Health inspection·July 23, 2025

F 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few care facility because of safety concerns. So the patient was sent to acute care facility as the patient was non-compliant and the [RP] was also non-compliant with the treatment plan .With underlying cognitive impairment with dementia .Patient and family both refusing to increase the dose of Seroquel. Patient need to go to acute care facility for further evaluation . A review of Resident 1's Progress Note, Type: Nurse's Note, dated 7/18/25 at 12:55 p.m., indicated .Received orders from [name of physician] to increase patients Seroquel from 6.25mg to 12.5mg due to increased behavioral issues. Patient has been combative, hitting care staff, throwing things at other patients, eating other patients food and hard to reorient and redirect. Patient's [RP] notified by charge nurse of increasing agitation this morning .called patient's [RP] to relay doctors order . writer notified her of .order to increase Seroquel from 6.25mg to Seroquel 12.5mg . or send patient to acute for increasing agitation and combativeness for patients/care staff safety if family not agreeable to medication changes. [RP] refused medication changes and was notified patient would be sent to acute for safety purposes . A review of Resident 1's Progress Note, Type: Nurse's Note dated 7/18/25 at 10:27 a.m., indicated .Called [RP] back at 10:42am .and explained to her .resident is still agitated and hitting staff members and going into other Resident's rooms . a safety risk -for our residents and our staff . [RP] was agreeable at this time and said she will be in the facility shortly to help with agitation and well as speak with [name of physician] of the POC [plan of care] going forward .Called [name of physician] .informed him of the above behaviors-he stated we could either 1-Increase Seroquel to 12.5 mg per dose. 2- Send resident out to acute for further evaluation due to increased agitation . [RP] was not agreeable to all options. Send out to acute was initiated due to safety concerns .' A review of Resident 1's Care Plan, The resident has a behavior problem r/t [related to] increased agitation, initiated 7/12/25, indicated . Goal .The resident will have fewer episodes of behavior by review date Target Date 9/25/25 . Interventions .Anticipate and meet The resident's needs .Caregivers to provide opportunity for positive interaction, attention .Praise any indication of The resident's progress/improvement in behavior . A review of Resident 1's Care Plan, [Resident 1] was noted with increased combativeness/ agitation 7/12/25 .revised 7/14/25, indicated .Interventions .Approach in a calm, reassuring manner .Encourage family visits and interactions .Monitor for signs and symptoms of decreased psychosocial well-being, adjustment issues, emotional distress, ineffective coping skills, poor impulse control, adverse effects on function, mental, physical, social, or spiritual wellbeing and report abnormal findings to physician .Reorient and redirect as necessary .A review of Resident 1's Care Plan, Psychosocial Behavior: Exhibits or is at risk for behavioral symptoms (i.e. striking out, grabbing others, combative, verbally, or physically abusive, inappropriate disrobing, smears/throws food/feces/objects due to delirium .initiated 7/2/25 . Goal Will be compliant with nursing care .Will not harm self-and/or others secondary to socially inappropriate and/or disruptive combative behavior . Target Date 9/25/25, .Interventions .Administer medication as ordered .Document and record behavioral episodes .Maintain a calm, slow, understandable approach . During a telephone interview on 7/22/25 at 11:45 a.m. with Resident 1's RP, Resident 1's RP stated she was notified in the morning of 7/18/25 that Resident 1 did not take her medications and was having behavior issues. The RP stated the facility wanted to double her Seroquel medication. The RP stated she was told that if you do not agree to Seroquel dosage increase, then the facility will send her to the acute hospital. Resident 1's RP stated she asked the facility not to send Resident 1 out until she arrived at the facility and she was on her way. Resident 1's RP stated she wanted to review with the physician the increase in medication before agreeing to increase. She stated she was called and notified that Resident 1 had been sent to the acute hospital. When asked if Resident 1's RP had been offered a bed- hold, the RP (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555801 If continuation sheet Page 2 of 4 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 07/23/2025 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)

