Health inspection·February 5, 2026

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on interview and record review, the facility failed to follow their policy and procedure for reporting an allegation of abuse for one of four sampled residents (Resident 1) when Resident 1 reported to nursing staff that she was injured by facility staff during patient care. This failure had placed Resident 1 and other residents in the facility at risk for potential physical abuse and/or psychosocial harm.Resident 1 was admitted to the facility October 2025 with multiple diagnoses which included muscle weakness and abnormalities of gait (manner of walking and limb movement) and mobility. A review of Resident 1's Minimum Data Set (MDS, an assessment tool) dated 11/5/25, indicated Resident 1 had moderate memory impairment. During an interview on 2/5/26, at 1:28 p.m., with Licensed Nurse (LN) 1, LN 1 confirmed Resident 1 had informed him that Resident 1 had gotten injured while receiving care by facility staff and that Resident 1 had felt unsafe. LN 1 stated he had not reported the allegation to facility management. During an interview on 2/5/26, at 2:52 p.m., with the Director of Staff Development (DSD), the DSD stated that her expectation from staff is that if they see a new injury they need to report immediately to the nurse. The DSD further stated that if a resident reports they got injured during care with another staff member the CNA is to report as potential abuse. During an interview on 2/5/26, at 3:10 p.m., with the Director of Nursing (DON), the DON stated the expectations were for staff to report to management any injury of unknown source or allegation of abuse. DON further stated if injuries or allegations of abuse were not reported, residents could potentially experience further abuse and be injured. During a review of Resident 1's Progress Note (PN), dated 11/5/25, the PN indicated, .patient [Resident 1] reported recent trauma to bilateral [both sides] legs/feet from dangling off of bed. Noted with large area of bruising to left lower leg.with 0.2cm [centimeter, unit of measurement] linear [straight] break in skin to lateral [side] aspect of L [left] lower leg.Patients preferences (using multiple staff members, gently moving legs) . During a review of Resident 1's hospital record titled, Inpatient Wound Care CAPI, date of service 11/6/25, indicated, Pt [patient] reports she was rolled by a CNA [Certified Nursing Assistant] at SNF [skilled nursing facility] and nearly fell OOB [out of bed] sustaining injuries to her left leg and right foot.Plantar [sole of foot] surface of L foot with circular red/maroon discoloration of unknown etiology [cause] possibly related to trauma. During a review of Resident 1's care plan initiated on 11/6/25, indicated, Resident has impaired skin integrity as evidenced by skin tear.related to trauma and is at risk for infection. During a review of the facility's policy and procedure (P&P) titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, revised 9/22, the P&P indicated, All reports of resident abuse (including injuries of unknown origin0 .are reported to local, state and federal agencies and thoroughly investigated by facility management.if resident abuse.injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law.within two hours of an allegation involving abuse or result in serious bodily injury; or.within 24 hours of an allegation that does not Page 1 of 2 055886 055886 02/05/2026 Roseville Care Center 1161 Cirby Way Roseville, CA 95661

F 0609 involve abuse or result in serious bodily injury. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 055886 Page 2 of 2