Other·June 1, 2018

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 complaint #CA00563561. Representing the Department of Public Health: HFEN, 38193 The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility.

F580 SS=D Notify of Changes (Injury/Decline/Room, etc.) CFR(s): 483.10(g)(14)(i)-(iv)(15)

F580 06/10/2018 §483.10(g)(14) Notification of Changes. (i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is(A) An accident involving the resident which results in injury and has the potential for requiring physician intervention; (B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); (C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or (D) A decision to transfer or discharge the resident from the facility as specified in §483.15(c)(1)(ii). (ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified 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: R4CR11 Facility ID: CA030000090 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: _______________ 055886 (X3) DATE SURVEY COMPLETED 05/10/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ROSEVILLE CARE CENTER 1161 Cirby Way Roseville, CA 95661 (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 §483.15(c)(2) is available and provided upon request to the physician. (iii) The facility must also promptly notify the resident and the resident representative, if any, when there is(A) A change in room or roommate assignment as specified in §483.10(e)(6); or (B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section. (iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident representative(s). §483.10(g)(15) Admission to a composite distinct part. A facility that is a composite distinct part (as defined in §483.5) must disclose in its admission agreement its physical configuration, including the various locations that comprise the composite distinct part, and must specify the policies that apply to room changes between its different locations under §483.15(c) (9). This REQUIREMENT is not met as evidenced by: Based on interview, and record review, the facility failed to consult with 1 of 3 sampled residents' (Resident 1) physician when Resident 1 experienced a significant change in health; Resident 1 was found to have signs of impaired circulation in his lower right leg and there was a delay notifying his physician. This failure led to a delay in the activation of physician services and a delay in medical treatment of the circulatory blockage. Findings: Resident 1 was a 79 year old male admitted to the facility in August of 2016 with multiple FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R4CR11 Facility ID: CA030000090 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: _______________ 055886 (X3) DATE SURVEY COMPLETED 05/10/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ROSEVILLE CARE CENTER 1161 Cirby Way Roseville, CA 95661 (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 medical problems including high blood pressure, diabetes (high sugar in the blood), and previous heart attack. A review of the clinical record, "Resident Progress Notes: [Resident 1]," dated 10/5/16, indicated he was transferred to the hospital in October of 2016, with what was described as "ischemic [restriction of blood supply to tissues] appearing L [left] LOWER EXTREMITY." Resident 1 returned to the facility after 5 days, on 10/4/16, with "...extensive DEEP VENOUS THROMBOSIS [blockage]..." diagnosis. During an interview with the Certified Nursing Assistant (CNA 1) on 1/17/18 at 3:10 p.m., she stated her shift began at 6:30 a.m. on 11/18/17 and she began her work at the bedside of Resident 1. CNA 1 stated at about 6:45 a.m., after she had him undressed, she noticed, "...that his right leg, from his knee down, was a pink-marble, mottled color, wasn't solid pink, had white in it, [it was] more pale than white." CNA 1 further stated, "Around his ankle and foot it was bluish-white, his foot was cold...I told the licensed nurse (LN 1) about it...she said she would get there when she had time. I don't recall seeing her go into Resident 1's room. I did see her go in when I told her a second time, approximately 10:00-10:30 a.m." During an interview with a licensed nurse (LN 1) on 1/19/18 at 6:40 a.m., she stated certified nurses (CNA) assist residents out of bed in the morning and help residents with transfers, hygiene and showers. She stated the CNA's let her know if they see anything different "so I can go look at it." LN 1 stated she went into Resident 1's room 3 times on 11/18/17, 8:30 a.m., 10:00 a.m., and 12:00 p.m. She stated, "Around 12:00 p.m. [I] went back into room because CNA 1 told me again it [Resident 1's lower extremity] looked different. He had a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R4CR11 Facility ID: CA030000090 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: _______________ 055886 (X3) DATE SURVEY COMPLETED 05/10/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ROSEVILLE CARE CENTER 1161 Cirby Way Roseville, CA 95661 (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 pulse, but it [the pulse] had faded. LN 1 stated she called the unit manager [LN 2] and LN 2 looked at it. At that point, the son was on the phone. No, we did not call him." During a phone interview with the son of Resident 1 on 1/19/18 at 3:56 p.m., he stated, "I came in to visit, nobody called me, got there around 10:30-10:45 [a.m.]. [I] walked in [my dad's] room. He was out of it. Nurse came in, [LN 1]. I felt his leg, it was cold. I touched his leg, it was ice cold. This ain't right. She, [LN 1], said, "I didn't know he had a blood clot (before)." During an interview with the DON on 1/17/18 at 4:15 p.m., she stated her expectation of the nursing staff in response to a resident change of condition was to assess, communicate with the doctor, follow orders, and document in the clinical record. During a concurrent interview and record review or Resident 1's clinical record with the Director of Nursing (DON) on 4/5/18 at 10:20 a.m., the DON confirmed Resident 1's clinical record contained no documented evidence of licensed nursing assessments or physician notification on 11/18/17 prior to 12:14 p.m. During a phone interview with the facility administrator (ADM) on 4/5/18 at 11:10 a.m., he confirmed there was no nursing documentation in the clinical record of Resident 1 on 11/18/17 prior to 12:14 p.m. The facility policy and procedure titled "Charting and Documentation" revised April 2008, indicated, "1. All observations...must be documented in the resident's clinical records...3. All incidents, accidents, or changes in the resident's condition must be recorded." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R4CR11 Facility ID: CA030000090 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: _______________ 055886 (X3) DATE SURVEY COMPLETED 05/10/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ROSEVILLE CARE CENTER 1161 Cirby Way Roseville, CA 95661 (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 The facility-provided document titled "Job Description[:] Charge Nurse" revised 3/1/14, indicated under "Essential Job Functions" the Licensed Vocational Nurse is to: "Immediately...consult with the resident's physician...when...a significant change in the resident's physical, mental or psycho social status; a need to alter treatment significantly or a decision to transfer or discharge the resident from the facility."

