Health inspection·July 21, 2025

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide services according to professional standards of quality for one of four sampled residents, Resident 1, when:1. Licensed Nurse 1 (LN 1) did not follow the physician's order; and2. LN 1 and Treatment Nurse (TN) demonstrated different techniques and knowledge in applying [NAME] wraps (adjustable compression wraps used to manage swelling associated with lymphedema, [swelling of a body part, usually an arm or leg, due to a buildup of fluid]) to Resident 1.These failures decreased the facility's potential to safely implement the physician's orders and possibly risk Resident 1's safety.Findings:A review of Resident 1's admission Record, indicated, Resident 1 was admitted to the facility in June 2024 with the diagnosis that included Chronic Venous Hypertension (CVH, high pressure in the leg veins, symptoms can include pain, swelling, varicose veins, and heaviness in the legs) and difficulty in walking.A review of Resident 1's Brief Interview for Mental Status, (BIMS- a tool to assess cognition level) dated 4/18/25, it showed a score of 15 which indicated Resident 1 was cognitively intact. 1. A review of Resident 1's Order Summary Report, dated 3/21/25, indicated, [NAME] wraps to bilateral legs to assist with lymphedema. On in AM, off at hs [bedtime] every day shift.During a concurrent observation and interview in Resident 1's room on 7/21/25 at 10:35 a.m., Resident 1 was seated on her bed, wearing a dress and both of her legs were exposed from her knees to her feet. Resident 1 stated she had Lymphedema, and she was frustrated with the nursing staff because her wrap was supposed to be applied in the morning according to the physician's order, and it should be removed before she goes to bed at night. However, the nurses usually apply it to her lower legs late in the afternoon. Resident 1 took out her wrap from the storage area beneath the seat of her walker, pointed out her lower legs and stated See, I'm not wearing it. Resident 1 stated the nurses do not know how to apply the wrap to her legs.During a concurrent observation and interview in Resident 1's room on 7/21/25 at 12:05 p.m., with LN 1, LN 1 confirmed Resident 1's [NAME] wrap was not currently applied to her lower legs as ordered by the physician. LN 1 stated the physician's order was to apply the wrap in the am and to be taken off at bedtime to help reduce leg swelling due to conditions like lymphedema. LN 1 further stated she should follow the physician's order.2. A review of Resident 1's Care Plan, date initiated 12/11/24, indicated, Resident has HX of weight fluctuations r/t [related to] bilat [bilateral] lower leg Lymphedema,During a concurrent observation and interview in Resident 1's room on 7/21/25 at 12:10 p.m., with LN 1, using Resident 1's right lower leg, LN 1 demonstrated the proper way to apply the [NAME] wrap to Resident 1 by wrapping/covering her right knee down to her ankle. Resident 1 disagreed with LN 1 and informed her that the other nurse did not wrap her knee with the [NAME] wrap just as how LN 1 demonstrated it. LN 1 stated she had explained and demonstrated to Resident 1 multiple times that the wrap should cover her knee but Resident 1 disagreed with LN 1. Finally, LN 1 applied the wrap to Resident 1's bilateral lower leg.During an interview with the Treatment Nurse (TN) on 7/21/25 at 1:44 p.m., the TN stated she Residents Affected - Few (continued on next page) 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. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 055308 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 055308 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elk Grove Post Acute 9461 Batey Avenue Elk Grove, CA 95624 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)