Health inspection·August 8, 2025

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few office team for follow up. I also communicated this with the nurse on duty and the CNA [Certified Nursing Assistant] and relay the information. According to the nurse on duty nothing was brought to her attention before .A review of Resident 1's Progress Note, dated 7/30/25 at 10:15 a.m., indicated .approximately 10:15am writer was walking down hallway and notice resident not up in w/c [wheelchair] today. Writer asked CNA why she wasn't up and that when CNA reported to me she has pain in her leg. Writer assessed and observed RLE with some swelling, no redness, slight discoloration observed to the lower part of the shin and tender to the touch .Resident's assigned charge nurse was informed .A review of Resident 1's Progress Note, dated 7/30/25 at 11:58 a.m., indicated .CNA reported to nurse that resident has pain in right leg with turning or getting resident out of bed. Assessed resident .pain observed on right lower leg above ankle with touching. Tylenol offered for pain, resident took half of dose and refused to take more . Notified MD, received order for STAT x-ray. Will carry out orders and continue to monitor .A review of Resident 1's Progress Note, dated 7/30/25 at 3:23 p.m. indicated .Resident expressed pain when touching right lower leg .A review of Resident 1's Progress Note, dated 7/30/25 at 4:40 p.m., indicated .Approximately 1520 [3:20 p.m.] hours with a follow up visit with resident to check on the pain management and effectiveness and the RLE skin integrity, the resident observed again with facial grimacing once the shin area was touched lightly .MD called, informed of the persistent tenderness to touch, requested for a routine pain management order and order to transfer to the ER [Emergency Room] for further evaluation, MD in agreement . A review of Resident 1's Progress Note, dated 7/30/25 at 4:42 p.m., indicated .MD acknowledged speaking to the resident's [RP] . A review of Resident 1's Progress Note, dated 7/30/25 at 4:50 p.m., .MD gave order .to send resident out to ER for assessment of RLE pain after X-ray was done .A review of Resident 1's Care Plan [Resident 1] has intense pain upon touching right leg, initiated 7/30/25, .Interventions .MD notified .Obtain x-ray .Transfer to ER for Eval [Evaluation] . A review of Resident 1's Care Plan Pain: [Resident 1] is At risk of pain or discomfort due to medical diagnosis of Dementia, initiated 11/22/24, .Interventions .Notify physician if resident experiences unmanageable or intolerable pain .A review of Resident 1's Radiology Report, for x-ray done at the facility, with report date 7/30/25 at 5:59 p.m., indicated .Tibia and Fibula [lower leg bones] .Right .Results .Impacted fracture deformity [ends of bone driven into each other] of the distal femur supracondylar region [thighbone just above the knee] with moderate anterior angulation [curvature angled forward]. Comminuted fracture deformity [bone breaks in three or more pieces] of the distal tibia shaft and possible the calcaneus [heel]. Conclusion: Multiple right lower extremity fractures . Handwritten note on report indicated sent to acute. During a telephone interview on 8/8/25 at 8:42 a.m. with Resident 1's Responsible Party (RP), RP stated Resident 1 had pain in her right leg beginning 7/16/25. The RP stated Resident 1 was not getting anything for pain management. RP stated she asked for MD to contact her regarding Resident 1's pain. The RP stated MD never contacted her. The RP stated on 7/28/25, Resident 1's private caregiver reported to her that Resident 1 still had pain in right leg. The RP requested MD call her. The RP stated the MD did not contact her. The RP stated on 7/30/25 Resident 1 was still in pain and she requested again to speak w/ MD. RP stated facility obtained x-ray that showed comminuted spiral fracture of the tibia. The RP stated Resident 1 is capable of reporting pain and was supposed to get Tylenol as needed for pain. During an interview on 8/8/25 at 11:51 a.m. with the Administrator (ADM), the ADM stated Resident 1 first reported pain on 7/30/25. The ADM stated Resident 1 received Tylenol on 7/30/25, but spit it out. During a joint interview on 8/8/25 at 12:12 p.m. with the ADM and the Director of Nursing (DON), the DON stated Resident 1's MAR did not indicate she had any pain. The DON stated the Assistant Director of Nursing (ADON) found out Resident 1 was having pain on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056410 If continuation sheet Page 2 of 4 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 08/08/2025 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)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 7/30/25 when she talked with the CNA who was not able to put Resident 1 in the wheelchair due to pain and then notified the nurse. The DON stated they use a communication binder to notify MD that family would like call back. The DON stated that MD spoke with family on 7/3/25 and not again until 7/30/25. The DON stated the MD had been on vacation one week in July. Requested documentation from communication binder that MD had been notified of family request for a return call. The ADM stated unable to provide. During an interview on 8/8/25 at 2:24 p.m. with CNA 1, CNA 1 stated approximately two weeks ago, Resident 