Health inspection·October 30, 2024

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 interview and record review, the facility failed to prevent elopement for one of 3 sampled residents (Resident 1 ) when he left the facility unaccompanied by staff. Residents Affected - Few This failure resulted in Resident 1 sustaining a fall, complained of neck and left knee pain and, verbalized he hit his head. Findings: Resident 1 was admitted to the facility in October 2024 with diagnoses which included cognitive impairment, dementia, difficulty in walking, and history of falling. Resident 1's admission MDS (Minimum Data Set-an assessment tool), dated 10/29/24 documented Resident 1 as having clear speech, sometimes able to understand others, sometimes able to make self-understood and his Brief Interview for Mental Status (BIMS) summary score as a 3 out of 15 (indicated severe impairment). The MDS described Resident 1 as not having delirium or behavioral symptoms but as having wandering behavior. Review of Resident 1's Wandering Risk Assessment, dated 10/16/24 indicated Resident 1 as moderate risk for wandering. Review of a Progress Note dated 10/22/2024 at 5:05 p.m. indicated, Resident had an unwitnessed fall on the pavement by the driveway outside the facility next door, he wandered outside looking for his wife. Resident was in a W/C (wheelchair) but able to ambulate with 1 person assistance. Family had been in the facility earlier to visit. Resident was a fall risk, and all precautions were in place, CNA had gotten resident up from bed because he would not stay in bed, he kept getting out of bed, she positioned the resident outside his room in the hallway for better visibility. Resident has not attempted to leave the facility before. The nurses were attending to another resident who had a change of condition and managed to wheel himself to the door by the lobby and during the commotion managed to ambulate across the street to the next building driveway. Resident stated he was going home to his wife, he was assessed by Nurses and writer, no injuries noted, resident alert x1 with confusion, verbally responsive, all extremities movable. Resident c/o (complain of) neck pain and LLE knee pain, paramedics notified to transfer resident for he [sic] ER for further evaluation . Review of a Progress Note dated 10/22/2024 at 6:19 p.m. indicated, A man from the street approach the discharge planner that there is a man with our name on his wrist band who is on the ground (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 10/30/2024 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)