Health inspection·July 22, 2024

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of Resident 1's NN, dated 7/3/24 at 12:23 p.m., the NN indicated that a Foley catheter (type of indwelling urinary catheter) with a balloon was inserted, and a sample of urine was obtained. During a review of Resident 1's care plan, last revised 7/11/2024, the care plan did not indicate that Resident 1 had an indwelling urinary catheter, and did not include interventions to manage an indwelling urinary catheter according to professional standards to prevent a urinary tract infection. The care plan did not indicate any updates to Resident 1's focus area of mixed bladder incontinence (lack of control over emptying the bladder). During a review of Resident 1's Nursing Weekly Summary Notes, dated 7/13/24 and dated 7/20/24, the Nursing Weekly Summary Notes indicated that Resident 1 was incontinent and in briefs. There was no documented evidence of an indwelling urinary catheter. During an observation on 7/22/24, at 9:50 a.m., in Resident 1's room, the urinary drainage bag, which was connected to the indwelling urinary catheter was on the floor. This increases the potential for dirt and germs to enter the bag through the drainage spout. The urine drainage bag was without a privacy cover, which is used to conceal the draining urine from public view and protect the dignity of the resident. During an interview on 7/22/24, at 9:55 a.m., with Certified Nurse Assistant (CNA), CNA confirmed that the bag was on the floor and stated, The bag should be covered. During an interview on 7/22/24, at 11:10 a.m., with the Infection Preventionist (IP), the IP stated that the indwelling urinary catheter bag should be covered, never be above the bladder, and should never rest on the floor. IP stated that these practices were needed to prevent urinary tract infections. During an observation and interview on 7/22/24 at 11:45 a.m., in Resident 1's room, Resident 1's urinary drainage bag had a privacy cover but was still resting on the floor. During an interview on 7/22/24, at 12:01 p.m., with Licensed Nurse (LN), LN confirmed Resident 1 had an indwelling urinary catheter. LN listed the care required for a resident with an indwelling urinary catheter as monitoring urinary output, cleaning around the catheter with soap and water every shift, and if leaking or clogged, flushing or replacing it. When asked to find these orders for the catheter, LN could not find them and stated, [Resident 1] doesn't have an order. Strange. LN stated that she could not find documentation of care or monitoring provided for Resident 1's indwelling urinary catheter. LN further stated that the urine collection bags should be covered and should not be on the floor. LN stated that if care was not completed as stated, the resident could develop an infection. During an interview and record review of Resident 1's medical record on 7/22/24, at 12:12 p.m., with the Director of Nursing (DON), the DON stated there was no active physician order for an indwelling urinary catheter for Resident 1. In addition, the DON stated that the indwelling urinary catheter was not in Resident 1's care plan and that there was no documentation of care and monitoring of the catheter. The DON stated that inserting and maintaining an indwelling urinary catheter required a physician order. The DON stated that the initial catheter order would trigger a set of orders to address the care and monitoring of the catheter. The DON stated that urinary catheter bags should be covered and never on the floor. The DON stated that failure to follow these practices can lead to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055886 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 055886 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Roseville Care Center 1161 Cirby Way Roseville, CA 95661 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 0690 increased risk for infection. Level of Harm - Minimal harm or potential for actual harm During a review of the facility's policy and procedure (P&P) titled, Indwelling Catheter Insertion, Female Resident, dated August 2022, the P&P indicated, Verify that there is a Physician's order, and, Report information in accordance with facility policy and professional standards of practice. Residents Affected - Few During a review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, dated March 2022, the policy indicated, .care plans are revised as information about the residents and the residents' conditions change. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055886 If continuation sheet Page 3 of 3