Other·November 22, 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 a Federal Recertification survey. Representing the Department of Public Health: Health Facilities Evaluator Nurse (HFEN), 29825 HFEN, 38970 HFEN, 39034 HFEN, 40585 HFEN, 42187 The facility census was 91. The sample size was 26. One (1) facility reported incident #CA00658638 was investigated during the Recertification Survey. The Department substantiated facility reported incident #CA00658638, and the findings are written under tags #(F-609) and #(F-610).

F550 SS=D Resident Rights/Exercise of Rights CFR(s): 483.10(a)(1)(2)(b)(1)(2)

F550 10/10/2019 §483.10(a) Resident Rights. The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section. §483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each 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: 3H7X11 Facility ID: CA030000280 If continuation sheet 1 of 34 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: _______________ 555219 (X3) DATE SURVEY COMPLETED 10/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE AUBURN OAKS CARE CENTER 3400 Bell Road Auburn, CA 95603 (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 resident's individuality. The facility must protect and promote the rights of the resident. §483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source. §483.10(b) Exercise of Rights. The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States. §483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility. §483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart. This REQUIREMENT is not met as evidenced by: In a concurrent observation and interview on 10/09/19 at 8:30 a.m., Resident 58 was sitting in bed, Resident 58's roommate was eating breakfast. When asked where Resident 58's breakfast was, CNA 2 stated, "Oh, she is a feeder, it will be coming soon." During an interview with the Director of Staff Development (DSD) on 10/9/19 at 3:58 p.m., the DSD stated she provided periodic inservices to staff on proper communication, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3H7X11 Facility ID: CA030000280 If continuation sheet 2 of 34 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: _______________ 555219 (X3) DATE SURVEY COMPLETED 10/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE AUBURN OAKS CARE CENTER 3400 Bell Road Auburn, CA 95603 (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 mannerisms, and individual approaches to take with each resident. When asked how staff were instructed to refer to residents who required assistance to eat their meals, the DSD stated those residents were called "Assisted Diners." The DSD stated the staff were not expected to refer to residents as "Feeders," and were expected to speak to the residents in a respectful manner. Review of a facility policy and procedure titled "Quality of Life - Dignity," dated 8/09, indicated "Staff shall speak respectfully to residents at all times, including addressing the resident by his or her name of choice and not "labeling" or referring to the resident by his or her room number, diagnosis, or care needs." Based on observation, interview, and policy review, the facility failed to treat two of 26 sample residents (Resident 63 and Resident 58) with dignity and respect when Certified Nurse Assistants (CNAs) were heard referring to residents as "Feeders." This failure had the potential to negatively impact the residents' quality of life. Findings: Resident 58 was admitted to the facility in 2011 with diagnoses which included dementia (a disorder causing loss of memory and other thinking skills that affect a person's ability to perform everyday activities). A Minimum Data Set (MDS, an assessment tool), dated 8/19/19, indicated Resident 58 had severe memory impairment. Resident 63 was admitted to the facility in early 2018 with diagnoses which included generalized muscle weakness from a spinal injury. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3H7X11 Facility ID: CA030000280 If continuation sheet 3 of 34 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: _______________ 555219 (X3) DATE SURVEY COMPLETED 10/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE AUBURN OAKS CARE CENTER 3400 Bell Road Auburn, CA 95603 (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 An MDS dated 8/26/19, indicated Resident 63 had no memory decline, and required extensive assistance from staff to eat his meals. On 10/7/19 at 8:09 a.m., a CNA was observed placing a breakfast tray on Resident 63's bedside table. As the CNA walked out of the room, she turned to Resident 63 and stated she would return to feed him later. During a concurrent interview with Resident 63 on 10/7/19 at 8:09 a.m., Resident 63 referred to himself as a "Feeder." When asked if that was how staff referred to him, he stated that was how they referred to him and his roommate. When asked if that term bothered him, Resident 63 stated it used to bother him but he was used to it now.

F609 SS=D Reporting of Alleged Violations CFR(s): 483.12(c)(1)(4)

