Other·June 19, 2019

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during an abbreviated survey for the investigation of facility reported incident # CA00633706. Representing the Department of Public Health: HFEN, 39797 The inspection was limited to the specific facility reported incident 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 06/30/2019 §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 observations, interviews, and record review the facility failed to protect one of seven 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: K1MW11 Facility ID: CA030000560 If continuation sheet 1 of 7 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 06/07/2019 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 sampled Residents (Resident 1) from abuse when: 1. Resident 1 developed a bruise to the right side of chin after an incident described as a squeeze to the face by Certified Nurse Assistant (CNA) 1. 2. Resident 1 verbalized concerns related to fear and safety. This failure caused Resident 1 to experience emotional and physical harm. Findings: Review of a facility's document titled "Resident Face Sheet: [Resident name] indicated Resident 1 was admitted to the facility in April 2015 with diagnoses of vascular dementia (a form of dementia caused by an impaired supply of blood to the brain), anxiety disorders (a sudden feeling of panic and fear, restlessness, and uneasiness), hemiplegia (total or partial paralysis of one side of the body), hemeiparesis (a partial weakness on one side of the body). and cerebrovascular disease (a disease that alters the blood supply to the brain). Resident 1's Brief Interview for Mental Status (BIMS, resident cognitive impairment) was scored as 4 (indicate severe cognitive impairment). According to the facility report titled 5 Day Follow- Up dated 4/18/19, on the night of 4/17/19, at approximately 3 a.m., Resident 1 informed staff she was afraid and asked staff to not allow CNA 1 to continue as her care provider. During an observation and interview with Resident 1 on 4/18/19 at 9:59 a.m., Resident 1 expressed "someone touched her face, he's long gone...Resident 1 verbalized , "...don't' FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: K1MW11 Facility ID: CA030000560 If continuation sheet 2 of 7 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 06/07/2019 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 want him anymore..." A deep purple bruise approximately a quarter size in diameter was present to Resident 1's right chin. Skin was intact. At the time of the interview, Resident 1 denied pain. During a observation and interview with Resident 1 and CNA 2 on 4/18/19 at 11:35 a.m., CNA 2 described Resident 1 as "Sometimes she will yell out, sometimes a little combative. Not overly aggressive, few and far between agitated days, if you try to push it (care assistance)... I would remove yourself, If she feels safe then return. Usually if you explain why, she is more compliant, reapproach works. (sic)" At the time of the observation and interview, bilateral bruises in various stages of healing were present to Resident 1's inner forearms and wrists. During an interview with CNA 1 on 4/19/18 at 10:14 a.m., CNA 1 described the incident as "I was trying to help a lady. She told me that her brief (adult incontinent brief) wasn't wet. I told her it was and that I couldn't leave her that way. I took it upon myself to remove the wet brief. I tore one side of it (brief) and then removed it from the other side...I put the new brief on and pulled it up on her legs. She started screaming, she didn't' want me to help her. She scratched me. I have pictures...So when she started yelling and scratching me, I didn't feel threatened, I went to the the door to get another CNA to help me...She (Resident 1) told them (CN and RNA) she did not want me taking care of her anymore..." Review of a facility document titled 5 Day Follow- Up (FU, an investigation report required 5 days after an allegation of abuse) dated 4/18/19 indicated the following: 1. On the night of 4/17/19 Resident 1 "yelled FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: K1MW11 Facility ID: CA030000560 If continuation sheet 3 of 7 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 06/07/2019 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 out". Per the FU, the charge nurse (CN) and rehabilitation nurse assistant (RNA) went to Resident 1's room to assess Resident 1's needs. Upon arrival to the room the alleged perpetrator (CNA 1) was exiting the room. Resident 1 was located in the bathroom upon their arrival to the room. The FU indicated the staff was informed by CNA 1, he was "scratched" by Resident 1 while attempting to provide care. 2. Resident 1 "was crying" and told the CN and RNA that she did not "want him to take care of her". Per the FU, It was the "CN and RNA's understanding that Resident 1 was talking about CNA 1." 