Health inspection·August 3, 2023

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 interview and record review the facility failed to follow Policy on reporting when one of three sampled Resident's (Resident 1) eloped from facility. This failure had the potential to cause serious health and psychosocial harm to a clinically compromised Resident (Resident 1). Findings: During review of resident 1s admission Record (General demographics) on ., indicates admitted to facility on June 23, 2023, with diagnosis (DX) of Primary Osteoarthritis (caused by the breakdown of cartilage, a rubbery material that eases the friction in your joints), Diabetes (a disease that occurs when your blood glucose, also called blood sugar, is too high), Rheumatoid Arthritis (the body's immune system attacks its own tissue, including joints. In severe cases, it attacks internal organs) Gout (occurs when urate crystals accumulate in your joint, causing the inflammation and intense pain) and Edema (occurs when tiny blood vessels in the body, also known as capillaries, leak fluid). During concurrent interview on June 30, 2023, at 1:00 PM with Director if Nursing (DON) and Administrator, they both stated the resident was only gone for 2 hours, resident walked home to get his hat . Resident resides 3 miles from the facility. They both states they did not report it because the resident was only gone for 2 hours, and he came back on an Uber. During an interview on July 10, 2023, at 11:15 AM with Licensed Vocational Nurse (LVN 1), he stated the resident left facility without notifying anyone. States they went to VA Hospital, and surrounding areas to locate resident and he was nowhere to be found. The sheriff's department was called, and they arrived and looked for resident also. Later that evening the resident arrived at facility with a hat on stating he went home to get hat. During record review, Progress Notes on June 25.2023 1745 by LVN 2, indicated 1745 attention was brought by Charge Nurse (CN) on duty that resident is not in his room, and he checked all room and around the building. Asked Certified Nursing Assistant (CAN 1) on duty at the time saying the resident at 1630 PM he saw resident on the hallway and asked him where you are going? Resident 1 said I'm walking around. This writer (LVN 2) called Acute ER. San [NAME] police notified at (number of police station ins San [NAME]) spoke with dispatcher all information's about the resident given. at 1809 I called Acute ER to check, triage told me resident not there. Doctor notified at 1818. Resident's daughter phone number unable to leave a message as it states busy. DON and administrator made aware. At 1847 Deputy Sheriff 1 from San [NAME] in the facility and reported given at 1921, I called San [NAME] Page 1 of 2 055299 055299 08/03/2023 Loma Linda Post Acute 25383 Cole Street Loma Linda, CA 92354

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few police office and spoke with dispatcher resident home address provided to her to go check to his home. At 2010 this writer calls back VA ER to check again if resident is there. 2015 resident walk himself in the facility saying he went home to get his hat. Writer called and spoke with [NAME] dispatcher from San [NAME] police office notified resident is back and DON/Administrator made aware. Doctor 1 notified resident is back. @ 2042 Deputy 1 from San [NAME] back to the facility to see and talk to resident, writer walk him thru the resident room. 6/25/23 at 2015 by LVN 1: Resident arrived saying that he rode the bus to his home to pick up some stuff (hat). He then found out that the bus service stopped when he wanted to go back here. He then called his friend who paid for his Uber to be taken back here. Resident says that he is sorry for not informing anyone about his intent. During a review of the facility's policy and procedure titled Elopements Revised December 2007, the Policy indicated: 4. If an employee discovers that a resident is missing from the facility, he/she shall: If the resident is not located, notify the Administrator and the Director of Nursing Services, the resident's legal representative (sponsor), the Attending Physician, law enforcement officials, and as necessary, (based on the regulatory guideline), required or volunteer agencies (i.e., Regulatory, Emergency Management, Rescue Squads, etc.) During a record review of the facility's policy and procedure titled Unusual Occurrence Reporting Revised December 2009, the Policy indicated, Policy Statement: Our facility reports, as required by federal or state regulations, unusual occurrences or other reportable events which affect the health, safety, or welfare of our residents, employees, or visitors. Policy Interpretation and Implementation: 1. Our facility will report the following events to appropriate agencies: h. Other occurrences shall be reported via telephone to the state survey agency (and other appropriate agencies as required by law) within twenty-four (24) hours of such incident or as required by federal and state regulations. 3. A written report detailing the incident and actions taken by the facility after the event shall be emailed, faxed, or sent by special carrier to the state agency (and other appropriate agencies as required by law) within forty-eight (48) hours of reporting the event or as required by federal and state regulations. 055299 Page 2 of 2