F609 10/01/2019 §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3H7X11 Facility ID: CA030000280 If continuation sheet 4 of 34 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: _______________ 555219 (X3) DATE SURVEY COMPLETED 10/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE AUBURN OAKS CARE CENTER 3400 Bell Road Auburn, CA 95603 (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 §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. This REQUIREMENT is not met as evidenced by: Based on interview and record review the facility failed to ensure an allegation of abuse/mistreatment was reported to the authorities in a timely manner for 1 of 26 sampled residents (Resident 58). This failure had the potential to put Resident 58 at risk of further mistreatment or harm. Findings: Resident 58 was admitted to the facility in 2011 with diagnoses which included dementia (a disorder causing loss of memory and and other thinking skills that affect a person's ability to perform everyday activities). A Minimum Data Set (MDS, an assessment tool), dated 8/19/19, indicated Resident 58 had severe memory impairment. A review of Resident 58's medical record revealed a progress note entered by the Transport Aide (TA), dated 9/11/19, which indicated "[Family Member, FM 1] approached writer at Station 1 and stated that residents (sic) roommate told her that she witnessed a staff member handling her mother roughly and that staff member no longer is employed at [initials of facility name]. writer (sic) referred [FM 1] to Social Services." In an interview on 10/10/19 at 10:35 a.m., the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3H7X11 Facility ID: CA030000280 If continuation sheet 5 of 34 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: _______________ 555219 (X3) DATE SURVEY COMPLETED 10/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE AUBURN OAKS CARE CENTER 3400 Bell Road Auburn, CA 95603 (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 Social Services Director (SSD) stated she was not made aware of any complaint by Resident 58's family member about rough handling by a CNA [Certified Nurse Assistant] and therefore no report or follow-up was done by the Social Services Department. In an interview on 10/10/19 at 10:45 a.m., the TA said she remembered the incident and stated, "I referred her [FM 1] to Social Services...I am not Social Services..." When asked if she was a mandated reporter, TA responded, "Yes...I don't know if it [the incident] was followed up on." She stated she did not report the allegation to the authorities or to a supervisor but instead, referred the complainant to the facility's Social Services Department. In an interview on 10/10/19 at 11:55 a.m., the Administrator stated, "It is unfortunate, I am the Abuse Coordinator and this is the first I have heard of it." In an interview on 10/10/19 at 3:33 p.m., FM 1 stated she remembered the incident and told someone at the nurse's station about the allegation. She stated, "I thought it was going to be looked into. I was never told I had to go anywhere else to report it...I didn't hear anything else about it." Review of a facility policy titled "Abuse Investigation and Reporting," revised 7/17, indicated "All reports of resident abuse...mistreatment...shall be promptly reported to local, state and federal agencies...and thoroughly investigated by facility management." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3H7X11 Facility ID: CA030000280 If continuation sheet 6 of 34 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: _______________ 555219 (X3) DATE SURVEY COMPLETED 10/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE AUBURN OAKS CARE CENTER 3400 Bell Road Auburn, CA 95603 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

F610 Investigate/Prevent/Correct Alleged Violation CFR(s): 483.12(c)(2)-(4)

F610 SS=D PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 10/01/2019 §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated. §483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. This REQUIREMENT is not met as evidenced by: Based on interview and record review the facility failed to report results of an investigation in response to an allegation of abuse for 1 of 26 residents (Resident 58) to the State Survey agency within 5 working days of the incident. This failure had the potential to put Resident 58 at risk for physical and psychological harm. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3H7X11 Facility ID: CA030000280 If continuation sheet 7 of 34 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: _______________ 555219 (X3) DATE SURVEY COMPLETED 10/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE AUBURN OAKS CARE CENTER 3400 Bell Road Auburn, CA 95603 (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 Findings: Resident 58 was admitted to the facility in 2011 with diagnoses which included dementia (a disorder causing loss of memory and and other thinking skills that affect a person's ability to perform everyday activities). A Minimum Data Set (MDS, an assessment tool), dated 8/19/19, indicated Resident 58 had severe memory impairment. A review of Resident 58's medical record revealed a progress note entered by the Transport Aide (TA), dated 9/11/19, indicated "[FM 1] approached writer at Station 1 and stated that residents (sic) roommate told her that she witnessed a staff member handling her mother roughly and that staff member no longer is employed at [initials of facility name]. writer (sic) referred [FM 1] to Social Services." In an interview on 10/10/19 at 10:35 a.m., the Social Services Director (SSD) stated she was not made aware of any complaint by Resident 58's family member about rough handling by a CNA [Certified Nurse Assistant]and therefore no report or follow-up was done by the Social Services Department. In an interview on 10/10/19 at 10:45 a.m., the TA stated she remembered the incident and stated, "I referred her [FM 1] to Social Services...I am not Social Services..." When asked if she was a mandated reporter TA responded, "Yes...I don't know if it [the incident] was followed up on." She stated she did not report the allegation to the authorities or to a supervisor but instead, referred the complainant to the facility's Social Services Department. In an interview on 10/10/19 at 11:55 a.m., the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3H7X11 Facility ID: CA030000280 If continuation sheet 8 of 34 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: _______________ 555219 (X3) DATE SURVEY COMPLETED 10/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE AUBURN OAKS CARE CENTER 3400 Bell Road Auburn, CA 95603 (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 Administrator stated, "It is unfortunate, I am the Abuse Coordinator and this is the first I have heard of it." In an interview on 10/10/19 at 3:33 p.m., FM 1 stated she remembered the incident and told someone at the nurse's station about the allegation. She stated, "I thought it was going to be looked into. I was never told I had to go anywhere else to report it...I didn't hear anything else about it." Review of a facility policy titled "Abuse Investigation and Reporting" revised 7/17, indicated "All reports of resident abuse...mistreatment...shall be promptly reported to local, state and federal agencies...and thoroughly investigated by facility management." Review of a facility policy titled "Abuse Prevention Program" revised 10/17, indicated "As part of the resident abuse prevention, the administration will: Identify and assess all possible incidents of abuse; Investigate and report any allegations of abuse within timeframe's as required by federal requirements; Protect residents during abuse investigations..."

