Health inspection·July 2, 2025

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 ensure one of three sampled residents (Resident 1) was free from accident hazards when Resident 1 eloped (the act of leaving a facility unsupervised and without prior authorization) from the facility. This failure had the potential for Resident 1 to be at risk of injury including heat or cold exposure, dehydration, medical complications, and being struck by a motor vehicle. Findings: During a review of Resident 1's admission record (AR), the AR indicated, Resident 1 was admitted to the facility September 2016 with multiple diagnoses which included schizophrenia (a mental illness that can affect thoughts, mood, and behavior). During a review of Resident 1's care plan (CP), revised 5/30/24, the CP indicated, .the resident has behaviors r/t [related to] schizophrenia .currently with delusions .Interventions .anticipate . resident's needs . During an interview with Director of Nursing (DON) on 7/2/25 at 9:35 a.m., the DON stated Resident 1 eloped from the facility on 6/29/25 at approximately 2:00 p.m. The DON acknowledged there was a risk of injury when the resident eloped from the facility. The DON further stated the expectation was for elopement to not happen. During an interview on 7/2/25 at 10:03 a.m. with Resident 1, Resident 1 confirmed he eloped from the facility on 6/29/25. Resident 1 stated he left the facility because he saw an actress he knew and wanted to follow her. During an interview on 7/2/25 at 10:34 a.m. with the Receptionist (RECP), the RECP stated she worked at the front desk when Resident 1 eloped from the facility on 6/29/25. The RECP further stated she notified staff when she realized Resident 1 was not sitting on the front patio and was not in the facility. The RECP further stated she did not know how long Resident 1 was missing from the facility. During a review of Resident 1's Interdisciplinary Care Conference (IDT) note, dated 6/30/25, the IDT note indicated, .Resident left the facility premises on Sunday June 29, 2025 without informing any of the staff member, therefore ended up being an elopement . During a follow up interview on 7/2/25 at 11:30 a.m. with the DON, the DON acknowledged Resident 1's schizophrenia diagnosis put him at risk for elopement and that it was the facility's Page 1 of 2 056238 056238 07/02/2025 Solano Post Acute 2200 Tuolumne Street Vallejo, CA 94589

F 0689 responsibility to keep residents safe. Level of Harm - Minimal harm or potential for actual harm During a review of the facility's policy and procedure (P&P) titled, Elopement, revised 2/21/25, the P&P indicated, .The residents .at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to .elopement risk . Residents Affected - Few 056238 Page 2 of 2