Other·March 24, 2017

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 complaint #CA00511986. Representing the Department of Public Health: HFEN, 26663 The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility.

F354 SS=F WAIVER-RN 8 HRS 7 DAYS/WK, FULL-TIME DON CFR(s): 483.35(b)(1)-(3)

F354 03/08/2017 (1) Except when waived under paragraph (e) or (f) of this section, the facility must use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week. (2) Except when waived under paragraph (e) or (f) of this section, the facility must designate a registered nurse to serve as the director of nursing on a full time basis. (3) The director of nursing may serve as a charge nurse only when the facility has an average daily occupancy of 60 or fewer residents. This REQUIREMENT is not met as evidenced by: Based on interview and facility document review, the facility failed to ensure it used the services of a registered nurse (RN) for at least 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: ONVX11 Facility ID: CA030000097 If continuation sheet 1 of 20 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: _______________ 055417 (X3) DATE SURVEY COMPLETED 02/17/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SAYLOR LANE HEALTHCARE CENTER 3500 Folsom Boulevard Sacramento, CA 95816 (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 8 consecutive hours a day, 7 days a week when there was no RN on duty over a weekend to assess residents when a respiratory outbreak occurred, for a census of 37. This failure had the potential to contribute to the potential risk of residents not reaching or maintaining their highest practicable well-being. Findings: Review of the "Nursing Staffing Assignment and Sign-In Sheet," dated Saturday 11/26/16, indicated all licensed nurses on the schedule for 3 shifts were listed as "RN/[Licensed Vocational Nurse (LVN)]," without any distinction, for each name. Review of the "Nursing Staffing Assignment and Sign-In Sheet," dated Sunday 11/27/16, indicated all nurses on the schedule for 3 shifts were listed as "RN/LVN." During an interview with the Director of Staff Development (DSD) on 12/8/16 at 2:45 p.m., the DSD reviewed the Saturday 11/27/16 and Sunday 11/28/16 schedules of staff that worked and stated, "All the nurses are LVN's, no RN is on schedule." During an interview with RN 2 on 12/8/16 at 3:15 p.m., RN 2 stated there was not a RN scheduled to work the weekends in the facility. In an interview with the Director of Nurses (DON) on 12/8/16 at 3:40 p.m., she stated, "We don't have RN's [working here] on the weekend." When asked who had been in charge of the building on the weekend, the DON responded, "Every nurse on the floor." In a concurrent interview with the Administrator on 12/8/16 at 3:40 p.m., he stated the facility had not had an RN on the schedule for "a long FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ONVX11 Facility ID: CA030000097 If continuation sheet 2 of 20 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: _______________ 055417 (X3) DATE SURVEY COMPLETED 02/17/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SAYLOR LANE HEALTHCARE CENTER 3500 Folsom Boulevard Sacramento, CA 95816 (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 time."

