Health inspection·September 24, 2024

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on interview and record review, the facility failed to report an allegation of abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) to the State Survey Agency and local law enforcement, and the facility failed to report the results of all investigations to the State Survey Agency within five working days of the incident for one of four sampled residents (Resident 1). This failure had the potential to result in a delayed investigation. Findings: Resident 1 was admitted to the facility in September 2024 with medical diagnoses which included hemiplegia and hemiparesis (paralysis of one side of the body) following cerebral infarction (when blood flow to the brain is blocked or reduced) affecting left dominant side and exhibiting facial weakness.A Brief Interview for Mental Status (BIMS, a cognitive screening tool used to assess a person's mental status) score showed 14 out of 15 (cognition intact). During a review of Resident 1's Grievance/Concern Form, dated 9/6/24, the Grievance/Concern Form indicated, [Certified Nursing Assistant 1's (CNA 1) name] disrespected [Resident 1]! Pushed her fingers in his chest and said, ' Listen Needy Boy ', there are many needs on this floor and you're pushing your button too many times . During an interview on 9/19/24 at 10:54 a.m. with Resident 4, Resident 4 reported Resident 1 had, .A bad run in . with CNA 1. Resident 4 reported Resident 1 was his previous roommate. Resident 4 reported hearing CNA 1 yelling at Resident 1 through the curtain. Resident 4 reported CNA 1 called Resident 1, Something, like boy. Resident 4 reported the language used by CNA 1 to Resident 1 was, Really demeaning .his wife was livid .got the forms .filled out a complaint. During a phone interview on 9/19/24 at 12:12 p.m. with Licensed Nurse 1 (LN 1), LN 1 stated, I didn't report it [the incident] because somebody else reported it .the CNA manager, transferred [CNA 1] to a different hallway. During an interview on 9/19/24 at 12:39 pm. with the Director of Staff Development (DSD), the DSD stated, I got a grievance from [Resident 1] .claimed [CNA 1] was rude and poking him in the chest and comments about being needy. DSD reported he spoke to Resident 1 on 9/10/24. DSD stated, There was no injury; he showed me his chest. I did a one on one inservice with the [CNA 1] on customer service. I did not report it to anyone else in the facility .It stopped with me as her supervisor .If it was a CNA I didn't know, I would have suspended her. (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 09/24/2024 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)