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 ensure one of three sampled residents (Resident 3) who
eloped (leaving a safe area without authorization and/or appropriate supervision from the facility) was
assessed to prevent or/and to minimize the risk for recurrence of elopement.
This failure had the potential to cause a delay in identifying care and support needs which could place
Resident 3 at risk for recurrence of elopement and at risk for injuries related to elopement.
Findings:
During a review of Resident 3 ' s medical record , the admission Record (contains demographic and
medical information), indicated Resident 3 was admitted to the facility on [DATE], with diagnoses which
included of schizoaffective disorder (a mental illness that can affect your thoughts, mood, and behavior),
delusional disorder (a type of mental health condition in which a person can't tell what's real from what's
imagined), and bipolar disorder (a mood disorder that can cause intense mood swings).
A review of a facility document to notify the State Agency regarding an elopement, dated January 6, 2024,
indicated .RE; Elopement Initial Letter .On Friday l/5/2024 (January 5, 2024), staff at [Facility name] could
not locate a resident name [Resident 3]. He was last seen by staff at smoke break at approximately 7:00
pm. After searching the facility and outside areas with no success staff called the police to report the
alleged elopement .
A review of Resident 3 ' s electronic health record progress notes, dated January 6, 2024, indicated
Resident arrived back to facility at 23:30 .
A review of Resident 3 ' s elopement risk assessments (a form to complete to determine if an individual
requires necessary safety intervention) revealed the last assessment completed was upon admission on
[DATE]. No other elopement risk assessments had been completed since September 11, 2023.
During an interview on February 9, 2024, at 3:30 PM, with License Vocation Nurse (LVN), LVN stated
elopement risk assessment should be completed upon admission, quarterly (every 3 months) basis and
after every episode of actual elopement for every resident in the Special Treatment Program Unit (STPsecure units that provide treatment to people with primary psychiatric issues).
During a concurrent record review and interview with the Administrator and LVN, on February 8, 2024, at
3:40 PM, the Administrator (Admin) and LVN reviewed Resident 3 ' s clinical record and
(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
02/10/2024
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)
F 0689
Level of Harm - Minimal harm
or potential for actual harm
confirmed that no other Elopement risk assessments had been completed for Resident 3 since September
11, 2023 (upon Resident 3 ' s admission). LVN stated the elopement risk assessment should have been
completed when Resident 3 returned to the facility after he had an elopement episode on January 6, 2024.
(34 days had passed without accurate clinical direction to determine if Resident 3 requires necessary
safety intervention to prevent or/and to minimize the risk for recurrence of elopement.)
Residents Affected - Few
During further interview and record review, with the Admin and LVN, on February 8, 2024, at 4:00 PM, the
Administrator and LVN acknowledged and reviewed the facility ' s policies and procedures (P&P) titled,
Wondering and Elopement, revised March 2019, and Emergency Procedure– Missing Resident
revised August 2018. The Administrator and LVN both stated the facility did not follow the policy.
A review of the facility ' s policy and procedure (P &P) titled, Wondering and Elopement, revised March
2019, indicated, .The facility will identify residents who are at risk of unsafe wandering and strive to prevent
harm while maintaining the least restrictive environment for residents .
A review of the facility ' s P&P titled Emergency Procedure– Missing Resident revised August 2018,
indicated, Policy Statement. Resident elopement resulting in a missing resident is considered a facility
emergency. Policy Interpretation and Implementation. 1. Residents at risk for wandering and/or elopement
will be monitored, and staff will take necessary precautions to ensure their safety .Emergency Job Tasks
-Missing Resident. Assign specific tasks to staff members during an emergency based on the following
criteria: . Nursing Staff . 9. Ensure the incident and events are documented objectively in the resident
record, including: . Results of reassessment upon the resident's return and the condition of the resident .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555514
If continuation sheet
Page 2 of 2
