Other·April 3, 2018

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 the investigation of one complaint. Complaint number: CA00572086 Representing the department: Health Facilities Evaluator Supervisor 33650 The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. One deficiency was issued as a result of the investigation of Complaint number CA00572086.

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

F626 03/09/2018 §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. 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: E52S11 Facility ID: CA020000092 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: _______________ 055775 (X3) DATE SURVEY COMPLETED 02/15/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ORINDA CARE CENTER, LLC 11 Altarinda Road Orinda, CA 94563 (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 (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, the facility failed to permit one of two residents (Resident 1) to return to the facility after hospitalization. Resident 1 was not offered the first available bed after the facility was informed that Resident 1 was ready for discharge and wanted to go back to the facility. This failure resulted in Resident 1 not being permitted to return to her home of two years. Resident 1 felt anxious and afraid of being discharge to an unknown location. Findings: Review of an undated Face Sheet, indicated Resident 1 was admitted to the facility on 9/5/15 and was discharged on 9/27/17 with diagnoses that included Pressure ulcer (areas of damaged skin caused by staying in one position for too long) of right buttock. The Face Sheet indicated "Discharge Status: Return FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: E52S11 Facility ID: CA020000092 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: _______________ 055775 (X3) DATE SURVEY COMPLETED 02/15/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ORINDA CARE CENTER, LLC 11 Altarinda Road Orinda, CA 94563 (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 Anticipated" During a telephone interview with Resident 1 on 2/1/18 at 12:30 p.m., Resident 1 stated she wanted to go back to the facility as the facility had been her home for few years. Resident 1 stated her Case Manager (CM) had called the facility on 1/26/18 and the facility informed Resident 1's CM that there was no available bed. Resident 1 stated on a subsequent interview on 2/2/18 at 5:40 p.m., that she was anxious to go back to the facility and afraid she will be discharged to another facility. Resident 1 stated she wanted to go back to the facility. During an interview with CM on 2/1/18 at 3:15 p.m., CM stated he called the facility on 1/26/18 to inform the facility that Resident 1 was ready for discharge and she intended to go back to the facility. The facility told CM that there was no available bed for Resident 1. During an interview with the Director of Staff Development (DSD) on 2/2/18 at 3:40 p.m., DSD stated Resident 1 was sent to the hospital on 9/27/17 for wound surgery and was anticipated to return to the facility after her surgery. During an interview with Admissions Coordinator (AC) on 2/2/18 at 4:30 p.m., AC stated he received a referral from Resident 1's case manager on 1/17/18 and the case manager called on 1/26/18 to inquire for an available bed because Resident 1 was ready for discharge. AC stated they informed the case manager there was no available beds. AC stated after 1/26/18, he did not follow up with the case manager to offer the available bed to Resident 1. Review of a facility letter dated 2/6/18 indicated on 1/26/18 Resident 1 was referred to the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: E52S11 Facility ID: CA020000092 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: _______________ 055775 (X3) DATE SURVEY COMPLETED 02/15/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ORINDA CARE CENTER, LLC 11 Altarinda Road Orinda, CA 94563 (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 for readmission and on 1/26/18 there were two female beds vacant at the time. Review of the facility's daily census sheet revealed the following: 1/27/18- two female beds available 1/28/18- two female beds available 1/29/18- two female beds available 1/30/18- one female bed available 1/31/18- one female bed available 2/1/18- one female bed available During an interview with the Social Service Designee on 2/5/18 at 2:22 p.m., SSD stated she was aware that Resident 1 will return to the facility after her surgery and Resident 1's belongings were kept in the facility. Review of the facility's policy and procedure tilted "Bed-Hold" indicated "The facility shall allow a resident, whose hospitalization or therapeutic leave exceeds the bed-hold period (7 days), to be readmitted to the facility immediately upon the first availability of a bed in a semi-private room..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: E52S11 Facility ID: CA020000092 If continuation sheet 4 of 4