Health inspection·January 7, 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure supervision for one of three sampled residents (Resident 1) when Resident 1 eloped (the act of leaving a facility unsupervised and without prior authorization) fell and sustained injuries. This failure resulted in Resident 1 sustaining a fracture (broken bone) of the left distal phalanx (a small bone on the tip of the thumb located under the nail) and abrasions (a partial loss of skin, usually due to scraping) to his face and both knees. Findings: A review of Resident 1's admission record indicated he was admitted on [DATE] with diagnoses including cerebral infarction (stroke- loss of blood flow to the brain). A review of Resident 1's clinical record included the following documents: A Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 2/14/24, indicated Resident 1 had severe memory impairment and had impairment in both arms and legs requiring assistance with walking. A Fall Risk Assessment, dated 2/7/24, indicated Resident 1 was at moderate risk for falls. A Fall Risk Care Plan, initiated 2/7/24, indicated Resident 1 was at high risk for falls related to neuromuscular/functional problems such as recent stroke. An Elopement Risk Assessment, dated 2/7/24, indicated Resident 1 was at low risk for wandering. A Wandering Risk Assessment (WRA), dated 2/7/24, indicated Resident 1 was at low risk for wandering. An Elopement Care Plan, initiated 2/15/24, indicated Resident 1 was an elopement risk related to his wandering around, trying to go outside or attempting to leave the facility. A Physician's Order, dated 2/15/24, indicated a brand name wandering device (WMD -a sensory device placed on residents that alarms if near a monitored exit) was to be placed on Resident 1. A nursing progress note, dated 2/15/24 at 1:06 p.m., indicated Resident 1 was confused, wandering, (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: 056090 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 056090 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Oak Post-Acute 850 Sonoma Ave Santa Rosa, CA 95404 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)