Health inspection·April 23, 2024

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 interview and record review, the facility failed to provide sufficient monitoring and supervision to one of two sampled residents (Resident 1) who eloped (the act of leaving a facility premises or a safe area without notifying anyone) from the facility. The facility found out that Resident 1 was missing on 4/20/24 at around 8 PM when a family member (FAM 1) called the facility to inform a staff that the resident went home. This deficient practice had the potential for Resident 1 and other residents who are at risk for elopement to be exposed to danger or harm that could lead to injury or death. Findings: A review of Resident 1 ' s admission Record indicated the facility initially admitted the resident on 3/27/24 with diagnoses that included metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood, not because of a head injury) and chronic obstructive pulmonary disease (COPD, a group of diseases that cause airflow blockage and breathing-related problems). A review of Resident 1 ' s History and Physical assessment, dated 3/28/24, indicated the resident did not have the capacity to understand and make decisions for himself. A review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and screening tool), dated 3/31/24, indicated the resident ' s cognition (mental action or process of acquiring knowledge and understanding through thought, experience, and senses) indicated that he needed substantial assistance (helper does more than half the effort) from a person when he needs to walk. A review of Resident 1 ' s Progress Notes, dated 4/20/24 at 10:13 PM, indicated that Resident 1 went home without asking permission from the staff. During a telephone interview on 4/23/24 at 9:05 AM, a family member (FAM 1) of Resident 1 stated that on 4/20/24, at approximately 8 PM, a family member of Resident 1 found him at their doorstep. FAM 1 stated they contacted the facility to inform them that the resident went home by himself. FAM 1 stated that the facility had no idea that the resident left the facility or that the resident was missing. FAM 1 stated that Resident 1 refused to go back to the facility and will stay home. During a telephone interview on 4/23/24 at 12:33 PM, Certified Nurse Assistant 1 (CNA 1) stated that she was the CNA caring for Resident 1 on 4/20/24 during the 3-11 PM shift. She stated during her shift, Resident 1 told Licensed Vocational Nurse 1 (LVN 1) that he wanted to go home but LVN 1 told (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 055989 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 055989 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heritage Manor 610 North Garfield Avenue Monterey Park, CA 91754 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)