Other·May 14, 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 #CA00627723. Representing the Department of Public Health: HFEN, 41197 HFEN, 26663 The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility.

F684 SS=G Quality of Care CFR(s): 483.25

F684 05/17/2019 § 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive personcentered care plan, and the residents' choices. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to prevent a significant delay in care and treatment, ensure identification and treatment of skin breakdown, and worsening infection to meet the needs for one of three sampled residents (Resident 1) when: 1. Skin assessment, bathing, and personal hygiene in the form of a bed bath or shower was not provided for 23 days. 2. A person-centered plan of care was not revised and implemented for identified 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: FYDV11 Facility ID: CA030000094 If continuation sheet 1 of 8 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 04/26/2019 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 persistent aggressive and resistant to care behaviors. 3. Continuously monitored high risk aggressive behaviors and refusal of care continued without goal-oriented intervention, and steps were not taken to identify underlying causes of behaviors and identify alternatives to meet resident needs. These failures resulted in Resident 1 not receiving care and services to prevent and identify skin breakdown, a delay in assessment, and a delay in treatment that contributed to the development of a severe lifethreatening skin infection requiring hospitalization and surgery. Findings: According to the Facesheet, Resident 1 was admitted to the facility in 2015 with diagnoses of dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning) with behavioral disturbance, anxiety disorder, and high blood pressure. Review of Resident 1's clinical record included: A facility document titled Short-Term Care Plan, dated 10/21/18, for increased combative and physically aggressive behaviors. Interventions listed included notifying the physician and resident representative, monitor vital signs and behavior, and to redirect resident and re-approach calmly. The care plan goal was Resident 1 "will be calm," and contained no measurable objectives or timeframes. A physician's order, dated 10/22/18, to monitor resident's behavior manifested by physically FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: FYDV11 Facility ID: CA030000094 If continuation sheet 2 of 8 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 04/26/2019 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 aggressive behavior with staff every shift. A clinical document titled, Monitoring Administration Record, dated 11/1/18-11/30/18, showed physically aggressive behaviors towards staff charted on 22 of 30 days. A clinical document titled, Monitoring Administration Record, dated 12/1/18-12/31/18, showed physically aggressive behaviors towards staff charted on 22 of 31 days. A clinical document titled, Monitoring Administration Record, dated 1/1/19-1/31/19, showed physically aggressive behaviors towards staff charted on 21 of 31 days. A clinical document titled, Monitoring Administration Record, dated 2/1/19-2/28/19, showed physically aggressive behaviors towards staff charted for 14 of the 14 days the resident was present in the facility. A Minimum Data Set (MDS - an assessment tool), dated 11/18/18 and 2/13/19, indicated Resident 1 had physical behavioral symptoms directed towards others (hitting, kicking, pushing, scratching, grabbing) and verbal behavioral symptoms directed at others (threatening others, screaming at others, cursing at others). A clinical document titled Interdisciplinary (IDT) Progress Notes, dated 1/19/18, contained no documentation regarding Resident 1's consistent aggressive and refusal of care behaviors. Monthly physician clinical notes dated 12/1/18, 1/7/19, and 2/1/19 signed by Resident 1's physician. All three notes contained no documentation regarding Resident 1's repeated physically aggressive and refusal behaviors. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: FYDV11 Facility ID: CA030000094 If continuation sheet 3 of 8 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 04/26/2019 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 physician noted the plan was to, "Continue same medication and treatment plan ...Patient is stable." A resident care plan titled, Potential for Skin Breakdown, initiated 11/30/18, with an intervention to shower/bathe 2 times weekly as scheduled, and the certified nursing assistant (CNA) to inspect skin at this time and notify licensed nurse of findings. This care plan had no problem identified of resident refusing showers/baths or being aggressive with care and no documentation of alternative interventions tried for resident's refusal. No nursing care plan was present in the clinical record related to combative behaviors or activities of daily living (ADL) care being refused with risks posed for declining condition. No nursing interventions were present related to alternatives to be attempted when resident was combative and refused or resisted ADL care. Nursing progress notes, dated 1/3/19, 1/18/19, 1/19/19, 1/20/19, 1/21/19, 2/9/19, and 2/14/19, indicated Resident 1 was agitated, physically aggressive, resistive to ADL care. A report titled Follow Up Question Report, dated 1/1/19-2/14/19, indicated for dates 1/24/19 and 2/4/19 Resident 1 had refused bathing. For dates 1/27/19, 1/28/19, 1/31/19, 2/6/19, and 2/7/19 the document contained a response documented as "Not Applicable," which indicated no bath or shower had been given. A form titled Shower Day Skin Inspection, dated 1/21/19, indicated Resident 1 had a shower