Other·November 1, 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 standard survey of facility reported incidents #CA00629803 and #CA00631272. Representing the Department of Public Health: Health Facility Evaluator Nurse (HFEN) 33361, HFEN 39797, and HFEN 38628. The inspection was limited to the specific facility reported incidents investigated and does not represent the findings of a full inspection of the facility.

F600 SS=G Free from Abuse and Neglect CFR(s): 483.12(a)(1)

F600 11/25/2019 §483.12 Freedom from Abuse, Neglect, and Exploitation The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. §483.12(a) The facility must§483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion; This REQUIREMENT is not met as evidenced by: Based on record review and interview the 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: 9GTI11 Facility ID: CA030000090 If continuation sheet 1 of 8 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 10/25/2019 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 ensure two of two sampled residents (Resident 1 and Resident 2) were protected from abuse when: 1. Resident 1 developed redness to his neck and pain to his hand after an altercation with Certified Nurse Assistant (CNA) 1, and 2. Resident 2 was reportedly verbally abused by CNA 1 subsequent to abuse of Resident 1 when CNA 1 was allowed to return to work. These failures caused emotional and/or physical harm to Resident 1 and Resident 2, and placed all residents in the facility at risk for abuse. Findings: 1. Review of Resident 1's clinical record included a document titled Face Sheet which indicated Resident 1 was admitted to the facility in 2019, with diagnoses including dementia (disorder of the mental processes) and depression. A review of the clinical record of Resident 1 included the following documents: A document titled Event Report dated 3/21/19 at 19:05 [7:05 p.m.] reflected, "Resident's roommates friend (Visitor 1) stated she was outside the room [Resident 1 and Resident 2's room] and heard that resident [Resident 1] was screaming twice...and scream sound [sic] resident was in distress...the scream was "not normal" and was a very "bad" scream." The document indicated Visitor 1 did not observe the resident screaming but heard it from outside the room. The document further indicated that Resident 1 told his wife that he had been choked by staff. The Event Report progress note dated 3/21/19 indicated the following: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9GTI11 Facility ID: CA030000090 If continuation sheet 2 of 8 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 10/25/2019 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 A. Resident 1 exhibited facial grimacing and frowning and was holding onto his right hand, B. The Physician Assistant (PA) was called and a stat (immediately) X-ray (medical imaging) of Resident 1's right hand was ordered, C. Resident 1 was unable to verbalize a description of the situation or events, speech was very slow, and he was unable to complete or form a sentence, D. A skin observation of Resident 1 was completed by Licensed Nurse (LN) 1 and noted a small red scratch above upper lip, 1.1 cm (centimeter - a unit of measure) to right side of cheek on crease towards nostril, slight redness to tip of nose, redness to chin, red scratch to L (left) flank, reddish-brown discoloration to left hand, red spot to right hand with small bump noted to R (right) side of hand near pinky (little finger) bone area R hand, redness to sacral coccyx area (area around the tailbone), redness to scrotal area and perineal area (portion of the body in the pelvis occupied by urogenital passages and the rectum), dime sized red spot to R knee with dryness to surrounding area. The progress note also indicated that the wife was present during the skin observations and was taking pictures. A document titled Skin Observation dated 3/21/19 indicated a circle on the right side of the chin and neck of Resident 1, which indicated "redness." Review of the facility final summary dated 3/25/19 regarding allegation of resident abuse, indicated that the wife of Resident 1 stated that a CNA choked her husband, but that she did not witness the event. The document further indicated that Resident 1 did not recall the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9GTI11 Facility ID: CA030000090 If continuation sheet 3 of 8 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 10/25/2019 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 incident. The document further indicated that CNA 1 would be returned to work but will not be assigned to that room. Review of a facility provided report dated 4/2/19, regarding a subsequent allegation of abuse, included a notation by CNA 2 that CNA 1 was overheard threatening Resident 2 [room mate of Resident 1] that he would slap the [expletive] out of him like he did his roommate. During an interview with Visitor 1 on 4/10/19 at 9 a.m., she stated that while she was in the facility visiting Resident 2 on 3/21/19, she had gone out in the hall while CNA 1 changed [provided care] to Resident 1. While in the hallway outside the room, Visitor 1 stated, that CNA 1 escorted Resident 2 out of the room and then returned to the room. Visitor 1 stated that she then heard screams a few minutes later. Visitor 1 stated that CNA 1 had a deep scratch on his arm, and that even though the hallways were full of staff, that CNA 1 had never asked for help. Visitor 1 also stated that Resident 1 told his wife "he choked me." Visitor 1 described red marks around the neck of Resident 1 and on his face after Resident 1's wife returned. During an interview with the wife of Resident 1 on 4/11/19 at 9:26 a.m., she indicated that when she returned to the facility from lunch on 3/21/19 that Resident 1 was noted to be shaking and told her that "CNA choked me." Resident 1's wife further stated she observed red marks around Resident 1's neck, as well as scratches and abrasions on his face and hand. RP [responsible party] stated that she took pictures of Resident 1's neck, face, and hand. RP stated that an X-ray was taken of Resident 1's hand to rule out fracture (broken bone). During an interview with LN 1 on 5/8/19 at 4:30 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9GTI11 Facility ID: CA030000090 If continuation sheet 4 of 8 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 10/25/2019 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 p.m., she verified that she performed a skin assessment of Resident 1 on 3/21/19 after the incident. LN 1 also stated that RP (responsible party - wife of Resident 1) was present during the assessment and took some pictures of Resident 1. LN 1 indicated that RP was concerned about a small abrasion on Resident 1's face. 2. According to the Face Sheet, Resident 2 was admitted to the facility in 2019 with diagnoses including cognitive communication disorder and cerebral infarction (stroke). Review of the clinical record of Resident 2 included the following documents: Review of the documents titled Event Report dated 4/2/19 and also the Resident Progress Notes dated 4/2/19 at 15:31 (3:21 p.m.), both indicated CNA [CNA 2] reported that she noticed a male CNA [CNA 1] pulling a resident [Resident 2] aggressively by the arm and making the statement to the resident "I'll slap the [expletive] out of you like I did your roommate." Both of the documents further noted that the male CNA (CNA 1) was asked to leave by the LN. During an interview with LN 2 on 4/26/19 at 3:30 p.m., she indicated that she had completed a follow up assessment of Resident 2 after receiving CNA 2's written statement about CNA 1 on 4/2/19. LN 2 also verified that she had asked CNA 1 to leave the facility at that time. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9GTI11 Facility ID: CA030000090 If continuation sheet 5 of 8 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 10/25/2019 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

