Other·July 11, 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 #CA00516747. Representing the Department of Public Health: Health Facilities Evaluator Nurse, 36586 The inspection was limited to the specific facility reported incident 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 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. (4) Report to the State nurse aide registry or 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: RJQ911 Facility ID: CA030000820 If continuation sheet 1 of 5 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 06/18/2019 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 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 by: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RJQ911 Facility ID: CA030000820 If continuation sheet 2 of 5 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 06/18/2019 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 Based on interview and record review, the facility failed to report an allegation of staff abuse within 24 hours as required, when the Physical Therapy Assistant (PTA), who was told by Resident 1 of the alleged abuse by a staff member, did not report it to the department. This failure resulted in a three day delay of the investigation and had the potential to leave Resident 1 in harm for those three days. Findings: Resident 1 was admitted to the facility in December of 2016 with diagnoses that included dementia with behavioral disturbances, gastroenteritis, anxiety, and kidney disease. Resident 1's 14 day Minimum Data Set (MDS, an assessment tool) indicated the resident had a BIMS of 15 (Brief Interview for Mental Status, 15-question evaluation of mental processes including perception, memory, judgment and reasoning; ideal score is 15). During an interview on 1/18/17 at 1:40 p.m., the Administrator (ADM) stated on 12/31/16, Resident 1 complained during therapy to a PTA a staff member hit her and she had not been taken to the bathroom since 5 a.m. The ADM stated the PTA did not inform any of the nursing staff. The PTA left a message on the office phones of the Director of Nursing (DON) and the ADM. Upon returning to the facility on 1/3/17, the ADM heard the message and notified the department of the abuse allegation. The ADM further stated an investigation was completed and the accused staff member was determined to be a Certified Nursing Assistant (CNA). Due to the delay in reporting, the CNA was not suspended during the investigation. The ADM stated the PTA did not follow the proper channels to notify the facility and the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RJQ911 Facility ID: CA030000820 If continuation sheet 3 of 5 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 06/18/2019 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 department of potential abuse. A review of the employee files for PTA and the accused CNA revealed abuse training was completed upon hire and yearly reviews were up to date. During an interview on 1/18/17 at 2:40 p.m., the Social Services Coordinator (SSC) stated Resident 1 said CNA hit her because she was asking for too much. Resident 1 later told the SSC that she could not identify the CNA nor could recall what time of day the abuse had occurred. When the SSC informed Resident 1 an abuse allegation required police notification, Resident 1 recanted the abuse allegation stating she was angry because the CNA did not come quickly enough. During an interview on 1/18/17 at 4:10 p.m., the PTA stated she informed her department coworkers of the abuse allegation and was instructed to complete the state required paperwork, call the ombudsman and notify law enforcement. The PTA stated the paperwork was completed and the ombudsman's office was notified. The PTA attempted to call local law enforcement but was "on hold for more than 10 minutes so I hung up, I needed to get home..." The PTA further stated "I was told by other coworkers I could report it on my next day back at work." When asked if the Nursing Supervisor or Unit Manager was notified, the PTA stated, "No." Review of Resident 1's medical record document titled Progress Notes, dated 1/3/17 and 1/4/17, revealed documentation by Social Services regarding resident behaviors of making false accusations. Further review of Resident 1's medical record title Care Plan, created on 12/16/16 and revised on 1/10/17, revealed care plans indicating "At risk for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RJQ911 Facility ID: CA030000820 If continuation sheet 4 of 5 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 06/18/2019 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 behavior symptoms r/t Agitation... false statements against others, confabulation." Review of the facility policy dated 2016 stipulated "The facility must implement written policies and procedures that: ...(2) Establish policies and procedures to investigate any such allegations... Procedures for Reporting... Employees are educated upon hire and annually on the abuse prevention program including the immediate reporting of any suspicion of abuse... involving a resident... Protective actions... Any allegation of abuse must be immediately reported to the supervisor and abuse prevention coordinator... Patient protection actions include immediately removing the patient from contact with the alleged abuser during the investigation. If the incident involves a center employee, the employee is suspended immediately after obtaining their statement, pending completion of the investigation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RJQ911 Facility ID: CA030000820 If continuation sheet 5 of 5