and skin was intact. A form titled Shower Day Skin Inspection, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: FYDV11 Facility ID: CA030000094 If continuation sheet 4 of 8 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 04/26/2019 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 dated 2/14/19, indicated Resident 1 had a bed bath and scrotum was swollen. No other documentation that Resident 1 was given a shower or bed bath and subsequent skin check, or refused a shower or bed bath and skin check for the 23 days between 1/21/19 and 2/14/19 was present in the clinical record. No other documentation was present in Resident 1's clinical record that indicated the physician or Resident Representative was notified regarding resident's lack of hygiene care or skin assessments for the 23 days between 1/21/19 and 2/14/19. No documentation was present in Resident 1's record related to the facility's attempts to identify underlying causes of resident's behavior, steps taken to offer alternative care options or promote basic hygiene and skin assessments, and physician or resident representative notification of aggressive and refusal behaviors interfering with basic ADL care needs. A nursing progress note, dated 2/12/19, indicated a certified nursing assistant noticed during incontinence care Resident 1 had redness and swelling to scrotum and the physician and conservator were notified. A nursing progress note on 2/12/19, indicated nursing staff had received a faxed order from the physician to start Resident 1 on oral antibiotics for "scrotum with swelling and redness and is hard and painful to touch." A nursing progress note, dated 2/13/19, indicated Resident 1 continued on antibiotics for scrotal area redness and swelling and there was no drainage noted. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: FYDV11 Facility ID: CA030000094 If continuation sheet 5 of 8 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 04/26/2019 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 A nursing progress note, dated 2/14/19, indicated a physician examined Resident 1's scrotum and it was red, swollen and sore with an opening oozing moderate yellowish drainage and Resident 1 was to be transferred to an emergency room for evaluation. An emergency room initial physical exam, dated 2/14/19, directed Resident 1 appeared cachectic (a general physical wasting and malnourished appearance), distressed and had a sickly appearance. Resident 1 presented with severe scrotal swelling, redness and pain consistent with necrotizing (a flesh-eating bacteria) infection of the scrotum requiring emergency surgery, kidney failure, and dehydration. In an interview with Certified Nursing Assistant (CNA) 1 on 3/18/19 at 12:48 p.m., CNA 1 reported Resident 1 rejected [ADL] care most of the time. CNA 1 stated staff would try talking to the resident and offer care multiple times but if Resident 1 continued to refuse care, they would stop trying and report to the nurse. In an interview with Licensed Nurse (LN) 1 on 3/18/19 at 12:57 p.m., LN 1 stated Resident 1 could be very aggressive at times with [ADL] care and staff would try to re-approach resident when calm. LN 1 also stated for residents in general refusing care, they would try multiple attempts to re-approach resident and then notify the doctor and family about resident's refusal of care. In an interview with the Director of Staff Development (DSD) on 3/18/19 at 2:00 p.m., the DSD stated all residents are bathed twice per week on the evening shift. The DSD stated Resident 1 had extremely few showers or bed baths charted and that no showers or bed FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: FYDV11 Facility ID: CA030000094 If continuation sheet 6 of 8 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 04/26/2019 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 baths were documented for the 23 days between 1/21/19 and 2/14/19. A review of the facility policy titled Activities of Daily Living (ADL), revised March 2018, directed "Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene ...If residents with cognitive impairment or dementia resist care, staff will attempt to identify the underlying cause of the problem and not just assume the resident is refusing or declining care. Approaching the resident in a different way or at a different time, or having another staff member speak with the resident may be appropriate ...The resident's response to interventions will be monitored, evaluated and revised as appropriate." A review of the facility policy titled Care Plans, Comprehensive Person-Centered, revised December 2016, directed resident care plans will; " ...Incorporate identified problem areas ...Aid in preventing or reducing decline in the resident's functional status and/or functional levels ...Reflect currently recognized standards of practice for problem areas and conditions ...The IDT must review and update the care plan when the desired outcome is not met." In an interview with the Director of Nursing (DON) on 3/25/19 at 2:33 p.m., the DON reported she was familiar with Resident 1 and he "always" had aggressive behaviors and refused [ADL] care. She stated the facility was monitoring the resident's behaviors every shift but was unable to locate or provide any further documented evidence related to interventions or assessment and care planning activities to provide adequate hygiene or steps taken to minimize consistent behavioral problems. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: FYDV11 Facility ID: CA030000094 If continuation sheet 7 of 8 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 04/26/2019 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: FYDV11 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 8 of 8