onset of Alzheimer's Disease. On 3/23/17 Resident 1 displayed a behavioral episode which included throwing silverware during lunch time in the facility's dining room. On 3/23/17 at 12:45 p.m., Resident 1 was transferred to the General Acute Care Hospital (GACH) with the assistance of the police department and ambulance staff. Review of the clinical record revealed a written bed-hold notification was not issued to Resident 1's representative until 3/28/17, 5 days after Resident 1 was transferred to the GACH. There was no documentation which indicated a bed-hold notice accompanied the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GYVJ11 Facility ID: CA030000084 If continuation sheet 2 of 3 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: _______________ 555542 (X3) DATE SURVEY COMPLETED 09/13/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PIONEER HOUSE 415 P Street Sacramento, CA 95814 (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 Resident when she was sent to the GACH. An interview was conducted with the Facility Administrator (FA) on 6/7/17 at 11:30 a.m. The FA stated Resident 1's situation was atypical because of the extreme behaviors she was exhibiting at the time of discharge, however the FA acknowledged a bed-hold notice was not issued at the time of discharge and the written notice was not generated until 5 days after discharge. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GYVJ11 Facility ID: CA030000084 If continuation sheet 3 of 3