Health inspection·November 5, 2025

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 safe and secured environment for Resident 1, who was identified as being at high risk for elopement (when a person with cognitive impairment leaves a safe area, such as a care facility or home, without awareness of potential dangers) and wandering (when a person roams and becomes lost or confused about their location) for one of two sampled residents (Resident 1). The facility failed to: Ensure that facility staff supervise Resident 1 and did not leave the resident unattended in the Activity/Dining Room, which was located adjacent to an exit door. Ensure that Activity Staff (AS) 1 was informed of Resident 1's high risk for elopement and need for monitoring, when Licensed Vocational Nurse (LVN) 1 observed the resident wandering out of her room and left the resident with AS 1 in the Activity Room. 3. Ensure that Resident 1 was continuously monitored and supervised by a facility staff in the Activity Room when AS 1 left the facility at the end of her shift on 10/28/2025 at around 5 PM. As a result of these deficient practices, on?10/28/2025 between the hours of 5 PM to 6 PM, Resident 1 wandered out of the facility unsupervised. Resident 1 was later found the same day, on 10/28/2025, at approximately 6:07 PM, sitting at a bus stop on a busy street?0.4 miles?from the facility. Resident 1 was located and returned to the facility by a family member (Responsible Party [RP] 1). Resident 1 was placed at significant risk and exposure from falls, injury from motor vehicular accidents, and extreme weather conditions due to the facility's failure to provide Resident 1 with a safe and secure environment, in accordance with the resident's care plan. Findings: During a review of the facility's Policy and Procedures (P&P) titled Wandering and Elopement revised 8/1/2014, the P&P indicated that resident's risk for elopement and preventative interventions will be documented in the resident's medical record, and will be reviewed and re-evaluated by the IDT upon admission, readmission, quarterly, and upon change of condition according to the RAI (Resident Assessment Instrument- a standardized process that nursing homes use to evaluate a resident's needs and develop an individualized care plan) guidelines. The P&P further indicated that the IDT may consider interventions listed in the Elopement Risk Reduction Approaches for residents identified to be at risk for elopement. During a review of the facility's P&P titled Elopement Risk Reduction Approaches, the P&P indicated As necessary, provide new residents (to the facility, wing, unit, etc.) with additional staff assistance until they are comfortable in their new environment. The P&P further indicated that for residents identified at risk for wandering, facility staff needs to know the following information: i. How to identify and understand the resident's needs. ii. The resident's propensity to wander and the triggering conditions. iii. Recognition of the consequences of limited mobility. iv. The consequences of unsafe wandering, the protocols to follow to minimize successful exiting During a review of Resident 1's admission Record, the record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses that included multiple fracture (a broken bone) of left side ribs, repeated falls, and dementia (a progressive Page 1 of 3 555616 555616 11/05/2025 Ararat Post Acute 1230 E. Windsor Rd. Glendale, CA 91205

