Other·February 24, 2020

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 standard survey to investigate a complaint. Complaint number: CA00629005 Representing the California Department of Public Health: Surveyor: 37837 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 written as a result of complaint number CA00629005

F623 SS=D Notice Requirements Before Transfer/Discharge CFR(s): 483.15(c)(3)-(6)(8)

F623 02/07/2020 §483.15(c)(3) Notice before transfer. Before a facility transfers or discharges a resident, the facility must(i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State LongTerm Care Ombudsman. (ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and 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: 78MC11 Facility ID: CA240000031 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: _______________ 055557 (X3) DATE SURVEY COMPLETED 01/29/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CREEKSIDE POST ACUTE 35253 Avenue H Yucaipa, CA 92399 (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) Include in the notice the items described in paragraph (c)(5) of this section. §483.15(c)(4) Timing of the notice. (i) Except as specified in paragraphs (c)(4)(ii) and (c)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged. (ii) Notice must be made as soon as practicable before transfer or discharge when(A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section; (B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section; (C) The resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(i)(B) of this section; (D) An immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (c)(1)(i)(A) of this section; or (E) A resident has not resided in the facility for 30 days. §483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following: (i) The reason for transfer or discharge; (ii) The effective date of transfer or discharge; (iii) The location to which the resident is transferred or discharged; (iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request; (v) The name, address (mailing and email) and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 78MC11 Facility ID: CA240000031 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: _______________ 055557 (X3) DATE SURVEY COMPLETED 01/29/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CREEKSIDE POST ACUTE 35253 Avenue H Yucaipa, CA 92399 (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 telephone number of the Office of the State Long-Term Care Ombudsman; (vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and (vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act. §483.15(c)(6) Changes to the notice. If the information in the notice changes prior to effecting the transfer or discharge, the facility must update the recipients of the notice as soon as practicable once the updated information becomes available. §483.15(c)(8) Notice in advance of facility closure In the case of facility closure, the individual who is the administrator of the facility must provide written notification prior to the impending closure to the State Survey Agency, the Office of the State Long-Term Care Ombudsman, residents of the facility, and the resident representatives, as well as the plan for the transfer and adequate relocation of the residents, as required at § 483.70(l). This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 78MC11 Facility ID: CA240000031 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: _______________ 055557 (X3) DATE SURVEY COMPLETED 01/29/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CREEKSIDE POST ACUTE 35253 Avenue H Yucaipa, CA 92399 (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 1. Provide a notice of Proposed Transfer or Discharge Notice 30 days prior to discharge for one of three sampled Residents (Resident 3). 2. Provide documentation of a resident transfer and discharge notification to the State Long Term Care Ombudsman office for one of three sampled Residents (Resident 3). This failure had the potential to result in one Resident (Resident 3) being inappropriately discharged and not being provided the added protection of the Ombudsman. Findings: 1. An abbreviated survey was conducted on March 19, 2019 at 12:29 PM to investigate a complaint related to resident rights. During a review of Resident 3's clinical record, the face sheet indicated an admission date of December 6, 2017 with diagnoses which included chronic obstructive pulmonary disease (disease in which one has a hard time breathing), depression, high blood pressure and gastroesophageal reflux disease (stomach acid backs up into the tube connecting your mouth and stomach). A review of the clinical record for Resident 3, reflected a Discharge Summary Note, dated January 11, 2018 at 11:56 AM, which indicated, "Social services designee met with the resident to discuss his discharge plan. Resident met with ...an agency for placement. Resident will discharge to Room and Board in (name of city.)" During a review of the clinical record for Resident 3, with Licensed Vocational Nurse (LVN 1), the Notice of Proposed Transfer and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 78MC11 Facility ID: CA240000031 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: _______________ 055557 (X3) DATE SURVEY COMPLETED 01/29/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CREEKSIDE POST ACUTE 35253 Avenue H Yucaipa, CA 92399 (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 Discharge dated January 17, 2018, indicated the document was given on the same date of discharge. A Review of a nursing note for Resident 3, dated January 17, 2018 at 8:19 PM, indicated "Resident 3 was discharged to (name of facility) at 7 PM ..." During an interview with the Social Services Designee (SSD), on March 19, 2019, at 2:45 PM, the SSD stated, "I'm not seeing anything, a note that stated the resident requested to be discharged." The SSD further stated, "The discharge, SSD 2 knew ahead of time. SSD 2 should have given it 30 days prior to his discharge." During an interview with the Director of Nursing (DON), on March 19, 2019, at 4:18 PM, the DON stated "The discharge was facility initiated because there is no proof that the resident initiated it. If its facility initiated, we have to give a 30 day notice. She gave a one day notice and it should have been given sooner." A review of the facility policy and procedure titled, "Transfer or Discharge Notice," dated 2001, indicated "Our facility shall provide a resident and/or the resident's representative with a thirty day written notice of an impending transfer or discharge. 1. A resident, and/or his or her representative, will be given a thirty (30) day advance notice of an impending transfer or discharge from our facility." 2. During a review of Resident 3's clinical record, the face sheet indicated an admission date of December 6, 2017 with diagnoses which included chronic obstructive pulmonary disease (disease in which one has a hard time breathing), depression, high blood pressure and gastroesophageal reflux disease (stomach FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 78MC11 Facility ID: CA240000031 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: _______________ 055557 (X3) DATE SURVEY COMPLETED 01/29/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CREEKSIDE POST ACUTE 35253 Avenue H Yucaipa, CA 92399 (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 acid backs up into the tube connecting your mouth and stomach). During a review of the clinical record for Resident 3, with Licensed Vocational Nurse (LVN 1), the Notice of Proposed Transfer and Discharge dated January 17, 2018, indicated the document was given on the same date of discharge. During an interview with the Social Services Designee (SSD), on March 19, 2019, at 2:45 PM, the SSD stated "I'm not seeing anything, a note that stated the resident requested to be discharged." The SSD further stated, "I do not know if this (Notice of proposed transfer/discharge) was sent over to the Ombudsman (public advocate for residents in a long term care facility)." The SSD could not provide any documented evidence to show that the document was sent to the Ombudsman. During an interview with the Director of Nursing (DON), on March 19, 2019, at 4:18 PM, the DON stated "The discharge was facility initiated because there is no proof that the resident initiated it. The Ombudsman was not notified." We could not find verification that (the transfer/discharge notice) was sent to the Ombudsman. A review of the facility policy and procedure titled, "Transfer or Discharge Notice" dated 2001, indicated "Our facility shall provide a resident and/or the resident's representative with a thirty day written notice of an impending transfer or discharge. 1. A resident, and/or his or her representative, will be given a thirty (30) day advance notice of an impending transfer or discharge from our facility ...4. A copy of the notice will be sent to the Office of the State Long Term Care Ombudsman." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 78MC11 Facility ID: CA240000031 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: _______________ 055557 (X3) DATE SURVEY COMPLETED 01/29/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CREEKSIDE POST ACUTE 35253 Avenue H Yucaipa, CA 92399 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) FORM CMS-2567(02-99) Previous Versions Obsolete ID PREFIX TAG Event ID: 78MC11 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) Facility ID: CA240000031 (X5) COMPLETE DATE If continuation sheet 7 of 7