Other·September 18, 2018

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE THIS FORM CMS-2567 HAS BEEN AMENDED TO DELETE F622 AND CORRECT THE SURVEY EXIT DATE. ALL OTHER ITEMS OF THIS FORM CMS-2567 REMAIN UNCHANGED AND EFFECTIVE. The following reflects the findings of California Department of Public Health during the investigation of a complaint. The investigation was limited to complaint investigated and does not represent the findings of a full inspection of the facility. Complaint Number: CA00601681 Representing the Department: Health Facilities Evaluator Nurse: 39939 One deficiency was issued related to the complaint number CA00601681.

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

F626 10/02/2018 §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 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: W7C211 Facility ID: CA020000038 If continuation sheet 1 of 4 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: _______________ 056457 (X3) DATE SURVEY COMPLETED 09/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GREENRIDGE POST-ACUTE 2150 Pyramid Drive El Sobrante, CA 94803 (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 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. §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, facility failed to ensure one (Resident 1) of three sampled residents was allowed to return to the facility after admission to Acute Care Hospital (ACH). This failure resulted in Resident 1 to be in psychosocial distress. Findings: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: W7C211 Facility ID: CA020000038 If continuation sheet 2 of 4 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: _______________ 056457 (X3) DATE SURVEY COMPLETED 09/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GREENRIDGE POST-ACUTE 2150 Pyramid Drive El Sobrante, CA 94803 (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 According to an undated Face Sheet, Resident 1 was originally admitted to the facility on 12/16/14 with diagnosis that included Atherosclerotic heart Disease of native coronary artery (hardening of heart blood vessels), Type 2 diabetes mellitus (a medical condition with abnormally high blood sugar) without complications, Chronic obstructive pulmonary disease (long term lung disease that makes breathing difficult), other chronic pain, other muscle spasm, hyperlipidemia (high lipid in the blood), peripheral vascular disease (a medical condition with the blood vessels outside of the heart and brain to narrow, block, or spasm). In a phone interview with Case Manager (CM 1) from an ACH, on 8/28/18, at 2:55 p.m., CM 1 stated that the facility was refusing to take Resident 1 back due to her behavior problems. Review of Nurses Notes dated 8/27/18 indicated Resident 1 was sent to ACH on the same date for Shortness of Breath and prior to that Resident 1 was verbally abusive towards another resident. In an interview with facility's Administrator (ADM), on 8/29/18, at 3:15 p.m., ADM stated it was not a good idea to readmit Resident 1 back to the facility because of her behaviors towards others. Review of ACH's Emergency Department (ED) Notes dated 8/28/18, showed Resident 1 was medically cleared for discharge back to the facility. It further indicated Resident 1 was not suffering from a psychiatric disorder. In an interview on 9/4/18, at 10:12 a.m., Director of Nursing Services (DON) at the facility stated, "We are not going to offer an assessment for her [Resident 1] to readmit her FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: W7C211 Facility ID: CA020000038 If continuation sheet 3 of 4 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: _______________ 056457 (X3) DATE SURVEY COMPLETED 09/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GREENRIDGE POST-ACUTE 2150 Pyramid Drive El Sobrante, CA 94803 (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 back to the facility." In an interview on 9/4/18, at 10:55 a.m., Social Services Manager (SSM) at ACH stated Resident 1 was still there and the facility had not attempted to reassess Resident 1 even after Resident 1 was medically cleared to go back to the Facility. In a phone interview on 9/5/18, at 2:19 p.m., Resident 1 stated that she felt abandoned by the facility. The facility's policy and procedure "Readmission to the Facility" revised 04/2013 indicated, "Residents who have been discharged to the hospital or for therapeutic leave will be given priority in readmission to the facility". FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: W7C211 Facility ID: CA020000038 If continuation sheet 4 of 4