Health inspection·April 25, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of a nursing note dated 3/31/24 at 1:10 p.m., indicated, patient [Resident 1] exhibited increased agitation this afternoon and attempted elopement through the front doors of [Name of facility]. Re-direction was provided in the parking lot, and patient agreed to return inside. He states he is ready to walk to Gualala however he is unable to correctly state his current location, appears confused. During a phone interview with Licensed Staff A (Who wrote the note on 3/31/24 at 1:10 p.m., above) on 4/25/24 at 11:30 a.m., she stated that on 3/31/24 Resident 1 attempted to elope from the facility by foot, although he was walking unsteady on his feet. Licensed Staff A stated that when she saw Resident 1, he was outside in the parking lot of the facility with another staff member, attempting to walk off. Licensed Staff A stated staff brought out Resident 1's wheelchair, and he agreed to come back inside the building. Licensed Staff A stated a decision was made to place a wander guard on Resident 1's wheelchair, as he did not want it placed on his body. Record review of a note dated 4/02/24 at 4:54 p.m., indicated, [Resident 1] has attempted to leave facility three times .staff run outside of facility trying to persuade resident to return to facility. Resident receptive to return to facility. Record review of a report sent to the DEPARTMENT on 4/14/24 of an elopement that occurred that same day (On 4/14/24) indicated, Around 8:45 AM (Morning) we received a call from a concerned citizen that a Caucasian male jumped over the fence. Staff alerted to check all residents. All Staff checked inside and surrounding area and at this time resident in 17A [Resident 1] cannot be located. Staff called [Local police department] for assistance. At 9:20 AM, received a phone call from the person who gave resident [Resident 1] a ride to make us aware that resident is in [Name of neighboring town} area, Police Officer [Name of Officer] made aware of resident's whereabouts. SAFE team (mental health team) brought resident back to the facility. Upon resident's return, LN (Licensed Nurse) made a thorough assessment. Resident made comfortable. Medicated for pain as needed. MD/RP (Medical doctor/Patient Representative) notified. Resident had a wander guard on in WC (Wheelchair). Therapy made him independent in the facility yesterday (Saturday). Record review of a nursing note dated 4/14/24 at 13:22 p.m. indicated, Pt (Patient [Resident 1]) has eloped this morning .PT is alert and verbalized that he fell by sliding down when he jumped out of the fence and leaned to his left shoulder, Pt noted to have no injuries. Record review of Resident 1's care plan for elopement, revised after the elopement on 4/14/24 indicated, 4/14/24 Wander guard applied on left ankle. During an interview with Resident 1 on 4/18/24 at 1:30 p.m., he stated that on 4/14/24 he wanted to leave the facility, so he left by foot, leaving the wheelchair with wander guard inside the building, which did not trigger the alarm. Resident 1 stated he jumped over the fence of the facility, and fell in the process, scraping his knee, but managed to get back up on his feet, and was given a ride by a vehicle passing by. Resident 1 stated he was driven to [Neighboring town 8.5 miles away, according to Google maps]. During an interview with the Director of Nursing (DON) on 4/25/24 at 11:00 a.m., she stated that after the elopement attempt on 3/31/24, facility staff should have placed a wander guard on Resident 1's wheelchair, and another one on his body to prevent him from eloping again. Record review of an e-mail sent to the DON and Medical Records Staff B on 4/24/24 at 10:53 a.m., (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055919 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 055919 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Apple Valley Post-Acute Rehab 1035 Gravenstein Hwy South Sebastopol, CA 95472 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 indicated the Surveyor requested the policy on wander guard use, among other documents. Other requested documents were e-mailed to the Surveyor by Medical Records Staff B on 4/24/24 at 1:50 p.m., but the policy on wander guard use was not provided. Record review of the facility policy titled, Elopements, last revised in December of 2007, indicated, If an employee observes a resident leaving the premises, he/she should: a. Attempt to prevent the departure in a courteous manner .Instruct another staff member to inform the Charge Nurse or Director of Nursing Services that a resident has left the premises .When the resident returns to the facility, The Director of Nursing Services or Charge Nurse shall: e. Complete and file an incident report and f. Document relevant information in the resident's medical record. Event ID: Facility ID: 055919 If continuation sheet Page 3 of 3