F441 SS=H INFECTION CONTROL, PREVENT SPREAD, F441 LINENS CFR(s): 483.80(a)(1)(2)(4)(e)(f) 03/08/2017 (a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: (1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards (facility assessment implementation is Phase 2); (2) Written standards, policies, and procedures for the program, which must include, but are not limited to: (i) A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility; (ii) When and to whom possible incidents of communicable disease or infections should be reported; (iii) Standard and transmission-based precautions to be followed to prevent spread of infections; FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ONVX11 Facility ID: CA030000097 If continuation sheet 3 of 20 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: _______________ 055417 (X3) DATE SURVEY COMPLETED 02/17/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SAYLOR LANE HEALTHCARE CENTER 3500 Folsom Boulevard Sacramento, CA 95816 (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 (iv) When and how isolation should be used for a resident; including but not limited to: (A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. (v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and (vi) The hand hygiene procedures to be followed by staff involved in direct resident contact. (4) A system for recording incidents identified under the facility’s IPCP and the corrective actions taken by the facility. (e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. (f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary. This REQUIREMENT is not met as evidenced by: Based on observations, interviews, and facility document review, the facility failed to effectively implement its infection control policy for 37 of 37 residents when: 1. An outbreak of respiratory infections was not recognized when four residents had developed a cough in the facility, and notification to the Department was not made until 9 residents FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ONVX11 Facility ID: CA030000097 If continuation sheet 4 of 20 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: _______________ 055417 (X3) DATE SURVEY COMPLETED 02/17/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SAYLOR LANE HEALTHCARE CENTER 3500 Folsom Boulevard Sacramento, CA 95816 (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 exhibited a cough; 2. The facility failed to implement any meaningful measures to prevent the spread of a respiratory illness which affected 2 employees and 16 residents, or 43% of the residents in the facility. As a result of these failures 16 residents developed symptoms of respiratory infection, 4 were hospitalized (Resident 3, Resident 5, Resident 12, and Resident 13), and 3 died after developing respiratory symptoms. Findings: A. Resident 1 was admitted to the facility in 2014 with diagnoses which included failure to thrive and chronic pain. Review of the clinical record for Resident 1 revealed: a. An 11/18/16 physician's order for a chest xray. b. An 11/18/16 physician's order for oxygen (O2) at 2 liters (a low O2 flow rate) per minute to keep her O2 saturation (O2 sat) above 90%. The order also included obtaining a, "Nasal swab for influenza A and B (flu)." Review of the Lippincott Manual of Nursing Practice, 9th Edition, on page 213, described, "Oxygen saturation, as measured by a pulse oximeter, is a non-invasive estimate of oxygen level in the blood." The normal range is 95100%, 90% or lower is considered to be a low oxygen level. c. An 11/18/16 chest x-ray report concluded, "Right basilar (base of lung) airspace disease commonly relates to pneumonia..." d. A laboratory report, dated 11/20/16, directed, "Improper collection. Received E Swab, please use flu kit." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ONVX11 Facility ID: CA030000097 If continuation sheet 5 of 20 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: _______________ 055417 (X3) DATE SURVEY COMPLETED 02/17/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SAYLOR LANE HEALTHCARE CENTER 3500 Folsom Boulevard Sacramento, CA 95816 (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 e. A laboratory report for the resubmitted specimen, dated 11/30/16, concluded tests for influenza A and B were both negative. During an observation on 11/28/16 at 2:12 p.m., Resident 1 was in her bed wearing oxygen tubing. She appeared to be asleep. B. Resident 2 was admitted to the facility in early 2016 with diagnoses which included diabetes. Review of the clinical record for Resident 2 included: a. An 11/21/16 note faxed to the physician which communicated, "Noted sore throat, no cough, slight runny nose...daughter keep saying 'my mother is sick call doctor,' please advise." The physician wrote the following on the return fax, "Claritin 5 [milligrams (mg)]...