Other·February 3, 2017

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE AMENDED The following reflects the findings of the California Department of Public Health during an abbreviated survey for investigation of two (2) complaints #CA00480931 and #CA00496976 Representing the Department of Public Health: HFEN, 36586 HFEN, 35598 The inspection was limited to the specific complaints investigated and does not represent the findings of a full inspection of the facility.

F205 SS=D NOTICE OF BED-HOLD POLICY BEFORE/UPON TRANSFR CFR(s): 483.12(b)(1)&(2)

F205 02/21/2017 Before a nursing facility transfers a resident to a hospital or allows a resident to go on therapeutic leave, the nursing facility must provide written information to the resident and a family member or legal representative that specifies the duration of the bed-hold policy under the State plan, if any, during which the resident is permitted to return and resume residence in the nursing facility, and the nursing facility's policies regarding bed-hold periods, which must be consistent with paragraph (b)(3) of this section, permitting a 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: YS2211 Facility ID: CA030000820 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: _______________ 555337 (X3) DATE SURVEY COMPLETED 02/02/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CITRUS HEIGHTS POST ACUTE 7807 Uplands Way Citrus Heights, CA 95610 (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 to return. At the time of transfer of a resident for hospitalization or therapeutic leave, a nursing facility must provide to the resident and a family member or legal representative written notice which specifies the duration of the bed-hold policy described in paragraph (b)(1) of this section. This REQUIREMENT is not met as evidenced by: Based on interviews, clinical record review, and facility policy and procedure review, the facility failed to: Provide a 7 day bed hold notice to 1 of 3 sampled residents (Resident 1) when Resident 1 was transferred to a General Acute Care Hospital (GACH 2). These failures had the potential to increase emotional distress for Resident 1 and worry to family members. Findings: Resident 1 was an 83 year old admitted to the facility in late February from the GACH 1 with dementia (a general term for a decline in mental ability severe enough to interfere with daily life) and Alzheimer's (a type of dementia that causes problems with memory, thinking and behavior). During a telephone interview on 3/15/2016 at 9:20 a.m., Resident 1's daughter stated "...on 3/11/2016 we received a Three Day Notice of transfer/discharge to another facility to occur on 3/14/2016... We are not happy with the decision and would like more time to find a more appropriate home for [Resident 1]." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YS2211 Facility ID: CA030000820 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: _______________ 555337 (X3) DATE SURVEY COMPLETED 02/02/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CITRUS HEIGHTS POST ACUTE 7807 Uplands Way Citrus Heights, CA 95610 (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 During an interview on 3/15/2016 at 1:15 p.m., the Social Services Assistant (SSA) stated they [the facility] "have exhausted options for the resident... We have sent requests all over Sacramento and Roseville... Either there are no beds or they are not a locked facility... Resident 1 has a bed at [named skilled nursing home] and [named locked assisted living facility]...the family would have to pay for the [assisted living facility] until Medi-Cal kicked in and they could then apply for a waiver... Family said they cannot afford." During an interview on 3/15/2016 at 1:30 p.m., the Administrator (ADM) stated "... I have rescinded the Three Day Notice to allow the family more time to find a place for [Resident 1]." During a telephone interview on 3/16/2016 at 11:15 a.m., Resident 1's family member stated Resident 1's Responsible Party received a new Three Day Notice of transfer/discharge to occur on 3/18/2016 to the same alternate facility in the prior notice. Review of Resident 1's clinical record document titled Progress Notes, dated 3/25/2016 at 12:27 p.m., indicated Resident 1 was transferred to the GACH 2 for medical management to "stabilize acute behaviors." On 3/28/2016 at 2:10 p.m. during a telephone interview with the facility ADM, the ADM stated "I did not issue a bed hold for the resident because we were not going to take him back." Review of facility document titled Bed Hold Agreement revised 9/2011 indicated "If I am away from the Center for more than 24 hours, I will be offered the option to pay for a bed hold to hold my bed and retain my belongings in the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YS2211 Facility ID: CA030000820 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: _______________ 555337 (X3) DATE SURVEY COMPLETED 02/02/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CITRUS HEIGHTS POST ACUTE 7807 Uplands Way Citrus Heights, CA 95610 (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 Center".