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few state of decline in mental abilities). During a review of Resident 1's Elopement- Wandering Risk Scale assessment dated [DATE], the Assessment indicated Resident 1 was identified at high risk for wandering/elopement due to forgetful/short attention span, diagnosis of dementia with psychosis (a collection of symptoms that affect the mind, where there has been some loss of contact with reality), and a known wanderer, including history of wandering. The Assessment did not indicate any recommendations from the facility's licensed nurse who completed the Elopement- Wandering Risk Scale Assessment. During a review of Resident 1's Care Plan titled At risk for wandering/elopement dated 10/22/2025, the Care Plan indicated the goal was to ensure Resident 1 would remain safe within the facility and free from injury and interventions included the following interventions: 1. Keep environment free from clutter; 2. Monitor resident whereabouts every 1 hour; 3. Redirect resident calmly when attempts to ambulate unassisted occurs. The Care Plan did not include to have all interdisciplinary care team made aware of Resident 1's high risk for elopement and the type of supervision required for Resident 1 to remain safe and secured between hours when no staff was monitoring the resident's whereabouts. During a review of Resident 1's Care Plan titled At risk for falls dated 10/22/2025, the care plan indicated that Resident 1 had cognitive impairment and history of recent falls resulting in rib fracture. The care plan interventions indicated that Resident 1 needs a safe environment including even floor, free from spills and clutters, adequate lighting, an accessible call light, and handrails on walls. During a review of the facility Minimum Data Set (MDS - a resident assessment tool) dated 10/25/2025, the MDS indicated Resident 1 had severely impaired (significantly limits one person's physical or mental ability to do basic work activities) cognition (thought process). The MDS also indicated Resident 1 required supervision or touching assistance (helper provides verbal cues and/or contact guard assistance as resident completes activity) during sit-to-stand, and partial/moderate assistance (helper does less than half the effort) on walking 50 feet. During a review of Resident 1's Monitoring Log dated 10/28/2025, the log timed 4 PM marked R indicated that Resident 1 was in the resident's room, and another one timed at 5 PM marked D indicated that Resident 1 was in the Dining Room (Activity Room). During a telephone interview conducted on?11/05/2025 at 11:30 AM, Certified Nurse Assistant (CNA) 1 stated that she was assigned to care for?Resident 1?on?10/28/2025. CNA 1 stated that Resident 1 was identified as being at risk for elopement and required?hourly monitoring. CNA 1 recalled that at approximately?5:00 PM on 10/28/2025,?Licensed Vocational Nurse (LVN 1)?escorted Resident 1 to the Activity Room. CNA 1 stated she was attending to another resident at that time and was?not asked by LVN 1?to supervise or monitor Resident 1 while the resident was in the Activity Room. CNA 1 further stated that she became aware that Resident 1 was missing from the facility at approximately?5:30 PM on 10/28/2025?and?immediately reported?the incident to the charge nurse. During a telephone interview conducted on?11/05/2025 at 11:44 AM,?LVN 1?stated that on?10/28/2025, between the hours of?4:00 PM and 5:00 PM, LVN 1 observed?Resident 1?walking out of his room. LVN 1 noted that Resident 1 was dressed and appeared to be wandering. LVN 1 stated that she redirected and accompanied Resident 1 to the?Activity Room, where she handed off the resident to AS 1. LVN 1 stated that she was?not certain whether AS 1 was aware?of Resident 1's high risk for elopement and the need for close monitoring. LVN 1 further stated that she assumed AS 1 would supervise Resident 1, as it is the facility's expectation that?no resident should be left unsupervised. During an interview conducted on?11/05/2025 at 12:20 PM,?AS 1?stated that she was?not informed by LVN 1?that?Resident 1?was at risk for elopement and was?not familiar?with the resident's medical history. AS 1 stated that she does not typically know most residents' diagnoses but acknowledged that?no resident should be left unsupervised. AS 1 stated that on?10/28/2025 at around 5:00 PM, as she was preparing to leave for the day, she 555616 Page 2 of 3 555616 11/05/2025 Ararat Post Acute 1230 E. Windsor Rd. Glendale, CA 91205

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few went to the?Nursing Station?to inform?Registered Nurse (RN) 1?that someone needed to get Resident 1 from the Activity Room. AS 1 stated that there were?two dietary staff members?present in the Activity/Dining Room when she stepped out to look for the nurse. AS 1 stated that it was?not appropriate to expect dietary staff?to supervise Resident 1 and stated that she?should not have left Resident 1 unsupervised in the Activity Room on 10/28/2025. During an interview on 11/05/2025 at 2:45 PM, RN 1 stated that she completed an elopement risk assessment for Resident 1 upon admission. RN 1 stated that all staff, including nurses and activity staff, were informed about Resident 1's high risk for elopement. RN 1 stated that on 10/28/2025, at around 5:00 PM, while making resident rounds prior to her 30-minute meal break, she observed Resident 1 with AS 1 in the Activity Room. RN 1 stated that she was on her meal break and was not aware of the time AS 1 ended her shift. RN 1 stated AS 1 did not inform her that Resident 1 needed someone to supervise Resident 1 in the Activity Room prior to leaving the facility at end of her (AS 1) shift, on 10/28/2025. RN 1 stated that upon returning from her break at approximately 5:35 PM, RN 1 stated she was notified by LVN 1 that Resident 1 was missing. During a telephone interview on 11/06/2025 at 2:10 PM, RP 1 stated that she received a call from the facility on 10/28/2025 at around 5:30 PM, informing her that Resident 1 was missing from the facility. RP 1 stated that she and other family members immediately took their car out to search for Resident 1. RP 1 stated that they found Resident 1 while driving toward the facility. Resident 1 was sitting at a bus stop near a busy street intersection, 0.4 miles away from the facility. RP 1 stated Resident 1 appeared to be sweating heavily from walking. RP 1 stated that Resident 1 looked lost and was surprised to see her and the other family members. Resident 1 did not respond when asked why he was there. During an interview on 11/05/2025 at 3:50 PM with the Administrator (ADM) and Director of Nursing (DON), the DON stated that the supervision and safety of residents is very important, and that staff communication should be thorough at all times. The ADM stated that AS 1 should not have assumed that any dietary or non-clinical staff present would be responsible for monitoring or supervising a resident. The ADM further stated that AS 1 should have remained with Resident 1 until relieved by a clinical staff member. 555616 Page 3 of 3