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 Page 1 of 2 555889 555889 10/30/2024 Mountain Manor Senior Residence 6101 Fair Oaks Boulevard Carmichael, CA 95608

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few .Discharge planner and writer found the resident lying down on the drive way of the next-door facility. Resident is on right side lying position with BLE [bilateral lower extremity] flex. Neuro assessment [checking the functional status of the nervous system] started by the writer. Resident c/o of neck pain right away and unable to explain pain level and verbalizing that he hit his head. During an interview on 10/30/24 at 9:39 a.m. with the Administrator, he stated Resident 1 was sitting in his W/C in front lobby area and got up and ambulated to the next-door facility. The Administrator stated Resident 1 left when the nurses were attending to another resident who had a change of condition. The Administrator stated staff have been monitoring him closely to avoid a fall as the resident had a history of falls. The Administrator further stated Resident 1 had no previous incident of trying to wander outside the facility. A review of the facility ' s ' Elopements ' policy dated 12/2007 addressed investigating and reporting elopements. The facility policy failed to address interventions that would be put in place to prevent residents from episodes of elopement. 555889 Page 2 of 2