1 was not responding to her as she usually does. CNA 1 asked another CNA to assist with turning her and Resident 1 would not respond. CNA 1 reported to the nurse who said do not get her up. CNA 1 stated she did not get Resident 1 up the next day. CNA 1 stated the next time she worked with Resident 1, between 7/22/25 and 7/24/25, she asked Resident 1 what was happening because she was not talking. CNA 1 stated Resident 1 responded and said pain. CNA 1 stated she notified nurse who said do not get her out of bed. CNA 1 stated on 7/30/25 she notified the ADON that Resident 1 had pain and moaned when touched. During an interview on 8/8/25 at 2:39 p.m. with Licensed Nurse (LN) 1, LN 1 stated on 7/30/25 she was notified by a CNA that Resident 1 had pain in her right leg. LN 1 stated she assessed Resident 1's pain and observed some discoloration present. LN 1 stated she offered Tylenol, but Resident 1 would not take it. LN 1 stated she was not aware if Resident 1 had any pain prior to 7/30/25.During a concurrent interview and record review on 8/8/25 at 2:52 p.m. with the Case Management Assistant (CMA), reviewed the Progress Note dated 7/28/25 that indicated Resident 1 had pain. The CMA stated she notified the nurse on duty to let her know. The CMA stated she had checked with the CNA and nurse who were not aware she was having pain. The CMA stated she did not know if the nurse then assessed Resident 1 for pain. During an interview on 8/8/25 at 3:32 p.m. with CNA 2, CNA 2 stated if resident complains of pain, she notifies the nurse. CNA 2 stated if a resident has pain she expects the nurse to assess pain and give pain medication. During a telephone interview on 8/14/25 at 9:11 a.m. with Resident 1's Caregiver (CG), the CG stated Resident 1 showed evidence of having pain several times starting the first or second week in July. The CG stated Resident 1 would yell out but when asked would say she was okay. The CG stated she notified the nurse on 7/23/25 that Resident 1 was having pain. CG stated the nurse came in and tried to give Resident 1 Tylenol but she would not take it. CG stated she did not see the nurse do anything else to assess or relieve pain. The CG stated the facility staff stopped getting Resident 1 out of bed on 7/23/25 because her leg was hurting. During a concurrent telephone interview and record review on 8/14/25 with the DON, reviewed Resident 1's CG report of pain to the nurse on 7/23/25. The DON stated she cannot prove that Resident 1's pain was assessed on 7/23/25 as there was no documentation in the progress notes. The DON stated she asked staff if Resident 1 had any complaints of pain or if they noticed anything to indicate pain prior to 7/30/25 and staff did not report anything prior to 7/30/25. Reviewed that Resident 1 was offered Tylenol on 7/23/25 but not indicated in the MAR or in a progress note. The DON stated if Resident 1 was offered Tylenol and refused it should be documented in a progress note. The DON stated the assessment should be documented, especially if offered medication and refused. The DON stated the pain scale in the MAR indicated Resident 1 did not have pain, even on 7/30/25 when she was sent to the hospital due to pain. Reviewed progress notes for 7/23/25, 7/28/25, and 7/29/25. Reviewed with the DON that CNA reported to the nurse that Resident 1 had pain between 7/22/25 and 7/24/25. The DON acknowledged that there are no progress notes that indicate Resident 1 was assessed for pain for 7/22/25 to 7/24/25. The DON stated her expectation if resident has pain, the nurse is to evaluate pain, where it is, what kind of pain it is, if repositioning helps and if medication may be given. A review of the facility's Policy and Procedure (P&P) titled Pain-Clinical Protocol, revised (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056410 If continuation sheet Page 3 of 4 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 08/08/2025 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)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete 4/25, indicated .The provider and staff will identify individuals who have pain or who are at risk for having pain .The nursing staff will assess each individual for pain .when there is onset of new pain .The provider will help identify causes of pain, for example, by examining the resident directly, reviewing the resident's history, and via discussion with the resident and staff .The provider will help identify the extent to which underlying causes of pain can be addressed or reversed . he provider will perform or order appropriate tests as needed to help clarify sources of pain. For example, an x-ray may help to identify the cause of joint pain .The provider will order appropriate non-pharmacologic and medication interventions to address the individual's pain .A review of the facility's P&P titled Resident Rights, revised 2/21, indicated .Federal and state laws guarantee certain basic rights to all residents of the facility. These rights include the resident's right to .communication with and access to people and services, both inside and outside the facility .be informed of, and participate in, his or her care planning and treatment .choose an attending physician and participate in decision-making regarding his or her care . Event ID: Facility ID: 056410 If continuation sheet Page 4 of 4