Inspection·March 14, 2025

F 0689 disorder, hallucinations, and used a cane as a mobility device. Level of Harm - Minimal harm or potential for actual harm A record review of a Minimum Data Set (resident assessment) dated 01/09/25, Section GG Functional Abilities, indicated that Resident 4 was able, with supervision or touching assistance, to walk 10 feet Residents Affected - Few A record review of Resident 4 Progress Notes dated 01/12/25 at 04:07am indicated that two Certified Nurse Assistants (CNA ' s) went to get the Resident 4 who had left the building and was opening the gate. The CNAs were trying to prevent the resident from entering the street/traffic, local law enforcement was called for help as the resident was fighting to get away, police officers arrived and assisted returning Resident 4 to the facility. A record review of Resident 4 Progress Notes dated 1/12/25 at 12 am indicated that Resident 4 was found in the parking lot and the and the family was notified. The family stated that he gets hallucinations and starts walking and takes off when he gets them. the family was informed that the plan was to put a wander guard device (a wearable device that triggers an alarm when approaching a restricted area or doorway) on Resident 4. Family stated, I thought they put one on his ankle earlier when he did this. A record review titled General Order dated 1/12/25 at 12:57 am, indicated Resident 4 was to have an Ankle Wander Guard related to elopement. A record review of Resident 4 ' s care plans dated 01/12/2025 indicated a new care plan was initiated post elopement for wandering/elopement risk related to strong desire to go home, Cognitive Loss, Parkinson ' s Disease due to history of attempts to leave facility unattended., Wandering into other residents ' rooms, and impaired safety awareness. A record review of admission 48-hour Baseline Person-Centered Care Planning dated1/02/25 at 8:40 pm, indicated that Resident 4 ' s family was present at the time of the care plan meeting. An interview with Registered Nurse (RN B) on 03/03/25 at 12:15 pm, RN B stated Resident 4 had requested to go home with family and was observed following them to the door when the family would leave. RN B explained she was aware that Resident 4 was an elopement risk 4 days after his admit, due to observing him hanging around the front door of the facility and overheard statements he made to his family about wanting to go home. RN B confirmed the behavior and statements made by Resident 4 would make him an elopement risk and should have been reassessed for it. During an interview with Director of Nursing (DON) on 03/03/25 at 1225, DON stated that Resident 4 had a recent room transfer which placed him in a room one door from the exit door. DON explained that on the evening of January 11th at about 6pm Resident 4 attempted to leave the facility by following family to the door after a visit. [NAME] stated at about 11pm Resident 4 again attempted to leave the facility, this time through the exit door near his room. DON agreed that he should have had a Wander Guard device on after the first attempt. DON confirmed no care conference was done during the admission and usually the goal was to have it done within the first 5 days of admission where families usually participate in plan of care. An interview with Licensed Nurse (LN C) on 03/03/25 at 3:50 pm, Resident 4 was confused and ran out of the building, the CNAs were able to stop him, but he was kicking and hitting them. LN C stated that behaviors such as a resident moving around the building or looking for a way out, would prompt a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555430 If continuation sheet Page 2 of 3 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 555430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fountains, The 1260 Williams Way Yuba City, CA 95991 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 reassessment of the risk for elopement. Level of Harm - Minimal harm or potential for actual harm An interview with Certified Nurse Assistant (CNA A) on 03/05/24 at 2:41 pm, Resident 4 ran from bed out of the facility. CNA A and another CNA were able to stop the resident at the sidewalk, outside of the gate to the facility. They feared the resident would be hit by a car and called law enforcement for assistance. Residents Affected - Few An interview with a family member (FM) of Resident 4 on 03/06/25 at 1135 am, Resident 4 had tried to leave the building earlier in the evening, prior to the elopement. FM discussed that prior to this incident staff would keep an extra eye on him to keep him from leaving the facility. Fm stated that Resident 4 ' s past psychosis and elopement behavior were discussed during his admit, and that it is why he was there. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555430 If continuation sheet Page 3 of 3