Health inspection·November 17, 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 interview and record review, the facility failed to provide supervision to 1 out of 3 residents (Resident 1) from leaving the facility, when1. Resident 1 did not have an out-on-pass order (OOP, a temporary leave of absence for a resident, typically for family visits, holidays, or other events, which must be approved by the facility, the resident's physician, and often included in the individual's care plan) before he left the faciity on 9/14/2025.2. The facility did not implement Resident 1's care plan to provide one-person assistance during ambulation (the medical term for walking, which is the ability to walk from place to place) and locomotion (the act or power of moving from place to place).3. The facility did not report this incident to the California Department of Public Health (CDPH) as an unusual Occurrence. These failures had the potential to compromise Resident 1's health, safety, and well-being. A review of Resident 1's face sheet (a summary document containing a patient's key demographic and medical information for quick reference by healthcare providers) indicated he was admitted to the facility on [DATE] with diagnoses including aftercare following joint replacement surgery (a medical procedure where a damaged or diseased joint is replaced with an artificial one to relieve pain, improve function, and restore mobility.), stimulant dependence (a type of substance use disorder characterized by the compulsive use of stimulant drugs like amphetamines and cocaine, leading to clinically significant impairment or distress) schizoaffective disorder (a chronic mental health condition characterized primarily by symptoms of schizophrenia, such as hallucinations or delusions), generalized muscle weakness (a widespread feeling of weakness or fatigue in multiple muscle groups throughout the body), abnormal posture (deviations from the ideal body alignment, resulting in musculoskeletal imbalances and potential health issues).A review of Resident 1's minimum data set (MDS, an assessment tool) dated 8/28/2025 indicated his brief interview for mental status (BIMS, assessment for cognition level) score was 13 (cognitive intact). A review of Resident 1's physician orders for August and September 2025 revealed no out-of-pass (a temporary leave of absence for a resident, typically for family visits, holidays, or other events, which must be approved by the facility) orders for Resident 1. 1. A review of Resident 1's nursing progress notes dated 9/14/2025 at 2:45 p.m., indicated Resident 1 left the facility around 11:30 a.m., has not come back to the facility yet. Mountain View police department called.A review of Resident 1's nursing progress notes dated 9/14/2025 16:05 p.m., indicated Resident 1 walked back to our facility at 4:06 p.m., by himself. Resident 1 stated that he went to (pharmacy store) to buy cigarettes, after that he felt tired, slept over the grass, and walked back to the facility. He said he didn't know he needed an MD's (doctor's) approval for OOP.During a concurrent record review and interview with the Director of Nursing (DON) on 10/20/2025 at 3:11 p.m., the DON reviewed Resident 1's physician orders for August and September 2025 and confirmed that Resident 1 did not have an out on pass order (OOP) to leave the facility. The DON stated that Resident 1 should not leave the facility without MD's OOP order.During a phone Page 1 of 2 055315 055315 11/17/2025 Camino Ridge Post-Acute 1949 Grant Road Mountain View, CA 94040

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few interview with Registered Nurse (RN) A on 10/27/2025 at 5:03 p.m., RN A confirmed that there was no OOP order for Resident 1 for him to leave the facility. A review of the facility's undated policy and procedure titled Therapeutic Leave (Resident absences for purposes other than required hospitalization) Policy indicated .The nurse will obtain an order from the practitioner specifying approval of a therapeutic leave. 2. A review of Resident 1's care plan of self-care deficit as evidenced by : needs limited to extensive assistance with ADLs (basic self-care tasks like eating, bathing, and dressing etc.) related to C2-C5 laminectomy and fusion [a posterior cervical surgery to relieve spinal cord compression by removing the lamina (the back part of the vertebrae) from C2 to C5], COPD (a progressive lung disease that causes breathing difficulties, leading to symptoms like shortness of breath, chronic cough, wheezing, and fatigue), stimulant dependence, schizoaffective disorder, psychosis, chronic viral hepatitis C, anxiety, chronic pain syndrome, depression, muscle spasms, insomnia, neuralgia/neuritis, BPH. The interventions include one-person physical assist required for ambulation and locomotion. During a concurrent record review and interview with the DON on 10/27/2025 at 4:09 p.m., the DON reviewed Resident 1's care plan and confirmed that Resident 1 needs one person assisting with ambulation and locomotion and that it was not safe for him to walk out of the facility by himself. A review of the facility's policy and procedure titled Care Plans, Comprehensive Person-Centered, Revised March 2022, indicated .The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. 3. During a phone interview with Certified Nursing Assistant (CNA) on 10/23/2025 at 2:44 p.m., CNA D stated that Licensed Vocational Nurse (LVN) B was looking for Resident 1 for his noon medication around 11:30 p.m., and found out that Resident 1 was not in the facility on September 14, 2025. Both of them looked everywhere and could not find Resident 1, and a staff member called the police. During a phone interview with LVN B on October 23, 2025, at 4:07 p.m., LVN B stated he was the nurse on duty that day and provided care for Resident 1. LVN B further stated that he did not know when Resident 1 left the facility and that Resident 1 did not take his scheduled noon medication on September 14, 2025. During a phone interview with the Receptionist on October 28, 2025, at 3:20 p.m., she stated that on September 14, 2025, between 11:00 a.m. and 12:00 p.m., she observed a person wearing an orange shirt walk out of the facility with a wristband (an armband used for positive resident identification) without checking out with her. She immediately attempted to follow the individual but was unable to locate the person outside the facility building. The Receptionist stated she was unsure which resident had left the facility. She also confirmed that it was her responsibility to monitor the front entrance and ensure residents checked out when leaving the facility. During a phone interview with Licensed Vocational Nurse (LVN) A on 10/29/2025 at 11:25 a.m., LVN A stated that staff conducted a room-to-room search to identify which resident wearing an orange shirt was missing. She further stated that she and other staff members also went to nearby stores to search for Resident 1. A review of the Mountain View Police Department Report Receipt dated on 9/14/2025 indicated the type of incident Found Missing Person.During an interview with the DON on 10/27/2025 at 11:40 a.m., the DON confirmed that the facility did not report this incident to CDPH. A review of the facility policy and procedures titled Unusual Occurrence Reporting, Revised December 2007, indicated that . As required by federal or state regulations, our facility reports unusual occurrences or other reportable events which affect the health, safety, or welfare of our residents, employees or visitors.Other occurrences that interfere with facility operations. 055315 Page 2 of 2