Other·September 5, 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 facility reported incident #CA00598135. Representing the Department of Public Health: HFEN, #29821 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(c)(1)(4)

F609 09/11/2018 §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 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: VDIP11 Facility ID: CA030000057 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: _______________ 555098 (X3) DATE SURVEY COMPLETED 08/28/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GREENHAVEN HEALTHCARE CENTER 455 Florin Road Sacramento, CA 95831 (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 procedures. §483.12(c)(4) Report the results of all 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 staff interview and document review, the facility failed to report an allegation of staff mistreatment of Resident 1 to the Department within 24 hours. This failure could have potentially caused a delay in the Department's investigation of the alleged incident. Findings: At 8:48 a.m., 8/3/18, the Department received a FAX with a cover letter titled, "Abuse Investigation [Resident 1]." The FAX included results of a facility investigation into an abuse allegation made by Resident 1 to Certified Nurse Assistant 1 (CNA 1) at approximately 7:30 p.m., 7/29/18. A Department representative immediately notified the facility that the Department had not received prior information regarding an abuse allegation made by this resident. At 9:24 a.m., 8/3/18, the Department received a FAX from the facility with a report including Resident 1's allegation of verbal abuse from a Certified Nurse Assistant (CNA 2). The report noted the "Date/Time of Incident" as "7/28/2018 noc shift [7/28/18 - 7/29/18 night shift]." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VDIP11 Facility ID: CA030000057 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: _______________ 555098 (X3) DATE SURVEY COMPLETED 08/28/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GREENHAVEN HEALTHCARE CENTER 455 Florin Road Sacramento, CA 95831 (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 In a 12:43 p.m., 8/17/18 interview and concurrent document review, the Director of Nursing (DON) indicated the facility had attempted to FAX the initial allegation report to the Department on 7/30/18. The facility's FAX machine made six attempts between 6:32 a.m. - 6:52 a.m. to send the SOC; the machine then notified the facility that the document had not been sent by displaying a "Send Again" alert on a document titled, "Transmission Report - Job Undelivered." The DON was unable to locate verification that the facility made additional attempts to resend the allegation report prior to 8/3/18. She stated, "Technically I don't have confirmation for a completed FAX on our end." Because a facility employee was aware of the alleged mistreatment at approximately 7:30 p.m., 7/29/18, reporting to the Department was required no later than 7:30 p.m., 7/30/18. Review of the facility's 11/28/17 "Elder and Dependent Abuse Suspected Abuse & Reporting [sic]" policy reflected, "The mandated reporter is responsible for completing a telephone report and written SOC 341 report...the licensing agency (CDPH [California Department of Public Health]) immediately or as soon as practicably possible. The written SOC 341 report must be completed within two working days unless the suspected/alleged abuse is physical abuse...." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VDIP11 Facility ID: CA030000057 If continuation sheet 3 of 3