Health inspection·September 10, 2025

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The DON stated she had not heard anything from the staff or Resident 1's FM. During an interview on 9/5/25 at 1:28 p.m. with the Assistant Director of Nursing (ADON), the ADON stated she manages the wing where Resident 1 was. The ADON stated she had not heard of any reports of rough treatment to Resident 1. During a telephone interview on 9/3/25 at 2:27 p.m. with CNA 2, CNA started she had worked with Resident 1 and does not recall her reporting any incidents with other CNAs. CNA 2 stated she works the night shift. During a telephone interview on 9/9/25 at 11:03 a.m. with Resident 1's FM1, FM 1 stated she visited Resident 1 on 8/27/25 and Resident 1 reported to her that she had been handled roughly on 8/25/25 by a staff member when being cleaned up after a bowel movement. FM 1 stated Resident 1 reported incident to CNA 2 on 8/25/25 or early morning 8/26/25. FM 1 stated that CNA 2 said she would report the incident. FM1 stated she reported the incident to the Social Services Director (SSD) on 8/27/25. FM 1 stated she reported the incident to the RN Case Manager (CM) on 8/29/25. The CM notified FM 1 that the CNA would not be working with Resident 1 again. During a telephone interview on 9/9/25 at 11:28 a.m. with Resident 1's FM 2. FM 2 stated she visited Resident 1 on 8/25/25. FM 2 stated she pushed call button between 2 p.m. and 3 p.m. to call CNA after Resident 1 had a bowel movement. FM 2 stated CNA was rough turning Resident 1, turned her hard, yanked the blanket, and lifted her legs. FM 2 stated CNA was very rough with [Resident 1]. FM 2 stated she did not notify any staff of the incident. During an interview on 9/10/25 at 10:10 a.m. with the SSD, the SSD stated Resident 1's FM 1 reported that Resident 1 did not like one of the CNAs and FM 1 did not want that CNA to work with Resident 1. The SSD stated she does not recall what day she spoke with FM 1. The SSD stated she notified FM 1 that the CNA would not be working with Resident 1. The SSD stated she followed up with the CM, the Director of Staff Development (DSD), and the Staffing Scheduler (SS) to make sure CNA would not work in that hall. The SSD stated she did not interview Resident 1 regarding the incident. The SSD stated that there was no documentation in the chart of the incident, the reporting of the incident, or what follow up was done. The SSD stated she did not make a note in the chart. During an interview on 9/10/25 at 10:24 a.m. with the CM, the CM stated Resident 1 had a complaint that a CNA was rough with her while being changed. The CM stated she found out who the employee was and notified the DSD. The CM stated she believed the DSD talked with the CNA. The CM stated she did not interview Resident 1 regarding the incident. The CM acknowledged that she did not document in the chart Resident 1's complaint, discussion with FM 1, follow up with the DSD, or any follow up with Resident 1 or FM1. During an interview on 9/10/25 at 10:37 a.m. with the DSD, the DSD stated she had been informed about 2 weeks ago that a CNA was a little rough while changing Resident 1. The DSD stated the decision was to not have that CNA work Resident 1 anymore. The DSD stated no one talked to the CNA about the incident. When asked if any disciplinary counseling, education, or in-service had been conducted with the CNA, the DSD stated nothing was done regarding this incident. The DSD stated someone should have talked with the CNA about the incident.During an interview on 9/10/25 at 11:04 a.m. with the DON, when asked if Resident 1's complaint of rough treatment warranted an investigation, the DON stated if the SSD or the CM had determined it was abuse, there would have been an investigation. The DON stated the investigation was done when the CNA was removed from Resident 1's hall. During a subsequent telephone interview on 9/10/25 at 11:58 a.m. with CNA 2, CNA 2 stated Resident 1 had asked her if she knew the name of the CNA that worked with her earlier in the day on 8/25/25. CNA 2 stated she told the resident that she would try and find out the CNA's name. CNA 2 stated Resident 1 reported the prior CNA had treated her roughly but did not provide details. CNA 2 stated the next night she asked Resident 1 if she still needed the name of the CNA, but Resident 1 reported her FM had taken care of it. During a joint interview on 9/10/25 at 12:30 p.m. with the DON and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555153 If continuation sheet Page 2 of 3 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 555153 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fair Oaks Healthcare Center 11300 Fair Oaks Blvd. Fair Oaks, CA 95628 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 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Administrator (ADM), the DON acknowledged that Resident 1 or the CNA had not been interviewed. The DON stated the incident was investigated and followed up by removing the CNA from working with Resident 1. During a telephone interview on 9/10/25 at 12:50 p.m. with CNA 4, CNA 4 confirmed she worked the pm (evening) shift on 8/25/25 and Resident 1 was assigned to her. CNA 4 stated she changed Resident 1's brief while FM was present. When asked if Resident 1 stated she was in pain while being changed, CNA 4 stated she would have stopped if Resident 1 had stated she had pain. When asked if the facility notified her of Resident 1's complaint of rough treatment, CNA 4 stated she was not aware of any complaints and This is the first time I heard about it. No one told me I wouldn't work on that wing.A review of the facility's Policy and Procedure (P&P) titled Grievances/Complaints, Filing, revised 4/17, indicated .Residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff .The administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident and/ or representative .Any resident, family member, or appointed resident representative may file a grievance or complaint concerning care, treatment .staff members . All grievances, complaints or recommendations stemming from resident or family groups concerning issues of resident care will be considered. Actions on such issues will be responded to in writing, including a rationale for the response .Grievances and/or complaints may be submitted orally or in writing . Upon receipt of a grievance and/or complaint, the grievance officer will review and investigate the allegations and submit a written report of such findings to the administrator within five (5) working days of receiving the grievance and/or complaint .The resident or person filing the grievance and/or complaint on behalf of the resident, will be informed (verbally and in writing) of the findings of the investigation and the actions that will be taken to correct any identified problems .The administrator, or his or her designee, will make such reports orally within___ working days of the filing of the grievance or complaint with the facility .A written summary of the investigation will also be provided to the resident, and a copy will be filed in the business office . Event ID: Facility ID: 555153 If continuation sheet Page 3 of 3