Health inspection·September 10, 2025

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Based on interview and record review, the facility failed to investigate a complaint of mistreatment for one of five sampled residents (Resident 1), when Resident 1's Family Member (FM) notified facility staff of Resident 1's complaint and facility did not conduct an investigation including resident and staff interviews and, staff education.This failure had the potential to place Resident 1 and other residents at risk for mistreatment leading to psychosocial distress. A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility in August 2025 with multiple diagnoses including malignant neoplasm of the cauda equina (a cancerous tumor affecting nerves at end of the spinal cord), chronic obstructive pulmonary disease (lung disease that blocks airflow and makes it difficult to breathe), neuromuscular dysfunction of the bladder (nerves and muscles that control bladder function are impaired), and anxiety disorder (mental health disorder characterized by feelings of worry, anxiety or fear that interfere with daily life). A review of Resident 1's Minimum Data Set (MDS- federally mandated assessment tool), Cognitive Patterns, dated 8/28/25, indicated Resident 1 had a Brief Interview for Mental Status (BIMS- tool to assess cognition) score of 15 out of 15 that indicated Resident 1 was cognitively intact. A review of Resident 1's MDS, Functional Abilities, dated 8/28/25 indicated Resident 1 required maximal assistance for toileting hygiene. Further review of Resident 1's MDS, Bladder and Bowel, dated 8/28/25, indicated Resident 1 was always incontinent of bowel.A review of Resident 1's Bowel and Bladder Elimination Task document indicated Resident 1 had a bowel movement on 8/25/25 at 1:58 p.m. A review of Resident 1's Nursing Daily Skilled Charting, dated 8/25/25 at 3:39 p.m., indicated .Pt [patient] A&0 [alert and oriented] x 4 [person, place, time, situation], no changes in LOC [level of consciousness] . Able to make needs known .Call light within reach . A review of Resident 1's Nursing Daily Skilled Charting, dated 8/25/25 at 9:50 p.m., indicated .Compliant with care. Cooperative with staff .Call light within reach .A review of Resident 1's Nursing Daily Skilled Charting, dated 8/26/25 at 11:13 p.m., indicated .Call light within reach and personal items within reach . A review of Resident 1's Nursing Daily Skilled Charting, dated 8/27/25 at 5:21 p.m., indicated .Call light and personal items in reach . Care staff Assisted with ADL'S [Activities of Daily Living] .A further review of Resident 1's nursing daily skilled charting and progress notes did not reflect any documentation that Resident 1 or Resident 1's FM reported concerns regarding inappropriate or rough handling of Resident 1 to staff. During an interview on 9/5/25 at 12:21 p.m. with Licensed Nurse (LN) 1, LN 1 stated she was familiar with Resident 1 but had not heard about any complaints she had regarding rough treatment by staff. During an interview on 9/5/25 at 12:26 p.m. with LN 2, LN 2 stated she was familiar with Resident 1 but was not aware of any complaints of rough treatment by a CNA (Certified Nursing Assistant).During an interview on 9/5/25 at 1:10 p.m. and a subsequent interview on 9/5/25 at 1:30 p.m. with the Director of Nursing (DON), the DON stated she was not aware of any complaint from Resident 1 or Resident 1's FM regarding rough treatment by a CNA. Page 1 of 3 555153 555153 09/10/2025 Fair Oaks Healthcare Center 11300 Fair Oaks Blvd. Fair Oaks, CA 95628

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 555153 Page 2 of 3 555153 09/10/2025 Fair Oaks Healthcare Center 11300 Fair Oaks Blvd. Fair Oaks, CA 95628

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 . 555153 Page 3 of 3