Health inspection·July 1, 2024

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 . Page 1 of 2 555083 555083 07/01/2024 Manzanita Healthcare Center 5318 Manzanita Avenue Carmichael, CA 95608

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. 555083 Page 2 of 2