Other·November 26, 2018

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during a complaint investigation. Complaint Number: CA00602103 Representing the Department: HFEN # 36202 The inspection was limited to the specific complaints investigated and does not represent the findings of a full inspection of the facility. Two deficiencies were written as the result of CA00602103

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

F623 §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 section; and (iii) Include in the notice the items described in LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE 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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R4BY11 Facility ID: CA970000117 If continuation sheet 1 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555165 (X3) DATE SURVEY COMPLETED 10/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HIGHLAND PARK SKILLED NURSING & WELLNESS CENTRE 5125 Monte Vista St Los Angeles, CA 90042 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 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; (v) The name, address (mailing and email) and telephone number of the Office of the State FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R4BY11 Facility ID: CA970000117 If continuation sheet 2 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555165 (X3) DATE SURVEY COMPLETED 10/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HIGHLAND PARK SKILLED NURSING & WELLNESS CENTRE 5125 Monte Vista St Los Angeles, CA 90042 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 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: Based on interview and record review, the facility failed to provide a written notice of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R4BY11 Facility ID: CA970000117 If continuation sheet 3 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555165 (X3) DATE SURVEY COMPLETED 10/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HIGHLAND PARK SKILLED NURSING & WELLNESS CENTRE 5125 Monte Vista St Los Angeles, CA 90042 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE proposed transfer and discharge when transferred one of three sampled residents (Resident 1) to a General Acute Care Hospital (GACH). Resident 1 was transferred to a GACH on 8/15/18 and facility's staff did not provide a notice of proposed transfer and discharge to the resident and the resident's representative. Resident 1 was not allowed to readmit to the facility on 8/27/18 when the GACH informed facility's staff that Resident 1 was stable to be discharged back to the facility. This deficient practice had the potential to result in missed opportunity for Resident 1 and the resident's representative to appeal the transfer if the transfer was believed to be inappropriate or involuntary. Findings: On 8/31/18 at 2:15 p.m., an unannounced visit was conducted in the facility to investigate a complaint allegation regarding Residents Rights. A review of Resident 1's Face Sheet (admission record) indicated Resident 1 was admitted to the facility on 4/18/18 and was readmitted on 8/14/18 with diagnoses that included muscle weakness and end stage renal disease (loss of kidney function that filter wastes and excess fluids from the blood, which are then excreted in your urine). A review of Resident 1's Initial History and Physical form, dated 6/4/18, indicated Resident 1 had the capacity to understand and make decisions. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R4BY11 Facility ID: CA970000117 If continuation sheet 4 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555165 (X3) DATE SURVEY COMPLETED 10/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HIGHLAND PARK SKILLED NURSING & WELLNESS CENTRE 5125 Monte Vista St Los Angeles, CA 90042 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of Resident 1's Minimum Data Set (MDS - standardized assessment and care planning tool), dated 7/29/18, indicated Resident 1's cognition (ability to think and process information) was intact. The MDS indicated Resident 1 required extensive assistance from staff with activities of daily living including transfer, walk in room and corridor, toilet use, and personal hygiene. A review of Resident 1's Physician and Telephone Order form, dated 8/15/18, indicated an order from the Physician to transfer Resident 1 to a GACH due to hematemesis (vomiting of blood) and blood in the stool. A review of Resident 1's Notice of Proposed Transfer and Discharge form, dated 8/15/18, indicated Resident 1's discharge was necessary for the welfare of Resident 1 and the needs cannot be met in the facility. On 10/23/18 at 2:25 p.m., during an interview, Social Service Director (SSD) stated the Notice of Transfer/Discharge form was completed by the nursing department and nursing staff was responsible for sending the form with the resident upon transfer and discharge. On 10/24/18 at 11:15 p.m., during an interview, Licensed Vocational Nurse 1 (LVN 1) stated Resident 1's Notice of Proposed Transfer/Discharge form was completed by nursing staff but the form was not provided to Resident 1 and the resident's representative due to Resident 1 was transferred out via 911 (emergency transportation). LVN stated it was not the facility practice to mail a written notice of proposed transfer and discharge to the resident and or resident's responsible party. A review of facility's policy and procedure titled "Notice of Transfer/Discharge," dated 10/2017, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R4BY11 Facility ID: CA970000117 If continuation sheet 5 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555165 (X3) DATE SURVEY COMPLETED 10/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HIGHLAND PARK SKILLED NURSING & WELLNESS CENTRE 5125 Monte Vista St Los Angeles, CA 90042 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE indicated for staff to provide the resident and the resident's responsible party with a written notice of transfer/discharge prior to or at the time of discharge/transfer and their appeal rights. The policy indicated when the resident is being discharged home or to another facility, the facility's representative will complete the Notice of Proposed Transfer and Discharge form and provide it to the resident, responsible party and Ombudsman prior to the transfer or discharge. Social Service will document discharge plans and services in accordance with the discharge planning policies and procedures.

