Other·January 4, 2018

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 two (2) complaints #CA00488423 and #CA00488688 and one (1) facility reported incident #CA00488483. Representing the Department of Public Health: HFEN, 36544 HFEN, 31463 The inspection was limited to the specific complaints and facility reported incident investigated and does not represent the findings of a full inspection of the facility.

F206 SS=D POLICY TO PERMIT READMISSION BEYOND BED-HOLD CFR(s): 483.12(b)(3)

F206 12/29/2017 A nursing facility must establish and follow a written policy under which a resident whose hospitalization or therapeutic leave exceeds the bed-hold period under the State plan, is readmitted to the facility immediately upon the first availability of a bed in a semi-private room if the resident requires the services provided by 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: BFEE11 Facility ID: CA030000094 If continuation sheet 1 of 13 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: _______________ 555160 (X3) DATE SURVEY COMPLETED 12/13/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CITY CREEK POST ACUTE 6248 66th Avenue Sacramento, CA 95823 (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 the facility; and is eligible for Medicaid nursing facility services. This REQUIREMENT is not met as evidenced by: Based on interviews, clinical record review, and facility document review, the facility failed to readmit Resident 1 after he eloped from the facility on 5/16/16 and was found in downtown Sacramento 5/18/16. Resident 1 was then taken to the General Acute Care Hospital (GACH) for evaluation. The GACH Emergency Department determined Resident 1 was cleared for discharge the same day. This failure had the potential for physical and psychosocial harm due to a disruption in ongoing medical and nursing care and other residential care services. Findings: Resident 1 eloped from the facility on 5/16/16 at between 8:45 p.m. and 9 p.m. He was located 2 days later (5/18/16) by the police and taken to the GACH for evaluation. An Emergency Department (ED) Physician Notes, dated 5/18/16 at 10:30 a.m., indicated, "...[Resident 1] presents to the ED with Sacramento Sheriff's department after being missing for the last day." The ED physician orders included, "Sitter" (an employee who stays with a resident to continuously monitor their whereabouts). An addendum ED report dated 5/18/16 at 3:20 p.m., included "[Resident 1] was at a facility and he wandered away from there and has [not been there] for 2 days. He was finally found by police and brought in here to make sure he is FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BFEE11 Facility ID: CA030000094 If continuation sheet 2 of 13 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: _______________ 555160 (X3) DATE SURVEY COMPLETED 12/13/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CITY CREEK POST ACUTE 6248 66th Avenue Sacramento, CA 95823 (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 medically cleared...We are trying to get him back to his facility. They are saying he cannot go there, but they are trying to work some other stuff out with case management at this time, but he is medically cleared." An interview was conducted with the Administrator on 5/18/16 at 3:40 p.m. He stated the hospital called about returning Resident 1 to the facility. he told the hospital they "will not take [Resident 1] back as they do not have the type of facility to care for him." An interview was conducted with the DON on 5/19/16 at 1:50 p.m. The DON stated the Admissions Coordinator (AC) had informed the hospital that Resident 1 was a "flight risk and they couldn't take resident back." The AC had confirmed with her (DON) and the Administrator that for Resident 1's safety, they could not take Resident 1 back. An interview was conducted with Family Member (FM) A on 5/19/16 at 2:53 p.m. FM A stated he wanted Resident 1 returned to the facility when discharged from the GACH. He stated having Resident 1 at the facility would provide him time to get a new apartment and larger place so Resident 1 could live with him. An interview was conducted with the AC on 5/19/16 at 3:50 p.m. The AC stated she had spoke with the Administrator, who stated they could not take Resident 1 back and with the facility owner, who stated they could not take Resident 1 back because the facility "could not provide the safety the resident needed." A follow-up interview was conducted with the Administrator on 5/19/16 at 4 p.m. He stated one hour after the police called the facility [no date or time given], the hospital called and stated this facility was "dumping" the resident. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BFEE11 Facility ID: CA030000094 If continuation sheet 3 of 13 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: _______________ 555160 (X3) DATE SURVEY COMPLETED 12/13/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CITY CREEK POST ACUTE 6248 66th Avenue Sacramento, CA 95823 (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 The Administrator related that he replied back to the caller, "No, he left." The Administrator stated he was able to meet the needs of Resident 1 when Resident 1 resided in the facility. He stated as Resident 1 improved, his needs became "less and less...steady...improvement." The Administrator stated Resident 1 needed services somewhere; however, as far as nursing needs, "We could help him." If Resident 1 had stayed in the facility, his health would have been affected because, "We would not have given him alcohol. We would have provided a better diet..." The Administrator stated there was no evidence other resident's health or safety would be endangered by Resident 1. An interview was conducted with the Director of Nurses (DON) on 5/19/16 at 1:50 p.m. The DON stated Resident 1 had improved and responded well to therapies. She indicated Resident 1 was at the facility for a short stay and her understanding was family would be taking him home upon discharge. The DON stated she did not think there was a physician order for Resident 1's transfer or discharge. The facility document titled "Discharges," dated 05/2016, included Resident 1's name, with a discharge date of 5/16/16. The document indicated Resident 1 left the facility "AMA (Against Medical Advice)." A review of the facility's "Standard Admission Agreement (Contract)," directed that residents "shall have the right...to be given reasonable advance notice to ensure orderly transfer or discharge. Such actions shall be documented in the patient's health record." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BFEE11 Facility ID: CA030000094 If continuation sheet 4 of 13 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: _______________ 555160 (X3) DATE SURVEY COMPLETED 12/13/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CITY CREEK POST ACUTE 6248 66th Avenue Sacramento, CA 95823 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

F323 FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES CFR(s): 483.25(h)

F323 SS=D PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 12/29/2017 The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. This REQUIREMENT is not met as evidenced by: Based on observations, staff interviews, clinical record review, and facility document review, the facility failed to ensure adequate supervision and monitoring was provided for 1 of 3 sampled residents (Resident 1) when: 1. Resident 1 eloped from the facility on 5/14/16 at approximately 4 p.m. and again on 5/16/16 at approximately 8:45 p.m.; and 2. Facility staff assigned to monitor resident's Wanderguards (electronic devices that notified staff when the resident attempted to leave the facility) and ensure the devices properly activated alarms at the nurse stations and exit doors were inadequately trained. These failures had the potential to result in significant resident harm or death. Findings: 1. Resident 1 was admitted to the facility on FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BFEE11 Facility ID: CA030000094 If continuation sheet 5 of 13 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: _______________ 555160 (X3) DATE SURVEY COMPLETED 12/13/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CITY CREEK POST ACUTE 6248 66th Avenue Sacramento, CA 95823 (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 4/4/16 with diagnoses including a fractured skull, brain injury, seizures and aphasia (loss of ability of organized thought and speech). The admission Minimum Data Set (MDS, an assessment tool) included a Brief Interview for Mental Status (BIMS), used to identify Resident 1's thinking ability and memory, indicated Resident 1 had severe thinking and memory impairment. An interview was conducted with the Physical Therapist Assistant (PTA) on 5/18/16 at 2:15 p.m. He stated when Resident 1 was admitted to the facility, he was weak and his communication poor. The PTA relayed Resident 1's "mumbling" improved and had the ability to say words that were understood, but the words were not connected with fluid speech or thought patterns. He stated Resident 1 was not able to have conversations, could answer yes or no, and was now starting to read his name. The PTA stated Resident 1 progressed to walking on his own; however, needed a Wanderguard after attempts to leave the facility on his own. He stated, "Maybe Friday [5/13/16] last week" Resident 1 was found down the street at the store. Skilled Daily Nurses Notes' included the following: 1. 4/25/16 at 2 p.m. - "Up in [wheelchair (w/c)] propel self around." 2. 4/25/16 at 5 p.m. - "Able to propel self around in his w/c. Wanders [at] time, had [Absence without Leave (AWOL) attempt this shift." 3. 4/26/16 - A physician's order was received for the use of Wanderguard. 4. 