Health inspection·January 25, 2024

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during an abbreviated survey for the investigation of Facility Reported Incident #CA00870839. Representing the Department of Public Health: Health Facilities Evaluator Nurse, 42291 The inspection was limited to the specific Facility Reported Incident investigated and does not represent the findings of a full inspection of the facility.

F609 SS=D Reporting of Alleged Violations CFR(s): 483.12(b)(5)(i)(A)(B)(c)(1)(4)

F609 §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. §483.12(c)(4) Report the results of all LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE 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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: H0DU11 Facility ID: CA030000002 If continuation sheet 1 of 4 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555265 (X3) DATE SURVEY COMPLETED 11/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE UNIVERSITY POST-ACUTE REHAB 2120 Stockton Boulevard Sacramento, CA 95817 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. This REQUIREMENT is not met as evidenced by: Based on observation, interviews, and record review, the facility failed to implement policies and procedures for ensuring the reporting of an allegation of abuse when Resident 1 complained of being inappropriately touched on her left breast by a male occupational therapist (OT 2- a health care worker who helps individuals resume daily tasks such as dressing). This failure resulted in the facility not meeting the mandated reporting requirement of an alleged abuse and prevented the facility from immediate investigation of the allegation. Findings: Resident 1 ' s Facesheet (demographic and medical information sheet) , dated 11/3/23, indicated she was admitted to the facility for aftercare following a knee surgery. A MDS (Minimum Data Set, an assessment tool) dated 11/7/23, described Resident 1 as cognitively intact (able to follow instructions and make decisions). On 11/17/23 Resident 1 informed OT 1 that a male occupational therapist (OT 2) inappropriately touched Resident 1 on her left breast. During an interview on 11/21/23 at 10:25 a.m. with Resident 1 in Resident ' s 1 room, Resident 1 was teary eyed and indicated that while unbuckling her gait belt (safety device to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: H0DU11 Facility ID: CA030000002 If continuation sheet 2 of 4 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555265 (X3) DATE SURVEY COMPLETED 11/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE UNIVERSITY POST-ACUTE REHAB 2120 Stockton Boulevard Sacramento, CA 95817 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE assist moving from bed to chair) the OT 2 reached over her right shoulder and touched/rubbed her left breast. Resident 1 indicated she did not recall the exact date of the event but did tell a physical therapist (PT) the next day or after. During an interview with OT 1 on 11/21/23 at 11:50 a.m., OT 1 indicated that on 11/17/23, at around 3 p.m., Resident 1 stated that she was inappropriately touched by OT 2 and would not work with him. OT 1 indicated that she did not know when the event occurred, but Resident 1 said it was the last time she worked with OT 2. OT 1 indicated she notified her director the same day. During an interview with the Rehabilitation Director (RD), on 11/21/23 at 11:08 a.m., the RD indicated OT 1 notified her in the afternoon on 11/17/23 (via text) that Resident 1 said the incident with OT 2 happened a few weeks ago. Resident 1 said it was the last time OT 2 and Resident 1 worked on dressing, and when trying to remove the gait belt, OT 2 rubbed and touched her breast. RD indicated she notified her Regional Director but not the Facility Administrator (FA). During an interview with the FA, on 11/21/23 at 10:04 a.m., the FA indicated he was notified of the allegation against OT 2 on the morning of 11/20/23. The FA indicated that the facility Abuse Policies and Procedures were not followed. Review of the facility policy titled "Abuse Prevention Program", dated 12/1/22, indicated " ... The facility shall report any and all allegations of abuse to the District CDPH, Local Ombudsman and/or Local Law Enforcement, either by phone, email or facsimile, within 2hour timeframe." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: H0DU11 Facility ID: CA030000002 If continuation sheet 3 of 4 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555265 (X3) DATE SURVEY COMPLETED 11/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE UNIVERSITY POST-ACUTE REHAB 2120 Stockton Boulevard Sacramento, CA 95817 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) FORM CMS-2567(02-99) Previous Versions Obsolete ID PREFIX TAG Event ID: H0DU11 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) Facility ID: CA030000002 (X5) COMPLETE DATE If continuation sheet 4 of 4