3. "At around 5 a.m." Resident 1 was reassessed by the CN. At the time of reassessment, "A bruise was found on the right chin" of Resident 1. 4. "At 9 a.m."., Resident 1 was interviewed by the facility' administrator (ADM) with the presence of the assistant director of nursing (ADON). During the interview, Resident 1 shared "he had grabbed her chin", "she did not want him [CNA 1] to take care of her and that she would like us to protect her." 5. The administrator interviewed CNA 1 after he heard Resident 1's allegation of abuse. Per the FU, CNA 1 denied the allegation. 6. "At 3:35p.m., local law enforcement officer (PD) arrived to investigate the allegation of abuse. During an interview with Resident 1, Resident 1 informed PD "He had grabbed her chin". PD "showed Resident 1 pictures of three males, one picture was of the alleged perpetrator CNA 1. The FU indicated, "Resident 1 identified CNA 1 as the one that grabbed her chin." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: K1MW11 Facility ID: CA030000560 If continuation sheet 4 of 7 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 06/07/2019 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 7. The FU confirmed "At this time, we believe that CNA 1 is not a appropriate CNA for [facility name]. CNA 1 has failed his 90 day probationary period and will be termed (terminated)..." Review of a facility document titled "Resident Progress Notes: [Resident Name] dated 4/17/19, at 11 a.m., confirmed Resident 1 "[Resident name] was interviewed and asked what had happened to her chin and how she had attained the discoloration. [Resident Name] replied, reaching for her chin area and stated "he squeezed" and proceeded to demonstrate how she was touched. [Resident name] was also asked who had done this act and she had replied "him" and stated she does not want said staff to handle her care. When [Resident name] was shown a picture of alleged abuser and had said "yes, that's him," staff ensured [Resident name] that said staff member will no longer be helping her in the future. CN notified all proper authorities:..and filled appropriate ...documents dt (due to)suspected case of abuse leading to physical harm...(sic)" Review of a facility's document titled "Hospice Progress Note" dated 4/17/19, no time provided, indicated the following: "A/O (alert and oriented): Reports pain to jaw from "someone squeezed her". Bruise 4 cm x 4 cm to rt. (right) jaw line. Small abrasion inside mouth from tooth...Pain 0-2 unless area touched. Normal jaw movement. ADON is investigating possible abuse. (sic)" "...visit to check on pt (patient) after abuse allegations. Pt tearful for a moment...Pt able to clearly state what happened. She expressed fear re (referenced) the accused returning to work. MSW (social worker) provided assurance she is safe and will be protected. She FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: K1MW11 Facility ID: CA030000560 If continuation sheet 5 of 7 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 06/07/2019 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 (Resident 1) said "I didn't know this actually happens..." Review of a facility's document titled "Physician's Orders" dated 4/17/19, no time provided, indicated an x-ray of the right face and neck was ordered to determine cause of injury (right chin bruise) of unknown origin. Xray results dated 4/17/19 failed to determine cause of rt.chin bruise. Review of facility's document titled "Skin Observation, weekly summary" included the following notation: "4/17/19 Discoloration to right chin, Discoloration to inner right forearm., 4/18/19 Discoloration to right chin 2.0 x 4.0 x 0 cm (centimeter, a unit of measure), Right upper arm (RUE) scattered discoloration and Left upper arm (LUE) scattered discoloration, dark skin pigmentation to coccyx, intact skin. (sic)" Review of a facility document titled "Abuse Investigation and Reporting", revised December 2018, indicated "...8. If the investigation reveals that the allegation(s) of abuse are founded, the employee(s) will be terminated..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: K1MW11 Facility ID: CA030000560 If continuation sheet 6 of 7 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 06/07/2019 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) FORM CMS-2567(02-99) Previous Versions Obsolete ID PREFIX TAG Event ID: K1MW11 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) Facility ID: CA030000560 (X5) COMPLETE DATE If continuation sheet 7 of 7