Health inspection·October 19, 2023

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure services provided by the facility met professional standards of practice for one of six sampled residents (Resident 1) when: Residents Affected - Few 1. A physician's (MD) order for carbidopa-levodopa (an anti-Parkinson's medication) 25-100 mg. (milligrams, a unit of measurement) tablet, 1 tablet every 6 hours was discontinued on 6/23/23 at 6:32 a.m., and not reordered until 6/23/23 at 12 p.m., causing Resident 1 to go without a dose of her medication for 11 hours; and, 2. One dose of the medication on 6/22/23, two doses of the medication on 6/25/23, and one dose on 7/1/23 were administered late. These failures had the potential to result in Resident 1 suffering negative side effects of the missed and late doses such as worsening tremors, increased rigidity and pain. Findings: A review of Resident 1's admission record indicated she was admitted on [DATE], with diagnoses including Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors). A review of Resident 1's clinical record included the following documents: 1. A Medication Administration Record (MAR), dated 6/1- 6/30/23, indicated the following MD orders: a. Carbidopa-levodopa 25-100 mg. tablet, 1 tablet every 6 hours for Parkinson's disease at 2 a.m., 8 a.m., 2 p.m. and 8 p.m. The order's start date was 6/22/23 at 8 p.m. and the end date was 6/23/23 at 6:32 a.m. b. Carbidopa-levodopa 25-100 mg. tablet, 1 tablet every 6 hours for Parkinson's disease at 12 a.m., 6 a.m., 12 p.m. and 6 p.m. The order's start date was 6/23/23 at 12 p.m. and the end date was 1:40 p.m. c. Carbidopa-levodopa 25-100 mg. tablet, 1 tablet every 6 hours for Parkinson's disease at 12 a.m., 6 a.m., 12 p.m. and 6 p.m. The order's start date was 6/23/23 at 6 p.m. and the end date was 7/2/23 at 12:01 a.m. A Medication Administration Audit Report (MAAR), dated 6/1- 6/30/23, indicated Resident 1 had (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: 555801 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 555801 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pine Creek Care Center 1139 Cirby Way Roseville, CA 95661 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)