Health inspection·September 18, 2023

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide adequate supervision for one of two sampled residents (Resident 1), when Resident 1 eloped (a situation in which a resident with impaired cognition or poor safety awareness or judgment successfully leaves the facility undetected or unsupervised by staff) across a street, on two separate occasions. This facility failure had the potential for Resident 1 to suffer negative outcomes. Findings: During a review of Resident 1's admission Record undated, indicated in part, Resident 1 was admitted to the facility on [DATE], with diagnoses including dementia, history of falling, mild cognitive impairment, muscle weakness and other abnormalities of gait and mobility. During a review of Resident 1's care plan, undated, indicated in part Resident 1 was a High Elopement Risk related to Cognitive impairment, exit seeking behaviors, ability to move around independently in wheelchair. Resident 1's care plan further indicated Resident 1 had actual elopement from the facility on 4/15/23, 5/9/23, and 6/4/23. During a review of Resident 1's Wandering and Elopement Risk Assessment form dated 4/15/23, indicated in part, Resident 1 had an episode of elopement on 4/15/23. The form also indicated Resident 1's wandering and elopement risk score was selected as a Significant Actual Risk. The form further indicated, The resident (Resident 1) makes repeated attempts to leave a safe place and is regularly close to or achieves this successfully. During a review of Resident 1's progress notes dated 5/7/23, indicated in part Housekeeping notified CNA (certified nursing assistant) that the front door was opened at the time CNA reported to nurse on station 3 about reported situation, charge nurse asked CNA's on station 3 to count residents, while nurse checked outside the front door, nurse noticed resident (Resident 1) across the street from the building. During an interview on 9/13/23, at 2:20 p.m., with the Director of Nursing (DON 1), the DON 1 was asked how Resident 1 had eloped from the facility and across the street, without staff being aware. The DON 1 verbalized during Resident 1's elopement on 5/7/23, the double doors by the main entrance, which were supposed to be locked until the receptionist arrived, to man the main lobby and main entrance of the facility, was unlocked by housekeeping. The DON 1 further verbalized that Resident 1 proceeded through the unlocked double doors, entered the main lobby, and exited the main entrance door, Page 1 of 2 055991 055991 09/18/2023 Mission Park Healthcare Center 623 West Junipero Street Santa Barbara, CA 93105

F 0689 all unseen by staff. Level of Harm - Minimal harm or potential for actual harm During a review of Resident 1's progress notes dated 6/4/23, indicated in part Resident 1 was Found across street at park; unwitnessed elopement. Residents Affected - Few During an interview on 9/13/23, at 3:31 p.m., with the DON 1, the DON 1 was asked if the facility had determined/concluded how Resident 1 had eloped out of the facility on 6/4/23. The DON 1 verbalized a belief that Resident 1 had eloped through the side entrance of the building, by nursing station 3, but the facility could not confirm Resident 1's path of travel, out of the facility on 6/4/23. During a review of the facility's policy and procedure titled, Elopement Behavior Management dated 12/16, indicated in part, It is the policy of this facility to ensure that each resident who is a elopement risk is identified, assessed and provided appropriate intervention, adequate supervision and assistive devices. 055991 Page 2 of 2