Other·March 21, 2018

F000 INITIAL COMMENTS

F000 DEFICIENCY) COMPLETE DATE The following reflects the findings of the California Department of Public Health during the investigation of one complaint. Complaint intake number: CA00571041 - Substantiated Representing the Department of Public Health: Surveyors ID# 33638 RN, HFEN #38942 RN, HFEN 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 issued for complaint number CA00571041.

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

F623 03/22/2018 §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 055181 02/22/2018 SAN GABRIEL CONVALESCENT CENTER 8035 Hill Dr Rosemead, CA 91770 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE section; and (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; 055181 02/22/2018 SAN GABRIEL CONVALESCENT CENTER 8035 Hill Dr Rosemead, CA 91770 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE (v) The name, address (mailing and email) and 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: 055181 02/22/2018 SAN GABRIEL CONVALESCENT CENTER 8035 Hill Dr Rosemead, CA 91770 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE Based on interview and record review, the facility failed to provide a copy of the written Notice of Transfer or Discharge and Ombudsman Notification information to the resident or his/her representative for a facilityinitiated transfer in writing, 30 days prior to the transfer for five of 27 sampled residents (Residents 1, 2, 3, 4, and 5). This deficient practice violated the residents' rights to be informed of where and how to appeal the proposed transfer. Findings: 1. A review of Resident 1's Admission Record indicated the resident was admitted to the facility on 11/7/16, with diagnoses that included hypertension, osteoporosis and unspecified dementia with behavioral disturbance. A review of Resident 1's Minimum Data Set (MDS / a standardized assessment and carescreening tool) dated 11/3/17, indicated Resident 1 was severely impaired in cognitive skills (ability to think and reason) for daily decision making. A review of Resident 1's Physician's Telephone Orders, dated 1/18/18, indicated the physician ordered to transfer the resident to a skilled nursing facility on 1/18/18. A review of Resident 1's clinical record indicated the Notice of Proposed Transfer/Discharge was provided to the resident or legal representative on 1/17/18, one day prior to discharge. The Notice had a signature indicating receipt or acknowledgement of the proposed transfer/discharge in writing, by the resident or legal representative on the resident's chart. 055181 02/22/2018 SAN GABRIEL CONVALESCENT CENTER 8035 Hill Dr Rosemead, CA 91770 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE During a telephone interview on 1/26/18, at 3:28 p.m., a family member of Resident 1 (Fam1) stated that he did not "feel like he had any choice and was not informed of his right to appeal on behalf of Resident 1." Fam 1 stated that he did not sign any paperwork regarding the transfer. Fam 1 also stated that the facility informed them that the transfer was temporary but did not give an approximate date of when Resident 1 would be transferred back to the facility. Fam 1 further stated that he was present when the facility announced that the facility was converting Station 1 to a sub-acute unit but was not informed of when they would start moving residents out of their rooms until 1/17/18, when the facility's social worker notified him of the proposed transfer to another facility, the following day (1/18/18). 2. A review of Resident 2's Admission Record indicated the resident was originally admitted to the facility on 5/9/11, and was re-admitted on 6/28/13, with diagnoses that included osteoporosis, contractures of both knees, and type 2 diabetes mellitus. A review of Resident 2's MDS dated 11/21/17, indicated Resident 2 was severely impaired in cognitive skills (ability to think and reason) for daily decision making. A review of Resident 2's History and Physical dated 7/3/17, indicated Resident 2 does not have the capacity to understand and make decisions. A review of Resident 2's Physician's Telephone Orders dated 1/22/18, indicated the physician ordered to transfer the resident to another skilled nursing facility on the same day. A review of Resident 2's clinical record 055181 02/22/2018 SAN GABRIEL CONVALESCENT CENTER 8035 Hill Dr Rosemead, CA 91770 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE indicated the Notice of Proposed Transfer/Discharge was provided to the resident or legal representative on 1/22/18, same day as discharge. The Notice had a signature indicating receipt or acknowledgement of the proposed transfer/discharge in writing, by the resident or legal representative on the resident's chart. During a telephone interview on 1/26/18, at 3:48 p.m., a family member of Resident 2 (Fam 2) stated no one informed him that Resident 2 would be transferred. Fam 2 stated he did not attend any meeting, however, approximately 2 months ago, someone informed him that the facility would be moving some residents out due to the construction but no one talked to him specifically about the plan for Resident 2. Fam 2 also stated that he found out about the transfer after Resident 2 was already transferred. Fam 2 further stated that he did not sign any paperwork regarding the transfer and that he was not informed of his right to appeal on behalf of Resident 2. 