F684 SS=G Quality of Care CFR(s): 483.25

F684 06/10/2018 § 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive personcentered care plan, and the residents' choices. This REQUIREMENT is not met as evidenced by: Based on interview, and record review, the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R4CR11 Facility ID: CA030000090 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: _______________ 055886 (X3) DATE SURVEY COMPLETED 05/10/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ROSEVILLE CARE CENTER 1161 Cirby Way Roseville, CA 95661 (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 failed to assess, monitor, intervene and report changes for 1 of 3 sampled residents' (Resident 1) for signs of impaired circulation. This failure to assess and monitor Resident 1 for signs of impaired circulation, led to a delay in the provision of physician services, a delay in treatment, and subsequent amputation of Resident 1's right lower leg. Findings: Resident 1 was a 79 year old male admitted to the facility in August of 2016 with multiple medical problems including high blood pressure, diabetes (high sugar in the blood), and previous heart attack. A review of the clinical record, "Resident Progress Notes: [Resident 1]," dated 10/5/16, indicated he was transferred to the hospital in October of 2016, with what was described as "ischemic [restriction of blood supply to tissues] appearing L [left] LOWER EXTREMITY." Resident 1 returned to the facility after 5 days, on 10/4/16, with "...extensive DEEP VENOUS THROMBOSIS [blockage]..." diagnosis. Further review of Resident 1's clinical record revealed a document titled Care Plan Snapshot dated 11/18/17. An entry dated 11/18/17 at 12:14 p.m. noted by licensed nurse (LN 2) indicated: "Problem...Start date 11/18/17...Ineffective tissue perfusion r/t [related to] possible interruption of venous flow AEB [as evidenced by] cold, painful, pale/blue, decreased pedal pulses, and cap refill [capillary blood flow] refill greater than 3 seconds to RLE [right lower extremity]...Interventions...Send to ER [emergency room]." There were no other care plans provided by the facility that addressed assessment and monitoring of Resident 1's history and risk of blood clots prior to 11/18/17 at 12:14 p.m.. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R4CR11 Facility ID: CA030000090 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: _______________ 055886 (X3) DATE SURVEY COMPLETED 05/10/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ROSEVILLE CARE CENTER 1161 Cirby Way Roseville, CA 95661 (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 LN 1 on 1/19/18 at 6:40 a.m., she stated certified nurses (CNA) assist residents out of bed in the morning and help residents with transfers, hygiene and showers. She stated the CNA's let her know if they see anything different "so I can go look at it." LN 1 stated she went into Resident 1's room 3 times on 11/18/17, 8:30 a.m., 10:00 a.m., and 12:00 p.m. She stated, "Around 12:00 p.m. [I] went back into room because CNA 1 told me again it [Resident 1's lower extremity] looked different. He had a pulse, but it [the pulse] had faded. LN 1 stated she called the unit manager [LN 2] and LN 2 looked at it. At that point, the son was on the phone. No, we did not call him." During a phone interview with the son of Resident 1 on 1/19/18 at 3:56 p.m., he stated, "I came in to visit, nobody called me, got there around 10:30-10:45 [a.m.]. [I] walked in [my dad's] room. He was out of it. Nurse came in, [LN 1]. I felt his leg, it was cold. I touched his leg, it was ice cold. This ain't right. She, [LN 1], said, "I didn't know he had a blood clot (before)." During an interview with the DON on 1/17/18 at 4:15 p.m., she stated her expectation of the nursing staff in response to a resident change of condition was to assess, communicate with the doctor, follow orders, and document in the clinical record. During a concurrent interview and record review or Resident 1's clinical record with the Director of Nursing (DON) on 4/5/18 at 10:20 a.m., the DON confirmed Resident 1's clinical record contained no documented evidence of licensed nursing assessments or physician notification on 11/18/17 prior to 12:14 p.m. