Health inspection·November 5, 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to supervise and ensure the safety of one (1) of 2 sampled residents (Resident 1) in accordance with the facility's Wandering and Elopement (leaving the facility without the staff's knowledge and/or supervision) Policy and Procedure (P&P).This failure resulted in Resident 1 eloping from the facility on 11/1/2025 around 4:15 PM which placed the resident at risk for exposure to extreme weather, medical complications, injury, serious harm, and/or death. Resident 1 was not found until approximately eight (8) hours later, on 11/2/2025, at 11:45 PM at the general acute care hospital (GACH).Findings:During a review of Resident 1's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of chronic (long term) chronic obstructive pulmonary disease (CODP; a group of lung diseases that block airflow and make it difficult to breathe) and chronic pulmonary edema (a condition where fluid builds up in the lungs causing persistent shortness of breath [SOB]). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 9/24/2025, the MDS indicated the resident was moderately impaired with cognitive (ability to think, remember, and reason) skills for daily decision making. Resident 1 was dependent (helper does all of the effort; resident does none of the effort to complete the activity or the assistance of 2 or more helpers is required for the resident to complete the activity) with toilet transfer (the ability to get on and off a toilet or commode), lower body dressing (the ability to dress and undress below the waist). Resident 1 needed substantial/maximal assistance (helper does more than half the effort) with chair/bed-to-chair transfers (the ability to transfer to and from bed to a chair or wheelchair), going from lying to sitting on the side of the bed, and needed supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with eating. During a review of Resident 1's Situation, Background, Assessment and Recommendation (SBAR) documentation, dated 11/1/2025 at 9 PM, the SBAR documentation indicated during shift change, Resident 1 was not in his room and the morning shift nurse reported that Resident 1 went to the patio after lunch. The SBAR further indicated Resident 1 did not return to his room at the usual time later in the evening. Registered Nurse 1 (RN 1) was notified and facility staff looked for Resident 1 in every unit and around 12 AM on 11/2/202,5 Resident 1 was confirmed to be admitted at GACH.During a review of Resident 1's RN (Registered Nurse) Note, dated 11/2/2025 at 12:20 AM, Resident 1's RN Note indicated the following:> At approximately 9 PM on 11/1/2025, Resident 1 was noted to be missing and facility staff began searching for the resident.> Resident 1 was last seen on 11/1/2025 around 4:09 PM leaving the patio area of the facility and going towards the facility's 200 and 300 units, as seen by Activities Director (AD). > At approximately 10 PM on 11/1/2025 when the footage from the facility security camera was reviewed, it showed that on 11/1/2025 around 4:15 PM, Resident 1 was sitting by the facility's parking lot gate wearing a black hat, grey Page 1 of 3 055293 055293 11/05/2025 Santa Anita Convalescent Hospital 5522 Gracewood Ave. Temple City, CA 91780

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few torso shirt with black short sleeves and an unknown pedestrian wearing a hat and light-colored clothing was seen approaching the resident. The pedestrian pressed on the button to open the parking lot gate and Resident 1 wheeled himself out of the facility. The pedestrian was then seen walking away but then turned around to help Resident 1 push his wheelchair towards the sidewalk.> Local authorities arrived at the facility approximately at 11:32 PM on 11/1/2025. > On 11/2/2025 at 12:11 AM, it was confirmed by the local authorities that Resident 1 was found at GACH. During a review of Resident 1's GACH Consult Cardiology (a branch of medicine that deals with the diagnosis, treatment, and prevention of disease of the heart and blood vessels) Note dated 11/1/2025, the GACH Consult Cardiology Note indicated Resident 1 was found by a neighbor who called the ambulance after finding the resident roaming on a wheelchair for a substantial period of time. Resident 1's chest x-ray (a test that uses radiation [energy that travels in the form of waves or particles] to create an image of the organs and structures in the chest used to help diagnose) showed Resident 1 had cardiomegaly (enlarged heart) with bilateral opacities (an area that appears whiter than the surrounding tissue indicating it is blocked or absorbed more of the x-rays) suggesting decompensated congestive heart failure (a sudden worsening of heart failure symptoms, occurring when the heart cannot pump enough blood to meet the body's needs) and pleural effusion (an abnormal buildup of excess fluid in the space between the lungs and the chest cavity). Resident 1 was then admitted to the GACH telemetry (a device used for the automatic, remote [far away in distance] measurement and transmission of data from various sources to a central monitoring station for analysis) unit. During an interview on 11/4/2025 at 11:18 AM with Quality Assurance Nurse (QAN), QAN stated Resident 1 had bilateral (both) below the knee amputation (removed through surgery). QAN stated