Health inspection·June 26, 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. Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent one of three sampled residents (Resident 1) from elopement (to leave an area of safety unsupervised and undetected) outside the facility. This failure had the potential to result in serious injury or death for Resident 1. Findings: A review of Resident 1's admission Record indicated, Resident 1 was admitted to the facility in 2025 with a diagnoses that included Dementia (a group of symptoms affecting memory, thinking, and social abilities). A review of Resident 1's, Minimum Data Set (MDS - an assessment tool used to guide care) Cognitive (having full understanding) Patterns, dated 6/23/25, indicated Resident 1 had a Brief Interview for Mental Status (a tool to assess a person's full understanding) score of 00 which indicated Resident 1 did not have full understanding and thus, not able to be interviewed. A review of Resident 1's, Wandering Risk Observation/Assessment dated 3/19/25, indicated Resident 1 had a score of 12 which indicated a high risk for elopement and wondering. A review of Resident 1's Care Plan dated 3/19/25, indicated Elopement: Resident is at risk for elopement/exit-seeking/wondering related to dementia . During an interview with the Director of Nursing (DON) on 6/25/25 at 11:36 a.m., the DON stated Resident 1 has dementia and is confused. The DON further stated Resident 1 is ambulatory (able to walk) and is at high risk for elopement. On 6/20/25 Resident 1 eloped from the facility and was missing for 45 minutes. Lastly the DON stated, The expectation is for no residents to elope. During an interview with the Licensed Nurse 1 (LN 1) on 6/25/25 at 12:27 p.m., LN 1 stated, Resident 1 had started exit seeking behavior a few days prior to the elopement. LN 1 further stated, We should have been watching him closer since he was exit-seeking. A review of Resident 1's Progress Note dated 6/20/25 indicated Resident 1 was last seen in their room on 6/20/25 at 1:45 p.m. by the DON. On 6/20/24 at 2:30 p.m., the facility received a call from the police department, Resident 1 had been found. A review of the facility policy titled, Wandering and Elopements dated 10/2024 indicated, The Page 1 of 2 555283 555283 06/26/2025 Crystal Ridge Care Center 396 Dorsey Drive Grass Valley, CA 95945

F 0689 facility will identify residents who are at risk of unsafe wandering and provide interventions to decrease the risk and keep residents safe. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 555283 Page 2 of 2