Other·April 13, 2017

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 complaint #CA00519088, #CA00519715, and #CA00519761. Representing the Department of Public Health: HFEN, 36601 HFEN, 38177 The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility.

F225 SS=D INVESTIGATE/REPORT ALLEGATIONS/INDIVIDUALS CFR(s): 483.12(a)(3)(4)(c)(1)-(4)

F225 04/19/2017 483.12(a) The facility must(3) Not employ or otherwise engage individuals who(i) Have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law; (ii) Have had a finding entered into the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property; or (iii) Have a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property. 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: 3X3J11 Facility ID: CA030000589 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: _______________ 555333 (X3) DATE SURVEY COMPLETED 03/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LINCOLN MEADOWS CARE CENTER 1550 3rd Street Lincoln, CA 95648 (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 (4) Report to the State nurse aide registry or licensing authorities any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff. (c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: (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 longterm care facilities) in accordance with State law through established procedures. (2) Have evidence that all alleged violations are thoroughly investigated. (3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. (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 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3X3J11 Facility ID: CA030000589 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: _______________ 555333 (X3) DATE SURVEY COMPLETED 03/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LINCOLN MEADOWS CARE CENTER 1550 3rd Street Lincoln, CA 95648 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE by: Based on staff interview and facility document review, the facility failed to 1) Report an allegation of abuse within 24 hours as required, 2) Have evidence of an investigative report and, send the results of the investigation to the state within 5 days of the incident and, 3) Provide evidence that the resident was protected while the incident was being investigated. This failure had the potential to place all residents at risk for continued abuse in an unsafe environment. Findings: 1) Resident 1 (R1) was an 82 year old resident. R1's Minimum Data Set (MDS, a standardized assessment tool), dated 6/5/16, revealed R1 had a Brief Interview for Mental Status (BIMS, an assessment screening tool used to assess cognition) score of 15. This score indicated R1 was cognitively intact. R1 and Resident 2 (R2) had shared a room in the facility during the months of April and May 2016. During an interview with R1, on 1/24/17 at 8:52 a.m., R1 stated "[I] saw my roommate get raped. He just came in and got in bed with her ...it was during the day...in room [room number provided]...only remember the one incident." When R1 was asked if she had told anyone about what she saw she stated "yes, I turned it in...all the girls came in...he still works here..." R1 stated her roomate (Resident 2) was not capable of speaking for herself stating "...that's why I felt bad about it..." R2 was an 80 year old admitted to the facility with diagnoses which included dementia with FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3X3J11 Facility ID: CA030000589 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: _______________ 555333 (X3) DATE SURVEY COMPLETED 03/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LINCOLN MEADOWS CARE CENTER 1550 3rd Street Lincoln, CA 95648 (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 behavioral disturbances, major depressive disorder, and anxiety disorder. The MDS dated 1/15/17 revealed R2 had a BIMS score of 00. This score indicated severe cognitive impairment and problems with memory. During an interview with Licensed Nurse (LN) 2, on 1/24/17, at 11:27 a.m., LN 2 stated he first heard about allegations of abuse that was sexual in nature from R1 "one time" and recalls the conversation was "last year" but could not recall the date or time of the year. LN 2 stated "I feel like I may have told someone, like social services or someone..." During an interview with Certified Nursing Assistant (CNA) 1, on 1/24/17 at 12:32 p.m., CNA 1 recalled "at least eight months ago" he had heard of an allegation of sexual abuse involving R2, that R1 had reported to various staff. CNA 1 recalled the Administrator had a conversation with him around this time regarding a sexual abuse allegation that he had been named in. During a review of the clinical record for R1, a Social Services progress note dated 5/30/16 at 1:03 p.m., indicated "Patient was interviewed in regards to accusations she made to several CNAs about a CNA being in bed with her roommate..." In an interview on 1/24/17, at 10:03 a.m., with LN 1, LN 1 stated she had a "strange conversation" with Resident 1 on 8/24/16. LN 1 stated she notified her upper management, via email, about what R1 told her during a treatment that day. The email, composed on 8/24/16, was sent to the Director of Nursing (DON), Administrator, and Social Services Director (SSD). LN 1 read aloud, from a printed copy of the e-mail, explaining that R1 had alleged she saw a guy (CNA 1's first name) in FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3X3J11 Facility ID: CA030000589 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: _______________ 555333 (X3) DATE SURVEY COMPLETED 03/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LINCOLN MEADOWS CARE CENTER 1550 3rd Street Lincoln, CA 95648 (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 bed with her roommate (R2) a while ago and that she (R1) had also told the night nurse. LN 1 then read an email reply sent from the Administrator indicating he was aware and that multiple times this has occurred with (R1) reporting rape accusations. In an interview on 1/24/17 at 10:03 a.m., with CNA 2, CNA 2 recalled that she was "in the room with social services talking to the Resident with the first accusation [May 2016] of a CNA raping her roommate ..." CNA 2 was unable to recall the exact date or time of this conversation. During an interview with the SSD, on 1/24/17, at 10:20 a.m., the SSD recalled R1 had a history of making false accusations and remembered in May 2016 a report that mentioned someone was lying on the roommate's bed. It was around that time that R1 started saying her roommate (R2) was raped by a staff member. The SSD described upon learning of an allegation of abuse, her investigative process was to interview those involved and report her findings to the Administrator then the Administrator decides the next steps. The SSD stated CNA 1 remained employed by the facility and that R1 has accused (CNA 1) of inappropriate sexual behavior before. During an interview with the Administrator on 1/24/17, at 10:31 a.m., the Administrator confirmed he was aware of the history of sexual abuse allegations made by R1 and was unable to produce an official investigative file for R1's allegation(s) nor any documentation or evidence that the allegation had been investigated. There was no indication that an allegation of sexual abuse had been filed with the Department for either of the allegations brought to his attention, in May 2016 or in FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3X3J11 Facility ID: CA030000589 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: _______________ 555333 (X3) DATE SURVEY COMPLETED 03/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LINCOLN MEADOWS CARE CENTER 1550 3rd Street Lincoln, CA 95648 (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 August 2016. The Administrator acknowledged that R1 had a history of making multiple allegations of a sexual nature occuring involving CNA 1 and R2. The Administrator explained that he had determined the allegation was false and that if the allegation had been substantiated he would have filed a report. The facility policy and procedure titled "Reporting Abuse to State Agencies and Other Entities/Individuals" revised August 2011, indicated "...All suspected violations and all substantiated incidents of abuse will be immediately reported to appropriate state agencies and other entities or individuals as may be required by law." 2) During an interview with the Administrator on 1/24/17, at 10:31 a.m., the Administrator was unable to produce an official file for any investigations of R1's allegation(s) or any documentation or evidence of an investigative report for the allegations brought to his attention either in May 2016 or August 2016. The facility policy and procedure titled "Abuse Investigations" revised August 2011, indicated "...15. The Administrator will provide a written report of the results of all abuse investigations and appropriate action taken to the state survey and certification agency, the local police department, the ombudsman, and others as may be required by state or local laws, within five (5) working days of the reported incident." 3) During an interview with the SSD, on 1/24/17, at 10:20 a.m., the SSD stated upon learning of an allegation of abuse, her investigative process was to interview those involved and report her findings to the Administrator then the Administrator decides the next steps. The SSD stated CNA 1 remained employed by the facility and that R1 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3X3J11 Facility ID: CA030000589 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: _______________ 555333 (X3) DATE SURVEY COMPLETED 03/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LINCOLN MEADOWS CARE CENTER 1550 3rd Street Lincoln, CA 95648 (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 has accused (CNA 1) of inappropriate sexual behavior before. During an interview with the Administrator, on 1/24/17 at 10:31 a.m., the Administrator confirmed that there was only one staff person employed with the name mentioned (CNA 1) by R1 and that CNA 1 had not been placed on leave as a result of either of these allegations. The facility policy and procedure titled "Protection of Residents During Abuse Investigations" revised August 2011, indicated "...During abuse investigations, residents will be protected from harm by the following measures: a. Employees accused of participating in the alleged abuse will be immediately reassigned to duties that do not involve resident contact or will be suspended until the findings of the investigation have been reviewed by the Administrator." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3X3J11 Facility ID: CA030000589 If continuation sheet 7 of 7