F656 SS=D Develop/Implement Comprehensive Care Plan F656 CFR(s): 483.21(b)(1) 10/01/2019 §483.21(b) Comprehensive Care Plans §483.21(b)(1) The facility must develop and implement a comprehensive person-centered FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3H7X11 Facility ID: CA030000280 If continuation sheet 9 of 34 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: _______________ 555219 (X3) DATE SURVEY COMPLETED 10/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE AUBURN OAKS CARE CENTER 3400 Bell Road Auburn, CA 95603 (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 care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). (iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record. (iv)In consultation with the resident and the resident's representative(s)(A) The resident's goals for admission and desired outcomes. (B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section. This REQUIREMENT is not met as evidenced by: Based on observation, interview and review of facility documents, the facility failed to reinstate FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3H7X11 Facility ID: CA030000280 If continuation sheet 10 of 34 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: _______________ 555219 (X3) DATE SURVEY COMPLETED 10/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE AUBURN OAKS CARE CENTER 3400 Bell Road Auburn, CA 95603 (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 and update a care plan for hearing loss for 1 of 26 sampled residents (Resident 29) when she returned from a hospital stay. This failure increased the risk that staff would not implement effective care planned interventions for communicating with Resident 29 with declining hearing loss, and possibly cause psychosocial distress to the resident. Findings: Resident 29 was admitted to the facility in 2008 and was readmitted, after a short hospitalization, in the spring of 2019 with multiple diagnoses which included bleeding into the brain. Resident 29's last three annual Minimum Data Set (MDS, an assessment tool) assessments for hearing, dated 8/9/17, 8/9/18 and 8/2/19 were reviewed. She declined from mild to moderate hearing loss between 8/9/17 and 8/9/18. A request was made for all care plans for communication or hearing loss. A care plan titled "COMMUNICATION CARE PLAN," dated 8/13/18, was discontinued on 4/12/19. Resident 29's most recent MDS, dated 8/2/19, indicated she had severe memory loss and required extensive assistance with most activities of daily living. During an observation of Resident 29 on 10/7/19 at 8:21 a.m., the surveyor had to stand close to the resident and speak loudly into her ear. The questions had to be repeated because Resident 29 had difficulty hearing them. Review of Resident 29's current care plans revealed no current communication or hearing FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3H7X11 Facility ID: CA030000280 If continuation sheet 11 of 34 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: _______________ 555219 (X3) DATE SURVEY COMPLETED 10/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE AUBURN OAKS CARE CENTER 3400 Bell Road Auburn, CA 95603 (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 loss care plan. Review of Resident 29's document titled "Clinical Admission", dated 4/12/19, indicated she was readmitted to the facility, and "Usually understands-misses some part/intent of message..." During an interview with the Director of Nurses on 10/9/19 at 8:09 a.m., she was asked what her expectations were for a care plan for a resident with hearing loss and said, "I would expect her to have a care plan for hearing loss if she was assessed or developed a loss of hearing..." During an interview with the Medical Records Director on 10/9/19 at 8:55 a.m., she said, "[Resident 29] went out to the hospital and came back [4/12/19]. There's not a current care plan for loss of hearing." During an interview with the MDS Coordinator on 10/9/19 at 11:33 a.m., she said, "Social Services does the hearing section [of the MDS]. I'm supposed to check the care plan is there. It's possible I missed it...A new care plan for hearing loss should have been done when she came back [from the hospital]." Review of the facility policy and procedure titled, "Care Plans - Comprehensive," revised 1/2011, "The Care Planning/Interdisciplinary Team is responsible for review and updating of care plans...When the resident has been readmitted to the facility from a hospital stay..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3H7X11 Facility ID: CA030000280 If continuation sheet 12 of 34 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: _______________ 555219 (X3) DATE SURVEY COMPLETED 10/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE AUBURN OAKS CARE CENTER 3400 Bell Road Auburn, CA 95603 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

F698 Dialysis CFR(s): 483.25(l)

