Health inspection·September 4, 2024

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a copy of the transfer/discharge notice was sent to the representative of the Office of the State Long-Term Care Ombudsman (LTC Ombudsman) for one of three sampled residents (Resident 1). This failure has the potential for the Ombudsman not to be able to advocate for the resident in protecting his rights from inappropriate transfer and discharge. Findings: On September 4, 2024, Resident 1's record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnoses which included muscle wasting (loss of muscle strength) and atrophy (thinning of muscles). A review of Resident 1 ' s History and Physical, dated April 4, 2024, indicated Resident 1 can make decisions. A review of Resident 1's Minimum Data Set (MDS-an assessment tool), dated June 27, 2024, indicated, Resident 1 had Brief Interview of Mental Status (BIMS-a tool to measure cognitive function in older adults), score of 14 (cognitively intact). A review of Resident 1 ' s SNF/NF to Hospital Transfer Form, dated July 15, 2024, indicated, .Sent to (name of hospital) .Reinsertion of dislodged suprapubic catheter (medical device that drains urine from bladder) . There was no documented evidence indicating the facility mailed or faxed a copy of the transfer notice to the LTC Ombudsman. On September 4, 2024, at 2:36 p.m., during a concurrent interview and review of Resident 1 ' s medical records with the Director of Nursing (DON), she stated the process for transfer or discharge was the resident would be given the notice upon transfer or discharge from the facility and the Social Service Director (SSD) will send the discharge notice to the LTC Ombudsman within 30 days. The DON stated Resident 1 was transferred to the hospital on July 15, 2024, and the discharge notice was not sent to the LTC Ombudsman. The DON further stated the SSD should have sent the notice to the Ombudsman. On September 4, 2024, at 2:56 p.m., during a concurrent interview and review of Resident 1 ' s (continued on next page) 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. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 555492 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 555492 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak Glen Post Acute 9246 Avenida Miravilla Cherry Valley, CA 92223 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)