[for] 10 days, Nasal swab for [influenza (flu virus)] A and B." Claritin is an over-the-counter allergy medication. b. A nurses note, dated 11/26/16 at 3 p.m., indicated, "Seen by MD [Medical Doctor] today. New order start [antibiotic]." c. A nurses note, dated 11/27/16, described the resident having "slight wheezing," an indication of lung issues. C. Resident 3 was a 90 year old woman admitted to the facility 1 year earlier with diagnoses which included unspecified mental disorders. Review of the clinical record for Resident 3 included: a. A physician's note, dated 11/25/16, which documented the resident had a "cough [for] 3 days," indicating the onset of the resident's cough was 11/23/16. b. Nurses notes, dated 11/25/16, included the resident had a "cold/cough." The note indicated her O2 sat was 94% without giving FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ONVX11 Facility ID: CA030000097 If continuation sheet 6 of 20 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: _______________ 055417 (X3) DATE SURVEY COMPLETED 02/17/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SAYLOR LANE HEALTHCARE CENTER 3500 Folsom Boulevard Sacramento, CA 95816 (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 supplemental oxygen. c. An physician's order, dated 11/25/16, directed staff to start antibiotics and obtain a chest x-ray. Another 11/25/16 order was to start oxygen at 2 liters per minute to keep the O2 sat over 90%. d. A report of a chest x-ray performed 11/26/16, indicated, "Results: There is increased density (usually due to fluid in the lung) at the right lung base." e. A complete blood count (CBC) done 11/26/16, revealed the white blood cell (WBC) count was 25.5, normal range was defined on the report as 4-10. Elevated WBC's indicated infection or inflammation. f. A Resident Transfer Form, dated 11/27/16, indicated the resident had "O2 sat 83% on 4 liters [oxygen], lethargic (sluggish), labored breathing." General Acute Care Hospital (GACH) clinical records for Resident 3 included: a. A chest x-ray, dated 11/27/16 at 7:50 a.m., indicated, "Findings...Thick linear band right lung base consistent with atelectasis [a partial collapse of the lung]." b. A Physician Consultation report, dated 11/27/16, indicated she was seen in the emergency department (ED) for "Acute respiratory failure." (Acute respiratory failure occurs when fluid builds up in the air sacs in the lungs. When that happens, the lungs can't release oxygen into the blood. In turn, the organs can't get enough oxygen-rich blood to function.) The History of Present Illness included, "Normally, she is fully alert and oriented walking around...currently totally ill, so she cannot really give any kind of history." The physician wrote, "I am concerned she may not survive hospitalization. We will focus on comfort measures alone." The GACH record indicated Resident 3 expired on 11/27/16 at 10:10 p.m., 14.5 hours after leaving the nursing FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ONVX11 Facility ID: CA030000097 If continuation sheet 7 of 20 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: _______________ 055417 (X3) DATE SURVEY COMPLETED 02/17/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SAYLOR LANE HEALTHCARE CENTER 3500 Folsom Boulevard Sacramento, CA 95816 (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 home. D. Resident 5 was most recently readmitted to the facility in early November 2016 with diagnoses which included kidney failure and cognitive decline. Review of the clinical record for Resident 5 included: a. A physician's order, dated 11/23/16, for Robitussin cough syrup every four hours as needed. b. A nurses note, dated 11/23/16 at 10 a.m., indicated the resident was using oxygen at 2 liters per minute and had an O2 sat of 92%. c. A nurses note, dated 11/27/16 at 7:30 a.m., revealed, "Resident was experiencing [increased] confusion, [low] O2 sat and twitching. O2 sat 88% on 4 [liters] O2. Body twitching. Labored breathing. Unable to answer questions appropriately...resident was sent to ER." The GACH records for Resident 5, dated 11/27/16, indicated she arrived in the emergency room at 7:51 a.m. and had a temperature of 103.2° Fahrenheit (F) and a respiratory rate of 28 breaths per minute [normal range 12-20], her pulse was 107 beats per minute [normal range 60-100], and the physician described her as "ill appearing." The chest x-ray was, "Minimal opacity (lack of transparency) at the right lung base." (Lung opacity is an indication of lung disease including pneumonia.) The WBC level was "18.4," significantly elevated. The "Hospitalist Discharge Summary," dated as completed 12/2/16, described Resident 5's final diagnoses as: "Hypoxemia [low oxygen levels in the blood]...Pneumonia of lower lobe due to infectious organism...Patient went into acute respiratory failure overnight...