Health inspection·August 2, 2024

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 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, record review, and facility policy review, the facility failed to provide one of one resident (Resident (R)118) reviewed for hospital transfers out of a total sample of 33 residents a written transfer notice when R118 was transferred to the hospital. This failure placed all residents and their representatives at risk of having incomplete information, misunderstand the reason of transfer/discharge, and the discharge appeal process. Findings include: Review of the facility's policy titled Transfer and Discharge Notice dated 06/2017 read in part 1. The resident and, if known, a family member or resident representative shall be notified in writing and in a language and manner they understand, of the transfer or discharge and the reason for the move before a transfer or discharge takes place. Review of R118's undated Facesheet located in the resident's electronic medical record (EMR) under the Profile tab revealed the resident was admitted to the facility on [DATE]. Review of R118's Notice of Transfer/Discharge, revealed R118 was transferred to hospital on [DATE]. Notice of Transfer/Discharge was not signed by R118 or R118's representative. The facility lacked evidence that written notice was given to R118 or the representative for R118. During an interview on 08/01/24 at 11:13 AM, the Social Worker (SW) confirmed the facility failed to provide the written notice of transfer/discharge form to R118 or the representative for R118 upon or soon thereafter the resident's transfer to the hospital. The SW confirmed the facility generated the form themselves and sent it to the ombudsman; however, residents nor their representatives were provided the written notice of transfer/discharge form. 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 3 Event ID: 555513 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 555513 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Village Retirement Comm. 703 W Herbert Ave Reedley, CA 93654 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)