Other·October 29, 2018

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during an abbreviated survey for the investigation of facility reported incident #CA00598108. Representing the Department of Public Health: HFEN, 40401 HFEN, 38970 The inspection was limited to the specific facility reported incident investigated and does not represent the findings of a full inspection of the facility.

F689 SS=D Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) 11/02/2018 §483.25(d) Accidents. The facility must ensure that §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents. This REQUIREMENT is not met as evidenced by: Based on observation, interviews, and record review, the facility failed to ensure that 1 of 95 residents (Resident 1) received adequate supervision to prevent accidents, when Resident 1 was not supervised per care plan instructions. 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: 6FDO11 Facility ID: CA030000560 If continuation sheet 1 of 4 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: _______________ 555801 (X3) DATE SURVEY COMPLETED 10/24/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PINE CREEK CARE CENTER 1139 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 This failure resulted in Resident 1 experiencing an avoidable fall with injuries which included facial bruising and abrasions, a skin tear on her right hand, and a wound on her left second finger. Findings: A review of Resident 1's "Resident Face Sheet" revealed she was admitted to the facility on 7/15/13; her diagnoses included unspecified dementia, personal history of traumatic brain injury, and history of falling. Review of resident's Minimum Data Set (an assessment tool), dated 7/19/18, indicated Resident 1 was severely impaired in daily decision making; required extensive assistance from 2 or more persons for transferring to a standing position; was not steady when moving from a seated to standing position; and had multiple falls since admission. Review of Resident 1's Quarterly Nursing Assessment, completed 7/18/18, indicated Resident 1 had the following Fall Risk factors: "intermittent confusion"; "one or two falls" in the prior 3 months; a "balance problem while standing"; "confined to chair, totally unable to ambulate without assist..."; incontinence; took 5 of the 13 medication types screened for under Fall Risk; and had three or more "predisposing diseases or conditions" which included "physical performance limitation", Psychiatric (related to mental illness)/Cognitive (related to thought processes) conditions, and "CVA/TIA [stroke]". Resident 1's Fall Risk status was listed as "At Risk - Continue to Care Plan". The Fall Care Plan for Resident 1, dated 5/2/15, instructed to "observe frequently and place in supervised area when out of bed." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6FDO11 Facility ID: CA030000560 If continuation sheet 2 of 4 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: _______________ 555801 (X3) DATE SURVEY COMPLETED 10/24/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PINE CREEK CARE CENTER 1139 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 Review of the Nursing Progress Note dated 8/2/18 at 5:45 p.m. indicated Resident 1 was found in the dining room by LN (Licensed Nursing) staff after "having apparently fallen from chair..." Resident 1 was noted to have a large contusion (bruise) on her forehead, abrasions (scrapes) on her forehead and nose, a skin tear on her right hand, and a wound on her left second finger. Resident 1's Hospice Agency was notified and a Hospice LN was in route to the facility. A review of the document titled, "(Facility Name) Investigation", involving Resident 1 on 8/2/18, indicated Resident 1 fell and the "only eye-witness" was a facility visitor. Review of the Social Services Progress Note dated 8/3/18 at 1:04 p.m. reported the resident complained she couldn't open her eyes all the way. Review of the Nursing Progress Note dated 8/3/18 at 3:32 p.m. indicated Resident 1's right eye was swollen shut, her left eye was slightly open, her forehead had redness, her face was discolored, and she complained of pain. Review of the IDT (Interdisciplinary Team) Progress Note dated 8/3/18 at 6:30 p.m. indicated Resident 1 was found on the floor of the dining lounge with injuries from falling forward from her wheelchair on 8/2/18. During an observation on 8/16/18 at 1:50 p.m., Resident 1 sat in a wheel chair at the nurses' station. Resident 1 had a large 2"x3" bruise on her forehead with additional smaller bruises on her right cheek and neck. During an interview on 8/16/18 at 2:05 p.m., Certified Nursing Assistant 1 (CNA 1) reported that Resident 1 had a history of falls and was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6FDO11 Facility ID: CA030000560 If continuation sheet 3 of 4 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: _______________ 555801 (X3) DATE SURVEY COMPLETED 10/24/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PINE CREEK CARE CENTER 1139 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 able to stand from her wheelchair so she was placed at the nursing station for supervision. In an interview on 8/16/18 at 3:40 p.m., Licensed Nurse 1 (LN 1) confirmed Resident 1 had a fall history and explained there was a communication error on 8/2/18 when CNA 3 placed Resident 1 in the dining room unattended. LN 1 reported Resident 1 was found on the floor of the dining room with her face and hands bleeding. During an interview on 8/16/18 at 3:55 p.m., CNA 4 reported that on 8/2/18 she instructed CNA 3 not to take Resident 1 to the dining room because Resident 1 can't be alone. CNA 4 explained the usual process is to take Resident 1 to the dining room last so that someone's always watching her. In an interview on 8/16/18 at 4:10 p.m., CNA 3 reported he brought Resident 1 into the dining room on 8/2/18 and left her there with no staff present. CNA 3 explained that he shouldn't have left Resident 1 alone, but he thought he could get another resident and be back in time. In an interview on 9/4/18 at 11:10 a.m., the Administrator verified Resident 1 had a history of falls and confirmed she had a fall with injury on 8/2/18 that resulted in facial bruising from hitting her face on the floor. The Administrator confirmed there were no staff members in the room when the incident occurred. In an interview on 9/13/18 at 4:29 p.m., the Director of Nursing reported Care Plans should be followed when providing care to residents. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6FDO11 Facility ID: CA030000560 If continuation sheet 4 of 4