[family] requested FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ONVX11 Facility ID: CA030000097 If continuation sheet 8 of 20 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: _______________ 055417 (X3) DATE SURVEY COMPLETED 02/17/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SAYLOR LANE HEALTHCARE CENTER 3500 Folsom Boulevard Sacramento, CA 95816 (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 patient to be made comfort care and hospice was consulted today. Patient was placed on morphine (narcotic pain medication also helpful in controlling shortness of breath) drip which was changed to [liquid morphine by mouth] prior to discharge to [skilled nursing facility (SNF)]...Condition on discharge: Guarded...She is oriented to person, place and time. She appears distressed." Review of an electronic health record note from Resident 5's primary care physician's office, dated 12/9/16, included, "Patients daughter called wanting to inform [doctor's name] that patient has passed away." With the onset of Resident 5's cough on 11/23/16, the facility had 4 residents with coughs and new orders to treat their coughs. During an observation on 11/28/16, starting at 12:45 p.m., 3 Certified Nursing Assistants (CNAs) were observed wearing masks near the nurse's station. More than 10 residents were observed in the dining room for lunch. In an interview with CNA 1 on 11/28/16 at 12:45 p.m., CNA 1 stated staff were wearing masks because, "Some people have a little cough." In an interview with (Licensed Vocational Nurse) LVN 1 on 11/28/16 at 12:50 p.m., LVN 1 stated 4 residents "have a cough." She provided the names of Resident 4, Resident 7, Resident 9, and Resident 8. LVN 1 stated chest x-rays had been done and those residents were all on an antibiotic. E. During a tour of the facility on 11/28/16 starting at 12:52 p.m., Resident 6 was observed in bed resting with her eyes closed. She was wearing an oxygen tube [cannula] in FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ONVX11 Facility ID: CA030000097 If continuation sheet 9 of 20 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: _______________ 055417 (X3) DATE SURVEY COMPLETED 02/17/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SAYLOR LANE HEALTHCARE CENTER 3500 Folsom Boulevard Sacramento, CA 95816 (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 her nostrils. Her roommate (Resident 3) was not in the room and the bed was made. F. During an observation and interview on 11/28/16 at 1 p.m., Resident 7 was observed in her room and she stated, "I can't be in the dining room because I have a cough." G. During an observation and interview on 11/28/16 at 1:03 p.m., Resident 8 was heard coughing productively. The resident was alert and appropriate and stated she had a cough for 4 days. She had a roommate in her room, Resident 15. H. During an observation and interview on 11/28/16 at 1:10 p.m., Resident 9 was observed in her room and she was heard to have a productive cough. Resident 9 stated, "I thought it was just a cold." She stated she had a chest x-ray and started antibiotics. She stated the cough and fever started 4 to 5 days earlier. She complained of a reduced appetite and stated the doctor saw her yesterday. Resident 9 was observed to have 2 roommates, Resident 11 and another woman. During the tour, all resident rooms were observed and none of the rooms contained isolation supplies or any signage that indicated protective measures against the spread of infection had been initiated. Review of a 24 Hour Report, dated 11/27/16, listed 2 residents who had been sent to the emergency room (Residents 3 and 5) and 4 other residents (Residents 7, 8, 9, and 10) who had been started on antibiotics for an "[upper respiratory infection (URI)]." The report also noted Resident 3 had, "Passed away at hospital." In an interview with the Director of Nurses FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ONVX11 Facility ID: CA030000097 If continuation sheet 10 of 20 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: _______________ 055417 (X3) DATE SURVEY COMPLETED 02/17/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SAYLOR LANE HEALTHCARE CENTER 3500 Folsom Boulevard Sacramento, CA 95816 (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 (DON) on 11/28/16 at 1:15 p.m., the DON