Health inspection·October 4, 2023

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on interview and record review, the facility failed to update one (1) of two resident's (Resident 1) care plan (a document that contains the resident's individualized problems, goals, and interventions) following Resident 1's four elopements (a vulnerable resident who leaves a facility unnoticed) from the facility during the night shift (11:00 PM through 7:00 AM) on 9/30/23. This failure resulted in the facility continuing to utilize ineffective interventions which jeopardized the health and safety of Resident 1, which could have resulted in injury or death. Findings: A review of Resident 1's clinical record titled, admission RECORD (a document that contains the resident's demographic information) indicated, Resident 1 was admitted to the facility with a diagnosis of sepsis (overwhelming infection) and Dementia (a condition which causes a decline in memory, reasoning, and other thinking skills). A review of Resident 1's clinical record titled, Progress Notes, dated 10/1/23 at 7:29 AM, by Licensed Nurse (LN 1), indicated, during the night shift of 9/30/23, Resident 1 eloped from the facility multiple times. The first incident was on 9/30/23 at 11:30 PM when Resident 1 eloped from the Hall B's alarmed exit door. The facility staff members went outside to bring Resident 1 back inside the facility; however, Resident 1 had quickly made her way towards the parking lot and was headed for the street. The police were called and assisted in deescalating the situation, resulting in Resident 1 returning to the facility. Once inside the facility, Lorazepam (antianxiety medication) was given. Shortly after medication administration, Resident 1 eloped from Hall A's alarmed exit door. The facility staff found Resident 1 in the facility's parking lot and Resident 1 was brought back inside the facility. The document further indicated, on 10/1/23, at 3:00 AM, the LN 1 went to check on Resident 1 and found other staff members looking for Resident 1 saying, Resident 1 was not in her room. The LN 1, another licensed nurse, and two Certified Nursing Assistants (CNA) began looking for Resident 1. Resident 1 was found outside the facility walking down the sidewalk. The facility staff were able to redirect Resident 1 back to the facility and to her room. At around 4:00 AM, Resident 1 exited the facility again for a very short time. The facility staff redirected Resident 1 back into the facility building. During an interview on 10/4/23 at 1:40 PM, with LN 2, LN 2 stated, when Resident 1 eloped from the facility, the care plan should have immediately been updated by the Licensed Nurse with new interventions. Page 1 of 5 055662 055662 10/04/2023 Bethany Home Society San Joaquin County 930 West Main Street Ripon, CA 95366

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of the facility document titled, Job Title: Charge Nurse/Registered Nurse (RN) or Licensed Vocational Nurse (LVN), dated 9/1/14, indicated, Essential Duties and Responsibilities include the following . Maintains awareness of comfort and safety needs of the patient . Maintain resident ' s records in accordance with established procedures, including daily charting when appropriated, . updating according to schedule, nursing care plans . Monitor nursing staff for implementation of resident plan for care, expected outcome and the quality of care . Safety and Security - Observes safety and security procedures; Determines appropriate action beyond guidelines; reports potentially unsafe conditions . During a concurrent interview and review of Resident 1's clinical record, on 10/4/23, at 1:45 PM, with the Administrator (Admin) and Assistant Director of Nursing (ADON), the document titled, Care Plan, dated 9/15/23, was reviewed. The Care Plan indicated, Resident 1 had a history of wandering (walking around without any clear purpose or direction) and was an elopement risk. Resident 1's goal was to not leave the facility unattended. The interventions included distraction, diversions, activities, and re-orientation. The ADON stated, the care plan should have been updated with new interventions following the elopement. The Admin stated, she thought the care plan had been updated during the Interdisciplinary Team meeting (IDT a multi-disciplinary group that meets to discuss the resident ' s current needs). The Admin and ADON acknowledged the care plan was not updated following Resident 1 ' s elopements from the facility. During a concurrent interview and record review on 10/4/23 at 2:00 PM, with the ADON, the facility ' s Policy and Procedure (P&P) titled, Comprehensive Person-Centered Care Planning Procedure, dated 11/15/23, was reviewed. The P&P indicated, 1. The Compressive Person-Centered care Plan is a document that is the written result of the inter-Disciplinary Team Assessment The comprehensive Person -Centered care Plan is the guide for care of the resident. I. notes strengths, potential and actual problems, and discharge planning 2. General Procedure . d. New or additional problems, goals and approach will be added to the Care Plan . as they arise . new interventions will be dated. The ADON stated, the P&P was not followed when the care plan was not updated with new interventions to keep the resident safe from eloping from the facility. 055662 Page 2 of 5 055662 10/04/2023 Bethany Home Society San Joaquin County 930 West Main Street Ripon, CA 95366