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

F607 SS=D PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 11/25/2019 §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, This REQUIREMENT is not met as evidenced by: Based on interview and record review the facility failed to implement the established abuse policy when the investigation of two abuse allegations (Resident 1 and Resident 2) excluded interviews of a visitor/witness and/or all events leading up to the event were not reviewed. These failures precluded the facility from conducting a thorough investigation of abuse allegations and resulted in conclusions that were not based on all of the facts of the incidents. This placed residents at increased risk for abuse. Findings: 1. According to the Face Sheet, Resident 1 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9GTI11 Facility ID: CA030000090 If continuation sheet 6 of 8 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 10/25/2019 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 was admitted to the facility in 2019, with diagnoses including dementia (disorder of the mental processes) and depression. A review of the clinical record of Resident 1 included a document titled event report dated 3/21/19 which reflected, "Resident's roommates friend (Visitor 1) stated she was outside the room and heard that resident was screaming twice...and scream sound [sic] resident was in distress...the scream was "not normal" and was a very "bad" scream." The document indicated Visitor 1 did not observe the resident screaming but heard it from outside the room. The document further indicated that Resident 1 told his wife that he had been choked by staff. During an interview on 6/19/19 at 10 a.m., The Director of Nurses (DON) verified that there was no statement obtained from Visitor 1 regarding the reported incident. 2. According to the Face Sheet, Resident 2 was admitted to the facility in 2019 with diagnoses including cognitive communication disorder and cerebral infarction (stroke). Review of the clinical record of Resident 2 included the documents titled Event Report dated 4/2/19 and Resident Progress Notes dated 4/2/19 at 15:31 (3:21 p.m.), which indicated CNA [CNA 2] reported that she noticed a male CNA pulling a resident aggressively by the arm and making the statement to the resident "I'll slap the [expletive] out of you like I did your roommate." The documents further noted that the male CNA (CNA 1) was asked to leave by the LN. During an interview with the DON on 6/19/19 at 10 a.m., she verified that this incident with Resident 2 was the second allegation of abuse FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9GTI11 Facility ID: CA030000090 If continuation sheet 7 of 8 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 10/25/2019 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 by CNA 1 within a few days. The DON stated that the investigations were kept separate. Review of the facility policy titled Abuse Investigation and Reporting dated December 2018 included the following: "Interview any witnesses to the incident...Interview the resident's roommate, family members, and visitors...Review all events leading up to the alleged incident." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9GTI11 Facility ID: CA030000090 If continuation sheet 8 of 8