Health inspection·April 18, 2023

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few manager immediately if a resident was yelling stop repeatedly, appears to be in pain or being cared for harshly in anyway as this could be an abusive situation that needed further investigation. Unlicensed Staff A stated if an alleged abuse was not reported immediately, it could result to continued abuse, resident would feel unhappy, hopeless, scared, and angry. Unlicensed staff A stated, all abuse allegations had to be reported to the state, the Ombudsman, and the law enforcement within 24 hours upon learning of the incident. During an interview on 3/27/23 at 3:02 p.m., Unlicensed Staff B stated, allegation of abuse should be reported immediately. Unlicensed Staff B stated hearing a resident yelling stop repeatedly or observing a harsh care being provided to a resident need to be reported immediately because that could be an indication of abuse. When asked what immediately meant, Unlicensed Staff B stated, I'm not really sure but I think all abuse allegations need to be reported within 24 hours. Unlicensed Staff B stated, if abuse allegations were not reported immediately, resident would not be safe. Unlicensed Staff stated, residents could get injured and experience emotional distress. Unlicensed Staff B stated, resident would end up feeling angry and scared. During an interview on 3/27/23 at 3:28 p.m., Licensed Staff C stated, all abuse allegations would need to be reported to the state, Ombudsman, and the law enforcement, immediately within 24 hours. Licensed Staff C stated he did not know which document he needed to fill out when reporting abuse to the state, the ombudsman, and the law enforcement agency. Licensed Staff C stated if a resident was yelling stop continuously and complaining of pain or if staff observed someone treating a resident harshly in any way, this could mean it was an abusive situation that would need further investigation and would need to be reported immediately. Licensed Staff C stated residents' safety was a top priority. Licensed Staff C stated, if an abuse allegation was not reported immediately, it could result to resident feeling alone, scared, depressed and angry. Licensed Staff C stated failure to report an abuse allegation immediately could result to further abuse. During an interview on 3/27/23 at 4:07 p.m., Licensed Staff D stated, if there was an abuse allegation, staff would need to fill out SOC 341. Licensed Staff D stated, all abuse allegations had to be reported to the state, Ombudsman, and local enforcement agency within 2 hours. Licensed Staff D stated, if a resident was being treated harshly in anyway, it could mean an abuse is going on and would need to investigate further. Licensed Staff D stated, residents' safety was always the priority. Licensed Staff D stated, if an abuse allegation was not investigated and reported timely, the abuse could continue. Licensed Staff D stated this could result to resident feeling angry and scared. Licensed Staff D stated, resident will not trust staff thinking staff did not do anything to help them anyway. During a concurrent interview and nursing note dated 3/23/23 9:30 p.m., record review on 3/27/23 at 4:51 p.m. the Director of Nursing (DON) verified that on the evening of 3/23/23, she was notified by Unlicensed Staff E regarding an incident involving Resident 1 and her son. The DON stated she could not recall the details of the call but was concerned on how Resident 1's son was treating the staff versus on how Resident 1's son was providing care for her. The DON stated she was not worried about Resident 1 when she received the report regarding an incident between Resident 1 and her son, but more so on Resident 1's son behavior towards the staff. The DON stated Licensed Staff E had concerns, among others, about Resident 1's son caring for her. The DON verified the nursing note on 3/23/23 9:32 p.m., indicated Resident 1's son was unsafely handling her while being repositioned in bed, flat on the bed, with GT feeding running . son was tugging the bedsheet harshly while repositioning her. When asked if this could be considered an alleged abuse situation, the DON stated it was hard to say. When asked if Resident 1's son tugging on Resident 1's sheets harshly while repositioning her (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055014 If continuation sheet Page 2 of 3 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055014 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fairfield Post-Acute Rehab 1255 Travis Blvd Fairfield, CA 94533 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Minimal harm or potential for actual harm and Resident 1's son unsafe handling while repositioning her could be considered an abuse, thus needing to be investigated and reported immediately, the DON stated it was a tricky question. The DON stated, based on the facility policy, the facility met the abuse reporting time frame since they had reported the abuse allegation within 24 hours anyway. The DON stated abuse that resulted to an injury would be reported within 2 hours. Residents Affected - Few During a telephone interview on 3/29/23 at 3:04 p.m., Unlicensed Staff E verified that on the night of 3/23/23, she had reported to the DON and the Administrator, an incident involving Resident 1 and her son. Unlicensed Staff E stated the call was prompted because she felt the situation was abusive in nature. Unlicensed Staff E stated, the situation did not feel right, the way Resident 1's son was caring for her. During a review of the facility's policy and procedure (P&P), titled Fairfield Post Acute Rehab Policy and Procedure- Nursing Administration, Residents Rights section, Abuse Prevention revised 12/2021, the P&P indicated, all alleged incidents of abuse are to be reported to the state immediately or within 24 hours .allegation of resident abuse, neglect, misappropriation of resident property or injury of unknown source will be reported within 24 hours to the appropriate state agency, the Department of health and the Ombudsman. A review of the Federal Regulation 609, 42 CFR 483.12(c) indicated all alleged violations should be reported immediately but not later than 2 hours if the alleged violation involves abuse or results in serious bodily injury. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055014 If continuation sheet Page 3 of 3