Inspection·June 12, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm 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 report an allegation by Resident 1 of verbal abuse to The Department within the regulatory timeframe. Residents Affected - Few This failure had the potential to put Resident 1 at risk of abuse if not investigated by The Department. A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility in November 2024 with multiple diagnoses including polyneuropathy (nervous system disorder that impacts nerve function in multiple areas of the body), chronic obstructive pulmonary disease (lung disease that blocks airflow and makes it difficult to breathe), schizoaffective disorder (mental health condition that is a combination of symptoms of schizophrenia and mood disorder), moderate protein-calorie malnutrition (a deficiency of both calories and protein causing nutritional deficiencies), and cannabis use and stimulant abuse. A review of Resident 1's Minimum Data Set (MDS- federally mandated assessment tool), Cognitive Patterns, dated 2/11/25, indicated Resident 1 had a Brief Interview for Mental Status (BIMS- tool to assess cognition) score of 13 out of 15 that indicated Resident 1 was cognitively intact. A review of Resident 1's Grievance/ Complaint Report Form, dated 3/3/25, indicated .Date of Incident: 3/2/25 .Time of Incident: Approx 11 AM [approximately 11:00 a.m.] Location of Incident: 507A .Detailed Description of Grievance/Complaint .[Resident 1's Family Member] stated staff named [Certified Nursing Assistant-CNA 2] threaten to hurt [Resident 1] .Administrator Acknowledgement Date Received 3/4/25 Name [name of current administrator] .Date of Resolution 3/4/25 . A review of the Investigation Summary indicated two staff, CNA 1 and CNA 2, were interviewed on 3/3/25 and CNA 2 stated he did not make any threatening statements toward the resident. During an interview on 6/12/25 at 11:20 a.m. with the Administrator (ADM), the ADM stated if an abuse allegation is reported, the facility has two hours to report the allegation to the state, the ombudsman (an advocate for residents of nursing homes) and law enforcement if harm. The ADM stated the facility has 24 hours to report if no harm. The ADM stated the facility then sends a 5 day follow-up report of the investigation to The Department and the ombudsman. During a concurrent interview and record review on 6/12/25 at 12:13 p.m. and subsequent interview at 12:53 p.m. with the ADM, reviewed Resident 1's Grievance/Complaint Report Form, dated 3/3/25, and allegation that CNA 2 had threatened Resident 1. When asked if a verbal threat is considered abuse, the ADM acknowledged that a verbal threat can be considered abuse. The ADM stated the verbal abuse (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 2 Event ID: 056410 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 056410 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/12/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Whitney Oaks Care Center 3529 Walnut Avenue Carmichael, CA 95608 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)