Other·August 28, 2019

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 an abbreviated survey for the investigation of facility reported incident #CA00626705. Representing the Department of Public Health: Health Facilities Evaluator Nurse, 38669 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 §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, This REQUIREMENT is not met as evidenced by: Based on observation, interviews, and record review, the facility failed to implement their 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: HMPS11 Facility ID: CA030000067 If continuation sheet 1 of 5 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: _______________ 056073 (X3) DATE SURVEY COMPLETED 08/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SACRAMENTO POST-ACUTE 5255 Hemlock Street Sacramento, CA 95841 (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 policy for abuse for providing a safe environment and ensuring 1 of 3 sampled residents (Resident 1) was free from verbal and mental abuse in a census of 94 when Resident 2 made repeated verbal insults. This failure caused Resident 1 to be fearful for her safety and had the potential to negatively impact her psychosocial well-being. Findings: On 2/28/19, the facility reported an incident to the Department, involving 2 residents. The incident had occurred 3 days prior, on 2/25/19. The victim [Resident 1] had reported that she feared for her safety due to the alleged abuser [Resident 2] challenging her to come outside to settle a dispute. Review of Resident 1's clinical chart indicated, Resident 1 was admitted to the facility late 2018 with diagnoses including post traumatic stress syndrome and anxiety. Resident 1's most recent Minimum Data Set (MDS, an assessment tool) dated 12/19/18, indicated Resident 1 was cognitively intact and had no history of maladaptive moods or behaviors. Review of Resident 2's clinical chart indicated, Resident 2 was admitted to the facility early 2018 with diagnoses including personality and mood disorders. Resident 2's most recent MDS dated 12/19/18, indicated Resident 2 was cognitively intact and had no history of maladaptive moods or behaviors. Review of Resident 2's clinical record indicated a Behavior Care Plan dated 9/17/18 which noted Resident 2 had "Altered behavior with potential to disrupt...others [by] provoking of other residents [with] verbal aggression, threatening statements along with statements towards becoming physically aggressive." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HMPS11 Facility ID: CA030000067 If continuation sheet 2 of 5 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: _______________ 056073 (X3) DATE SURVEY COMPLETED 08/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SACRAMENTO POST-ACUTE 5255 Hemlock Street Sacramento, CA 95841 (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 with Resident 1 on 2/28/19 at 4:33 p.m., Resident 1 stated, "[Resident 2] is kind of a bully. He was teasing me. [Resident 2] started yelling...he told me I was ugly... [Resident 2] has yelled at me before. It makes me scared to death when he yells at me. My dad used to yell at me and kick me too...My nurse says to ignore [Resident 2] but I'm scared he's going to get mad at me and yell at me again someday. I know he will." During an interview with the Social Services Director (SSD) on 2/28/19 at 4:53 p.m., the SSD relayed the facility does not tolerate abusive behaviors. During an interview with Resident 2 on 2/28/19 at 5:03 p.m., Resident 2 stated, "I don't have no problems with anyone in here. I went and talked to [Resident 1] already. Now we're friends." During an interview with Resident 3 on 2/28/19 at 5:45 p.m., Resident 3 stated, "While we were in the dining room playing Bingo, [Resident 2] told [Resident 1] 'I'll beat the hell out of you.' Everybody is afraid to say anything. The activities lady [Activities Assistant, (AA)] just kept going on like it didn't happen. [AA] was afraid to do anything." During an interview with the Administrator (ADM) on 2/28/19 at 6:25 p.m., the ADM stated, "As far as I know, [Resident 1] and [Resident 2] yelled at each other during Bingo. We talked to them, separated them, and they just resolved it between themselves." Resident 2 interrupted the interview, observed to selfpropel his wheelchair to the door of ADM's office and began yelling curse words at the ADM. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HMPS11 Facility ID: CA030000067 If continuation sheet 3 of 5 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: _______________ 056073 (X3) DATE SURVEY COMPLETED 08/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SACRAMENTO POST-ACUTE 5255 Hemlock Street Sacramento, CA 95841 (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 Review of Resident 2's Nursing Progress Note dated 2/25/19 indicated, "Noted [Resident 2] being loud and verbally aggressive towards another resident...advised resident to keep it down...seen [Resident 2] yelling at alleged victim in the hallway once again..." A Progress Note written by a different Licensed Nurse (LN) on the same day indicated, "Appears frustrated and angry...yelling, cussing, and using negative labels...unable to calm him down...A few minutes later, resident suddenly became verbally aggressive to alleged victim, cornering her, and yelling at her in the hallway." Review of Resident 1's Nursing Progress Note dated 2/25/19 indicated, "Staff witnessed [Resident 2] angry and upset, yelling and threatening [Resident 1] in the hallway... [Resident 1] reported fear for her safety...stated alleged abuser challenged her to settle situation outside of the facility threatening her...calling her names and using negative labels." Review of an undated incident 'Summary and Progress Notes' indicated, "Due to the findings and [Resident 2's] continual harassment [occurring twice on 2/25/29] along with verbal threats, [Resident 2 is] found to be unsafe for the environment of the other resident's (sic)." Review of a facility policy titled 'Abuse and Neglect-Clinical Protocol' revised July 2017 indicated, "The facility management and staff will institute measures to...minimize the possibility of abuse." Review of a facility policy titled 'Abuse Investigation and Reporting' revised July 2017 indicated, "The administrator will ensure that any further potential abuse...or mistreatment is prevented...An alleged violation of abuse...will be reported immediately, but not later FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HMPS11 Facility ID: CA030000067 If continuation sheet 4 of 5 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: _______________ 056073 (X3) DATE SURVEY COMPLETED 08/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SACRAMENTO POST-ACUTE 5255 Hemlock Street Sacramento, CA 95841 (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 than...two (2) hours if the alleged violation involves abuse." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HMPS11 Facility ID: CA030000067 If continuation sheet 5 of 5