Other·May 10, 2019

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE AMENDED The following reflects the amended findings of the California Department of Public Health during an abbreviated survey for the investigation of facility reported incident #CA00626678. Representing the Department of Public Health: HFEN, 40059 The inspection was limited to the specific facility reported incident investigated and does not represent the findings of a full inspection of the facility.

F607 SS=D Develop/Implement Abuse/Neglect Policies CFR(s): 483.12(b)(1)-(3)

F607 04/30/2019 §483.12(b) The facility must develop and implement written policies and procedures that: §483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, §483.12(b)(2) Establish policies and procedures to investigate any such allegations, and §483.12(b)(3) Include training as required at paragraph §483.95, 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: TFKY11 Facility ID: CA030000046 If continuation sheet 1 of 3 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: _______________ 055402 (X3) DATE SURVEY COMPLETED 04/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVER CITY POST ACUTE 2540 Carmichael Way Carmichael, CA 95608 (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 This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to report a physical abuse allegation to the facility administrator and official agencies within the required timeframe (24 hours) for 1 of 3 sampled residents (Resident 1), when nursing staff did not report witnessed physical abuse between Licensed Nurse 1 (LN 1) and Resident 1. This failure caused a delay in the investigation of abuse by the Department and had the potential to cause physical and psychosocial harm to Resident 1 and other Residents in the facility. Findings: Resident 1 was admitted in with diagnoses which included dementia with behavioral disturbances. Resident 1 had a Brief Interview Mental Score (BIMS of 7 which indicated moderate cognitive disorder). Resident 1 required a Patient Representative (RP). Review of Resident 1's clinical record titled, "Progress Notes," dated 2/18/19 at 4:02 a.m., indicated LN 1 documented Resident 1 had aggressive behavior and spit at him. Resident 1's clinical record titled, "Progress Notes-Nursing," dated 2/28/19 at 12:16 a.m., indicated Resident 2 and Certified Nurse Assistant 1 (CNA 1) witnessed LN 1 physically abuse Resident 1, but could not recall what day the incident happened. It was also documented that Resident 2 stated LN 1 held Resident 1 by her face and pushed her back into her wheel chair (w/c), and blocked Resident 1's room door with a chair so she could not exit her room. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: TFKY11 Facility ID: CA030000046 If continuation sheet 2 of 3 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: _______________ 055402 (X3) DATE SURVEY COMPLETED 04/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RIVER CITY POST ACUTE 2540 Carmichael Way Carmichael, CA 95608 (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 During an interview on 3/8/19 at 12:10 p.m., Resident 2 stated she was present the day of the incident although she could not remember the exact date. When asked when she reported the alleged abuse to the facility, Resident 2 stated she told LN 2 about 1 week after the incident happened. Resident 2 stated Resident 1 was upset and throwing things and then spit in LN 1's face. LN 1 pushed Resident 1 down in her w/c and placed a chair in front of Resident 1's room door to block her inside. During an interview on 3/19/19 at 3:04 p.m., CNA 1 stated she could not remember the exact date of the incident, but she reported it about 1 week later. She also stated she witnessed LN 1 place his hand over Resident 1's face and push her into her w/c. During an interview on 3/28/19 at 12:42 p.m., the Social Services Assistant (SSA) stated LN 2 reported the alleged abuse to her on 2/28/19, 1 week after the alleged incident on 2/21/19. A review of the facility's policy and procedure titled, "Abuse Prohibition and Prevention Policy and Procedure and Reporting Reasonable Suspicion of a Crime in the Facility Policy and Procedure", revised 3/2018, indicated, "The facility will report allegations of abuse...No later than 24 hours- all other conduct (actual, alleged, or potential neglect mistreatment ... And did not result in serious bodily injury ..." During an interview on 3/28/19 at 12:05 p.m., the DON confirmed CNA 1 had been trained as a mandated reporter on 1/16/19 and should have reported the alleged abuse incident immediately. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: TFKY11 Facility ID: CA030000046 If continuation sheet 3 of 3