Health inspection·July 9, 2025

F 0557 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. Based on interview and record review, the facility failed to ensure one of 5 sampled residents (Resident 1) was treated with dignity and respect, when Restorative Nursing Assistant (RNA 1) spoke inappropriately to Resident 1.This failure caused Resident 1 to feel upset, humiliated, and disrespected and had the potential to negatively impact Resident 1's psychosocial well-being.A review of the facility's ‘Resident Rights' policy dated 2021, indicated, Employees shall treat all residents with kindness, respect, and dignity. A review of the admission Record indicated the facility admitted Resident 1 in the spring of 2025 with multiple diagnoses which included paraplegia (loss of movement and/or sensation, to some degree, of the legs), muscle weakness, and anxiety.A review of Resident 1's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 5/17/25, indicated the resident had no cognitive impairment and had no behavioral symptoms including hallucinations and delusions.During a concurrent observation and interview on 7/9/25, at 9:45 a.m., Resident 1 was sitting in wheelchair in her room. Resident 1 answered appropriately and was speaking in a soft low tone voice. When Resident 1 was asked to recall the 7/4/25 incident in the dining room, the resident became very tearful and lowered her voice to a whisper. Resident 1 explained that she had been sitting at the same table with two residents [Resident 2 and Resident 3] every day since her admission and added that everyone knew that they liked to sit together during activities and eating meals. Resident 1 added, On July 4th, I went to sit to my usual spot. [Resident 3's name and [Resident 2's name] were already seated there. Someone brought another patient to sit at our table. [RNA 1] approached me and in authoritative tone told me, You have to move to another table. Resident 1 stated that she attempted to explain to RNA that this was her table where she usually sat with her two friends, but RNA 1 insisted that I have to be moved and told her, Your name is not here. Resident 1 stated she felt bad and disrespected that [RNA 1] picked on her. Resident 1 stated that two other staff, Activity Director and dietary head, [RD] overheard the entire conversation and one of them put her hand on my shoulder and said, It's ok [Resident 1's name], you can sit here.During a continued interview on 7/9/25, commencing at 9:45 a.m., Resident 1 stated that a few minutes later, RNA 1 brought her lunch tray and the resident noted that there were some food and drink that she could not eat due to her medical condition. Resident 1 stated she politely asked RNA 1 if she would take away the food and drink that she could not eat. Resident 1 became tearful again and added, I did not request anything, just told her that I can't have strawberries and juice, but RNA 1 raised her voice and said, I am not a waitress here, I am not here to serve you. Resident 1 stated RNA 1 walked away and started texting on her phone. During a continued interview on 7/9/25 at 9:45 a.m., Resident 1 added, I felt very humiliated and disrespected. I tried to tell her that I thought she was here to help some of us that needed help, but she was totally disrespectful and did not give me chance to talk .I did not argue with her, I am not a confrontational person, I gave her 100% of respect and expected her to be respectful to us and I felt very upset about the incident. Resident 1 stated that the same day RNA Page 1 of 3 555337 555337 07/09/2025 Citrus Heights Post Acute 7807 Uplands Way Citrus Heights, CA 95610

F 0557 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 1 spoke in a very disrespectful tone of voice to her friend, Resident 2 when he asked for something. Resident 1 stated that later that day she explained to a nurse at the desk what happened in the dining room and how humiliated she felt. Resident 1 added she woke up at 3 a.m., cried uncontrollably and called nursing station asking for her nurse to come. Resident 1 stated she detailed the incident in the dining room to her nurse (Licensed Nurse, LN 1) and told the nurse how humiliated she felt. Resident 1 added that she had a history of PTSD (Post Traumatic Stress Disorder, a mental condition caused by an extremely stressful or terrifying event; symptoms may include flashbacks, nightmares, and severe anxiety) and the incident at the dining room surfaced her PTSD condition. During an interview with Activity Director (AD) on 7/9/25, at 11:45 a.m., the AD stated that Resident 1, Resident 2, and Resident 3 always sit together during activities and 3 of them always sit together for meals. The AD stated there was a commotion in the dining room on July 4th and added that staff wanted to move Resident 1 to another table because it was too crowded at that table. The AD continued, [Resident 1] had told me that she was upset, but I was not sure why she was upset. During an interview with Registered Dietician (RD) on 7/9/25, at 11:58 a.m., the RD stated she witnessed RNA 1 telling Resident 1 that she needed to be moved to another table because it was too crowded, and the resident refused to be moved. The RD stated that Resident 2 mentioned that [Resident 1's name] was upset because [RNA1's name] had said something inappropriate to her.During an interview with Certified Nursing Assistant (CNA 2) on 7/9/25, at 12:12 p.m., CNA 2 stated that she overheard Resident 1 talking to nursing staff at the desk telling them that RNA 1 was rude to her during lunch in the dining room. CNA 2 stated that normally Resident 1 goes around the facility and socialized with other residents but that day she observed the resident staying in her room.During an interview with RNA 2 on 7/9/25, at 12:42 p.m., CNA 2 stated Resident 1 was picky about her food, always complains that she did not receive what she likes to eat . she likes to have food specially catered to her. RNA 1 validated that on July 4th during a conversation with Resident 1 and Resident 2 she replied to Resident 1 I am not a waitress here. RNA 1 added, I did not mean to disrespect her when I said I' not a waitress, but she reported to the entire facility that I disrespected her. RNA 1 stated that she assisted residents in the dining room with eating and telling a resident I'm not your waitress was inappropriate.During a telephone interview with LN 1 on 7/9/25, at 1:10 p.m., LN 1 stated the morning of 7/5/25, around 3 a.m., Resident 1 called nursing station crying. LN 1 stated that she went to the resident's room and talked to Resident 1. LN 1 continued, Initially she said that she had bad dreams, then she mentioned that she was really upset because earlier in the day someone was verbally aggressive to her. LN 1 stated that Resident 1 calmed down after they talked but did not go into details and did not tell the nurse who the person was that spoke inappropriately with the resident. LN 1 stated she informed her charge nurse what Resident 1 had told her but was told that there was nothing to report since the resident did not want to give any information who was that person.During an interview with Administrator (ADM) on 7/9/25, at 1:15 p.m., the ADM stated that Resident 1 was different type of resident and explained that the resident easily involves in areas that do not involve her. The ADM stated she was informed by RD there was an incident when Resident 1, Resident 2, and Resident 3 did not like that another resident was seated at the same table and requested to move that resident to another table. The ADM stated she was not aware that Resident 1 was upset because someone was disrespectful to her and added, It is the resident's interpretation, but I don't know if it happened or not. The ADM agreed that residents have rights to choose who they want to sit with, talk to, or eat together with and it was inappropriate and unacceptable to say, ‘I'm not a waitress here to residents.A review of the facility's policy titled, Resident Rights, dated 2021, indicated, Federal and state laws guarantee 555337 Page 2 of 3 555337 07/09/2025 Citrus Heights Post Acute 7807 Uplands Way Citrus Heights, CA 95610

F 0557 Level of Harm - Minimal harm or potential for actual harm certain basic right s to all residents of this facility. These rights include the resident's rights to . a dignified existence .be treated with respect, kindness, and dignity .self-determination .exercise his or her rights as a resident of the facility and . citizen of the United states . be supported by the facility in exercising his or her rights .Staff will have appropriate in-service training on resident rights prior to having direct care responsibilities for residents. Residents Affected - Few 555337 Page 3 of 3