Health inspection·February 10, 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 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 Page 1 of 2 555514 555514 02/10/2024 Heritage Park Nursing Center 275 Garnet Way Upland, CA 91786

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 . 555514 Page 2 of 2