stated, "Whoever coughs or exhibits cold symptoms is kept in their room and we use Universal Precautions (the practice in medicine of avoiding direct contact with patients' bodily fluids, by means of the wearing of nonporous articles such as medical gloves)." The DON was asked what constituted an outbreak of symptoms to her, she stated, "More than 3 - 4 cases we consider an outbreak." The DON stated the outbreak had not been reported to local health officials or the Department, although it was to be done "Immediately when more than 2 - 3 people had symptoms." She stated the outbreak started "Some time last week." During an interview with the Director of Staff Development (DSD) on 11/28/16 at 2:15 p.m. the DSD stated an outbreak was, "three cases of the same virus or symptoms." The DSD stated she had not been at work over the weekend. The DSD stated she advised staff to keep an eye on residents, check their temperatures, and if more people or symptoms we report it to local health officials and the Department. Review of the facility's policy titled, "Outbreak of Communicable Disease," dated as revised December 2009, directed, "Outbreaks of communicable diseases within the facility will be promptly identified and appropriately handled. An outbreak of most communicable disease can be defined as one of the following...Occurrence of three (3 - 4) or more cases of the same infection over a specified time and in a defined area." In an interview with the MD on 11/29/16 at 4:15 p.m., the MD stated, "Until yesterday I wasn't aware [of the outbreak], I should have been notified." The MD verified all patients in the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ONVX11 Facility ID: CA030000097 If continuation sheet 11 of 20 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: _______________ 055417 (X3) DATE SURVEY COMPLETED 02/17/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SAYLOR LANE HEALTHCARE CENTER 3500 Folsom Boulevard Sacramento, CA 95816 (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 sample were his patients. Review of a letter to the Department, dated 11/28/16 and faxed at 4:40 p.m., by the Administrator, included: "This letter is to inform you of a potential outbreak at [facility] of common cold symptoms. As of 11/28/16 there are six possible cases of [upper respiratory illness (URI)] where antibiotics were ordered by the physician. One of the six is positive for pneumonia...Three of the residents received a chest x-ray that came back clear." In an interview with the Administrator on 12/8/16 at 3:40 p.m., the Administrator agreed the outbreak had occurred approximately 11/24/16. When asked if the facility had responded to the outbreak promptly, he stated, "No." He stated, "I should have been notified." Four other residents (Residents 4, 7, 8, and 9) were affected by the outbreak before the Department was notified. I. Resident 4 was most recently readmitted to the facility in October 2016 with diagnoses which included chronic lung disease. Review of the clinical record for Resident 4 included: a. A nurses note, dated 11/25/16, indicated, "Has a bad cough and yellow sputum..." Later the same day another nurses note included, "Continues to cough up sputum." b. A physicians order, dated 11/26/16, for antibiotics and cough medicine. Another order the same date was for a CBC. c. A physician's order, dated 11/27/16, for a chest x-ray and a pertussis (whooping cough, a highly contagious respiratory tract infection) antibody test. d. Results of the 11/27/16 CBC included white blood cells at the high end of normal range, at FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ONVX11 Facility ID: CA030000097 If continuation sheet 12 of 20 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: _______________ 055417 (X3) DATE SURVEY COMPLETED 02/17/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SAYLOR LANE HEALTHCARE CENTER 3500 Folsom Boulevard Sacramento, CA 95816 (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 9.6. e. A report of a chest x-ray, dated 11/28/16, concluded, "Possible early left lower lobe infiltrate (fluid filled area of the lung)." During an interview with the local public health nurse (LPHN) on 1/12/17 at 9 a.m., the LPHN stated Resident 4 had tested positive for Respiratory Syncytial Virus (RSV), a common wintertime respiratory virus that affects persons of all ages and is the major cause of serious lower respiratory tract infections in young children. However, RSV is also an important pathogen in adults, particularly in the elderly, patients with chronic lung disease or those with impaired immunity. J. Resident 7 was admitted to the facility most recently in the