F698 SS=E PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 10/01/2019 §483.25(l) Dialysis. The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. This REQUIREMENT is not met as evidenced by: Based on interview and review of facility documents, the facility failed to ensure consistent communication with the dialysis facility (dialysis or hemodialysis is the process of removing waste products and excess fluid from the body) when the Dialysis Communication Forms were not completed for two of 26 sampled residents (Resident 46 and Resident 52). This failure increased the risk for an adverse event. Findings: 1.) Resident 46 was admitted to the facility in the summer of 2019 with diagnoses which included kidney failure. Review of Resident 46's care plan titled "HEMODIALYSIS CARE PLAN," dated 7/31/19, indicated "Follow Dialysis Recommendation for Dressing to Catheter Site [place where a tubular medical device is inserted into a blood vessel to permit injection or withdrawal of fluids or to keep a passage open]...Hemodialysis @ [at] Center...Intake and Output As Indicated...Monitor Skin Care...Notify MD [physician] if edema [swelling from fluid in FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3H7X11 Facility ID: CA030000280 If continuation sheet 13 of 34 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: _______________ 555219 (X3) DATE SURVEY COMPLETED 10/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE AUBURN OAKS CARE CENTER 3400 Bell Road Auburn, CA 95603 (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 tissues], chest pain, elevated blood pressure or shortness of breath occur...Observe Shunt/Catheter site for s/sx [signs and symptoms] of complication...Vital Signs As Indicated..." Review of Resident 46's most recent Minimum Data Set (MDS, an assessment tool), dated 8/7/19, indicated he was alert, oriented and required supervision to limited assistance with his activities of daily living (ADLs). Review of Resident 46's physician orders, dated 8/15/19, indicated he was to have renal (kidney) dialysis three times a week on Tuesday, Thursday and Saturday. Review of the document titled "Dialysis Communication Form," dated 9/10/19, 9/12/19, 9/17/19, 9/19/19, 10/1/19, and 10/3/19, indicated the name of the dialysis facility but the assessment information, which included the state of the access site [catheter site], was not filled in. It was blank. During a concurrent record review and interview with Licensed Nurse 5 (LN 5) on 10/9/19 at 7:40 a.m., she verified the missing assessment on the above documents and said, "We have a problem with the dialysis center filling in their portion. It's hit and miss..." 2.) Resident 52 was admitted to the facility in the middle of 2019 with diagnoses which included end stage renal disease (kidneys with minimal functioning) and diabetes (inability to regulate blood sugar). Review of Resident 52's care plan titled "HEMODIALYSIS CARE PLAN," dated 7/10/19, indicated "Follow Dialysis Recommendation For Dressing To Catheter Site...Hemodialysis @ Center...Observe Shunt/Catheter site for s/sx of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3H7X11 Facility ID: CA030000280 If continuation sheet 14 of 34 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: _______________ 555219 (X3) DATE SURVEY COMPLETED 10/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE AUBURN OAKS CARE CENTER 3400 Bell Road Auburn, CA 95603 (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 complication...Vital Signs As Indicated..." Review of Resident 52's "Physician Orders," dated 7/12/19, indicated she was to have renal dialysis three times a week on Monday, Wednesday and Friday. Review of the "Dialysis Communication Form," dated 8/2/19, 8/5/19, 8/7/19, 8/9/19, 8/12/19, 8/16/19, 8/21/19, 8/23/19, 8/26/19, 8/28/19, 8/30/19, 9/2/19, 9/4/19, 9/6/19, 9/9/19, 9/11/19, 9/13/19, 9/16/19, 9/18/19, 9/20/19, 9/23/19, 9/25/19, 9/27/19, 9/30/19, 10/2/19, 10/4/19, and 10/7/19, revealed the "Site Assessment Information" was blank. A record review of the "Dialysis Communication Form," dated 8/23/19, revealed the "Vital Signs" information was blank. A record review of the "Dialysis Communication Form," dated 8/30/19, 9/2/19, and 9/16/19 revealed the "Cognitive Status" information was blank. During an interview with LN 1 on 10/8/19 at 3:03 p.m., LN 1 stated, "The access site information, vital signs and cognitive status should be filled out by the dialysis facility. It is not." During an interview with the Director of Nursing (DON) on 10/10/19 at 9:28 a.m., the DON stated the access site assessment post-dialysis should have "absolutely" been documented by the dialysis nurse. The DON stated the assessment should be documented every time, otherwise they (the facility) would not know the condition of the site after dialysis. A review of a facility policy titled "Dialysis Services," dated 11/17, indicated "It is the policy of the facility that each resident receives FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3H7X11 Facility ID: CA030000280 If continuation sheet 15 of 34 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: _______________ 555219 (X3) DATE SURVEY COMPLETED 10/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE AUBURN OAKS CARE CENTER 3400 Bell Road Auburn, CA 95603 (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 care and services for the provision of hemodialysis consistent with professional standards of practice including the...ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments...ongoing assessment of the resident...after dialysis treatments, including monitoring the resident's condition...monitoring for complications...ongoing communication and collaboration with the dialysis facility regarding dialysis care and services...monitoring of the access site...Vital Signs before and after dialysis..."

F745 SS=D Provision of Medically Related Social Service CFR(s): 483.40(d)

F745 10/01/2019 §483.40(d) The facility must provide medicallyrelated social services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. This REQUIREMENT is not met as evidenced by: Based on observation, interview and review of facility documents, the facility failed to provide an audiology consult for 1 of 26 sampled residents (Resident 29) who had a decline in hearing. This failure had the potential to delay treatment of and interventions for Resident 29's hearing loss. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3H7X11 Facility ID: CA030000280 If continuation sheet 16 of 34 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: _______________ 555219 (X3) DATE SURVEY COMPLETED 10/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE AUBURN OAKS CARE CENTER 3400 Bell Road Auburn, CA 95603 (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 Findings: Resident 29 was admitted to the facility in 2008 and readmitted to the facility in the spring of 2019 with multiple diagnoses which included bleeding into the brain. Resident 29's last four Minimum Data Set assessments (MDS, an assessment tool) for hearing, dated 8/9/16, 8/9/17, 8/9/18 and 8/2/19 were reviewed. She had declined from mild to moderate hearing loss from between 8/9/17 to 8/9/18. Resident 29's most recent MDS, dated 8/2/19, indicated she had severe memory loss and required extensive assistance with most activities of daily living (ADLs). During an observation of Resident 29 on 10/7/19 at 8:21 a.m., the surveyor had to stand close to the resident and speak loudly into her ear. The questions had to be repeated because Resident 29 had difficulty hearing them. Resident 29's current medical record was reviewed. No social service note was found for hearing loss or a referral to an audiologist (a specialist in hearing loss). During an interview with the Social Services Director (SSD) on 10/9/19 at 11:42 a.m., she said, "Our department [Social Services] does the hearing section on the MDS. A change of condition is talked about in IDT (Interdisciplinary Team meeting) when there is a change in two or more ADLs. The [family member] should have been called to see if he wanted her referred to an audiologist. I didn't find one [referral]." Review of the facility policy and procedure titled "Social Services," revised 10/10, indicated "The FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3H7X11 Facility ID: CA030000280 If continuation sheet 17 of 34 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: _______________ 555219 (X3) DATE SURVEY COMPLETED 10/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE AUBURN OAKS CARE CENTER 3400 Bell Road Auburn, CA 95603 (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 social services department is responsible for...Maintaining appropriate documentation of referrals and providing social service data summaries..."

