Inspection·May 1, 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement measures to prevent an elopement for one of three sampled residents (Resident 1), when he was observed in front of the facility without staff assistance. This failure had the potential for injury from falls and other negative impacts on Resident 1's safety and security. Findings: A review of Resident 1 ' s admission record indicated he was admitted [DATE] with Diagnoses that included Traumatic Brain Injury (Brain injury related to an accident), Muscle Weakness, Cognitive Communication Deficit (Difficulty in making needs known), Psychosis (A brain condition that results in difficulties determining what is real and what is not real), Anxiety, Insomnia (Inability to sleep or stay asleep), Bipolar (A mental disorder characterized of depression and elevated mood that may last days or weeks) and Schizophrenia (A mental disorder characterized by hallucinations, seeing things that are not there and disorganized thoughts). A review of Resident 1 ' s clinical record included documentation of elopement attempts since admission. Review included medical orders that indicated on [DATE], an individual alarm known as a Wander Guard, was placed on Resident 1, tracking his elopement attempts. Medical orders included staff to check placement of the Wander Guard every shift. An order for a sit-stand alarm was initiated [DATE]. A review of Resident 1 ' s clinical record included the following documents: A Minimum Data Set (MDS - a federally-mandated resident assessment tool), dated [DATE], indicated Resident 1 had severe memory impairment, with a Brief Interview for Mental Status (BIMS) score of 5 (0-10 score indicated resident was severely cognitively impacted). During an interview on [DATE] at 12:20 p.m., the Receptionist stated Resident 1 had a consistent pattern of wanting to walk home. She stated he had a Wander Guard device, and a sit-stand alarm. She stated he was supposed to be escorted back to his room after every meal. She stated she was not working on the day of his elopement, [DATE]. She stated she monitored the doors when she was working but did not know how the front doors were monitored on the weekends. During an interview on [DATE] at 12:55 p.m., Unlicensed Staff C stated Resident 1 was a, Runner. He stated Resident 1 was supposed to be escorted to the dining room for meals and, immediately after (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: 056296 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 056296 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/01/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crescent City Care Center 1280 Marshall Street Crescent City, CA 95531 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)