4/28/16 at 6:30 p.m. - "[Resident] up in w/c [and] propel self around with confusion, redirected as needed...went out from facility x 2 but redirected to come back inside by FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BFEE11 Facility ID: CA030000094 If continuation sheet 6 of 13 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: _______________ 555160 (X3) DATE SURVEY COMPLETED 12/13/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CITY CREEK POST ACUTE 6248 66th Avenue Sacramento, CA 95823 (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 staff...Wanderguard...placed to alert staff of AWOL attempts." 5. 4/29/16 at 1 p.m. - "Episodes of AWOL attempts on monitoring with Wanderguard attach (sic)." 6. 4/26/16 at 6:30 p.m. - "No change in [level of consciousness], ambulatory with supervision and stand by assist, had 2 AWOL [attempts] this shift." A short-term care plan titled "AWOL episodes," initiated 4/28/16, included frequent visual check, check Wanderguard "placement frequency," redirect as needed, and on safety watch every hour. The care plan goal included, "No AWOL episodes time three days." A second short-term care plan titled "AWOL episodes," initiated 5/14/16, included keep near station and check Wanderguard. The care plan goal included, "Will have no AWOL episodes in 72 hours." A care plan titled "Wandering Care Plan," initiated 5/14/16, identifying the problem of "Wanders out of facility." The goal was, "Resident will not wander out of the facility every shift." The goal date was "8/16." The approaches included, "Avail use of Wanderguard." An interview was conducted with Licensed Nurse (LN 3) on 5/18/16 at 3:20 p.m. LN 3 stated, on 5/14/17, Resident 1 was seen "down the street" by a facility employee. An interview was conducted with Employee 1 on 5/26/16 at 1 p.m. Employee 1 stated on 5/14/16, he had completed the workday at 2:30 p.m. and drove home. Approximately 4 p.m. to 4:30 p.m.. Employee 1 observed Resident 1 at a store down the street from the facility. Employee 1 stated he called the facility, spoke FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BFEE11 Facility ID: CA030000094 If continuation sheet 7 of 13 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: _______________ 555160 (X3) DATE SURVEY COMPLETED 12/13/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CITY CREEK POST ACUTE 6248 66th Avenue Sacramento, CA 95823 (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 with a Licensed Nurse (LN) and then drove Resident 1 back to the facility. A follow-up interview was conducted with Employee 1 on 5/26/16 at 3:30 pm. He stated the store where Resident 1 was found on 5/14/16 was located approximately a quarter of a mile from the facility and necessitated crossing a traffic-lighted intersection, since the store was located on the other side of the intersection. A follow-up interview was conducted with LN 3 on 6/1/16 at 2:50 p.m. LN 3 stated until she received a call from Employee 1, "No one said anything about Resident 1 missing." A Nurses' Notes, dated 5/16/16 at 4:50 p.m. and included an unreadable signature, indicated "...[Resident 1] still in his room [at] [9 p.m.] his [Certified Nurse Assistant (CNA)] called me stated [Resident 1]is not in his room we search all the rooms inside and outside the facility [Resident 1] is not there [at 9:30 p.m.]" An interview was conducted with CNA 1 on 5/18/16 at 2:30 p.m. CNA 1 stated the "weekend CNA" told her Resident 1 had tried to "escape." CNA 1 stated after her dinner break on 5/16/16 at 8:45 p.m., she observed Resident 1 in his room with his jacket and shoes on watching T.V. She relayed that usually Resident 1 removed his shoes when in his room watching T.V. She stated she observed Resident 1's Wanderguard on [his person], but the wheelchair alarm was off. CNA 1 stated she asked Resident 1 to lie down, then left to check on another resident. Upon her return 15 minutes later, he was not in his room. CNA 1 stated she began an immediate search and reported to the Charge Nurse that Resident 1 was missing. CNA 1 stated between 8:45 p.m. and 9 p.m., she did not hear any alarms FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BFEE11 Facility ID: CA030000094 If continuation sheet 8 of 13 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: _______________ 555160 (X3) DATE SURVEY COMPLETED 12/13/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CITY CREEK POST ACUTE 6248 66th Avenue Sacramento, CA 95823 (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 activated. An interview was conducted with LN 1 on 5/18/16 at 2:55 p.m. LN 1 stated on 5/16/16 she was advised Resident 1 was missing and began a search. She stated she was sitting at the desk at the nurses' station between 8:45 p.m. and 9 p.m. LN 1 stated she did not hear any alarms; specifically, the Wanderguard alarm, door alarm, or wheelchair alarm. On 5/18/17, Resident 1 was found by the police in downtown Sacramento approximately seven miles from the facility. 