Other·June 17, 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 complaint #CA00585174. Representing the Department of Public Health: HFEN, 17069 The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility.

F689 SS=G Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) 05/16/2019 §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 interview, clinical record review, and facility policy review, the facility failed to prevent an avoidable fall for one of three sampled residents (Resident A) when she fell from her bed while being changed by Certified Nursing Assistant 1 (CNA 1) and failed to investigate the fall per the facility's policy. This failure resulted in Resident A sustaining a subdural hematoma (blood between the brain 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: 540G11 Facility ID: CA030001605 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: _______________ 555744 (X3) DATE SURVEY COMPLETED 05/01/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIENA SKILLED NURSING & REHABILITATION CENTER 11600 Education Street Auburn, CA 95602 (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 and its outermost covering) and subsequent death when she fell from the bed. Findings: 1. Resident A was 68 years old and admitted to the facility on 3/6/18. Her diagnoses included sepsis (life threatening complication of an infection), CVA (Cerebrovascular accidentdamage to the brain from interruption of blood supply), and lack of coordination. Review of Resident A's Admission Minimum Data Set (MDS, an assessment tool), dated 3/13/18, described her as having clear speech, able to make herself understood, and able to understand others. Resident A's Brief Interview for Mental Status (BIMS) score was 13 out of 15 which indicated she was cognitively intact. The MDS also described Resident A as having no signs or symptoms of delirium (disturbed state of mind) or behavioral symptoms. The MDS described Resident A as needing extensive assistance (resident involved in activity, staff provided weight bearing support) with bed mobility under "ADL Self-Performance" and as needing two plus person physical assist under "ADL Support Provided" (code for most support provided by staff over all shifts). The MDS also described Resident A as needing extensive assistance with personal hygiene and toilet use. Review of Resident A's CAA (Care Area Assessment) Worksheet, dated 3/14/18, under the section "ADL [Activities of Daily Living] Functional/Rehabilitation Potential," indicated, "Patient requires extensive to total assistance with ADLS r/t [related to] weakness and impaired mobility r/t end-stage diagnosis, sepsis, s/p [status post] CVA [stroke], lupus [inflammatory disease caused when the immune system attacks its own tissue]. Patient FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 540G11 Facility ID: CA030001605 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: _______________ 555744 (X3) DATE SURVEY COMPLETED 05/01/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIENA SKILLED NURSING & REHABILITATION CENTER 11600 Education Street Auburn, CA 95602 (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 is on hospice care [care of patients who are terminally ill], with goal of comfort. Continued decline in ADL functioning is anticipated." Review of Resident A's "Fall Risk Assessment Tool," dated 3/7/18, indicated her score was "6." The tool indicated, "A score of 4 or more is considered at risk for falling." Review of Resident A's Medication Review Report (MRR), for 3/1/18-3/31/18, contained an order, dated 3/6/18, for "Fall Precautions." On the MRR, no documentation defined what fall precautions were. Review of Resident A's "Bed Safety Evaluation," dated 3/9/18, indicated "generalized weakness" as the reason for determination of unsafe bed mobility. The evaluation recommended no side rails be used and recommended Resident A's bed be against the wall. Review of Resident A's ADL care plan, dated 3/14/18, included "[Resident A] has an ADL Self Care Performance Deficit r/t to Sepsis [a life threatening complication of an infection], CDiff [Clostridium difficile - a bacterium that causes diarrhea and more serious intestinal conditions], s/p CVA with left sided weakness/left-hand contracture [shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints]." The Interventions/Tasks" section indicated, "[Resident A] is essentially totally dependent on staff for transfers, toileting, and dressing, and extensive to total assist for bed mobility, eating, and grooming." Review of Resident A's clinical record contained a care plan, dated 3/14/18, regarding "Alteration in musculoskeletal [muscles and bones] status" related to status post CVA with FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 540G11 Facility ID: CA030001605 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: _______________ 555744 (X3) DATE SURVEY COMPLETED 05/01/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIENA SKILLED NURSING & REHABILITATION CENTER 11600 Education Street Auburn, CA 95602 (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 left sided weakness and left hand contracture. Review of Resident A's clinical record also contained a care plan for falls, dated 3/14/18, which indicated "[Resident A] is at risk for falls r/t weakness..." Review of a Progress Note, dated 3/16/18, indicated Resident A rolled or fell off the bed while being changed. Resident A "was found laying on her back on the floor close to bed." Upon assessment, a lump was observed on the right side of her face. Review of Resident A's "Post Fall Investigation," dated 3/16/18, indicated Resident A rolled or slid out of bed while the resident was being changed by a CNA. The physician was notified