Health inspection·January 26, 2024

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on observation, interview, and record review, the facility failed to ensure their closed observation protocol (a protocol for observing residents who are at risk for harm every fifteen minutes) documentation was complete in accordance with the facility ' s policy and procedure (P&P) for one resident (Resident 1) when Resident 1 returned to the facility after he eloped on January 7, 2024. This failure has the potential to result in Resident 1 to be at risk for further elopement without supervision of his whereabouts which could increase Resident 1 ' s risk for harm. Findings: During an interview on January 19, 2024, at 11:08 AM, with Resident 1, Resident 1 stated he left the facility because the voices made him uncomfortable in the facility. Resident 1 further stated he opened the emergency exit door by pushing the door [LP1] [SJ2] and running out. Resident 1 stated he came back to the facility because he needed a roof over his head. During an observation on January 19, 2024, at 11:11 AM, with Resident 1, Resident 1 demonstrated how he pressed the fire alarm then proceeded to press open the emergency exit door located next to his assigned room. During an interview on January 19, 2024, at 11:40 AM, with Certified Nursing Assistant (CNA 1), CNA 1 stated she was preparing her Q15 ' s (Q-medical abbreviation for every 15-minute monitoring- a documentation where staff will document time, location, behavior observed, interventions and initials of the staff who saw them) when the emergency exit door alarm set began ringing. CNA 1 further stated she ran out the door and attempted to redirect Resident 1 back into the facility, but he was too far away. During a review of Resident 1 ' s Incident Note, dated January 7, 2024, the Incident Note indicated, .Per Night shift nurse no s/s (abbreviation of signs or symptoms) of change from baseline behavior. Observed walked to his room (room number), He [Resident 1] then pulled the fire alarm near exit and ran out of the emergency exit . AM CNA exited and followed Resident . Observed Resident running, off the property turned right (street name) . During a review of Resident 1 ' s IDT (Interdisciplinary Team- a team that brings together knowledge from different health care disciplines to help people receive the care they need) Note, dated January 9, 2024, the IDT Note indicated, .Reminds Q (Q-medical abbreviation for every) 15 checks minute monitoring .IDT Recommendation: 01/08/2024 .3. Monitor resident by initiating safety checks q 15 min. 4. Monitor resident ' s whereabouts frequently . (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 555514 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555514 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heritage Park Nursing Center 275 Garnet Way Upland, CA 91786 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)