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. Based on observation, interview, and record review, the facility failed to ensure adequate supervision for one (1) of two residents (Resident 1) at risk for elopement (a vulnerable resident who leaves a facility unnoticed) when Resident 1 left the facility four times during the night shift (11:00 PM - 7:00 AM) on 9/30/23 through 10/1/23. This failure jeopardized the health and safety of Resident 1, which could have resulted in injury or death. Findings: A review of Resident 1's clinical record titled, admission RECORD (a document that contains the resident's demographic information) indicated, Resident 1 was admitted to the facility with a diagnosis of sepsis (overwhelming infection) and Dementia (a condition which causes a decline in memory, reasoning, and other thinking skills). A review of Resident 1's clinical record titled, Progress Notes, dated 10/1/23 at 7:29 AM, by Licensed Nurse (LN 1), indicated, during the night shift of 9/30/23, Resident 1 eloped from the facility multiple times. The first incident was on 9/30/23 at 11:30 PM when Resident 1 eloped from the Hall B's alarmed exit door. The facility staff members went outside to bring Resident 1 back inside the facility; however, Resident 1 had quickly made her way towards the parking lot and was headed for the street. The police were called and assisted in deescalating the situation, resulting in Resident 1 returning to the facility. Once inside the facility, Lorazepam (antianxiety medication) was given. Shortly after medication administration, Resident 1 eloped from Hall A's alarmed exit door. The facility staff found Resident 1 in the facility's parking lot and Resident 1 was brought back inside the facility. The document further indicated, on 10/1/23, at 3:00 AM, the LN 1 went to check on Resident 1 and found other staff members looking for Resident 1 saying, Resident 1 was not in her room. LN 1, another licensed nurse, and two Certified Nursing Assistants (CNA) began looking for Resident 1. Resident 1 was found outside the facility walking down the sidewalk. The facility staff were able to redirect Resident 1 back to the facility and to her room. At around 4:00 AM, Resident 1 exited the facility again for a very short time. The facility staff redirected Resident 1 back into the facility building. A review of Resident 1's clinical record titled, Progress Notes, dated 10/2/23 at 3:15 PM, written by the Administrator (Admin), indicated, on 10/1/23 at approximately 3:00 AM, Resident 1 was noted to be absent from her bed. The facility staff searched for Resident 1 and found her outside the facility on the sidewalk. It was determined Resident 1's wander guard alarm (a small alarm censored bracelet) did not activate because Resident 1 exited a side door which was not alarmed with the wander guard system. A review of Resident 1's clinical record titled, [FACILITY NAME] HOSPITALIST HISTORY AND PHYSICAL, dated 9/23/23, written by Physician (Phys.1), indicated, Resident 1 was unable to provide an accurate past medical history due to Dementia. Resident 1's medical history included frequent falls and shaking spells for the past three months (information was provided by Resident 1's husband). 055662 Page 3 of 5 055662 10/04/2023 Bethany Home Society San Joaquin County 930 West Main Street Ripon, CA 95366