Summer of 2016 with fractured ribs and anemia (low red blood cell count). Review of the clinical record for Resident 7 included: a. A physician's order, dated 11/27/16, for a chest x-ray, breathing treatments, and an antibiotic. b. A chest x-ray report, dated 11/28/16, performed for a "cough," was negative for any changes. K. Resident 8 was admitted to the facility in October 2016 with diagnoses which included falls and a fractured leg. Review of the clinical record for Resident 8 included: a. A physician's order, dated 11/26/16, for cough medicine every 4 hours as needed. b. A physician's order, dated 11/27/16, for a chest x-ray and antibiotics. c. A chest x-ray report, dated 11/28/16, performed for a "cough," concluded, "Left basilar airspace (lower portion of lung) disease FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ONVX11 Facility ID: CA030000097 If continuation sheet 13 of 20 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: _______________ 055417 (X3) DATE SURVEY COMPLETED 02/17/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SAYLOR LANE HEALTHCARE CENTER 3500 Folsom Boulevard Sacramento, CA 95816 (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 commonly relates to pneumonia in the acute clinical setting...Atelectasis (a partial collapse of the lung) or scarring can appear similar." During an interview with the LPHN on 1/12/17 at 9 a.m., the LPHN stated Resident 8 had tested positive for RSV. L. Resident 9 was admitted to the facility most recently in early 2016 with diagnoses which included knee replacement and heart failure. Review of the clinical records for Resident 9 included: a. A physicians order, dated 11/26/16, for cough medicine every 4 hours as needed. b. A physicians order, dated 11/27/16, for a chest x-ray and antibiotics. c. A chest x-ray report, dated 11/28/16, performed for a "cough," was negative for any disease. The facility failed to notify the Department about 3 additional residents (Resident's 6, 10, and 11): M. Resident 6 was a 90 year old, most recently readmitted to the facility in early 2015 with diagnoses which included Alzheimer's disease. Review of the clinical record for Resident 6 included: a. A chest x-ray, dated 11/26/16, indicated, "Possible mild right middle lung consolidation." b. A CBC, dated 11/26/16, included the WBC were 15.9, elevated above normal, usually indicative of an infection or inflammation. c. Nurses notes, dated 11/29/16, indicated the resident was unable to swallow foods, only thickened liquids. d. A physician's order, dated 11/29/16, for hospice care to be initiated with the family's agreement. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ONVX11 Facility ID: CA030000097 If continuation sheet 14 of 20 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: _______________ 055417 (X3) DATE SURVEY COMPLETED 02/17/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SAYLOR LANE HEALTHCARE CENTER 3500 Folsom Boulevard Sacramento, CA 95816 (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 Resident 6 expired on 11/30/16 at approximately 6 p.m., under hospice care. N. Resident 10 was admitted to the facility most recently in early 2015 for diagnoses including Alzheimer's disease and blood clots. Review of the clinical record for Resident 10 included: a. A physician's order, dated 11/26, for cough medicine every 4 hours as needed. b. A physician's order, dated 11/27/16, for antibiotics for a cough. O. Resident 11 was admitted to the facility in 2012 with diagnoses which included back pain. Review of the clinical record for Resident 11 included: a. A physician's order, dated 11/26/16, for cough medicine every 4 hours as needed. On 11/28/16 there were 11 residents who had exhibited symptoms of an upper respiratory tract infection. 2A. Following the recognition by the facility on 11/28/16, there was an outbreak of respiratory symptoms in the facility. As of 12/12/16, the following 5 residents (Residents 12, 13, 14, 15, and 16) became symptomatic. Resident 12 was an 87 year old admitted to the facility on 11/19/16 with a fracture. Review of Resident 12's GACH clinical record included: a. An emergency physician's note, dated 12/5/16, "Presents with worsening cough that began 2 weeks ago. Patient stated that his cough is productive with yellow phlegm (sputum). He also complains of associated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ONVX11 Facility ID: CA030000097 If continuation sheet 15 of 20 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: _______________ 055417 (X3) DATE SURVEY COMPLETED 02/17/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SAYLOR LANE HEALTHCARE CENTER 3500 Folsom Boulevard Sacramento, CA 