Health inspection·October 25, 2023

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident 1's nurses' progress note, dated 10/25/23, indicated, .Resident was found by El Dorado St. close to the Baptist church. Brought back to facility by Nurse .and CNA . Review of Resident 1's IDT progress note, dated 8/8/23, indicated, .IDT reviewed Elopement risk assessment, noted resident is ambulatory and stayed most of the time in his room. No elopement noted nor signs of leaving the facility for the last 6 months. Per current elopement risk assessment .dated on 8/4/23. IDT recommend to d/c [discontinue] wander guard . Review of Resident 1's record Elopement Risk Evaluation - V 2 dated 8/4/23, indicated, .Score: 7 .RESIDENT EVALUATION FACTORS .4. Does the resident have a history of elopement (1.e Home, SNF, ALF, etc.)? . No .6. Is the resident cognitively impaired with poor decision-making skills (i.e [that is] intermittent confusion, cognitive deficit or disoriented all the time)? . No .9. Does the resident have a history of leaving or attempting to leave the facility without supervision or informing staff? . No . During a concurrent interview and record review on 10/25/23, at 7:10 p.m., the Director of Nursing (DON) stated Resident 1 was cognitively impaired, had dementia and a history of elopement. The DON added sometimes Resident 1 had episodes of confusion. The DON stated the elopement risk assessment was completed quarterly to assess residents' risk of elopement. The DON further stated the IDT reviewed the risk assessment and developed a care plan accordingly. Resident 1's elopement risk evaluation from 8/4/23 was reviewed with the DON. The DON stated the elopement risk assessment score of 7 meant no risk of elopement. The DON stated the responses to Resident 1's elopement risk evaluation factor number (#) 4 Does the resident have h/o elopement, #6 Is resident cognitively impaired with poor decision-making skills and #9 Does resident has h/o leaving or attempting to leave the facility without supervision or informing staff, should have been yes. The DON stated those 3 factors were answered incorrectly. The DON stated Resident 1's elopement risk evaluation was not done accurately. The DON stated if the elopement risk assessment was done correctly, Resident 1 would have had a higher score which meant Resident 1 was at high risk of elopement. The DON stated historically Resident 1 had been at high risk except his elopement risk evaluation from 11/3/2022, which indicated low risk. Resident 1's elopement risk evaluation from 11/3/22 reviewed with the DON, which indicated, .Score: 2 .Low Risk for Wandering . Elopement risk evaluation factor mobility was coded as ambulated with one assist. Elopement risk evaluation factors disoriented, forgetful and h/o elopement were not checked. The DON stated orientation, forgetful, h/o elopement and mobility factors were not completed correctly on the assessment. The DON stated there had not been any changes to Resident 1's condition including cognition and mobility. The DON verified Resident 1's elopement risk assessment dated [DATE] and 8/4/23 were not done accurately. The DON stated the assessments should have reflected the actual condition of the resident. The DON stated if Resident 1's elopement risk assessment would have been done correctly, the plan of care would have been different. The DON added they would not have removed the wander guard. The DON stated once a resident had a history of elopement they could not predict when the resident would attempt to elope again. The DON further stated even if Resident 1 no longer had exit seeking behavior staff should not have removed his wander guard. The DON added he might not have succeeded in eloping if the wander guard was left on. The DON stated Resident 1 succeeded in eloping which put his safety at risk and put him at risk for injury. The DON stated Resident 1 was found around 5:30 p.m. today. The DON stated Resident 1 was missing for over 24 hours which resulted in missing his medications and spending the night outdoors. The DON stated it was really cold at night which put Resident 1 at risk for developing infections. The DON added they did not know if Resident 1 ate any food while he was missing for over 24 hours. Review of a facility policy titled, Elopement Prevention and Management Standard indicated, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055833 If continuation sheet Page 2 of 3 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055833 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fulton Gardens Post Acute, LLC 537 E. Fulton Street Stockton, CA 95204 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete .Resident safety is a primary concern of the facility. Elopement, the unplanned absence of a resident from the facility poses potential hazards including but to limited to overexposure to weather elements, drowning, being struck by a motor vehicle, accosted by a perpetrator and medical possible complications related to lack of care during the elopement period. Using standards of practice .the interdisciplinary team .Comprehensively evaluate the resident for the risk of elopement .The interdisciplinary team develops an[sic] person-centered care plan based on the elopement risk assessment to decrease the risk for a resident to elope, to the extent possible. Consideration of the resident's mobility, cognition, locomotion, behavior, and ambulation should be evaluated for the purpose of implementing effective strategies to promote safety . Event ID: Facility ID: 055833 If continuation sheet Page 3 of 3