Inspection·December 18, 2025

F 0689 Level of Harm - Actual harm Residents Affected - Few a.m., the PN indicated, Resident [1] last seen at facility (12/13/24) around 8:40 p.m. by CNA [Certified Nursing Assistant]. They were [sic] [Resident 1] in room sleeping covered by blanket. Resident [1] was noticed missing around 9:30 p.m. CNA reported it to nurse at that time. All the facility was searched each bathroom and room, no sign of resident present inside. DON [Director of Nursing] .called at 9:53 p.m. to report that resident was unable to be found. Staff then continued to search outside and drive around neighborhood to see if they can find resident. Police were called around @ [at] 10:40 p.m. and report was filed. Police arrived to facility and took report from charge nurse and staff to get accurate description of resident [1]. Each staff member wrote statements. They [staff] then searched facility for possible exits resident may have taken. Police stated to charge nurse that door near resident's room was tested x3 [times three] and no alarm went off. Rp [responsible party] public guardian left message and Dr [doctor] made aware.During a review of the Ambulance Documentation (AD) dated 12/14/25 at 7:09 a.m., the AD indicated, Patient Condition hypothermia/cold injury.complaint.skin numbness.Per [name of town] PD [police department] the patient has been missing since approximately 8:00 p.m. last night.the patient was cold to the touch. EMS [emergency medical services] removed the patients wet socks once she was on the gurney and placed hot packs on her feet. EMS also gave the patient hot for her hands and armpits.EMS noted that the patient's heart rate was elevated at 142 sinus tachycardia [heart rate faster than normal, normal heart rate is 60-100].During a review of Resident 1's PN dated 12/14/25 at 9:28 a.m., the PN indicated, Investigator informed staff of resident being found around 7:00 a.m. and transferred to [hospital], writer spoke with ER [emergency room] nurse.he updated, resident has hypothermia, resident alert and conscious, vital heart rate fast/tachycardia [fast heart rate], right now she is on the warmer, resident is still under evaluation, MD [Medical Doctor] notified, family made aware.During a review of Resident 1's hospital's History and Physical (H&P) dated 12/14/25 at 2:29 p.m., the H&P indicated, Chief Complaint.Found down after eloping from facility.This is a [AGE] year-old female with past medical history of schizophrenia and major depression who presents to the Emergency Department for evaluation following eloping from [facility name]. The patient [Resident 1] was found this morning approximately 1 mile from her facility in a field after having eloped overnight. EMS reports that efforts were made to rewarm patient after she was found.Assessment and Plan 1. Exposure/Hypothermia.Elevated lactate [made in your muscles and red blood cells when they break down food for energy] and abnormal blood gas [shows how well your lungs are oxygenating blood] findings consistent with cold exposure.2. Leukocytosis with left shift.Assessment: Markedly elevated WBC [increased white blood cells] at 21.83 [normal range is 4,500-11,000 cells per microliter] with neutrophils [body's first responders to infection] at 91.5% [very high proportion of these infection-fighting white blood cells] and lymphopenia [too few lymphocytes- a type of white blood cell] in your blood, weakening your immune system and increasing infections risk). Concerning for infectious process versus stress response from exposure.3. Metabolic Acidosis.Assessment: Venous [vein] pH [a scale from 0 to 14 that measures how acidic or basic a substance is] 7.29 with elevated lactate at 3.8 [normal range is below 2 mmol/L [millimoles per liter-a unit of measurement], elevated anion gap [blood test calculation used to diagnose acid-base imbalances] at 21.3 [normal range is 10-18 mmol/L]. Likely secondary to cold exposure and possible tissue hypoperfusion [not enough oxygenated blood flowing to the body's tissues] .4. Facility elopement/neglect concern.Assessment: Second time patient has eloped from facility. Report filed for abuse and neglect per resident physician documentation.During an interview on 12/17/25 at 2 p.m. with DON, DON stated on 12/13/25 at approximately 9:52 p.m. the nurse called and reported Resident 1 was missing. DON stated Resident 1 was last seen by CNA 1 at approximately 8:45 p.m. DON stated the police were called (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055916 If continuation sheet Page 2 of 4 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 055916 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sequoia Vista 3710 West Tulare Avenue Visalia, CA 93277 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 - Actual harm Residents Affected - Few and all staff were out looking for Resident 1. DON stated Resident 1 was found alive on 12/14/25 at approximately 7 a.m. a mile away in an empty lot. DON stated Resident 1 was found lying down and taken to the hospital and diagnosed with hypothermia.During an interview on 12/17/25 at 2:32 