Health inspection·April 14, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide adequate supervision for one of four sampled residents (Resident 1) when Resident 2 punched Resident 1 in the stomach which caused Resident 1 to fall and hit her head. This failure resulted in an injury to Resident 1's head. Findings: Resident 1 was admitted to the facility late 2021 with diagnoses which included memory loss, weight loss, muscle wasting, and depression. During a review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 3/10/25, the MDS indicated a Brief Interview for Mental Status (BIMS, a standardized test that screens for cognitive impairment) score of 9/15 which showed moderate cognitive impairment. During a review of Resident 1's eINTERACT Change in Condition Evaluation [eCOCE], dated 4/7/25 at 5 p.m. the eCOCE indicated, .Resident was punched by other resident in the stomach, fell down, hit back of her head on the metal door frame, bleeding a lot. Send out via 911 . During a review of Resident 1's Order Summary Report [OSR], dated 4/8/25, the OSR indicated, Monitor laceration to head . During an observation on 4/14/25 at 2:52 p.m. of Resident 1's scalp with Licensed Nurse 2 (LN 2), Resident 1 had a small area of dried dark material on the back of her head and yellow discoloration on her left shoulder. Resident 2 was admitted to the facility mid 2023 with diagnoses which included memory impairment caused by impaired blood flow to the brain, behavioral disturbances, progressive degenerative disorder that caused a decline in memory, thinking and behavior, and a language disorder. During a review of Resident 2's MDS dated [DATE], the MDS indicated a BIMS score of 0/15, which showed severe cognitive impairment. During a review of Resident 2' s eCOCE dated 4/7/24 at 5:37 p.m. the eCOCE indicated, . resident [Resident 2] was witnessed making contact with other resident [Resident 1] stomach resulting in resident [Resident 1] to lose balance and fall to floor . (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: 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 04/14/2025 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)