Health inspection·January 21, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 ensure four of five sampled residents (Residents 1, 2, 3, 5) were free from accident and hazards by failing to: 1. Complete a Wandering and Elopement (leaving the facility unsupervised and without prior authorization) Risk Assessment for (Residents 1, 2, 3, 5) upon readmission to the facility and quarterly according to its policy and procedure (P&P) titled, Wandering & Elopement. 2. Ensure facility door alarms were always armed according to Resident 1 ' s care plan. 3. Maintain a photograph in the medical record for Resident 1 who was a risk of elopement, according to the facility ' s undated P&P titled Wandering & Elopement These failures had the potential to result in Residents 1, 2, 3, and 5 eloping from the facility, be exposed to harsh environmental conditions, motor vehicle accident, and death. 1.) During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated Resident 1 ' s diagnoses included Schizophrenia (a mental illness that is characterized by disturbances in thought), encephalopathy (mental condition that can cause confusion and memory loss), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), visual and auditory hallucinations (hearing or seeing something that is not present in reality). During a review of Resident 1 ' s Minimum Data Set (MDS, a resident assessment tool), dated 12/6/2024, the MDS indicated Resident 1 was cognitively intact. The MDS indicated Resident 1 required supervision to touch assistance (staff provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) for Activities of Daily Living (ADLs) such transferring from a sitting to standing position and ambulating (walking) ten to 150 feet. During a review of Resident 1 ' s care plan dated 12/13/2024, the care plan indicated Resident 1 was at risk for wandering/elopement. The Care plan interventions included staff to use measures to provide for Resident 1 ' s safety by always keeping alarms on (armed). During a review of Resident 1 ' s History and Physical (H&P), dated 12/18/2024, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1 ' s Wandering Risk Scale, dated 1/2/2025, the Wandering Risk Scale Page 1 of 4 555273 555273 01/21/2025 Manchester Healthcare Center 837 W. Manchester Ave. Los Angeles, CA 90044

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some indicated Resident 1 had a history of wandering. The Wandering Risk Scale indicated Resident 1 had voiced he wanted to leave the facility, and the resident was at high risk for wandering and elopement. During a review of Resident 1 ' s Change of Condition (COC) Evaluation dated 1/3/2025, the COC assessment indicated Resident 1 ' s had increased agitation and grandiose ideations (a false or unusual believe about one ' s power, wealth, talents and other traits). The COC indicated Resident 1 paced around the facility and was not redirectable. The COC also indicated Resident 1 was on monitoring for attempting to elope from the facility. During a review of Resident 1 ' s Medication Administration Record (MAR, a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 1/2025, the MAR indicated Resident 1 wandered and attempted to elope from the facility on 1/16/2025, 1/18/2025, and 1/19/2025. During an observation on 1/21/2025 at 9:26 a.m., the facility exit door, next to the dining room, was observed to be unlocked and the door alarm was disarmed. No facility staff was observed monitoring the exit door and Surveyor was able to walk out of the facility door to the parking lot, exiting the building. During an interview on 1/22/2025 at 9:28 a.m. with the Activities Director (AD), the AD stated the alarm on the exit door was not armed during the day. The AD also stated there was not an assigned staff to monitor the exit door. During a concurrent interview and record review on 1/22/2025 at 10:15 a.m. with Licensed Vocational Nurse (LVN 1), Resident 1 ' s care plan dated 11/26/2024 was reviewed. LVN 1 stated Resident 1 ' s care plan indicated door alarms must always be armed. LVN 1 stated all residents who were ambulatory and able to propel self (use the hand-rims on the large rear wheels to push forward) in a wheelchair were at risk of elopement from the facility if door alarms were not armed. LVN 1 stated a resident could suffer health complications and death if a resident eloped from the facility. LVN 1 also stated Resident 1 ' s photo was not in the resident ' s chart. LVN 1 stated Resident 1 ' s photo should have been maintained in the chart to identify the resident and minimize risks of elopement. During a concurrent interview and record review on 1/22/2025 at 1:25 p.m. with the Director of Nursing (DON), Resident 1 ' s Wandering Risk Assessment was reviewed. The DON stated Resident 1 was at high risk of wandering. The DON stated Licensed Nurses should have completed a Wandering and Elopement Risk Assessment for Resident 1 upon readmission to the facility on 1/13/2025, however was not done. The DON stated residents who did not receive a Wandering Risk Assessment and Elopement Risk Assessment may not receive adequate, safe care and would be at risk of elopement. 2.) During a review of Resident 2 ' s admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated Resident 2 ' s diagnoses included cerebral infarction (stroke, loss of blood flow to a part of the brain) and major depressive disorder. During a review of Resident 2 ' s Wandering Risk Assessment, dated 5/28/2024, the Assessment indicated Resident 2 was at low risk for wandering. The assessment indicated Resident 2 could move without assistance while in a wheelchair. 555273 Page 2 of 4 555273 01/21/2025 Manchester Healthcare Center 837 W. Manchester Ave. Los Angeles, CA 90044

