Health inspection·September 25, 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to adhere to its safety and supervision of resident ' s policy when one of the three sampled residents (Resident 1) left the facility without the staff ' s knowledge. This failure resulted in Resident 1 eloping for a duration of approximately 6 hours and traveling a distance of about 17 miles away from the facility, posing a potential safety risk to the clinically compromised resident (Resident 1). Findings: During a review of Resident 1's clinical record, the face sheet (contains demographic and medical information), indicated Resident 1 was admitted on [DATE] with a diagnosis that included unspecified dementia (a general term for a group of symptoms that affect a person ' s ability to think, remember, and reason, and can interfere with their daily life), Alzheimer ' s disease (a general term for memory loss and other cognitive abilities serious enough to interfere with daily life). During a review of the clinical record for Resident 1 ' s the Brief Interview for Mental Status (BIMSscreening tool to identify and monitor cognitive decline), dated 7/05/2024, indicated, Resident 1 ' s score was a 4 which indicated Resident 1 had severe cognitive impairment. During an interview on 9/25/2024, at 11:00 a.m. with Assistant Director of Nursing (ADON) 1, ADON 1 mentioned that Resident 1 left the facility unnoticed by the staff around lunchtime and was located approximately 17 miles away at 4:30 PM on the same day. During a review of the facility documented titled 5 Day Look Back/Follow-up, dated 9/16/2024, the document indicated Resident 1 was reported missing from the facility around lunchtime and was later found at an acute general hospital at 4:30 PM. Upon further review, it was revealed that Resident 1 was interviewed regarding the incident. According to Resident 1, she travelled to her previous residence by taking the bus. During a telephone interview on 10/03/2024, at 9:59 a.m. with the Director of Nursing (DON) 1, DON 1 indicated Resident 1 went missing on 9/16/2024, approximately around lunch time, without any of the staff noticing. Upon expressing concern that the facility ' s safety and supervision policy for residents was not followed, DON 1 did not provide a specific response. During a review of the undated facility provided policy and procedure (P&P) titled, Safety and Page 1 of 2 555025 555025 09/25/2024 University Post Acute 2278 Nice Ave Mentone, CA 92359

F 0689 Level of Harm - Minimal harm or potential for actual harm Supervision of Residents, the P&P indicated, Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident ' s assessed needs and identified hazards in the environment. Residents Affected - Few 555025 Page 2 of 2