95816 (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 shortness of breath...Symptoms are described as moderate in severity." The note referenced chest x-ray results, "Left lower lobe pneumonia and is needing an increased amount of oxygen. White [blood cell] count (WBC) is elevated, he is tachycardia [heart rate over 100]." b. A CBC, dated 12/5/16, included a WBC of 15.1 (normal range was 4 to 11). c. The discharge Summary, dated 12/9/16, listed his diagnosis as "Pneumonia of left lower lobe due to infectious organism." d. Sputum cultures reported on 12/8/16 were negative. B. Resident 13 was admitted to the facility 11/9/16 with diagnoses which included heart disease. Review of the GACH clinical record for Resident 13 included: a. An Emergency physician's note, indicated, "78 year old with a history of ... [chronic lung disease (COPD)] ...presents with worsening shortness of breath tonight ....Had had a productive cough with yellow and green sputum for the past few days ...febrile [fever] at 103.1 degrees Fahrenheit. She has room air oxygen saturations of 83% ..." b. A Hospitalist History and Physical (H&P), dated 12/5/16, included, the resident was "not showing improvement," after 2 hours on aggressive oxygen therapy and then, "Admitting the patient to [Intensive Care Unit (ICU)] ...Respiratory failure likely secondary to [pneumonia] ...severe sepsis (infection in the blood)." In an interview with the GACH Clinical Coordinator for Quality (CCQ) on 12/12/16 at 9:30 a.m., the CCQ stated Resident 13 had been in intensive care on a breathing machine and was still in the hospital on 12/12/16. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ONVX11 Facility ID: CA030000097 If continuation sheet 16 of 20 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: _______________ 055417 (X3) DATE SURVEY COMPLETED 02/17/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SAYLOR LANE HEALTHCARE CENTER 3500 Folsom Boulevard Sacramento, CA 95816 (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 C. Resident 14 was a 94 year old admitted to the facility in 2014 with diagnoses which included chronic lung disease. Review of the clinical record for Resident 14 included: a. Nurse's notes, dated 12/1/16, indicated, "Noted cold/flu [symptoms] runny nose and occasional cough, sore throat...O2 sat 86% on room air [without supplemental oxygen]... MD notified O2 at 2 liters by [nasal cannula (NC)] (tubing that delivers oxygen into the nose) started, sat reached 93%." b. A physician's order, dated 12/1/16, for Zyrtec, an allergy medication, and oxygen at 2 liters per minute by NC. c. Nurse's notes, dated 12/2/16, indicated, "[change of condition (COC)] low O2 sat on 2 liters and increased [temperature]. Also noted resident not eating only drinking liquids and resident has congestion and wheezing also." The note indicated the physician had been contacted. d. A physician's order, dated 12/3/16, for aerosolized (delivered as a mist) medication as needed, for shortness of breath. e. Nurse's notes, dated 12/3/16, indicated, "Non-productive occasional cough. O2 sat 91% on 2 [liters] O2." Later that day she had a fever of 100.8° Fahrenheit. D. Resident 15 was admitted to the facility on 11/23/16 for diagnoses which included a urinary infection. Review of a Resident Roster, dated 12/13/16, documented the resident developed respiratory symptoms on 12/1/16 and continued through 12/11/16. E. Resident 16 was a 92 year old, admitted to the facility on 12/3/16 with diagnoses which included kidney and bladder conditions. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ONVX11 Facility ID: CA030000097 If continuation sheet 17 of 20 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: _______________ 055417 (X3) DATE SURVEY COMPLETED 02/17/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SAYLOR LANE HEALTHCARE CENTER 3500 Folsom Boulevard Sacramento, CA 95816 (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 Review of a Resident Roster, dated 12/13/16, documented the Resident 16 developed respiratory symptoms on 12/13/16. In an observation at the Administrator's office on 11/28/16 at 3 p.m., the Dietary Manager (DM) was observed to have a productive cough and heard saying to the Administrator, "I've had this cough for a week." The DM was observed to move her mask below her nose and to partly remove it. In an interview with the DM on 11/28/16 at 3 p.m., the DM stated, "I've been off 4 days. I had it [cough] 2 days last week, but covered up all the time." In an observation of the kitchen on 11/28/16 at 3:10 p.m., the kitchen where food was prepared for facility residents was observed to be a long, narrow, open room with 2 people working in it. A desk was observed in a narrow alcove near the hand washing sink, without walls or a door. A staff member was observed walking past the desk chair to get to the dry storage area beyond the desk, then returning to the food preparation area. In an interview with Cook 1 on 11/28/16 at 3:10 p.m., Cook 1 was asked about the DM's cough. Cook 1 stated, "It's been about a week ...