Health 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 Page 1 of 2 056410 056410 06/12/2025 Whitney Oaks Care Center 3529 Walnut Avenue Carmichael, CA 95608

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few allegation was not reported to The Department. The ADM stated he did not recognize it, at the time, as verbal abuse. The ADM stated, Should have been reported on 3/3/25 with a follow-up 5 day report. The ADM stated he will take the blame for not reporting Resident 1's abuse allegation. During an interview on 6/12/25 at 1:02 p.m. with Director of Staff Development (DSD), the DSD stated abuse allegations are to be reported, depending on injury, immediately or within 24 hours to The Department, the ombudsman, and law enforcement, if needed. The DSD stated the staff is advised to report abuse within the regulatory timeframe. When asked if a verbal threat to resident would be considered abuse, the DSD acknowledged that a verbal threat would be considered abuse. A review of the facility's Policy and Procedure (P&P) titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised 4/21, indicated .Residents have the right to be free from abuse .This includes but is not limited to freedom from .verbal .abuse .Identify and report any allegations within timeframes required by federal requirements . A review of the facility's P&P titled Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, revised 9/22, indicated .All reports of resident abuse . are reported to local, state and federal agencies (as required by current regulations) .If resident abuse .is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law .The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: .The state licensing/certification agency responsible for surveying/licensing the facility .The local /state ombudsman .Law enforcement officials .Immediately is defined as: .within two hours of an allegation involving abuse or result in serious bodily injury; or .within 24 hours of an allegation that does not involve abuse or result in serious bodily injury .Within five (5) business days of the incident, the administrator will provide a follow-up investigation report . 056410 Page 2 of 2