Health inspection·November 24, 2025

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few Based on interview and record review the facility failed to provide appropriate and adequate supervision to prevent an avoidable accident when one of three sampled residents (Resident 1) left the facility without the facility's knowledge and supervision.This failure resulted in Resident 1 experiencing falls outside the facility, leading to multiple abrasions on the hands and knee and increased the risk of cold exposure and potential injury from passing motor vehicles. Findings: Resident 1 was admitted to the facility in the fall of 2025 with diagnoses which included traumatic brain injury (an injury to the brain caused by a sudden bump, or jolt to the head, which can disrupt its normal function), muscle weakness, and difficulty walking. During a review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 11/6/25, the MDS indicated Resident 1 had moderate impairment of his memory and was independent with most activities of daily living (ADLs). During a review of Resident 1's document titled FALL RISK EVAL [FRE, fall risk evaluation], dated 10/30/25, the FRE indicated Resident 1 had intermittent confusion. During a review of Resident 1's document titled Wandering Risk Assessment [WRA], dated 11/3/25, the WRA indicated Resident LACKS capacity to understand and make decisions.low to moderate risk of elopement. During a review of Resident 1's document titled Progress Notes [PN], dated 11/17/25, the PN indicated It was reported by [Licensed Nurse (LN) 1] at 4:30 a.m. while doing rounds the cna [Certified Nurse's Assistant 1] identified [Resident 1] as missing.the last time she had a visual check on [Resident 1] was 3:30 a.m. Staff immediately following (sic) missing resident protocol.without success.Resident was located by staff members [family member] around 8:15 am.the charge [LN 1] did a body check on resident he has several abrasions.he stated he left the facility around 4am and headed to his home.he also stated he had several falls while he walked. During a review of Resident 1's facility Discharge Instruction Form [DIF], dated 11/17/25, the DIF indicated [right] hand, scattered abrasions.Scrape to [right] knee, outside area of [right] foot, reddened area to [left] great toe. During an interview on 11/24/25 at 8:34 a.m. with CNA 2, CNA 2 indicated [Resident 1] was more unsteady when he returned. I heard he left about three or four in the morning.He came back [11/17/25] around 8:45 a.m. [with a staff family member by car] soaking wet, was very cold.He was a little confused and a little unsteady. He had scratches on his right hand like he had fallen. They were fresh. There were scratches on his left knee, too.He never mentioned why he left. He mentioned he wanted to get keys for the church.The same day he left it was pouring [rain]. During an interview on 11/24/25 at 12:04 p.m. with the Director of Nurses (DON), the DON said, My expectation is to keep all our residents safe. [Resident 1's] long-term memory is good, but his short-term memory is bad. He thought the scratches were from an old motorcycle accident. During an interview on 12/25/25 at 6:52 a.m. with LN 1, LN 1 said, At 3:30 to 4 in the morning [11/17/25], [CNA 1] told me he was not in his room.He was found at the post office of [name of town]. It's about half an hour from here. He may have got a ride or walked there. We don't know. During a review of the facility policy and procedure (P&P) titled Safety and Supervision of Residents, dated Page 1 of 2 055640 055640 11/24/2025 Grass Valley Healthcare Center 355 Joerschke Dr Grass Valley, CA 95945

F 0689 2001, the P&P indicated Resident safety and supervision and assistance to prevent accidents are facility wide priorities. Level of Harm - Actual harm Residents Affected - Few 055640 Page 2 of 2