Health inspection·August 9, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Based on observation, interview and record review, the facility failed to ensure residents' dignity were promoted for three residents (Resident 1, Resident 2, and Resident 3) for a census of 98 when Resident 1 and Resident 3 were left in urine-soaked briefs and Resident 2 lay in a wet brief on the transfer lift sling (a mesh or padded fabric material with belt straps to attach to the lift hooks) in bed. This failure resulted in Resident 1 staying in a cold brief and feeling insignificant, and increased the potential for developing skin issues for the residents who were confused. Findings: During a phone interview on 8/7/23 at 8:45 a.m., the complainant stated on 7/25/23, when she began her shift, the residents in her care had not been changed, but left soaked wet in urine when she started her night shift duty. The complainant stated the previous shift Certified Nurse Assistant (CNA) 1, who was from a registry agency, did not change the residents' briefs or answer the residents call lights during the PM shift. In an interview on 8/7/23 starting at 11:10 a.m., the Director of Staff Development /Assistant Director of Nursing (DSD/ADON), with the Staffing Coordinator (SC) present, stated the wet briefs issue was brought up to Licensed Nurse (LN) 1, the PM shift nurse on 7/25/23. The DSD stated LN 1 and LN 2, the night shift nurse, immediately checked on the residents that CNA 1 had been assigned to and found almost all residents were not changed and had been left in wet briefs. The SC stated most of the residents were confused or fairly confused in the section; therefore, there were no complaints from the residents about the wet briefs. However, the SC stated the facility took it as residents' dignity and care issue. In an interview on 8/7/23 at 12:52 p.m., in the activity room, Resident 1 was in her wheelchair among other residents. Resident 1 stated recently she was left in a soaking wet brief for a long period during the night. Resident 1 stated she used the call light for help, but no one answered so she had to stay in a wet brief. Resident 1 stated the wet brief felt cold and waiting for help in a wet brief made her feel insignificant. Review of Resident 1's clinical record, care plan for Skin: At risk for skin breakdown ., reviewed 6/12/23, included interventions to Keep the call light within reach and encourage resident to call for assistance .Monitor for incontinence and provide pericare every shift and after each incontinence episode. Page 1 of 2 555801 555801 08/09/2023 Pine Creek Care Center 1139 Cirby Way Roseville, CA 95661

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In a telephone interview on 8/7/23 at 3:37 p.m., LN 1 stated she worked the PM shift on 7/25/23 with CNA 1. LN 1 stated she was supposed to sign CNA 1 off at the end of the shift as she was from a registry company but was not able to locate her when the shift changed. LN 1 stated, She [CNA 1] was gone. LN 1 recounted that the night shift CNA complained to her at around midnight that the residents had not been changed during the PM shift. LN 1 went room to room and checked the residents and found Resident 2 was in a wet brief and laying on the transfer lift sling in her bed. LN 1 stated CNAs were supposed to remove the sling after the resident was transferred back in bed, but the sling was not removed. LN 1 indicated Resident 2 was confused and unable to tell staff to remove the sling underneath her and stated had she not checked the resident, Resident 2 could have been laying on the transfer sling all night. LN 2 stated, That was unacceptable .That was not right .they were dignity issues. Review of the facility's policy and procedure, Dignity, revised February 2021, stipulated, Each resident shall be care for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem .Residents are treated with dignity and respect at all times. 555801 Page 2 of 2