Health inspection·March 22, 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 provide a plan of care and adequate supervision to prevent one of three residents reviewed for elopements from leaving the facility (Resident 1). As a result, Resident 1 went missing from the facility without staff ' s knowledge and placed Resident 1 at risk for harm. Findings: Resident 1 was admitted to the facility on [DATE] with diagnoses including dementia (an impairment of brain function, such as memory loss and judgment) according to the facility ' admission Record. During an interview on 3/15/24, at 9:46 A.M. with Resident 1, Resident 1 stated a week ago on Monday, 3/4/24 he walked out of the facility to look for a house for sale then came back. Resident 1 stated this past Monday, 3/11/24 he left the facility again when it was still dark outside and staff from the facility found him outside during the day. An interview was conducted on 3/15/24, at 10:22 A.M. with Resident 1 ' s assigned certified nurse assistant (CNA) 1. CNA 1 stated he was assigned to Resident 1 on 3/9/24 when Resident 1 eloped from the facility. CNA 1 stated resident ate breakfast on 3/9/24 and assumed Resident 1 ate lunch in the dining room. CNA 1stated Resident 1usually attended activity programs then ate lunch in the dining room. CNA 1stated meal trays for Resident 1 were delivered to his room unless he was in the dining room. CNA 1 stated at around 2-2:30 P.M. on 3/9/24, another CNA notified him that Resident 1was found outside the facility by the street. CNA 1 stated he then saw Resident 1 walking towards his room at that time and did not know that Resident 1 was not in the facility. During a concurrent review and interview on 3/15/24, at 12:15 P.M. with the activity director (AD), the AD reviewed the activity log for 3/9/24 and stated Resident 1 attended the morning activity but did not attend the afternoon activity. The AD further stated Resident 1did not have lunch in the dining room because there were no dining room meals served on the weekends, and 3/9/24 was a Saturday. During a review of the facility ' s progress note (PN) dated 3/9/24 written at 4:30 P.M., the PN indicated, The resident was observed by staff ambulating on the walkway near Felicita Road close to traffic. Staff feared he may inadvertently wander into traffic . An elopement risk assessment for Resident 1 dated 2/5/24 was reviewed. The assessment indicated, SC1. Score >1-At Risk for Elopement. Page 1 of 2 555427 555427 03/22/2024 Ocean View Post Acute 1980 Felicita Road Escondido, CA 92025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 3/15/24, at 12:21 P.M. with licensed nurse (LN) 3, LN 3 stated she created an at risk for elopement care plan for Resident 1 on 3/9/24. LN 3 stated there was no plan of care to address Resident 1 ' s elopement risk upon admission. The attending physician ' s history and physical (H&P) dated 2/7/24 was reviewed. The H&P indicated, .patient resides at Board and Care. Patient was wandering and went missing for several days. He was found by local police and brought in the hospital and placed on 5150 hold (involuntarily committing someone to a mental health facility) . A review of the facility ' s policy and procedure (P&P) titled, Elopements and Wandering Residents, dated 12/19/22 was reviewed. The P&P indicated, .This facility ensures that residents who exhibit wandering behavior and/or at risk for elopement receive adequate supervision to prevent accident, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk .Elopement occurs when a resident leaves the premises or a safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so . An interview was conducted with the Director of Nurses (DON) on 3/22/24, at 11:25 a.m. The DON stated there should have been a plan of care for Resident 1upon admission to the facility because Resident 1 had a history of elopement. 555427 Page 2 of 2