3. A review of Resident 3's Admission Record indicated the resident was originally admitted to the facility on 1/27/11, and was re-admitted on 5/19/16, with diagnoses that included chest pain, difficulty in walking, and Parkinson's disease. A review of Resident 3's MDS dated 11/16/17, indicated Resident 3 was severely impaired in cognitive skills for daily decision making. A review of Resident 3's History and Physical dated 4/20/17, indicated Resident 3 had the capacity to understand and make decisions. A review of Resident 3's Physician's Telephone Orders, dated 1/18/18, indicated the physician ordered to transfer the resident to a skilled 055181 02/22/2018 SAN GABRIEL CONVALESCENT CENTER 8035 Hill Dr Rosemead, CA 91770 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE nursing facility on 1/18/18. A review of Resident 3's clinical record indicated the Notice of Proposed Transfer/Discharge was provided to the resident on 1/17/18, one day prior to discharge. The Notice had a signature indicating receipt or acknowledgement of the proposed transfer/discharge in writing, by the resident on the resident's chart. A telephone call was attempted to reach the resident's family or representative but was unable to reach them for an interview. 4. A review of Resident 4's Admission Record indicated the resident was admitted to the facility on 9/27/16, with diagnoses that included unspecified abnormalities of gait and mobility, muscle weakness, benign prostatic hyperplasia and hypertension. A review of Resident 4's Physician's Telephone Orders, dated 1/19/18, indicated the physician ordered to transfer the resident to another skilled nursing facility on 1/19/18. A review of Resident 4's clinical record indicated the Notice of Proposed Transfer/Discharge was provided to the resident on 1/18/18, one day prior to discharge. The Notice had a signature indicating receipt or acknowledgement of the proposed transfer/discharge in writing, by the resident or legal representative on the resident's chart. A review of Social Services Progress Notes dated 1/18/18, indicated that Social Services called Resident 4's son on 1/18/18, to inform him of the temporary discharge to another skilled nursing facility. Telephone call was made but was unable to 055181 02/22/2018 SAN GABRIEL CONVALESCENT CENTER 8035 Hill Dr Rosemead, CA 91770 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE reach the family or the resident's representative for an interview. 5. A review of Resident 5's Admission Record indicated the resident was admitted to the facility on 8/3/16, with dignoses that included Atrial Fibrillation, hypertension, chromic obstructive pulmonary disease, and type 2 diabetes mellitus. A review of Resident 5's MDS dated 10/25/17, indicated Resident 5 was severely impaired in cognitive skills for daily decision making. A review of Resident 5's History and Physical dated 4/20/17 indicated Resident 3 does not have the capacity to understand and make decisions. A review of Resident 5's Physician's Telephone Orders, dated 1/23/18, indicated the physician ordered to transfer the resident to a skilled nursing facility on 1/23/18. A review of Resident 5's clinical record indicated the Notice of Proposed Transfer/Discharge was provided to the resident on 1/22/18, one day prior to discharge. The Notice had a signature indicating receipt or acknowledgement of the proposed transfer/discharge in writing, by the resident or legal representative on the resident's chart. A review of Social Services Progress Notes, dated 1/22/18, indicated the social worker called Resident 5's family on 1/22/18, and informed him of the resident's temporary discharge to another skilled nursing facility. Resident 5's family or representative could not be reached for interview . 055181 02/22/2018 SAN GABRIEL CONVALESCENT CENTER 8035 Hill Dr Rosemead, CA 91770 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE During an observation and concurrent interview on 1/26/18, at 1:32 p.m., the Director of Nursing (DON) stated the total capacity of the facility is 151 beds. DON stated the facility is currently under construction to convert 44 beds (in Station 3) to a sub-acute care. DON also stated that out of the 44 beds, 27 more beds need to be vacated which involved 27 more residents. During an interview, on 1/26/18, at 1:40 p.m., the Administrator (ADM) stated the construction was initiated in March 2017 and so far, only 25% had been completed. ADM stated there were meetings held approximately 6 months before the construction started, with residents/residents' family regarding renovation of the facility and to ask permission to move/transfer residents. ADM stated that "we did not specifically tell them the reason for moving out is the sub-acute conversion." ADM stated it was a general meeting and not specific to each resident/ resident's family. ADM also stated prior to January 2018, the residents discharged from the facility have either expired or have planned discharges (i.e. to home, assisted living or another nursing facility). ADM stated the construction was moving on a slow pace because they were following the normal way of discharging residents. ADM also stated that starting January 2018, the facility started to transfer residents to other facilities so that the project can advance. The ADM stated, "The construction needed to proceed at a faster pace, and so far, five residents have been discharged to other facilities." During a concurrent interview and record review on 1/26/18, at 2:03 p.m., the Social Worker (SW) stated that the Notices were given the day before or the day of discharge and the resident or resident's representative 055181 02/22/2018 SAN GABRIEL CONVALESCENT CENTER 8035 Hill Dr Rosemead, CA 91770 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE agreed. A review of the facility's undated policy and procedure titled "Residents' Rights," indicated that documentation will be placed in the resident's chart specifying, among other things, that the resident or resident's agent has been notified of the transfer or discharge 30 days prior to the transfer. According to Federal Regulation under 483.15(c) (3), Notice before transfer, indicated that before the transfer and discharge occur, the law requires that the facility notify the resident and the resident's representative of the transfer or discharge, at least 30 days before the resident is transferred or discharged, the reasons for the move, in writing, and in a language and manner they understand.