Health inspection·August 7, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to timely develop and implement a care plan to prevent elopement (leaving the facility without authorization or a discharge order) for one of one sampled resident (Resident 1) who was at risk for elopement. This failure had the potential for Resident 1 to elope from the facility and sustain injury. Findings:During a review of Resident 1's admission Record (AR), dated 8/1/25, the AR indicated, Resident 1 was admitted to the facility on [DATE] with a primary diagnosis of hemiplegia and hemiparesis (paralysis and severe weakness of one side of the body after a stroke).During a review of Resident 1's Care Plan (CP), dated 7/22/25, the CP indicated, Resident 1 had a BIMs [Brief Interview for Mental Status - a cognitive assessment] score of 3 [scores of 0-7 indicated severe cognitive impairment].During a review of Resident 1's Progress Note (PN), dated 7/23/25 at 1:28 pm, the PN indicated, Resident 1 was oriented x2 (Resident 1 knew who he was and where he was but did not know the current date/time or his current circumstances).During a review of Resident 1's PN dated 7/24/25 at 6:45 pm, the PN indicated, [Resident 1] was angry and yelling at staff.and spoke to a family member asking her to get him out of this place.and stated you're trying to lock me up.During a review of Resident 1's PN dated 7/29/25 at 5:20 pm, the PN indicated, [Resident 1] has been having behaviors of shouting and yelling in the hallway. claims he wants to go home. wanted to go live with his ‘homeboy'.During a review of Resident 1's PN dated 7/30/25 at 3:31 pm, the PN indicated, [Resident 1] repeatedly stated I am going to leave, or sign the AMA [Against Medical Advice - a form residents/patients sign when they self-discharge from a healthcare facility] or I'll just walk out of here.During a review of Resident 1 PN dated 7/31/25 at 10:55 am, the PN indicated, [Resident 1] stated I'm going home. I don't care, I'm going home. I don't care who you tell, I'm going home.During a review of Resident 1 PN dated 7/31/25 at 1:38 pm, the PN indicated, [Resident 1] noted with repeatedly stating he wants to leave [the facility].During a review of Resident 1's SBAR [Situation Background Assessment & Recommendation] Summary for Providers (SBAR) note, dated 7/31/25 at 7:09 p.m., the SBAR indicated, [Resident 1] stated I'm going to start walking out, I don't care you call the cops.During a review of Resident 1's Q (every)15 Minutes Visual Observation Form (VOF), dated 7/31/25, the VOF indicated Resident 1 was placed on direct observation by staff every 15 minutes starting at 3 pm. The VOF indicated at 7:15 pm, Resident 1 walked out of facility.During a review of Resident 1's CP dated 7/31/25, the CP indicated, Resident [1] noted to have increased in behavior and tried to leave the facility. Resident [1] was placed on staff supervision every 15 minutes and then 1:1 [one on one , one staff monitoring] continuous supervision on 7/31/25. There were no previous care plans addressing Resident 1's risk for elopement.During a review of Resident 1's IDT (interdisciplinary, group of management staff) Notes (IDTN), dated 8/1/25 at 2:42 p.m., the IDTN indicated, [Resident 1] noted to have increased behaviors for the past days. Resident [1] was attempting to elope with staff member and was in the neighborhood. Staff were with the Page 1 of 2 555053 555053 08/07/2025 Valley View Care Center 729 Browning Road Delano, CA 93215

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few resident near the church close to facility until Law Enforcement and EMS [Emergency Medical Services, is a system that provides emergency medical care] arrived.During an interview on 8/7/25 at 11:30 am with Licensed Vocational Nurse 1 (LVN) 1, LVN 1 stated he was at the facility on 7/31/25 and witnessed Resident 1 leaving the facility. LVN 1 indicated that on 7/31/25 at around 6 p.m. he (LVN 1) was at the nurse's station and observed Resident 1 in the hallway agitated and yelling at staff. LVN 1 stated Resident 1 then exited the facility through the front door. LVN 1 stated he followed Resident 1 to the parking lot where Resident 1 remained for a period. LVN 1 stated Resident 1 then left the parking lot and strolled through the neighborhood until he stopped in front of a house where he was picked up by ambulance and taken to Hospital. LVN 1 stated he stayed with Resident 1 the whole time he was out of the facility. LVN 1 stated Resident 1 had indicated several times in the days before his elopement that he (Resident 1) wanted to leave the facility. During an interview on 8/7/25 at 10:50 am with Director of Nursing (DON), DON stated Resident 1 was at risk for elopement and an elopement care plan was only created on 7/31/25, the day Resident 1 eloped from the facility. DON stated an elopement care plan should have been created prior to his elopement when Resident 1 first started to say he wanted to leave the facility.During a review of facility policy and procedure (P&P) titled Elopements and Wandering Residents, dated 2025, the P&P indicated, This facility ensures that residents who exhibit wandering behavior and/or are 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 wandering or elopement risk.During a review of facility P&P titled Comprehensive Care Plans, dated 2025, the P&P indicated, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs. 555053 Page 2 of 2