F755 SS=D Pharmacy Srvcs/Procedures/Pharmacist/Records CFR(s): 483.45(a)(b)(1)-(3)

F755 10/01/2019 §483.45 Pharmacy Services The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(g). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse. §483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. §483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who§483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility. §483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3H7X11 Facility ID: CA030000280 If continuation sheet 18 of 34 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: _______________ 555219 (X3) DATE SURVEY COMPLETED 10/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE AUBURN OAKS CARE CENTER 3400 Bell Road Auburn, CA 95603 (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 §483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and facility policy review, the facility failed to safely handle and store medications for a census of 91 when: 1. Expired medications and supplies were found in the medication and treatment cart drawers; and, 2. Narcotics were disposed of in a way that did not prevent their potential diversion (the transfer of a legally prescribed controlled substance from the individual for whom it was prescribed to another person for illicit use.) These failures increased the potential for medication errors and/or diversion of controlled substances. Findings: 1. In an observation of the treatment cart and concurrent interview with Licensed Nurse 2 (LN 2) on 10/8/19 at 2:42 p.m., two bottles of miconazole nitrate 2% powder (antibiotic powder) for Resident 42 with expiration dates of 9/18 and 1/19 and four packages of oil emulsion dressings (used for wound dressing) with the expiration date of 2/19 were found in the treatment cart drawer. LN 2 verified the observation and stated all expired supplies and medications should have been removed from the cart and placed in the medication room cabinet for disposal. In an observation and concurrent interview on 10/8/19 at 5:50 a.m., a package of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3H7X11 Facility ID: CA030000280 If continuation sheet 19 of 34 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: _______________ 555219 (X3) DATE SURVEY COMPLETED 10/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE AUBURN OAKS CARE CENTER 3400 Bell Road Auburn, CA 95603 (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 hydrocodone (a narcotic pain medication), with an expiration date of 10/2/19, was accessible for use in the narcotics drawer of the #2 Back Medication Cart. LN 4 verified the observation and stated all expired medications should have been placed in a separate section of the cart to prevent their accidental use. 2. In a concurrent observation and interview on 10/10/19 at 6:16 a.m., a large white bin with a blue lid was observed in Medication Room 1. The approximately 6 inch round cover was easily removed and packages of unused medications and partially filled IV (intravenous) bags were observed to fill the bin to 3/4 of the way full. The Director of Nurse's (DON) verified the observation and stated all expired and discontinued narcotics were disposed of into the white bin in the presence of a pharmacist. She stated any discarded liquid medication would have eventually deteriorated any exposed pills. In an interview on 10/10/19 at 8:09 a.m., the Pharmacy Consultant (PC) stated, "Expired medications should be removed from the med (medication) carts immediately so they are not accidentally used..." The PC stated expired and discontinued controlled substances (narcotics) should have been placed in a container and mixed with a substance to make them unusable. The PC stated the facility should have used a substance other than discarded liquids and medications to render the narcotics unusable. In a concurrent observation and interview on 10/10/19 at 8:43 a.m., the white drug disposal bin with a blue lid in Medication Room 1 was accessed and multiple undissolved medications were easily removed from the bin. The DON verified the observation and stated no substance was added to the medication FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3H7X11 Facility ID: CA030000280 If continuation sheet 20 of 34 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: _______________ 555219 (X3) DATE SURVEY COMPLETED 10/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE AUBURN OAKS CARE CENTER 3400 Bell Road Auburn, CA 95603 (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 disposal bin to render the narcotics unusable. Review of a facility policy titled, "Medication Storage in the Facility," dated 3/18, indicated "Outdated...medications...are immediately removed from stock...Drugs shall not be kept in stock after the expiration date on the label and no contaminated or deteriorated drugs shall be available for use. Discontinued drug containers shall be marked, or otherwise identified...stored in a separate location..." Review of the Department of Justice October 2014 ruling for disposal of narcotics, accessed at https://www.deadiversion.usdoj.gov/fed_regs/ru les/2014/2014-20926.pdf, on 10/15/19, indicated "Where multiple controlled substances are commingled, the method of destruction shall be sufficient to render all such controlled substances nonretrievable...A substance is rendered nonretrievable when its physical or chemical state is permanently and irreversibly altered..."

