Health inspection·July 29, 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 provide close supervision for two of seven sampled residents (Resident 1 and Resident 2) reviewed for elopement (the act of leaving a facility unsupervised and without prior authorization) risk, by failing to ensure: 1. One-to-one (1:1- a dedicated nurse assigned to continuously observe and attend to a single resident, providing close supervision and immediate interventions when needed) monitoring every shift as indicated in the care plan. 2. The functionality of the wander guard system (a technology solution designed to detect, track, and alert staff when at high risk for elopement resident attempt to exit a designated area).These deficient practices resulted in Residents 1 and 2 eloping from the facility on 7/19/2025, unsupervised for several hours, placing the residents at risk for serious harm, including injury, exposure to environmental hazards, and death. Findings: a. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including schizophrenia (a mental illness that is characterized by disturbances in thought), major depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), hypertension (HTN- high blood pressure), and anxiety (a feeling of fear). During a review of Resident 1's History and Physical (H&P), dated 3/2/2025, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 6/5/2025, the MDS indicated Resident 1's cognition (process of thinking) was severely impaired. The MDS indicated Resident 1 required moderate (helper does less than half the effort) assistance from staff with activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 1's care plan titled Resident is an elopement risk/wanderer., initiated 5/7/2025, the care plan indicated interventions included use a wander guard bracelet and one-to-one staff monitoring on every shift to maintain the resident's safety due to elopement risk. During a review of Resident 1's Change of Condition (COC), dated 7/19/2025, timed at 11:45 a.m., the COC indicated on 7/19/2025 at approximately 10:00 a.m., Resident 1 was observed in the hallway pushing another resident (Resident 2) in a wheelchair. The COC also indicated at 11:00 a.m., during visual check rounds, the staff could not locate Resident 1 anywhere in the facility. Staff also were unable to locate the resident in the surrounding neighborhood. Resident 1 was returned to the facility on 7/19/2025 at approximately 4:45 p.m., by the Administrator (ADM). b. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses which included dementia (a progressive state of decline in mental abilities), anxiety, dysphagia (difficulty swallowing), and muscle weakness (loss of muscle strength). During a review of Resident 2's H&P, dated 1/30/2025, the H&P indicated Resident 2 did not have the capacity to understand and make medical decisions. During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2's cognition was Page 1 of 3 555057 555057 07/29/2025 Las Flores Convalescent Hospital 14165 Purche Ave. Gardena, CA 90249

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few severely impaired. The MDS indicated Resident 2 required moderate assistance from staff with ADLs and did not have the ability to walk. The MDS indicated Resident 2 required the use of a wheelchair for mobility. During a review of Resident 2's COC, dated 7/19/2025, timed at 11:45 a.m., the COC indicated on 7/19/2025 at approximately 10:00 a.m., Resident 2 was observed in the hallway in her wheelchair being pushed by another resident (Resident 1). The COC indicated at 11:00 a.m., the staff could not locate Resident 2 in the facility or the surrounding neighborhood. The COC indicated Resident 2 was brought back to the facility on 7/19/2025 at approximately 3:22 p.m., by a local hospital ambulance. During an interview on 7/29/2025 at 12:02 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated on 7/19/2025 at approximately 10:00 a.m., Resident 1 was observed in the hallway pushing Resident 2 in her wheelchair towards nurses' station near the front exit door. LVN 1 stated Resident 1 was high risk for elopement and had been issued a wander guard bracelet. LVN 1 stated Resident 1 was not on one-to-one monitoring, and instead was being checked during hourly visual rounds. LVN 1 stated Resident 2 was non-ambulatory (able to walk), used a wheelchair, and required staff assistance for mobility. LVN 1 stated at 11:00 a.m., during scheduled visual rounds check, staff were unable to locate Residents 1 and 2. LVN 1 stated she reported the missing residents to the charge nurse and staff initiated a search. LVN 1 stated she did not observe the residents exiting the facility and did not hear the front door alarm which indicated that staff were not monitoring the exit door as required to prevent residents from exiting the facility unsupervised. LVN 1 stated it was the responsibility of the Director of Staff Development (DSD) to ensure