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of Resident 2 ' s H&P, dated 5/31/2024, the H&P indicated Resident 2 had the capacity to understand and make decisions. During a review of Resident 2 ' s MDS, dated [DATE], the MDS indicated Resident 2 was cognitively intact. The MDS indicated Resident 2 used a walker and manual wheelchair. The MDS indicated Resident 2 required supervision or touch assistance to wheel 50 to 150 feet (once seated in wheelchair, the ability to wheel at least 50 to 150 feet). During an interview on 1/22/2025 at 10:46 a.m. with LVN 2, LVN 2 stated Resident 2 propelled himself in a wheelchair and could wheel himself out of the facility without staff assistance. LVN 2 stated Resident 2 needed to be assessed to ensure appropriate elopement prevention measures were provided. During a concurrent interview and record review on 1/22/2024 at 1:25 p.m. with the DON, Resident 2 ' s Wandering assessment dated [DATE] was reviewed. The DON stated Resident 2 ' s Wandering and elopement Risk Assessments were not performed when the resident was readmitted to the facility and should have been completed (on 12/6/2024). The DON stated Resident 2 should have had an Elopement Risk Assessment performed to evaluate Resident 2 ' s care needs and decrease the risk of elopement. 3.) During a review of Resident 3 ' s admission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE]. The admission Record indicated Resident 3 ' s diagnoses included Alzheimer ' s disease (a disease characterized by a progressive decline in mental abilities), cerebral infarction, schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), schizophrenia, and major depressive disorder. During a review of Resident 3 ' s H&P, dated 10/31/2023, the H&P indicated Resident 3 did not have the capacity to understand and make decisions. During a review of Resident 3 ' s MDS dated [DATE], the MDS indicated Resident 3 ' s cognition was moderately impaired. The MDS indicated Resident 3 used a walker and wheelchair. The MDS indicated Resident 3 required set-up or clean-up assistance (staff sets up or cleans up, resident completes activity) to wheel 50 to 150 feet During a review of Resident 3 ' s Wandering Risk Scale, dated 9/19/2024, the assessment indicated Resident 3 was at low risk for wandering due to cognitive impairment and Resident 1 ' s ability to move without assistance in a wheelchair. During a concurrent interview and record review on 1/22/2024 at 1:25 p.m. with the DON, Resident 3 ' s Wandering and Elopement Risk assessment dated [DATE] was reviewed. The DON stated Resident 3 ' s Wandering Risk Assessment was not performed quarterly and did not have an Elopement Risk Assessment. The DON stated Resident 3 should have had a Wandering and Elopement Risk Assessment performed to evaluate Resident 3 ' s care needs and decrease risk of elopement. 4.) During a review of Resident 5 ' s admission Record, the admission Record indicated Resident 5 was admitted to the facility on [DATE] with diagnosis including Schizophrenia. During a review of Resident 5 ' s H&P, dated 8/22/2023, the H&P indicated Resident 5 did not have the capacity to understand and make decisions. During a review of Resident 5 ' s Wandering Risk Assessment, dated 4/24/2024, the Assessment 555273 Page 3 of 4 555273 01/21/2025 Manchester Healthcare Center 837 W. Manchester Ave. Los Angeles, CA 90044

F 0689 indicated Resident 5 was a low risk for wandering. Level of Harm - Minimal harm or potential for actual harm During a review of Resident 5 ' s care plan titled Resident is a risk for wandering/elopement, dated 4/24/2024, the care plan indicated an intervention to use measures to provide for safety. Residents Affected - Some During a review of Resident 5 ' s MDS, dated [DATE], the MDS indicated Resident 5 was cognitively intact. The MDS indicated Resident 5 required partial or moderate assistance (helper does less than half the effort) from staff to wheel 50 to 150 feet. During a concurrent interview and record review on 1/22/2025 at 1:25 p.m. with the DON, Resident 5 ' s Wandering assessment dated [DATE] was reviewed. The DON stated Resident 5 ' s Wandering Risk Assessment was not performed quarterly and should have been updated. The DON stated Resident 5 should have had a Wandering Risk Assessment performed to evaluate Resident 5 ' s care needs and decrease risk of elopement. During a review of the facility ' s undated P&P titled Wandering & Elopement indicated licensed nurses, in collaboration with the IDT, will assess residents upon admission, readmission, quarterly, and with significant change in condition to determine their risk of wandering and elopement. The P&P indicated residents with a history of wandering will have a photograph maintained in their medical record. 555273 Page 4 of 4