F756 SS=D Drug Regimen Review, Report Irregular, Act On CFR(s): 483.45(c)(1)(2)(4)(5)

F756 10/01/2019 §483.45(c) Drug Regimen Review. §483.45(c)(1) The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist. §483.45(c)(2) This review must include a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3H7X11 Facility ID: CA030000280 If continuation sheet 21 of 34 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: _______________ 555219 (X3) DATE SURVEY COMPLETED 10/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE AUBURN OAKS CARE CENTER 3400 Bell Road Auburn, CA 95603 (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 the resident's medical chart. §483.45(c)(4) The pharmacist must report any irregularities to the attending physician and the facility's medical director and director of nursing, and these reports must be acted upon. (i) Irregularities include, but are not limited to, any drug that meets the criteria set forth in paragraph (d) of this section for an unnecessary drug. (ii) Any irregularities noted by the pharmacist during this review must be documented on a separate, written report that is sent to the attending physician and the facility's medical director and director of nursing and lists, at a minimum, the resident's name, the relevant drug, and the irregularity the pharmacist identified. (iii) The attending physician must document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record. §483.45(c)(5) The facility must develop and maintain policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility's Pharmacy Consultant (PC) failed to identify and report a medication regimen review irregularity for 1 of 26 sampled residents (Resident 63). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3H7X11 Facility ID: CA030000280 If continuation sheet 22 of 34 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: _______________ 555219 (X3) DATE SURVEY COMPLETED 10/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE AUBURN OAKS CARE CENTER 3400 Bell Road Auburn, CA 95603 (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 failure increased the potential for Resident 63 to have received an unnecessary medication. Findings: Resident 63 was admitted to the facility in early 2018 with diagnoses which included generalized muscle weakness from a spinal injury, and depression. Review of Resident 63's medical record revealed: A physician order for "Trazodone [an antidepressant medication]...for depression AEB [as evidenced by] insomnia--inability to sleep. At Bedtime - PRN [as needed]..." The physician prescribed the medication to start on 5/28/19 and end on 11/28/19. The order did not indicate documented evidence of a rational for ordering the medication PRN for longer than 14 days. Medication administration records for 6/19, 7/19, 8/19, and 9/19 indicated Resident 63 received Trazadone for his depression 69 times. PC progress notes dated 6/10/19, 7/14/19, 8/11/19, 9/15/19, and 10/14/19, indicated medication regimen reviews were completed. A document titled "Psychotropic Gradual Dose Reduction (GDR) Review," dated 8/18/19, indicated the Interdisciplinary Team (IDT), comprised of the Social Services Director, the Assistant Director of Nursing, and the Pharmacy Consultant, reviewed Resident 63's Trazodone. The document indicated "Name/Dose/Frequency of Drug: Trazodone 25 mg [milligram, a unit of measure] po [oral] @ HS [bedtime] PRN." The IDT's evaluation and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3H7X11 Facility ID: CA030000280 If continuation sheet 23 of 34 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: _______________ 555219 (X3) DATE SURVEY COMPLETED 10/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE AUBURN OAKS CARE CENTER 3400 Bell Road Auburn, CA 95603 (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 recommendation indicated "Recommend no changes at this time, Cont. [Continue] to monitor, review next quarter." During an interview with the PC on 10/10/19 at 8:12 a.m., the PC agreed a psychotherapeutic medication was not to be ordered PRN for longer than 14 days unless the ordering physician documented a rationale for prescribing it longer. The PC stated, if the physician did not provide a rationale, she would have provided a recommendation to the physician to document his rationale. Review of a facility policy and procedure titled "Medication Regimen Review," dated 4/07, indicated "The Consultant Pharmacist will provide a written report to physicians for each resident with an identified irregularity."