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of Resident 1's clinical record titled, BRIEF INTERVIEW FOR MENTAL STATUS (BIMS - a screening tool used to measure short term memory and orientation), dated, 9/18/23, indicated, Resident 1 had a BIMS score of 7 (score of 0-7 = severe cognitive impairment). A review of Resident 1's clinical record titled, Minimum Data Set (MDS) Section E Behavior (a standardized assessment tool that measures the health status in nursing home residents), dated, 7/1/23, indicated, Resident 1 had a history of wandering (walking around without any clear purpose or direction) in the past 1-3 days and the wandering placed Resident 1 at a significant risk of going to a potentially dangerous place (e.g., stairs, outside of the facility). A review of Resident 1's clinical record titled, Care Plan (a document that contains the resident's individualized problems, goals, and interventions), dated 9/15/23, indicated, Resident 1 had a history of wandering and was an elopement risk. Resident 1's goal was to not leave the facility unattended. The interventions included distraction, diversions, activities, and re-orientation. During an interview on 10/4/23, at 10:00 AM, the Admin stated, on 9/10/23 through 10/1/23, the wander guard and door alarms were in working order, however; the problem was the side door alarm shuts off automatically when the door closes. Resident 1 exited through a side door and the elopement was undetected by staff. During a concurrent observation and interview on 10/4/23, at 10:30 AM, with the Maintenance Supervisor (MS), all the door alarms in the facility were tested. The observation yielded; the facility's side exit door alarms stopped alarming once the door was closed. The MS stated, Hall A's exit door, Hall B's exit door, Hall C's exit door, Hall D's exit door and the East Dining Room's exit door, have door alarms which are activated when the door opens, and the alarm stops automatically when the door closes. The MS stated, the front entrance door has a wander guard alarm system which only activates when a resident who has a wander guard on their person, exits the front entrance. The staff enter a code into the keypad to reset the alarm. The MS stated, the West Dining Hall door has an alarm system by [ALARM COMPANY NAME] and the alarm can be reset by the staff entering a code into the alarm keypad. The MS stated, there was a problem with the current alarm system because some of the exit doors stop alarming automatically and don't require a staff member to enter a code to reset the alarm. The MS stated, this placed Resident 1 at risk for harm. During an interview on 10/4/23, at 11:22 AM, CNA 1, stated, when the door alarm shuts off automatically, the staff could have had a false perception the resident was found. During an interview on 10/4/23, at 12:10 PM, with the Admin, stated, she was unaware the side door alarms stop alarming automatically when the doors shut. The Admin stated, this is not OK because it poses a safety risk to the residents. During a concurrent interview and record review on 10/4/23 at 12:15 PM, with the Assistant Director of Nursing (ADON), Resident 1's clinical record titled, MEDICATION ADMINISTRATION RECORD, dated, 10/1/23, was reviewed. The record indicated; Resident 1 received Lorazepam (an antianxiety medication) on 10/1/23 at 2:29 AM. The ADON stated, based on the time the staff administered Lorazepam and when Resident 1 was found outside (around 3:00 AM), it was concluded that Resident 1 had eloped from the facility and was undetected for approximately 30 minutes. The ADON stated, this was an avoidable accident because the door alarms should have been set up to require a staff member to reset the alarm with a code. 055662 Page 4 of 5 055662 10/04/2023 Bethany Home Society San Joaquin County 930 West Main Street Ripon, CA 95366

F 0689 Level of Harm - Minimal harm or potential for actual harm A review of the facility document titled, Job Title: Charge Nurse/Registered Nurse (RN) or Licensed Vocational Nurse (LVN), dated 9/1/14, indicated, Essential Duties and Responsibilities include the following . Maintains awareness of comfort and safety needs of the patient . Safety and Security - Observes safety and security procedures; Determines appropriate action beyond guidelines; reports potentially unsafe conditions . Residents Affected - Few During a concurrent interview and record review, on 10/4/23, at 1:57 PM, with the ADON, the facility's Policy and Procedure (P&P) titled, Resident Rights Policy and Procedure, dated November 28, 2016, was reviewed. The P&P indicated, Purpose: To inform resident of his or her rights as a resident . to ensure resident has the ability to exercise his or her rights in a secure and safe environment . I. Safe environment 1. The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safety. The ADON stated, the P&P was not followed when Resident 1 was not provided a safe environment. 055662 Page 5 of 5