F 0658
Ensure services provided by the nursing facility meet professional standards of quality.
Level of Harm - Minimal harm
or potential for actual harm
Based on interview and record review, the facility failed to provide care according to accepted standards of
quality for one of 3 sampled residents (Resident 3) when Resident 3 had no documented behavior
monitoring for the use of an antipsychotic medication (medication that affects brain activity associated with
mental processes and behavior).
Residents Affected - Few
This failure had the potential to result in an ineffective management of Resident 3's psychological health
needs.
Findings:
A review of an admission Record for Resident 3 indicated she was admitted in 6/2024 with diagnoses
including schizophrenia and bipolar disorder (mental illness that cause extreme mood swings that include
emotional highs and lows).
A review of Resident 3's Physician Orders, dated 6/25/24, indicated an order for Invega 156 milligrams
(mg., a unit of measurement) per milliliter (ml., a unit of measure) given once a month for schizophrenia.
A review of Resident 3's Progress Notes, dated 6/28/24 at 4:47 p.m., indicated that a nurse from a
psychiatric clinic came to the facility and administered/injected Invega to Resident 3 as ordered.
During a concurrent interview and record review on 7/1/24 at 1:40 p.m. with the Minimum Data Set
Coordinator (MDSC), Resident 3's Medication Administration Record (MAR) and Progress Notes were
reviewed. MDSC confirmed that the antipsychotic medication was administered to Resident 3 but there was
no behavior monitoring documented by staff.
In an interview on 7/1/24 at 3 p.m. with the Director of Nursing (DON), the DON stated Resident 3's order
for an antipsychotic medication should have been properly written and monitored for the targeted behavior
and side effects to ensure proper care for the resident.
A review of the facility's Policy and Procedure (P&P) titled Psychotropic Medication Use dated 7/2022 the
P&P stipulated Residents will not receive medications that are not clinically indicated to treat a specific
condition .Drugs in the following categories are considered psychotropic medications are subject to
prescribing, monitoring : Anti-psychotics .
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:
555083
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
555083
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/01/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Manzanita Healthcare Center
5318 Manzanita Avenue
Carmichael, CA 95608
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 0689
Level of Harm - Minimal harm
or potential for actual harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
Based on observation, interview, and record review, the facility failed to assess one of three sampled
residents (Resident 1) at a high risk for elopement.
Residents Affected - Few
This failure placed Resident 1 at an increased risk for elopement.
Findings:
A review of Resident 1's admission Record indicated she was admitted to the facility in May 2024 with
diagnoses including unspecified dementia with behavioral disturbance.
A review of Resident 1's Minimum Data Set (MDS, an assessment tool used for care), dated 5/23/24,
indicated that Resident 1 had a Brief Interview for Mental Status (BIMS, an assessment tool) score of 4 out
of 15, with memory problems. The MDS further indicated Resident 1 could independently transfer and
ambulate using a walker.
During observations on 7/1/24 at 11:40 a.m., 12:25 p.m., and 1:32 p.m., Resident 1 was observed
ambulating alone without a walker by the hallways unable to go back to her own room without assistance.
A review of Resident 3's Progress Notes, dated 6/24/24 at 6:43 p.m. and at 11:36 p.m., indicated Resident
3 exhibited verbal and physical aggression towards staff with severe confusion wanting to go outside to
park her car.
During an interview on 7/1/24 at 1:40 p.m. with the MDS Coordinator (MDSC) the MDSC confirmed that
Resident 1 had behaviors of wandering and was at risk for elopement.
During an interview 7/1/24 at 2:30 p.m. with the Social Services Director (SSD) the SSD stated that
Resident 1 is considered at high risk for elopement but there was no record that an elopement assessment
had been completed for her.
During an interview on 7/1/24 at 3 p.m. with the Director of Nursing (DON) the DON confirmed that
Resident 1 wanders and was at risk for elopement and should have been assessed properly to be able to
plan appropriate interventions for the resident's safety.
A review of the facility's Policy and Procedure (P&P) titled Wandering and Elopements revised 3/2019 the
P&P stipulated The facility will identify residents who are at risk of unsafe wandering and strive to prevent
harm .If identified as at risk for wandering, elopement or other safety issues, the resident's care plan will
include strategies and interventions to maintain resident's safety.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555083
If continuation sheet
Page 2 of 2