F626 SS=D Permitting Residents to Return to Facility CFR(s): 483.15(e)(1)(2)

F626 §483.15(e)(1) Permitting residents to return to facility. A facility must establish and follow a written policy on permitting residents to return to the facility after they are hospitalized or placed on therapeutic leave. The policy must provide for the following. (i) A resident, whose hospitalization or therapeutic leave exceeds the bed-hold period under the State plan, returns to the facility to their previous room if available or immediately upon the first availability of a bed in a semiprivate room if the resident(A) Requires the services provided by the facility; and (B) Is eligible for Medicare skilled nursing facility services or Medicaid nursing facility services. (ii) If the facility that determines that a resident who was transferred with an expectation of returning to the facility, cannot return to the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R4BY11 Facility ID: CA970000117 If continuation sheet 6 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555165 (X3) DATE SURVEY COMPLETED 10/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HIGHLAND PARK SKILLED NURSING & WELLNESS CENTRE 5125 Monte Vista St Los Angeles, CA 90042 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE facility, the facility must comply with the requirements of paragraph (c) as they apply to discharges. §483.15(e)(2) Readmission to a composite distinct part. When the facility to which a resident returns is a composite distinct part (as defined in § 483.5), the resident must be permitted to return to an available bed in the particular location of the composite distinct part in which he or she resided previously. If a bed is not available in that location at the time of return, the resident must be given the option to return to that location upon the first availability of a bed there. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to allow one of three sampled residents (Resident 1) to return to the facility after hospitalization. Resident 1 who was transferred to a General Acute Care Hospital (GACH) on 8/15/18 due to blood in the stool. On 8/27/18, the facility received Resident 1's referral (included discharge summary), but facility's staff shredded the referral due to the facility's administrative staff decided not to readmit Resident 1. This deficient practice resulted in Resident 1 was not able to readmit when the resident was stable to return to the facility. Findings: On 8/31/18 at 2:15 p.m., an unannounced visit was conducted in the facility to investigate a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R4BY11 Facility ID: CA970000117 If continuation sheet 7 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555165 (X3) DATE SURVEY COMPLETED 10/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HIGHLAND PARK SKILLED NURSING & WELLNESS CENTRE 5125 Monte Vista St Los Angeles, CA 90042 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE complaint allegation regarding Residents Rights. A review of Resident 1's Face Sheet (admission record) indicated Resident 1 was admitted to the facility on 4/18/18 and was readmitted on 8/14/18 with diagnoses that included muscle weakness and end stage renal disease (describes as loss of kidney function that filter wastes and excess fluids from the blood, which are then excreted in your urine). A review of Resident 1's Initial History and Physical form, dated 6/4/18, indicated Resident 1 had the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS - standardized assessment and care planning tool), dated 7/29/18, indicated Resident 1's cognition (able to think and process information) was intact. The MDS indicated Resident 1 required extensive assistance from staff with activities of daily living including transfer, walk in room and corridor, toilet use, and personal hygiene. A review of Resident 1's Physician and Telephone Order form, dated 8/15/18, indicated an order from the Physician to transfer Resident 1 to a GACH due to hematemesis (vomiting of blood) and blood in the stool. A review of Resident 1's Notice of Proposed Transfer and Discharge form, dated 8/15/18, indicated Resident 1's discharge was necessary for the welfare of Resident 1 and the resident's needs cannot be met in the facility. A review of GACH Pulmonary Progress Note Final Report form, dated 8/23/18, indicated the plan for Resident 1 were to continue present medications and to discharge the resident back FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R4BY11 Facility ID: CA970000117 If continuation sheet 8 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555165 (X3) DATE SURVEY COMPLETED 10/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HIGHLAND PARK SKILLED NURSING & WELLNESS CENTRE 5125 Monte Vista St Los Angeles, CA 90042 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE to the Skilled Nursing Facility where the resident resided but the facility refused to take Resident 1 back. On 8/31/18 at 2:28 p.m., during an interview, the Administrator stated the facility's administrative staff decided not to readmit Resident 1 back to facility because they feel that Resident 1 needs a higher level of care. On 10/23/18 at 1:20 p.m., during an interview, the Admission Coordinator (AC) stated Resident 1 was not readmitted back to the facility due to facility's administrative staff believed that Resident 1 needed higher level of care based on Resident 1's recurrent readmission to the facility. On 10/23/18 at 1:50 p.m., during an interview and concurrent review of Resident 1's medical record, Registered Nurse 1 (RN 1) stated she did not know the reason to why Resident 1 was not readmitted back to the facility. On 10/24/18 at 11:15 p.m., during an interview, Licensed Vocational Nurse 1 (LVN 1) stated Resident 1's Physician did not order to transfer Resident 1 to GACH but to continue to monitor for bleeding from the stool. LVN 1 stated according Physician 1, spot bleeding was common after the surgery and Resident 1's Physician ordered to monitor the laboratory test. LVN 1 stated Resident 1 also refused to be transferred to GACH but staff was able to convince Resident 1 to transfer to GACH for further evaluation. On 10/24/18 at 1:20 p.m., during an interview, the AC stated that staff from the GACH sent a referral and informed facility's staff that Resident 1 was ready to be discharged back to the facility. The AC stated facility's staff received the referral packet (included discharge FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R4BY11 Facility ID: CA970000117 If continuation sheet 9 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555165 (X3) DATE SURVEY COMPLETED 10/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HIGHLAND PARK SKILLED NURSING & WELLNESS CENTRE 5125 Monte Vista St Los Angeles, CA 90042 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE summary) from GACH via fax on 8/27/18, but the packet was shredded due to facility's administrative staff decided not to readmit Resident 1. On 10/25/18 at 12:10 p.m., during an interview, the Director of Nurses (DON) stated Resident 1 was transferred to a GACH and she did not know when facility's staff received a call that Resident 1 was ready to be readmitted. The DON stated she did not inquire the condition of Resident 1 duet to facility's distractive staff decided not to readmit Resident 1, they believed that it was better for Resident 1 to be in a subacute care (provides more intensive care to the patient until the condition is stabilized) facility. A review of the facility's policy and procedure, title "Readmission," dated 10/01/2013, indicated the facility will allow residents who were previously residents of the facility to be readmitted to the facility. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R4BY11 Facility ID: CA970000117 If continuation sheet 10 of 10