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R4CR11 Facility ID: CA030000090 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: _______________ 055886 (X3) DATE SURVEY COMPLETED 05/10/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ROSEVILLE CARE CENTER 1161 Cirby Way Roseville, CA 95661 (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 a phone interview with the facility administrator (ADM) on 4/5/18 at 11:10 a.m., he confirmed there was no nursing documentation in the clinical record of Resident 1 on 11/18/17 prior to 12:14 p.m. A review of Resident 1's clinical record, "Resident Progress Notes: [Resident 1]," dated 11/18/17 at 12:14 p.m., indicated the licensed nurse (LN 2) "...contacted [hospital] on-call... [ambulance company] contacted...ED [emergency department] contacted and report given to [personal name] RN." A review of Resident 1's clinical record, "Discharge & Transfer --Hospital Transfer Form," dated 11/18/17 at 12:20 p.m., indicated the form was completed by LN 2. During an interview with LN 1 on 3/14/18 at 12:30 p.m., when asked who gives report to the ambulance company when transferring someone to the hospital, stated, "It is always a nurse. It could be me, it could be a charge nurse, it could never be a CNA." A review of Resident 1's clinical record, "[ambulance company] Patient Care Report," dated 11/18/17, indicated, "...STAFF SAID THEY NOTICED PT [patient] HAD A COLD, MOTTLED EXTREMITY AT ABOUT 0630." A review of Resident 1's clinical record, "[hospital] Encounter-Level Documents," dated 11/18/17, indicated, "Since 0630 [6:30 a.m.], [right] lower leg blue/cold." A review of Resident 1's clinical record, "[hospital] Consult/H&P [history & physical]," dated 11/18/17, indicated Resident 1's right leg "...has been cold/blue since at least 0600 this morning." Ultrasound imaging (internal images of the arteries and veins) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R4CR11 Facility ID: CA030000090 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: _______________ 055886 (X3) DATE SURVEY COMPLETED 05/10/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ROSEVILLE CARE CENTER 1161 Cirby Way Roseville, CA 95661 (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 Resident 1 had a blood clot in his right leg. Due to the extent of ischemia, above knee amputation [removal of a limb] /or palliative care (reduction in the discomfort of symptoms rather than a cure) were recommended. A review of Resident 1's clinical record, "[hospital] Discharge Summaries DISCHARGE SUMMARY," dated 11/21/17, documentation referred to Resident 1 by indicating, "Vascular [blood supply] surgery evaluated him and rushed him to OR [operating room]; where he underwent right above knee amputation." The facility policy and procedure titled "Charting and Documentation" revised April 2008, indicated, "1. All observations...must be documented in the resident's clinical records...3. All incidents, accidents, or changes in the resident's condition must be recorded." The facility-provided document titled "Job Description[:] Charge Nurse" revised 3/1/14, indicated under "Essential Job Functions" the Licensed Vocational Nurse is to: "Perform physical observations of new admissions and current residents as indicated by change in condition or as required by regulation...Based on observation of the resident's condition, develop or revise the plan of care with interventions and time measurable objectives to assist resident to attain or maintain highest practicable physical, mental, and psychosocial well being... Immediately...consult with the resident's physician...when...a significant change in the resident's physical, mental or psycho social status; a need to alter treatment significantly or a decision to transfer or discharge the resident from the facility." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: R4CR11 Facility ID: CA030000090 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: _______________ 055886 (X3) DATE SURVEY COMPLETED 05/10/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ROSEVILLE CARE CENTER 1161 Cirby Way Roseville, CA 95661 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) FORM CMS-2567(02-99) Previous Versions Obsolete ID PREFIX TAG Event ID: R4CR11 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) Facility ID: CA030000090 (X5) COMPLETE DATE If continuation sheet 10 of 10