Other·August 30, 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 abbreviated survey for the investigation of complaint #CA00518158. Representing the Department of Public Health: HFEN, 29825 HFEN, 38571 The inspection was limited to the specific complaint 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 08/31/2017 (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; 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: HFC111 Facility ID: CA030000097 If continuation sheet 1 of 7 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: _______________ 055417 (X3) DATE SURVEY COMPLETED 08/04/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SAYLOR LANE HEALTHCARE CENTER 3500 Folsom Boulevard Sacramento, CA 95816 (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 (iii) The nursing facility’s policies regarding bedhold 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 interview and clinical record review, the facility failed to provide written information regarding a bed hold to 1 of 3 sampled residents (1) when Resident 1 was sent to a general acute care hospital (GACH). This failure potentially deprived Resident 1 of information regarding her rights to return to the facility. Findings: Resident 1 was admitted to the facility with multiple diagnoses. During the Initial Tour of the facility on 1/23/17 starting at 9:17 a.m., Resident 1 was not found residing in the facility. Review of the facility document titled Resident Roster, dated 1/23/17, did not have Resident 1 listed as present in the facility. Review of the document titled "Resident Transfer Form", dated 12/21/16, indicated Resident 1 was sent out because she needed FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HFC111 Facility ID: CA030000097 If continuation sheet 2 of 7 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: _______________ 055417 (X3) DATE SURVEY COMPLETED 08/04/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SAYLOR LANE HEALTHCARE CENTER 3500 Folsom Boulevard Sacramento, CA 95816 (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 evaluation and treatment. The facility indicated they were "unable to provide care needed." The facility document titled "Resident Roster" was reviewed from 12/21/16 to 12/28/16. There was no bed hold documented for Resident 1. During an interview with the Social Services Director on 1/23/17 at 10:08 a.m., she said, "She went out 12/21/16...We did not give her a verbal or written bed hold." Review of the facility policy and procedure titled "Holding Bed Space", dated December 2006, indicated, "1. ...when a resident is transferred for hospitalization...a representative of our business office will provide information concerning our bed hold policy. 2. When emergency transfers are necessary, the facility will provide the resident or representative (sponsor) with information concerning our bed hold policy within 48 hours of such transfer."

F206 SS=D POLICY TO PERMIT READMISSION BEYOND BED-HOLD CFR(s): 483.15(e)(1)(2)

F206 08/31/2017 (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 residentFORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HFC111 Facility ID: CA030000097 If continuation sheet 3 of 7 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: _______________ 055417 (X3) DATE SURVEY COMPLETED 08/04/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SAYLOR LANE HEALTHCARE CENTER 3500 Folsom Boulevard Sacramento, CA 95816 (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) 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. (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 observation, interview, and review of the clinical record and facility policies and procedures, the facility failed to follow their policy permitting 1 of 3 sampled residents (Resident 1) in a census of 37 to return to the facility following hospitalization. This failure increased the risk for psychosocial distress. Findings: Resident 1 was admitted to the facility with multiple diagnoses. Resident 1's Minimum Data Set (MDS, an assessment tool) indicated Resident 1 had moderate impairment of her cognition (the activities of thinking, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HFC111 Facility ID: CA030000097 If continuation sheet 4 of 7 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: _______________ 055417 (X3) DATE SURVEY COMPLETED 08/04/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SAYLOR LANE HEALTHCARE CENTER 3500 Folsom Boulevard Sacramento, CA 95816 (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 understanding, learning, and remembering). During the Initial Tour observation of the facility on 1/23/17 starting at 9:17 a.m., Resident 1 was not found residing in the facility. Review of the facility document titled Resident Roster, dated 1/23/17, did not have Resident 1 listed as present in the facility. Review of the document titled "Resident Transfer Form", dated 12/21/16, indicated Resident 1 was sent out to the acute care because she needed "psychiatric evaluation and treatment." During an interview with the Social Services Director on 1/23/17 at 10:08 a.m., she said, "[Resident 1] went out 12/21/16...We did not give her a verbal or written bed hold..." Review of the acute care Online Referral for Resident 1, dated 1/5/17 at 3:55 p.m., indicated "This patient is from your facility and once medically stable, if she does not DC [discharge] to a [different] facility first, will return to your facility since she has been at your facility for long term placement..." The SSD responded on the same form on 1/6/17 at 9:37 a.m., "When resident went out I did not put her on a bed hold, and I have no long term beds..." Resident 1 was medically cleared to leave the acute care on 1/13/17. Facility responded on 1/13/17 at 2:09 p.m. "No, unable to accept patient...Unable to meet her needs..." Review of the acute care Consult Progress Note, dated 1/13/17, indicated, "Much calmer...cooperation with [name of acute care hospital] staff has been fair since delirium resolved 1/6/17...taking most scheduled meds [medications]. Appears at baseline..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HFC111 Facility ID: CA030000097 If continuation sheet 5 of 7 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: _______________ 055417 (X3) DATE SURVEY COMPLETED 08/04/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SAYLOR LANE HEALTHCARE CENTER 3500 Folsom Boulevard Sacramento, CA 95816 (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 with the Licensed Clinical Social Worker/Case Manager at the acute care on 1/31/17 at 11:35 a.m., she said, "[Resident 1] is stable...[Resident 1] could go back to the facility because she [is medically cleared]...I spoke to [SSD] and she said they [facility] would not take her back..." During a subsequent telephone interview with the Licensed Clinical Social Worker/Case Manager at the acute care on 5/15/17 at 12:02 p.m., she indicated Resident 1 was cleared medically on 1/13/17, and discharged 2/6/17 back to the facility. A voice mail was left for the Department by the facility Administrator on 2/7/17 at 9:34 a.m. The message indicated Resident 1 was readmitted to the facility 2/6/17. The facility document titled "Resident Roster" was reviewed from 1/13/17 through 2/6/17. There were multiple empty beds in semi private FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HFC111 Facility ID: CA030000097 If continuation sheet 6 of 7 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: _______________ 055417 (X3) DATE SURVEY COMPLETED 08/04/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SAYLOR LANE HEALTHCARE CENTER 3500 Folsom Boulevard Sacramento, CA 95816 (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 rooms on a daily basis at the facility for those dates. Resident 1 was not on the Resident Roster from 1/13/17 through 2/5/17. It was 24 days from the time Resident 1 was cleared by the acute care to return on 1/13/17 until she was readmitted on 2/6/17. Review of the facility policy and procedure titled "Holding Bed Space", dated December 2006, indicated "...8. A Medicaid resident ... whose hospitalization or therapeutic leave exceeds the bed-hold period established by the State Medicaid Plan will be readmitted when a bed in a semi-private room becomes available." During a concurrent record review and interview with SSD on 4/7/17 at 2:45 p.m. she verified Resident 1 was not readmitted to the first available semi private room when the acute care was ready to discharge her. During a subsequent concurrent record review and interview with the SSD on 5/17/17 at 1:15 p.m., she verified there were between two and six female beds available in semi private rooms 1/13/17 through 2/5/17. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HFC111 Facility ID: CA030000097 If continuation sheet 7 of 7