Health inspection·February 9, 2026

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 1/6/26, indicated, Educate/remind resident to call for assistance with all transfers.During a concurrent observation and interview on 2/9/26 at 1:30 p.m. with Resident 6, in Resident 6's room, Resident 6 was observed lying on her bed, awake, and her call light button was on the floor, under the bottom of her bed. Resident 6 stated she could not reach her call light button at the moment.During a concurrent observation and interview on 2/9/26 at 1:46 p.m. with CNA 2, in Resident 6's room, CNA 2 confirmed that Resident 6's call light button was on the floor, under the bottom of her bed and the call light chord was stuck on the bed frame. CNA 2 stated Resident 6 was able to use call light button. CNA 2 also stated Resident 6's call light button should always be within her reach so she could call if she needed help with anything. CNA 2 further stated there would safety issues like risk for falls if Resident 6 would not be able to call for help when she needs assistance.2. A review of Resident 7's clinical record indicated Resident 7 was admitted in August of 2025 and had diagnoses that included fracture of left upper arm, diabetes, muscle weakness, and congestive heart failure (a condition in which the heart cannot pump oxygen-rich blood efficiently to the rest of the body).A review of Resident 7's MDS Cognitive Patterns, dated 12/4/25, indicated Resident 7 had a BIMS score of 13 out of 15 which indicated Resident 7 had an intact cognition. A review of Resident 7's MDS Functional Abilities, dated 12/4/25, indicated Resident 7 needed substantial/maximal assistance with toileting hygiene, shower/bathing self, upper and lower body dressing, and putting on/taking off footwear, and needed partial/moderate assistance with personal hygiene. A further review of Resident 7's MDS Functional Abilities indicated Resident 7 needed supervision or touching assistance with rolling left and right, sit to lying, and lying to sitting on side of bed, and needed partial/moderate assistance with sit to stand, chair/bed-to-chair transfer, and toilet transfer.A review of Resident 7's care plan, revised 8/28/25, indicated, Falls: [Resident 7] is at risk for falls with or without injury related to .Fx [fracture], Fall hx [history] .heart failure .Educate/remind resident to call for assistance with all transfers .Keep call light within reach.During an interview on 2/9/26 at 1:46 p.m. with CNA 2, CNA 2 stated Resident 7's call light usually gets broken and would not work. CNA 2 further stated staff would try to fix Resident 7's call light but then it would get broken again.During an interview on 2/9/26 at 2:05 p.m. with Resident 7, at the therapy room, Resident 7 stated he just recently got transferred to his room, but he feels annoyed and he does not feel comfortable staying in his room because his call light has been broken since last Thursday [2/5/26]. Resident 7 further stated facility staff were aware that his call light button was broken but had not fixed it.During a concurrent observation, interview, and record review on 2/9/26 at 2:14 p.m. with CNA 3, in Resident 7's room, CNA 3 checked and confirmed that Resident 7's call light system was broken, and Resident 7 was not provided with an alternative call system. CNA 3 stated she was not aware that Resident 7's call light was broken. CNA 3 also stated Resident 7 should be provided with a functioning call system because Resident 7 should always be able to call for assistance and in cases of emergency, Resident 7 should be able to call for help. CNA 3 further stated they would write in the maintenance logbook or directly call the maintenance staff if a facility equipment was broken. The Maintenance Logbook was then reviewed and CNA 3 confirmed that there was no report that Resident 7's call light has been broken. During a concurrent observation and interview on 2/9/26 at 2:23 p.m. with the Maintenance Supervisor (MS), in Resident 7's room, the MS checked and confirmed that Resident 7's call light system was broken and stated he needs to replace it. The MS stated a staff told him this morning that Resident 7's call light was broken but he has not fixed it.During an interview on 2/9/26 at 4:50 p.m. with the Director of Nursing (DON), the DON stated she would expect that residents would be provided with a working call light system and it should be placed within the reach of the residents. The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555801 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 555801 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/09/2026 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 0558 Level of Harm - Minimal harm or potential for actual harm DON further stated there would be safety concerns if residents' call lights were not working or not within their reach.A review of the facility's policies and procedures titled, Answering the Call Light, dated 10/2010, indicated, 5. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident .7. Report all defective call lights to the nurse supervisor promptly. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555801 If continuation sheet Page 3 of 3