Other·March 16, 2018

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 entity reported incident #CA00548200. Representing the Department of Public Health: HFEN, 36681 The inspection was limited to the specific entity reported incident investigated and does not represent the findings of a full inspection of the facility.

F226 SS=D DEVELOP/IMPLMENT ABUSE/NEGLECT, ETC POLICIES CFR(s): 483.12(b)(1)-(3), 483.95(c)(1)-(3)

F226 03/22/2018 483.12 (b) The facility must develop and implement written policies and procedures that: (1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, (2) Establish policies and procedures to investigate any such allegations, and (3) Include training as required at paragraph §483.95, 483.95 (c) Abuse, neglect, and exploitation. In addition to the freedom from abuse, neglect, and exploitation requirements in § 483.12, facilities must also provide training to their staff that at a 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: NSNB11 Facility ID: CA030000025 If continuation sheet 1 of 3 PRINTED: 05/14/2026 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: _______________ 055855 (X3) DATE SURVEY COMPLETED 03/13/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ARDEN PARK POST ACUTE 3400 Alta Arden Expressway Sacramento, CA 95825 (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 minimum educates staff on(c)(1) Activities that constitute abuse, neglect, exploitation, and misappropriation of resident property as set forth at § 483.12. (c)(2) Procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property (c)(3) Dementia management and resident abuse prevention. This REQUIREMENT is not met as evidenced by: Based on interview and document review, the facility failed to follow their procedure for reporting an allegation of abuse for 1 of 3 sampled residents (Resident 1). This failure increased the potential for inadequate protection of residents. Findings: Resident 1 was admitted on 12/9/2016 with diagnosis including muscle weakness. Resident 1's Physician's Order dated 12/09/2016 indicated, "Resident has the capacity to understand choices & make medical decisions." Resident 1's Brief Interview for Mental Status (BIMS, a tool used to assess cognition) from the Minimum Data Set (MDS, an assessment tool) dated 6/9/17 indicated a score of 15 which means Resident 1 was cognitively intact. Resident 2 was admitted to the facility on 10/2/2013 with diagnosis including cognitive communication deficit. Resident 2's Physician Order dated 10/02/2013 indicated, "Resident does not have the capacity to understand and make decisions as R/T [related to]: developmental delay." Resident 2's BIMS FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NSNB11 Facility ID: CA030000025 If continuation sheet 2 of 3 PRINTED: 05/14/2026 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: _______________ 055855 (X3) DATE SURVEY COMPLETED 03/13/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ARDEN PARK POST ACUTE 3400 Alta Arden Expressway Sacramento, CA 95825 (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 dated 6/29/17 indicated a score of 12 which means moderately impaired for cognition. A Nurse's Notes dated 8/05/17 at 1200 from Resident 1's medical record indicated, "Yelled at his roommate [Resident 2] who was trying to use a bathroom. Poured cup of milk on his roommate [Resident 2] using foul-foul language. No physical contact/damage happened. Per charge nurse and CNAs [Certified Nursing Assistant], [Resident 1] has angry outburst toward all his roommates all the time... His roommate got moved to a different room. Continue to monitor for inappropriate behavior." An interview with the Administrator (AD) was conducted on 8/23/17 at 1:10 p.m. The AD stated the incident on 8/5/17 with Resident 1 and Resident 2 was not reported to him or to the Director of Nursing (DON). In an interview with the Supervisor Nurse (SN) on 8/23/17 at 2:05 p.m., she confirmed she did not call the AD or the DON because the incident was witnessed and there was no physical contact. An undated document titled, "Allegation of Abuse Guidance for Department Manager, Unit Manager, RN [registered nurse] supervisor, and Licensed Nurse"...For Allegation of Resident vs Resident Abuse: "...IMMEDIATELY notify Abuse Coordinator, Administrator, AND Director of Nursing". FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NSNB11 Facility ID: CA030000025 If continuation sheet 3 of 3