F 0583
Keep residents' personal and medical records private and confidential.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to ensure resident medical records were
maintained, private and confidential for one out of three sampled residents (Resident 2) when the
Medication Administration Record (MAR) was exposed and visible in the hallway.
Residents Affected - Few
This failure decreased the facility's potential to protect residents' personal information being accessible to
unauthorized staff, residents, and visitors.
Findings:
During a concurrent observation and interview conducted on 7/25/23 at 11:39 a.m., Licensed Nurse 1 (LN
1) went into room [ROOM NUMBER] and left the computer 's screen open exposing the MAR outside the
hallway. There were other staff in the hallway.
During an interview with the Director of Nursing (DON) on 7/25/23 at 12:14 p.m., the DON confirmed the
resident's medical record should have been lock and closed. The DON stated, It 's a HIPAA [Health
Insurance Portability and Accountability Act] violation.
Review of a facility policy titled, HIPPA: Privacy Policies and Procedure, dated 4/14/03, indicated, 'Protected
health information' consists of health information about an individual that is in individually identifiable form.
It includes all information, regardless of the format, whether in written, oral, or electronic form.
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 3
Event ID:
555555
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
555555
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/26/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Eskaton Village Care Center
3939 Walnut Ave.
Carmichael, CA 95608
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 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview, and record review, the facility failed to provide resident-centered care and
services for one of three sample residents (Resident 2) when her call light was not within reach.
Residents Affected - Few
This failure decreased the potential for the resident to receive effective treatment and necessary personal
care when needed.
Findings:
According to the resident 's face sheet, Resident 2 was admitted to the facility in mid-2017 with diagnoses
including mild cognitive impairment, dementia (loss of memory, language, problem-solving and other
thinking abilities that are severe enough to interfere with daily life), and depression.
A review of a Minimum Data Set (MDS, a comprehensive assessment tool), dated 6/14/23, indicated
Resident 2 was totally dependent on assistancefrom one or two staff for transfering, bed mobility, getting
dressed, toilet use and personal hygiene.
During a concurrent observation and interview on 7/25/23 at 11:45 a.m., Resident 2 was in bed with nasal
cannula in her nose delivery oxygen. Resident 2 stated she could not locate the call light and could not find
it. The call light was clipped and hanging off the bed. Resident reported she wanted a shower.
During an interview on 7/25/23 at 11:50 a.m. in the residents room, Certified Nursing Assistant 2 (CNA 2)
stated, I don 't see the call light, and immediately put the call light cross the resident 's body when noticed.
CNA 2 confirmed the purpose of having the call light was for the resident to use when needing assistance.
During an interview on 7/25/23 at 12:14 p.m., the Director of Nursing (DON) confirmed the call light should
be clipped to the resident, chair, or bed and should always be within reach of the resident.
Review of a facility policy titled, Call Light System, revision date 3/5/02, indicated, Each resident will have
their call light system within reach while in their room.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555555
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
555555
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/26/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Eskaton Village Care Center
3939 Walnut Ave.
Carmichael, CA 95608
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 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted
professional principles; and all drugs and biologicals must be stored in locked compartments, separately
locked, compartments for controlled drugs.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to ensure medications were stored securely for a
census of 32, when a medication cart was left open and unattended.
This failure had the potential for medication misuse and drug diversion.
Findings:
During a concurrent observation and interview conducted on 7/25/23 at 11:39 a.m., Licensed Nurse 1 (LN
1) went into room [ROOM NUMBER] and left the medication cart in the hallway unlocked and unattended.
There were other staff in the hallway. LN 1 confirmed the medication cart should have been locked when
left unattended.
During an interview with the Director of Nursing (DON) on 7/25/23 at 12:14 p.m., the DON confirmed the
medication cart should have been locked at all times.
Review of a facility policy titled, Storage of Medications, dated 2007, indicated, Medication rooms, cabinets
and medication supplies should remain locked when not in use or attended by persons with authorized
access.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555555
If continuation sheet
Page 3 of 3