F 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated a bed-hold was never mentioned. During a joint interview on 7/23/25 at 9:50 a.m. with the Administrator (ADM) and the Director of Nursing (DON), the DON reviewed the process for resident transfer to acute hospital. The DON stated process is to receive physician's order for transfer, notify resident or RP, call ambulance for transport, and provide report to hospital. The DON stated Notice of Proposed Transfer/ Discharge is provided to resident or RP and sent to the ombudsman. The DON stated a bed hold option is offered to resident or RP, but it may be a private pay bed hold. The ADM and DON stated Resident 1 was sent to acute hospital on 7/18/25 due to increased behaviors, combativeness, direct threat to residents, wandering into patients' rooms, throwing things at residents, and was non-redirectable. The DON stated the provider wanted to increase the Seroquel but Resident 1's RP refused, and Resident 1's RP was informed Resident 1 would be sent to the acute hospital. The ADM stated if the Resident 1's RP had agreed to the medication change, would have tried that out to see if effective and Resident 1 would not have been sent out that day. During an interview on 7/23/25 at 2:25 p.m. with Licensed Nurse (LN) 1, LN 1 stated Resident 1 started having increased behaviors including hitting and punching staff, threatening residents and families, and became non-redirectable. LN 1 stated when transferring a resident to the hospital the Notice of Proposed Transfer/Discharge is completed to notify family of hospital transfer. During a subsequent joint interview on 7/23/25 at 4:10 p.m. with the ADM and DON, ADM stated that Resident 1's RP was not offered bed- hold because the determination had already been made that Resident 1 was not appropriate for the facility. The ADM stated it was an unplanned discharge due to severity of behavior. During a telephone interview on 7/23/25 with the Medical Doctor [MD], the MD stated Resident 1 was sent to the acute hospital on 7/18/25 due to behaviors. The MD stated Resident 1 had become more agitated, more combative, was going into residents' rooms, and had risky behavior. The MD stated Resident 1's RP was given option to increase dose of Seroquel, but did not agree to the increase, so was sent to the acute hospital.During a concurrent telephone interview and record review on 7/30/25 at 9:53 a.m. with the ADM, the ADM stated Resident 1 was discharged , not transferred, from the facility on 7/18/25. Reviewed Resident 1's Progress Notes from 7/18/25 and that there was no documentation that Resident 1's RP was notified it was a facility discharge and not an acute transfer. The ADM stated it was communicated to Resident 1's RP it was a discharge, and the Notice of Proposed Transfer/Discharge was given as a notice of discharge. The ADM stated a bed hold was not offered because the facility knew they were not accepting Resident 1 back. When asked how the facility determined that upon the transfer to acute hospital on 7/18/25, that Resident 1 would not return to the facility if behaviors were able to be managed, the ADM stated Resident 1 had escalating behaviors and the MD made the decision she was not safe in the facility. Reviewed with the ADM, facility policy Bed-Holds and Returns that indicated residents are provided written bed-hold information at the time of transfer and that residents be permitted to return to the facility following hospitalization. The ADM stated Resident 1's RP had not been agreeable to interventions prior to acute transfer so MD made decision she would not be safe in facility after hospitalization. A review of the facility's Policy and Procedure (P&P) titled Bed-Holds and Returns, revised 10/22, indicated .Residents and/or representatives are informed (in writing) of the facility and state (if applicable) bed-hold policies .All residents/representatives are provided written information regarding the facility and state bed-hold policies, which address holding or reserving a resident's bed during periods of absence (hospitalization or therapeutic leave). Residents, regardless of payer source, are provided written notice about these policies at least twice .notice 2: at the time of transfer (or, if transfer was an emergency, within 24 hours) .The written bed-hold notices provided to the residents/ representatives explain in detail .the facility return policy .The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555801 If continuation sheet Page 3 of 4 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 07/23/2025 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)

F 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete requirement that residents be permitted to return to the facility, following hospitalization or therapeutic leave applies to all residents regardless of payer source .A review of the facility's P&P titled Transfer or Return, revised 3/25, indicated .Once admitted to the facility, residents have the right to remain in the facility. Transfers and discharges must meet specific criteria and require resident/ representative notification, orientation, and documentation in the medical record .Transfer refers to the movement of a resident from a bed in one certified facility to a bed in another certified facility when the resident expects to return to the original facility .When the facility transfers or discharges a resident, the following information is documented in the medical record .That an appropriate notice was provided to the resident and/or legal representative . Event ID: Facility ID: 555801 If continuation sheet Page 4 of 4