Health inspection·March 27, 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 provide adequate supervision to one of three sampled residents (Resident 1) when Resident 1 eloped from the facility without the facility ' s knowledge on March 12, 2025. This failure had the potential to place Resident 1 at increased risk for falls and injuries, heat or cold exposure, dehydration, and/or death. Findings: During a review of Resident 1 ' s clinical record, the face sheet (contains demographic and medical information) indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included dementia (brain disorder that causes loss of memory, language, thinking abilities severe enough to interfere with daily life), hypertension (condition where the force of blood pushing against your artery walls is consistently too high), and mood affective disorder (mental health condition that affects your emotional state, causing long periods of extreme happiness or sadness). Further review indicated Resident 1 was in the Memory Care Unit (a unit specifically for residents who have diagnoses such as dementia or Alzheimer ' s [a brain disorder that slowly destroys memory, thinking skills, and the ability to perform everyday tasks]). During a review of Resident 1 ' s nursing notes, dated March 13, 2025, at 7:53 PM, it indicated, At 11:45 PM on 3/12/25, resident attempted to leave facility and was seen wandering outside. Resident was brought in back to the facility. Several minutes later, he was able to get out again. Resident not found in facility premises, so police were called in. Resident was brought back to facility by police. MD was notified. Resident's son was notified. During a concurrent observation and interview with Resident 1, on March 14, 2025, at 3:26 PM, in Resident 5 ' s room, Resident 1 was lying on his bed, resting. He had no visible injuries. Resident 5 stated he does not recall eloping from the facility March 13, 2025. During a concurrent observation and interview with the Maintenance Director (MD), on March 14, 2025, at 3:38 PM, in the Memory Care Unit, the MD demonstrated the alarm activation and how to access the door for the emergency exit door across the hall from Resident 1 ' s room. After the demonstration, the MD reset the alarm, and stated the alarm is checked daily to ensure proper efficiency, and it needs to be reactivated per use. During a telephone interview with Registered Nurse (RN 1), on March 14, 2025, at 4:00 PM, RN 1 Page 1 of 2 055650 055650 03/27/2025 Highland Care Center of Redlands 700 E Highland Ave Redlands, CA 92374

F 0689 Level of Harm - Minimal harm or potential for actual harm stated Resident 1 had two elopement attempts last March 13, 2025, one of which was timely intervened, and the other one required police intervention to bring Resident 1 back to the facility. RN 1 further stated staff did not monitor Resident 1 after he was brought back to the facility after the first elopement attempt. RN 1 stated the alarm was not activated during Resident 1 ' s second attempt, allowing him to successfully elope. Residents Affected - Few During a telephone interview with the Director of Nursing (DON), on March 14, 2025, at 4:15 PM, the DON stated the alarm was not reset in a timely manner after Resident 1 was brought back to the facility following the first elopement attempt. The DON further stated that he was unsure if Resident 1 was monitored by staff following his return to the facility. The DON stated the alarm should have been reset in a timely manner and there should have been staff to monitor Resident 5. During a concurrent telephone interview and record review on March 26, 2025, at 11:26 AM, with the Administrator (Admin), the facility ' s policy and procedure (P&P) titled, Safety and Supervision of Residents, revised July 2023, was reviewed. The P&P indicated, .Resident supervision is a core component of the systems approach to safety. The type of frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment .Resident supervision may need to be increased when there are temporary hazards in the environment (such as construction) or if there is a change in the resident's condition. The Admin stated the facility staff should have followed the P&P. 055650 Page 2 of 2