because Resident A had a lump to the right side of her face and an order was received to transfer Resident A to the emergency room (ER) for evaluation. Review of a Progress note, dated 3/16/18, indicated Resident A was transferred to the ER on 3/16/18 at 1:45 p.m. In an interview with Licensed Nurse 1 (LN 1) on 5/9/18 at 11:10 a.m., he stated he was called to Resident A's room. LN 1 saw Resident A on the floor lying on her back. He noticed Resident A had a lump on her right forehead. LN 1 stated the NP (Nurse Practitioner) was in the facility at the time and he informed her of what happened. He stated he received a new order to send Resident A to the ER for further evaluation. LN 1 described CNA 1 as being a tall man and Resident A's bed was up high because CNA 1 was changing her. LN 1 stated CNA 1 told him that he turned Resident A on her side (toward the window). Then, as CNA 1 tried to reach for wipes on the bedside table, Resident A rolled off the bed. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 540G11 Facility ID: CA030001605 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: _______________ 555744 (X3) DATE SURVEY COMPLETED 05/01/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIENA SKILLED NURSING & REHABILITATION CENTER 11600 Education Street Auburn, CA 95602 (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 A telephone interview was conducted with CNA 1 on 5/24/18 at 4:58 p.m. CNA 1 stated he was changing Resident A's brief. Resident A was on her left side facing CNA 1. CNA 1 stated he reached for linen which was on a shelf behind him. CNA 1 stated Resident A's bed was up right below his hip. CNA 1 was asked how Resident A rolled out of bed if he was standing next to the bed. CNA 1 replied that he must have stepped a little ways away from the bed. According to CNA 1, when Resident A rolled out of bed she "rolled down my legs." According to CNA 1 there were no side rails on Resident A's bed and the bed was not against a wall. CNA 1 further stated it was not possible for Resident A's bed to be against a wall due to the setup of the room. Review of a facility form titled, "Preventing Resident Falls," signed by CNA 1 and dated 10/18/17, indicated, "Bed Position: putting bed in lowest position before leaving resident...Anticipate resident needs." During an interview with the Director of Staff Development (DSD) on 7/8/18 at 9:08 a.m., the DSD stated there were no signs or symbols on the door/wall outside a resident's room to indicate a resident was a fall risk. The DSD stated the CNAs get information on a resident or how to care for a resident from shift to shift report from other CNAs. The DSD stated if a CNA doesn't know how to care for a resident, then "Don't guess," "Don't assume," "Get more help." The DSD further stated she does not go over with CNAs, upon hire, specifically how to change a resident's brief or linen. Per the DSD, she "assume already" [sic] the CNAs know how to do that from their CNA training. The DSD stated she would expect a CNA to gather all their needed supplies before starting care on a resident. The DSD was asked what she would have expected a CNA to do if they FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 540G11 Facility ID: CA030001605 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: _______________ 555744 (X3) DATE SURVEY COMPLETED 05/01/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIENA SKILLED NURSING & REHABILITATION CENTER 11600 Education Street Auburn, CA 95602 (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 needed more supplies and a resident was positioned on her side. The DSD replied she would expect the CNA to position the resident on their back, "in the middle" of the bed, in a "more stable" position. During interview with LN 1 on 7/11/18 at 8:45 a.m., LN 1 confirmed he had not discussed with CNA 1 how to provide care for Resident A or any precautions regarding Resident A. LN 1 was asked if CNA 1 knew Resident A was a fall risk. LN 1 replied, "I believe so." LN 1 was asked what he would expect a CNA to do if they needed more supplies to perform care for a resident. LN 1 replied he would expect the CNA to "call" on their walkie-a hand held portable two-way radio (per LN 1 all CNAs have a walkie) or reposition resident on their "back" in the "middle" of the bed and lower the bed. Review of Resident A's "Certificate of Death," dated 4/19/18, indicated the "immediate cause" of death was "subdural hematoma" related to fall. The "Certificate of Death" indicated the injury date as "3/16/18" and the "Decedent sustained a witnessed ground level fall." 2. Review of the facility's policy, "Fall Management," revised 10/14/15, indicated, "The Interdisciplinary Care Plan team will complete a review of the Change in Condition Report-Post Fall. This will be completed within 72 hours..." The policy also indicated, "All care staff should be interviewed and the first responder should be interviewed as soon as possible." During an interview with the Director of Nursing (DON) on 5/9/18 at 11:42 a.m., she was asked if the facility conducted an investigation or if the interdisciplinary team had completed a review of Resident A's fall. The DON confirmed they FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 540G11 Facility ID: CA030001605 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: _______________ 555744 (X3) DATE SURVEY COMPLETED 05/01/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SIENA SKILLED NURSING & REHABILITATION CENTER 11600 Education Street Auburn, CA 95602 (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 did not and didn't interview CNA 1. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 540G11 Facility ID: CA030001605 If continuation sheet 7 of 7