Resident 1 wheels around the facility in his wheelchair. QAN stated on 11/1/2025, Resident 1 was in the activity room in the afternoon and then went back to unit 200 (where Resident 1's room was located ) and was not sure what happened. QAN stated Resident 1 was able to wheel himself out to the parking gate on the side of the facility where an unknown pedestrian passed by, pressed the button to request to open the parking lot gate which the receptionist did. QAN stated this side parking gate to the left of the facility only opens if staff have a key card, with a clicker (remote control) or if anyone pressed the parking gate button which alerts the receptionist who can then open the gate from the front desk. During an interview on 11/4/2025 at 11:35 AM with Activity Director (AD), AD stated on 11/1/2025 at 3:45 PM, he last saw Resident 1 in the smoking patio by himself and was not sure if a facility staff was supposed to be supervising the resident. During an interview on 11/4/2025 at 11:56 AM with RN 1, RN 1 stated on 11/1/2025 around 9 PM, he was notified that Resident 1 was last seen by AD at 4 PM. RN1 stated AD called a code green (missing resident alert) on the facility's overhead system. RN 1 stated all rooms at the facility were checked including the back parking lot and around the neighborhood, but the facility did not find Resident 1. RN 1 stated at approximately 12:11 AM on 11/2/2025, the facility was informed by the local authorities that Resident 1 was found at GACH. During an interview on 11/3/2025 at 12:27 PM with Certified Nursing Assistant 1 (CNA1), CNA1 stated on 11/1/2025 between 3:20 PM to 3:30 PM, she noticed Resident 1 was not in his room. CNA 1 stated at around 4:45Pm to 5PM, during dinner tray distribution, she again noticed Resident 1 was not in his room, so she reported to Licensed Vocational Nurse 1 (LVN1). CNA 1 stated a code green was called but the facility staff could not find Resident 1. CNA 1 stated it was important to check on the residents every 30 minutes to an hour to ensure the residents were safe. During an interview on 11/4/2025 at 1:21 PM with LVN 1 stated on 11/1/2025 at 3PM, Resident 1 was in the patio with other residents and staff members . LVN 1 stated around 4:45 PM to 5 PM, while passing dinner trays, CNA 1 informed her that Resident 1 had not yet come back to his 055293 Page 2 of 3 055293 11/05/2025 Santa Anita Convalescent Hospital 5522 Gracewood Ave. Temple City, CA 91780

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few room. LVN 1 stated she then went to the patio to look for Resident 1 and when she did not find him. LVN 1 stated he notified RN 1 around 5 PM. LVN 1 stated a code green was called but the facility staff did not find Resident 1. LVN 1 stated Resident 1 was then found later that night at GACH. LVN 1 further stated residents are checked every 1 to 2 hours to ensure their safety. During an interview on 11/4/2025 at 1:28 PM with Receptionist 1, Receptionist 1 stated when someone presses the button located on the side of the facility's side parking gate, it rings the phone in at the reception desk. Receptionist 1 stated, she is then able to enter a code that opens the gate. Receptionist 1 also stated she typically does not speak to the person who pressed the button to ask for their identity. During an interview on 11/4/2025 at 2:38 PM with Receptionist 2, Receptionist 2 stated she was the Receptionist on 11/1/2025 and stated on 11/1/2025, when the phone notified her that someone was at the parking gate, she did not ask who was requesting to open the gate and input the code to open it. Receptionist 2 stated she was not aware and was never trained that she needed to speak to the person at the gate to ask or screen who they were. During an interview on 11/5/2025 at 1:33 PM with Assistant Administrator (AADM), AADM stated the normal process for when someone presses the side parking gate button is for the receptionist to ask the person's name and what they are there for since it is only authorized personnel who are allowed to use the back parking lot. AADM stated on 11/1/2025 when the person pressed the side parking button, the receptionist should have asked who they were, for their name and if they were an employee and because that process was not followed, Resident 1 was able to leave the facility. During an interview on 11/5/2025 at 2:05 PM with QA, QA stated that staff became complacent with Resident 1's behavior of always staying out in the patio or his room and did not expect that he would ever wheel himself out to the back parking lot side gate and leave. QA stated the receptionist probably assumed the person who pressed the side parking lot gate button was either staff or a delivery coming in. During a review of the facility's policy and procedure (P&P) titled, Wandering and Elopement, revised 6/1/2017, the P&P indicated its purpose was, To enhance the safety of residents of the facility, and further indicated:a. If Facility Staff observes a resident leaving the premises without having followed proper procedures, he/she may:a. Try to prevent departure in a courteous manner.b. Get help from other Facility Staff in the immediate vicinity, if necessary; andc. Direct another Facility Staff member to inform the Charge Nurse or Director of Nursing Services that a resident is trying to leave the premises. 055293 Page 3 of 3