Health inspection·August 6, 2024

F 0559 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. Based on observation, interview and record review, the facility failed to ensure one of three sampled resident's (Resident 3's) rights were exercised when the resident was moved to another room without advance notice. This failure resulted in a violation of Resident 3's rights and left the resident confused. Findings: Review of Resident 3's medical record, admission RECORD, indicated the resident was admitted to the facility in the spring of 2024 with diagnoses that included heart problems. The admission Record indicated Resident 3 was his own responsible party (RP). In an interview on 8/6/24 at 11:15 a.m., Resident 3 was in his wheelchair near the door of a room in the hallway. Resident 3 stated he was being moved to the room at that time and stated he did not know why he was moving. Resident 3 stated someone came in his room that morning and said, You're moving, while clapping his hands. Resident 3 said he did not receive any notification regarding the room change, did not know where his new room was, or who the new roommate would be and still had not met the roommate. Resident 3 stated, I did not give my consent to the room change and indicated staff were packing his stuff while he was waiting outside his new room to be moved in. Resident 3 stated that he might be being moved because he did not get along well with one of the staff. Review of the facility's May 2027 revised policy and procedure, Room Change/Roommate Assignment, stipulated, Prior to changing a room or roommate assignment all parties involved in the change/assignment (e.g., residents and there representatives (sponsors)) will be given advance notice of such change .Advance notice .will include why the change is being made and any information that will assist the roommate in becoming acquainted with his or her new roommate. In an interview on 8/6/24 at 12:30 p.m., in the conference room, the Administrator stated Resident 3 was moved to another room with a male resident at the request of the facility for a new female resident admission. The Administrator stated the room change should have been discussed with the resident and consent obtained from the resident prior to the room change. The Administrator stated the room change for Resident 3 was discussed during the Interdisciplinary Team (IDT) stand up meeting that morning. The Administrator stated resident's room changes were handled by the Social Services and verified that Resident 3 had no history of false accusation. In a concurrent interview and record review on 8/6/24 at 1:05 p.m. in the conference room, the Social Service Director (SSD) stated it was the facility policy to ask the resident or the resident (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: 555889 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 555889 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mountain Manor Senior Residence 6101 Fair Oaks Boulevard 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)