F758 SS=D Free from Unnec Psychotropic Meds/PRN Use F758 CFR(s): 483.45(c)(3)(e)(1)-(5) 10/01/2019 §483.45(e) Psychotropic Drugs. §483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories: (i) Anti-psychotic; (ii) Anti-depressant; (iii) Anti-anxiety; and (iv) Hypnotic Based on a comprehensive assessment of a resident, the facility must ensure that--§483.45(e)(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record; FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3H7X11 Facility ID: CA030000280 If continuation sheet 24 of 34 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: _______________ 555219 (X3) DATE SURVEY COMPLETED 10/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE AUBURN OAKS CARE CENTER 3400 Bell Road Auburn, CA 95603 (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 §483.45(e)(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs; §483.45(e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and §483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in §483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order. §483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure the limited use of a PRN (as needed) psychotherapeutic medication (any drug that affects brain activities associated with mental processes and behavior) for 1 resident in a sample of 26 (Resident 63) when a psychotherapeutic medication was ordered PRN for greater than 14 days. As a result of this failure, Resident 63 continued to receive an as needed FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3H7X11 Facility ID: CA030000280 If continuation sheet 25 of 34 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: _______________ 555219 (X3) DATE SURVEY COMPLETED 10/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE AUBURN OAKS CARE CENTER 3400 Bell Road Auburn, CA 95603 (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 psychotherapeutic medication for longer than 14 days without a rational. Findings: Resident 63 was admitted to the facility in early 2018 with diagnoses which included generalized muscle weakness from a spinal injury, and depression. Review of Resident 63's medical record revealed: A physician order for "Trazodone [an antidepressant medication]...for depression AEB [as evidenced by] insomnia--inability to sleep. At Bedtime - PRN..." The physician prescribed the medication to start on 5/28/19 and end on 11/28/19. The order did not contain documented evidence of a rational for ordering the medication PRN for longer than 14 days. Medication administration records for 6/19, 7/19, 8/19, and 9/19, indicated Resident 63 received Trazadone for his depression 69 times. A document titled "Psychotropic Gradual Dose Reduction (GDR) Review," dated 8/18/19, indicated the Interdisciplinary Team (IDT), comprised of the Social Services Director, the Assistant Director of Nursing, and the Pharmacy Consultant (PC), reviewed Resident 63's Trazodone. The document indicated "Name/Dose/Frequency of Drug: Trazodone 25 mg [milligram, a unit of measure] po [oral] @ HS [bedtime] PRN." The IDT's evaluation and recommendation indicated "Recommend no changes at this time, Cont. [Continue] to monitor, review next quarter." During an interview with the PC on 10/10/19 at FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3H7X11 Facility ID: CA030000280 If continuation sheet 26 of 34 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: _______________ 555219 (X3) DATE SURVEY COMPLETED 10/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE AUBURN OAKS CARE CENTER 3400 Bell Road Auburn, CA 95603 (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 8:12 a.m., when asked to describe her process for reviewing psychotherapeutic medications that were ordered PRN, the PC stated she would have looked for a documented rational by the ordering physician for ordering a psychotherapeutic medication PRN greater than 14 days. The PC stated, if the physician did not provide a rational, she would have provided a recommendation to the physician to document his rational. Review of a facility policy and procedure titled "Gradual Dose Reduction Psychotropic," dated 11/17, indicated "PRN Psychotropic drug orders (other than PRN Antipsychotics) are limited to 14 days. If it is appropriate to extend the order beyond 14 days, the Attending Physician or prescribing practitioner shall document the rationale in the medical record, and indicate duration for the PRN order."

F761 SS=D Label/Store Drugs and Biologicals CFR(s): 483.45(g)(h)(1)(2)

F761 10/01/2019 §483.45(g) Labeling of Drugs and Biologicals Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3H7X11 Facility ID: CA030000280 If continuation sheet 27 of 34 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: _______________ 555219 (X3) DATE SURVEY COMPLETED 10/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE AUBURN OAKS CARE CENTER 3400 Bell Road Auburn, CA 95603 (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 instructions, and the expiration date when applicable. §483.45(h) Storage of Drugs and Biologicals §483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys. §483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected. This REQUIREMENT is not met as evidenced by: Based on observation, interview and facility policy review, the facility failed to ensure two of five medication carts were locked for a census of 91. This failure increased the risk for unauthorized access to medications. Findings: In a concurrent observation and interview on 10/8/19 at 6:30 a.m., the 100 hall front medication cart was observed to be unattended and unlocked. When Licensed Nurse 3 (LN 3) returned to the cart, she stated, "Yeah, it doesn't latch all the way if the drawers are not pushed in all the way." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3H7X11 Facility ID: CA030000280 If continuation sheet 28 of 34 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: _______________ 555219 (X3) DATE SURVEY COMPLETED 10/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE AUBURN OAKS CARE CENTER 3400 Bell Road Auburn, CA 95603 (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 a facility policy and procedure titled, "Security of Medication Cart," revised April 2007, indicated "Medication carts must be securely locked at all times when out of the nurse's view." During an observation on 10/8/19 at 7:55 a.m., the top drawer of the Hall 2 front medication cart was unlocked and unattended. During a concurrent observation and interview with LN 6 on 10/8/19 at 7:59 a.m., he verified the medication cart was unlocked and said, "I should check the drawers to make sure they lock. You have to slam it." During an interview with the Maintenance Director on 10/8/19 at 8:14 a.m., he said, "If you can't use the cart correctly, you should put it away." He also verified the facility had trouble with the medication carts locking. During an interview with the Director of Nurses on 10/8/19 at 8:19 a.m., she was asked what her expectation was regarding the locking of the medication cart and said, "Medication carts should be locked when they're [LN] not using it."

F803 SS=E Menus Meet Resident Nds/Prep in Adv/Followed CFR(s): 483.60(c)(1)-(7)