such assignments as exit monitoring were reflected in the daily staff assignment. LVN 1 stated the front exit door should be continuously monitored by staff to prevent residents from leaving the facility unsupervised, especially those at high risk for elopement. LVN 1 stated someone should have been watching the exit. During a telephone interview on 7/29/2025 at 1:06 p.m., with Registered Nurse (RN) 1, RN 1 stated she was the charge nurse on duty the morning of 7/19/2025. RN 1 stated she was made aware by LVN 1 that Residents 1 and 2 were missing during the 11:00 a.m. visual check rounds. RN 1 stated Resident 1 had a wander guard bracelet, but she was unaware if the system was active or functioning. RN 1 stated she was not able to recall if Resident 1 was on one-to-one monitoring at the time of the elopement incident on 7/19/2025. RN 1 stated she did not receive any alerts from the wander guard system. RN 1 stated she did not see or hear the residents exiting the facility. RN 1 stated staff should have been assigned to monitor the front exit to prevent residents from leaving unsupervised, especially those with elopement risk. RN 1 stated she believed a staff member (unable to recall name) had been assigned to monitor the front exit on the morning of 7/19/2025, but she was not able to confirm whether that assigned staff was present at the time of the elopement. RN 1 stated I was busy with other duties, and I honestly don't know if they were at the door. RN 1 stated the facility did not have a written policy for monitoring the exit door, it was an informal expectation, and everyone was responsible for the residents' supervision. During a concurrent interview record review on 7/29/2025 at 4:07 p.m., with the Director of Staff Development (DSD), the facility record titled Nursing Staffing Assignment and Sign-in-Sheet, dated 7/19/2025, was reviewed. The staff assignment record indicated Certified Nursing Assistant (CNA) 1 had initially been assigned to monitor the facility's front exit door and observe for any resident attempting to leave unsupervised. The DSD stated all staff were expected to monitor residents by keeping an eye on them, especially those with documented elopement risks. The DSD stated the facility did not have a formal, written protocol requiring staff to be specially assigned to monitor exit doors. The DSD stated she was responsible for preparing the staff assignment sheet for 7/19/2025. The DSD stated CNA 1 was reassigned to provide care to another resident in room [ROOM NUMBER]. The 555057 Page 2 of 3 555057 07/29/2025 Las Flores Convalescent Hospital 14165 Purche Ave. Gardena, CA 90249

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few DSD stated there was no one to replace CNA 1 after his reassignment and staff at the nurses' station (located near the exit) were to assist with watching and monitoring the exit. The DSD stated this oversight resulted in Residents 1 and 2's elopement on the morning of 7/19/2025. During an interview on 7/29/2025 at 4:50 p.m., with the Administrator (ADM), the ADM stated on the morning of 7/19/2025, while Resident 1 pushed Resident 2 in her wheelchair, the residents exited the facility without staff knowledge. The ADM stated both residents were later located off-site and returned to the facility in the afternoon. The ADM stated Resident 1 had a wander guard bracelet, but the system failed to function at the time of the elopement, and no alarm was received by staff. The ADM stated the facility did not have a specific written policy designating which staff member was responsible for monitoring the front exit. The ADM stated it was an informal facility process that available staff were assigned to monitor the exit. The ADM stated it was expected that all staff would be vigilant and visually monitor the front exit and monitor the residents to prevent the residents from leaving the facility unsupervised. The ADM stated current practices were inadequate and that steps would be taken to create a formal front exit monitoring system. During a review of the facility's policy and procedures (P&P) titled Safety-Resident Monitoring, undated, the P&P indicated:1. The facility would ensure the safety and well-being of all residents by establishing guidelines for effective monitoring, supervision, and timely interventions.2. Staff must ensure resident whereabouts, especially for residents at risk of elopement.3. All staff would be informed of residents under 1:1 observation. During a review of the facility's P&P titled Wandering & Elopement, revised 5/1/2023, the P&P indicated the facility would identify and monitor residents at risk for elopement and facility staff would prevent residents from leaving the facility unsupervised. During a review of the facility P&P titled Safety of Residents, revised 5/1/2023, the P&P indicated the facility would provide a safe environment for residents at the facility. 555057 Page 3 of 3