Health inspection·September 18, 2024

F 0571 coverage and copay obligations with the admissions packet. Level of Harm - Minimal harm or potential for actual harm On 9/18/24 at 1:47 P.M., an interview and concurrent record review of Resident 1's clinical record was conducted with the AD. The AD stated the admissions packet and accompanying financial breakdown of coverage from the business office was not provided to or signed by Resident 1 and/or RP. A review of Resident 1's clinical record indicated the facility had no evidence of a signed admissions packet for Resident 1. The AD stated he runs a monthly quality assurance performance improvement (QAPI) program report that indicates the names of residents who have not had an admissions packet reviewed and signed. The AD stated Resident 1 had been listed on the QAPI report for incomplete admissions packet review since March 2023 Residents Affected - Few The AD stated the admission packet reviewed financial obligations, resident rights, and facility accommodations. The AD stated if the admissions packet was not signed and uploaded to the electronic health record, it was not completed. The AD acknowledged Resident 1, and the RP were not informed of resident rights and financial obligations at the time of admission, and they should have been. On 9/18/24 at 2:24 P.M., a subsequent interview and record review was conducted with the BOM at the facility. The BOM stated a few days before resident's skilled nursing facility (SNF) benefit became exhausted, the facility would inform the resident and/or RP that Medicare-covered services would be ending, and the resident would be charged as private pay if they did not have secondary insurance coverage. The BOM stated if the resident/RP requested to continue non-covered treatment services, they would receive a written financial statement estimating the cost of those charges on a weekly basis. The BOM stated charges for non-Medicare covered physical and occupational therapies were collected one week in advance from the resident/RP before the services were provided. The BOM stated Resident 1's RP requested physical therapy and occupational therapy services to continue following benefit exhaustion on 6/23/24. The BOM stated the facility started to charge Resident 1 for physical and occupational therapy services on 7/1/24. A review of the facility document titled Transaction Report Effective Date May 1, 2024[DATE] printed 9/18/24, indicated one check for $2,400 on 6/28/24 and a second check for $1,100, on 8/11/24, was provided to the facility by Resident 1's RP for physical and occupational services. A review of the letter provided to the RP from the BOM, regarding physical and occupational therapy charges, dated 8/12/24, was conducted with the BOM. The BOM stated the resident and RP had not been provided with written information regarding payment and charges for skilled physical and occupational therapy services prior to this letter. On 9/27/24 at 11:54 A.M., an interview with the director of nursing (DON) was conducted. The DON stated it was the expectation that residents are given written financial information upon admission regarding covered services and share of cost by the business office. The DON stated the expectation was that the admission packet, which included the financial information provided by the BOM, was reviewed and signed by the resident or the RP. On 9/27/24 at 12:05 P.M. a concurrent interview was conducted with the DON and the administrator (ADMIN). The ADMIN stated it was facility practice to provide a pricing sheet to the resident or RP for services requested not covered by insurance before those services were provided. The ADMIN stated a written estimate for those services should be provided prior to the services starting. The ADMIN stated he could see how it would create a financially unfair situation to the resident and RP if a cost estimate of uncovered services was not provided before receiving those services. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555136 If continuation sheet Page 2 of 3 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555136 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Poway Healthcare Center 15632 Pomerado Road Poway, CA 92064 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0571 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete The ADMIN acknowledged Resident 1 and RP was not provided written financial information regarding the cost of covered and non-covered services at admission or before non-covered physical and occupational therapy services were requested to continue. A review of the facility policy, revised March 2019, titled admission Criteria indicated, . Policy Interpretation and Implementation 1. The objectives of our admission criteria policy are to . d. review with the resident, and/or his/her representative, the facility's policies and procedures relating to resident rights, resident care, financial obligations . Event ID: Facility ID: 555136 If continuation sheet Page 3 of 3