F803 10/01/2019 §483.60(c) Menus and nutritional adequacy. Menus must§483.60(c)(1) Meet the nutritional needs of residents in accordance with established national guidelines.; §483.60(c)(2) Be prepared in advance; FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3H7X11 Facility ID: CA030000280 If continuation sheet 29 of 34 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: _______________ 555219 (X3) DATE SURVEY COMPLETED 10/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE AUBURN OAKS CARE CENTER 3400 Bell Road Auburn, CA 95603 (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 §483.60(c)(3) Be followed; §483.60(c)(4) Reflect, based on a facility's reasonable efforts, the religious, cultural and ethnic needs of the resident population, as well as input received from residents and resident groups; §483.60(c)(5) Be updated periodically; §483.60(c)(6) Be reviewed by the facility's dietitian or other clinically qualified nutrition professional for nutritional adequacy; and §483.60(c)(7) Nothing in this paragraph should be construed to limit the resident's right to make personal dietary choices. This REQUIREMENT is not met as evidenced by: Based on observation, interview and review of facility documents, the facility failed to ensure proper portions of food were accurately measured when lunch was prepared for four random residents in a census of 91. This failure potentially increased the risk for weight loss and lack of appropriate nutrition. Findings: Review of the document titled "Diet SpreadSheet," dated 10/8/19, indicated a (white) #6 scoop was used to dish up a 2/3 cup portion of mashed Greek Chicken Salad for those on mechanical soft diets. During a lunch tray line observation on 10/8/19 from 11:53 a.m. to 12:45 p.m., Cook 1 used a white #6 scoop to measure the portion for mashed Greek Chicken Salad for residents on mechanical soft diets. The scoop was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3H7X11 Facility ID: CA030000280 If continuation sheet 30 of 34 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: _______________ 555219 (X3) DATE SURVEY COMPLETED 10/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE AUBURN OAKS CARE CENTER 3400 Bell Road Auburn, CA 95603 (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 approximately 2/3 to 3/4 full. It was witnessed as not completely filled three times. During a concurrent observation and interview with the Dietary Manager (DM) on 10/8/19 at 12:02 p.m., she checked the dietary spread sheet and verified Cook 1 used the white #6 scoop which would provide 2/3 cup and said, "She [Cook 1] should be filling it full..." At 12:06 p.m., the surveyors and DM noted Cook 1, once again, filled the #6 scoop partially and the DM reminded her to fill it completely. Review of the facility policy and procedure titled "PORTION CONTROL," dated 2018, indicated "To be sure portions served equal portion sizes listed on the menu, portion control equipment must be used and utilized by employees portioning food...Scoops are sized by number (the number of scoopfuls needed to equal one quart)..."

F812 SS=E Food Procurement,Store/Prepare/ServeSanitary CFR(s): 483.60(i)(1)(2)

F812 10/01/2019 §483.60(i) Food safety requirements. The facility must §483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities. (i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations. (ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3H7X11 Facility ID: CA030000280 If continuation sheet 31 of 34 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: _______________ 555219 (X3) DATE SURVEY COMPLETED 10/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE AUBURN OAKS CARE CENTER 3400 Bell Road Auburn, CA 95603 (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 (iii) This provision does not preclude residents from consuming foods not procured by the facility. §483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety. This REQUIREMENT is not met as evidenced by: Based on observation, interview and review of facility documents, the facility failed to prepare, distribute, and serve food to those residents in a census of 91, who ate food prepared in the kitchen, in accordance with professional standards for food service safety when: 1. Beverages were served in an unsanitary manner; 2. Hairnets did not completely cover the hair of 3 kitchen staff; and, 3. Undated open food items were found in the resident refrigerator. These failures increased the risk for contamination. Findings: 1. During an observation of the lunch meal service in the dining room on 10/7/19 at 12:25 p.m., Certified Nurse Assistant 1 (CNA 1) was serving beverages to residents who were waiting for their meals to be served. CNA 1 stirred the beverages by the tips of the stir straws with her bare hands. CNA 1 then served the beverages with the same, potentially contaminated stir straws. Residents then sipped their beverages through the stir straws. During an interview with CNA 1 on 10/7/19 at 12:30 p.m., CNA 1 confirmed the observation FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3H7X11 Facility ID: CA030000280 If continuation sheet 32 of 34 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: _______________ 555219 (X3) DATE SURVEY COMPLETED 10/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE AUBURN OAKS CARE CENTER 3400 Bell Road Auburn, CA 95603 (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 and proceeded to put on gloves. During an interview with the Director of Staff Development (DSD) on 10/10/19 at 9:05 a.m., the DSD stated, "It's probably not okay to touch the straw with their [CNAs'] bare hands." The DSD stated the CNA should have worn gloves, or discarded the straw and given the resident a clean straw. During an interview with the DM on 10/10/19 at 9:14 a.m., the Dietary Manager (DM) agreed the CNA's method of beverage service was unsanitary. 2. During an observation on 10/8/19 at 11:30 a.m., three kitchen staff wore hairnets over the crowns of their heads that did not completely cover their hair. Strands of hair were falling over their ears and down the nape of their necks. During a concurrent observation and interview with the Dietary Manager on 10/8/19 at 11:33 a.m., she verified the hairnets were not covering the kitchen staff's hair and said, "The hair should be completely covered." Review of the facility policy and procedure titled "Food Service/Distribution," revised 11/10, indicated "Dietary staff shall wear hair restraints (hair net...) so that hair does not contact food."3. In a concurrent observation and interview on 10/9/19 at 11:26 a.m., undated pudding and applesauce were observed in the butter compartment of the resident refrigerator in Medication Room 2. The Assistant Director of Nurses stated, "Oh! I didn't look in there." She confirmed the items should have been dated. Review of a facility policy titled, "Food Receiving and Storage," revised 12/08, indicated "All foods stored in the refrigerator or FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3H7X11 Facility ID: CA030000280 If continuation sheet 33 of 34 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: _______________ 555219 (X3) DATE SURVEY COMPLETED 10/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE AUBURN OAKS CARE CENTER 3400 Bell Road Auburn, CA 95603 (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 freezer will be covered, labeled and dated..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3H7X11 Facility ID: CA030000280 If continuation sheet 34 of 34