2. An observation was made of the facility's main front lobby entrance and exit door and front-side service door [door where employees and visitors may enter and leave after-hours] on 5/18/16 at 12:58 p.m. Informational signs were posted on the outside of the building near the front lobby and the after-hours entrance and exit door, instructing readers the doors were locked from 6:30 p.m. to 5:30 a.m. An interview was conducted with the Maintenance Supervisor (MS) on 5/18/16 at 1 p.m. The MS stated a resident's Wanderguard would automatically activate an [door] alarm. He stated, in the evening, doors were locked by staff and the alarms activated by nurses. An observation and test of the Wanderguard equipment and activation system was conducted with the Director of Staff Development (DSD) on 5/18/16 at 4:07 p.m. When the front lobby doors were tested, the alarms did not activate after three attempts. A follow-up interview was conducted with LN 1 on 5/18/16 at approximately 4:10 p.m. LN 1 stated the charge nurse or supervisors locked the doors at night, but she did not activate the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BFEE11 Facility ID: CA030000094 If continuation sheet 9 of 13 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: _______________ 555160 (X3) DATE SURVEY COMPLETED 12/13/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CITY CREEK POST ACUTE 6248 66th Avenue Sacramento, CA 95823 (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 door alarms on 5/16/16 and did not know how to do it. An interview was conducted with the DON on 5/19/16 at 1:50 p.m. The DON stated staff wasn't clear about [Resident 1's] level of safety awareness. She stated interventions for Resident 1 consisted of hourly checks, a wheelchair alarm, a Wanderguard, and seating him by the nursing station. A follow-up interview was conducted with the Maintenance Supervisor (MS) on 5/19/16 at 2:30 p.m. He stated "nursing" is suppose to do routine checks [door alarm checks]. An interview was conducted with LN 2 on 5/19/17 at approximately 2:40 p.m. LN 2 stated the Restorative Nurse Aides (RNAs) check alarms on doors for Wanderguards and they [RNAs] keep the log books During an observation and concurrent interview, on 5/19/17 at approximately 2:40 p.m., RNA 1 verified Wanderguard monitoring logs for Nurse Station 1 and Nurse Station 2 did not contain Wanderguard monitoring documents for 2016. The facility document titled "Wanderguard Monitoring," dated 5/2016, consisted of columns, dated 1 through 31, and a grid with checkmark boxes. Resident's with Wanderguards were listed in the column at the left side of the log. Resident 1's name was not documented on the log. A second facility document titled "Wanderguard Monitoring," dated 5/22/16, consisted of 7 columns with resident names listed in the first column. Columns 2 - 6 were designated for weeks 1 - 5. Column 7 was designated for "Remark." The document was utilized to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BFEE11 Facility ID: CA030000094 If continuation sheet 10 of 13 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: _______________ 555160 (X3) DATE SURVEY COMPLETED 12/13/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CITY CREEK POST ACUTE 6248 66th Avenue Sacramento, CA 95823 (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 validate a Wanderguard check was performed weekly for each listed resident. Resident 1's name was not documented on the log. An interview was conducted with RNA's 2 and 3 on 6/1/16 at approximately 2 p.m. RNA 2 and RN 3 stated they were never instructed to check the alarms at the exit doors. A follow-up interview was conducted with RNA 3 on 6/2/16 at 3:50 p.m. RNA 3 confirmed the doors weren't checked until 5/22/16, because they (the RNA's) were never told to check the doors. The facility policy and procedure titled "[Manufacturer Name] System," (undated), included, "The Director of Nurses will assign a staff member to check all wristbands on a weekly basis to ensure that all wristbands are functioning. Wristbands found to be inoperative will be replaced with a new one. Results of weekly wristband checks will be recorded by the staff member performing the checks. The bracelet can be checked by looking at the date to ensure that it has been 90 days or less and by moving the Resident within a short distance of an open exit door." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BFEE11 Facility ID: CA030000094 If continuation sheet 11 of 13 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: _______________ 555160 (X3) DATE SURVEY COMPLETED 12/13/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CITY CREEK POST ACUTE 6248 66th Avenue Sacramento, CA 95823 (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: BFEE11 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) Facility ID: CA030000094 (X5) COMPLETE DATE If continuation sheet 12 of 13 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: _______________ 555160 (X3) DATE SURVEY COMPLETED 12/13/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CITY CREEK POST ACUTE 6248 66th Avenue Sacramento, CA 95823 (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: BFEE11 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) Facility ID: CA030000094 (X5) COMPLETE DATE If continuation sheet 13 of 13