[DM] worked Monday, Tuesday, and Wednesday last week." The Cook further stated Cook 2 had been sent home early that day (11/28/16), due to an illness. Cook 1 verified the DM's desk was situated on the edge of the kitchen without any walls or doors. Some diseases are spread via droplets when people cough. In an interview with the Administrator on 11/28/16 at 3:05 p.m., he stated the DM did not FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ONVX11 Facility ID: CA030000097 If continuation sheet 18 of 20 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: _______________ 055417 (X3) DATE SURVEY COMPLETED 02/17/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SAYLOR LANE HEALTHCARE CENTER 3500 Folsom Boulevard Sacramento, CA 95816 (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 handle food. He stated, "If a dietary aide or cook is sick, we send them home." Review of the facility's policy titled, "Outbreak of Communicable Disease," dated as revised December 2009, directed, "Symptomatic residents and employees are to be considered potentially infected and will be assessed for appropriate actions. The Administrator will be responsible for: Telephoning a report to the health department; Restricting admissions to the facility as indicated or as authorized by health department/Medical Director; Submitting periodic progress reports to the health department, as requested; Calling emergency meetings of the Infection Control Committee; Discontinuing group activities, as indicated; Limiting visitors if indicated ... The Director of Nursing will be responsible for: receiving surveillance information and tabulating data; Notifying the Medical Director ....nursing staff will be responsible for: Notifying the DON of symptomatic residents; providing infection surveillance data in a timely manner; obtaining laboratory specimens; initiating isolation precautions as directed or as necessary and confining symptomatic residents to their rooms as much as feasible.." Review of the "Recommendations for the Prevention and Control of Influenza California Long-Term Facilities, dated as revised 12/2011, directed: "Influenza, other respiratory viruses, and some bacteria cause similar illnesses, particularly elderly long-term care (LTCF) residents...In most infected persons the symptoms progressively resolve after 3 to 7 days...complications, especially in unvaccinated long-term care residents, include pneumonia, worsening of chronic health conditions, and dehydration...The virus is primarily spread by viral particles coming into contact with the respiratory tract after they are FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ONVX11 Facility ID: CA030000097 If continuation sheet 19 of 20 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: _______________ 055417 (X3) DATE SURVEY COMPLETED 02/17/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SAYLOR LANE HEALTHCARE CENTER 3500 Folsom Boulevard Sacramento, CA 95816 (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 expelled short distances into the air (approximately 6 feet or less) when an infected person coughs or sneezes (droplet transmission)." In an interview with LVN 1 on 12/8/16 at 2 p.m., LVN 1 verified she had worked the weekend after the cough started. LVN 1 stated on Sunday 11/27/16 at the start of the day shift 2 residents, Resident 3 and Resident 5, were sent out to the emergency room. LVN 1 stated she had not notified the Director of Nurses about the number of residents who were symptomatic over the weekend, and had not isolated the residents with coughs. During an interview on 12/8/16 at 2:45 p.m., the Director of Staff Development (DSD) stated that prior to Monday 11/28/16, residents with coughs were encouraged to stay in their rooms. The DSD stated, "Nobody was on isolation." The DSD stated the facility had not suspended group activities or community dining, and the facility was still admitting new residents. In an interview with the DON on 12/8/16 at 3:40 p.m., the DON stated, "I think we did what we were supposed to do. The best we can do is isolate the virus. Some residents wore masks, roommates were 3-5 feet distance [from each other]." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ONVX11 Facility ID: CA030000097 If continuation sheet 20 of 20