Health inspection·July 10, 2023

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 provide a notice prior to transfer or discharge to the resident, the resident's representative and representative of the Office of the State Long-Term Care Ombudsman for one of two sampled facility-initiated discharges (Resident 1). This failure had the potential for the resident or resident's responsible party to not having an opportunity to respond or seek help from ombudsman to confer or to contest the discharge. Findings: Review of Resident 1's record indicated he was admitted to the facility on 12/2018 and was discharged to a board and care (BHC) home on 3/17/23. Review of a faxed documentation indicated, the ombudsman office was notified of Resident 1's discharge on [DATE]. Review of Resident 1's face sheet (document providing resident information at a quick glance) indicated a family member was a responsible party (person responsible for making healthcare and/or financial decisions on behalf of a resident). Review of Resident 1's Minimum Data Set, (MDS, an assessment tool), dated 12/27/22, indicated the resident did not have any problems with memory or with daily decision-making skills. There was no documentation in Resident 1's record indicating he was informed of his discharge. During a follow-up interview on 6/27/23 at 1 p.m., the SSD stated Resident 1 was a combination of family and facility-initiated discharge and the facility did not give discharge or transfer notices. During an interview on 6/27/23 at 2:05 p.m., the administrator acknowledged understanding the transfer or discharge notices were to be provided prior to discharge. Review of Transfer or Discharge Notice policy, dated January 2018, indicated a resident, and/or his or her representative was to be given a thirty-day advance notice of an impending transfer or discharge from the facility. A copy of the notice was to be sent to the Office of the State Long-Term Care Ombudsman. All Facilities Letter (AFL) 17-27, dated 12/26/17 and addressed to long-term care facilities indicated, Effective January 1, 2018, AB 940 requires a LTC facility to notify the local LTC Ombudsman at the same time notice is provided to the resident or the resident's representatives when a facility-initiated transfer or discharge occurs. The facility must send notice to the local LTC Ombudsman for any transfer or discharge that is initiated by the facility, whether the resident agrees with the (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 4 Event ID: 555838 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 555838 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Camden Postacute Care, Inc 1331 Camden Avenue Campbell, CA 95008 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)