F329 SS=D DRUG REGIMEN IS FREE FROM UNNECESSARY DRUGS CFR(s): 483.25(l)

F329 03/02/2017 Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used in excessive dose (including duplicate therapy); or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or any combinations of the reasons above. Based on a comprehensive assessment of a resident, the facility must ensure that residents who have not used antipsychotic drugs are not given these drugs unless antipsychotic drug therapy is necessary to treat a specific condition as diagnosed and documented in the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YS2211 Facility ID: CA030000820 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: _______________ 555337 (X3) DATE SURVEY COMPLETED 02/02/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CITRUS HEIGHTS POST ACUTE 7807 Uplands Way Citrus Heights, CA 95610 (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 clinical record; and residents who use antipsychotic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. This REQUIREMENT is not met as evidenced by: Based on observations, resident and staff interviews, clinical record reviews, and review of the facility's policies and procedures, the facility failed to ensure adequate monitoring for effectiveness of a psychotherapeutic (a drug used for treatment of mental or emotional disorder) medication for 1 of 3 sampled residents (Resident 1) when a p.r.n. (as needed) dose was administered without an indication for use. This failure had the potential to place Resident 1 at higher risk for adverse effects of an antipsychotic. Findings: Resident 1 was an 83 year old admitted to the facility in late February from the General Acute Care (GACH 1) with dementia (a general term for a decline in mental ability severe enough to interfere with daily life) and Alzheimer's (a type of dementia that causes problems with memory, thinking and behavior). A review of Resident 1's medical record, document titled Progress Notes, Admission History and physical exam, dated 2/25/16 at 9:25 a.m., admitting physician indicated "...More recently prior to being in the hospital he was started on Seroquel [brand name for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YS2211 Facility ID: CA030000820 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: _______________ 555337 (X3) DATE SURVEY COMPLETED 02/02/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CITRUS HEIGHTS POST ACUTE 7807 Uplands Way Citrus Heights, CA 95610 (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 quetiapine fumarate, an antipsychotic used to treat mental illness] for behavior problems. He was verbally abusive and sometimes physically aggressive... On admission showed nursing facility the patient having trouble adapting to roommate attempting to block roommates entrance to the room....spoke to consulting psychiatrist patient was admitted with orders for Seroquel. Order for dose reduction. Discontinuing morning dose of Seroquel continue 50 mg at bedtime and order Seroquel 25 mg every 12 hours if needed.." A review of Resident 1's medical record, document titled Order Summary Report with start date of 2/24/16 and end date of 2/24/16 indicated "QUEtiapine Fumarate Tablet 50 mg Give 1 tablet by mouth at bedtime for Dementia with agitation." A review of Resident 1's medical record, document titled Order Summary Report with start date of 2/25/16 and end date of 3/2/16 indicated "SEROquel Tablet 25 mg Give 1 tablet by mouth every 12 hours as needed for dementia with behavioral disturbances m/b (manifested by) physical and verbal aggression." A review of the document titled Progress Notes dated 2/27/16 at 10:06 a.m., indicated "patient not letting Certified Nursing Assistant (CNA) provide morning care, keep closing door, wife at bedside, requested Licensed Nurse (LN) to give medication to husband, patient not following directions..., PRN (as needed) Seroquel [sic] given". In a telephone interview on 9/29/16 at 3:45 p.m., the Consulting Pharmacist (CP) stated the p.r.n. Seroquel given on 2/27/16 at 10:06 a.m. for refusal of care was not administered for an ordered or monitored behavior. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YS2211 Facility ID: CA030000820 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: _______________ 555337 (X3) DATE SURVEY COMPLETED 02/02/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CITRUS HEIGHTS POST ACUTE 7807 Uplands Way Citrus Heights, CA 95610 (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 facility policy titled Psychopharmacological Medication Use revised 11/31/11 indicted "The facility should comply with the Psychopharmacological Dosage Guidelines created by the Centers for Medicare and Medicaid Services (CMS), the State Operations Manual (SOM), and all other Applicable Law relating to the use of psychopharmacologic medications.." Review of the facility document titled Behavior Practice Guide dated 7/2015 indicated under the subheading Documentation..."The behavioral symptoms are entered on the Mood/ Behavior Symptom Log" It further indicated "Each resident's drug regime must be free from unnecessary drugs. An unnecessary drug is any drug when used: (iv)without adequate indication for use..." The document further references the Investigative Protocol for Unnecessary Drugs located in the State Operations manual. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YS2211 Facility ID: CA030000820 If continuation sheet 7 of 7