Health inspection·July 2, 2024

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1's) right was exercised timely when the resident's representative (RR) was not notified of Resident 1's change in condition and/or the resident's emergency transfer to a hospital. This failure resulted in RR feeling astounded and upset when the hospital contacted her regarding Resident 1's care. Findings: Review of Resident 1's clinical record, admission Record, indicated the resident was admitted to the facility with diagnoses that included memory problem with agitation and aphasia (loss of ability to understand or express speech). In the resident's admission Record, Resident 1's spouse was listed as the Emergency Contact #1 and also as his Responsible Party. In a telephone interview on 7/1/24 at 3:50 p.m., the RR stated that the facility did not notify her of her husband (Resident 1's) change in condition nor his hospital transfer to the emergency department on 6/12/24. The RR stated the hospital called her the following day and only then she knew her husband was in the hospital, and that he was transferred to the emergency room the previous day. The RR indicated she was astounded at the phone call that her husband was not in the facility but at the hospital and emphasized the upsetting part was the facility transferred her husband without her knowledge. Review of Resident 1's clinical record, eINTERACT Change in Condition Evaluation-V5.1, dated 6/13/24, indicated, Resident physically abusive towards the staff, agitated unable to redirect the resident. Resident continued to go into other resident's room, laying on the beds. In the behavior description section of the form documented Resident 1's physical aggression was dangerous. A Licensed Nurse (LN) documented the resident exhibited the change in condition starting in the afternoon of 6/12/24, the physician was notified on 06/12/2024 17:16 [5:16 p.m.] and obtained the order for a hospital transfer. In the evaluation form, it was documented that the RR was notified 06/12/2024 00:00 [12 a.m.]. In a concurrent interview and record review on 7/2/24 at 10:37 a.m. at the nursing station, Licensed Nurse (LN) 1 stated on 6/12/24 Resident 1 had a change in condition exhibiting very aggressive and combative behaviors and the resident was transferred to the emergency department to ensure safety of the resident and others. LN 1 stated it was the facility practice that LNs were to obtain a physician order prior to resident's hospital transfer, notify the resident representative and document the person, time and their response in the resident's clinical record. LN 1 verified the 6/12/24 (continued on next page) 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. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 555333 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 555333 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lincoln Meadows Care Center 1550 Third Street Lincoln, CA 95648 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)