p.m. with Administrator, Administrator stated Resident 1 was reported missing on 12/13/25 at 9:15 p.m. Administrator stated Resident 1 was last seen by staff sitting on the edge of the bed at approximately 8:45 p.m. Administrator stated the police department found Resident 1 the next morning at 7:15 a.m. in a ravine hidden away approximately a mile from the facility. Administrator stated Resident 1 was missing approximately 10 hours and was admitted to the hospital for hypothermia. Administrator stated Resident 1 had a prior elopement attempt in June 2025.During an interview on 12/17/25 at 3 p.m. with DON, DON stated she did not know where Resident 1 exited the facility at but her best guess was the exit door closest to her room. [NAME] stated Resident 1 was wearing a gray shirt, knit shawl and socks. DON stated when Resident 1 was found she was wearing socks and had no shoes. DON stated the temperature was in the 40's (Fahrenheit, cold) the night Resident 1 went missing.During an interview on 12/17/25 at 3:19 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated she was assigned to Resident 1 at the time she went missing. LVN 1 stated she was informed around 9 p.m. that Resident 1 was missing. LVN 1 stated staff looked for Resident 1 throughout the facility and were unable to locate her. LVN 1 stated she notified the DON and the police. LVN 1 stated she had last seen Resident 1 at approximately 6 p.m. walking in the hall towards the shower and Resident 1 was redirected back to her room. LVN 1 stated she did not know where Resident 1 exited the facility.During an interview on 12/17/25 at 4:01 p.m. with CNA 2, CNA 2 stated she was assigned to Resident 1 at the time she was discovered missing. CNA 2 stated she last seen Resident 1 during last rounds at approximately 8:45 p.m. CNA 2 stated she had seen Resident 1's feet and she had a blanket over her sitting on the bed. CNA 2 stated shortly after that CNA 1 and her, went to Resident 1's room and noticed she wasn't there and immediately started looking for her. CNA 2 stated she did not know where Resident 1 exited the facility.During an interview on 12/18/25 at 1:48 p.m. with LVN 2, LVN 2 stated at times Resident 1 would peek out of her room to see who was in the hallway and wander in the facility looking at the doors exit seeking (attempt to leave). LVN 2 stated she last seen Resident 1 exit seeking four days prior to the 12/13/25 elopement.During an interview on 12/22/25 at 4:46 p.m. with CNA 1, CNA 1 stated she was assigned to Resident 1 on the night she went missing. CNA 1 stated she had last seen Resident 1 sitting on her bed with her feet on the floor around 7 p.m. CNA 1 stated she went to break around 8:40 p.m. and when she returned, she helped another CNA with her rounds and then went to check on her residents. CNA 1 stated when she noticed Resident 1 was missing, she notified the other staff and began looking for her. CNA 1 stated she did not know where Resident 1 exited the facility.During an interview on 1/9/26 at 9:11 a.m. with Administrator, Administrator stated every hour on the POCRH, the task would appear for the staff to document the hourly monitoring that was to be completed for Resident 1. Administrator stated in the POCRH, the time in the monitoring was done but did not contain the ability to enter the physical whereabouts of Resident 1. Administrator stated he expected staff to complete the task and document it (monitoring and whereabouts) every hour. During a review of the facility's policy and procedure (P&P) titled, Elopements andWandering Residents dated 3/2025, the P&P indicated, Wandering is random or repetitive locomotion that may be goal-directed (e.g., the person appears to be searching for something such as an exit) or non-goal directed or aimless. The facility shall establish and utilize systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055916 If continuation sheet Page 3 of 4 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 055916 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sequoia Vista 3710 West Tulare Avenue Visalia, CA 93277 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 - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete for effectiveness and modifying interventions when necessary. Monitoring and managing residents at risk for elopement or unsafe wandering.residents will be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the interdisciplinary care plan team.the interdisciplinary team will evaluate the unique factors contributing to risk in order to develop a person-centered care plan.interventions to increase staff awareness of the resident's risk associated with hazards will be added to the resident's care plan and communicated to appropriate staff.adequate supervision will be provided to help prevent accidents or elopements.charge nurses and unit managers will monitor the implementation of interventions, response to interventions, and document accordingly.the effectiveness of interventions will be evaluated, and changes will be made as needed. Event ID: Facility ID: 055916 If continuation sheet Page 4 of 4