Health inspection·November 5, 2024

F 0689 observation and care for a single resident) to the resident to ensure that the resident is always in the facility. Level of Harm - Minimal harm or potential for actual harm LVN 1 stated Resident 1 was identified as at risk for elopement upon admission and was on 1:1 monitoring. LVN 1 stated the Certified Nursing Assistants (CNAs) did the 1:1 monitoring, and they rotated with the task hourly. LVN 1 stated Resident 1 attempted to leave the night he was admitted and was placed on 1:1 monitoring. LVN 1 stated Resident 1 eloped from the facility on October 13, 2024, during her shift and she was not sure if the assigned CNA for 1:1 monitoring, CNA 2, was outside Resident 1's room, or if she stepped out. LVN 1 stated CNA 2 could not tell her what happened. LVN 1 stated they looked around the facility and were unable to locate Resident 1. LVN 1 stated Resident 1 could have escaped the facility by jumping off the gate. LVN 1 stated the facility had gates which required a key to enter and exit. LVN 1 stated at the beginning of the shift, Resident 1 was calm and did not have any exit seeking behavior. Residents Affected - Few On November 5, 2024, at 11:58 a.m., during an interview with CNA 1, CNA 1 stated Resident 1 was on 1:1 monitoring. CNA 1 stated on October 13, 2024, he took his ten-minute-break at 8:45 p.m., or 9:00 p.m. and by the time he came back he could not find Resident 1. CNA 1 stated CNA 2 was assigned to do the 1:1 monitoring from 9:00 p.m., to 10:00 p.m. CNA 1 stated CNA 2 was not outside Resident 1's room. On November 5, 2024, at 12:38 p.m., during telephone interview with CNA 2, CNA 2 stated she was working when Resident 1 left the facility. CNA 2 stated Resident 1 was on 1:1 monitoring, and she was supposedly doing the 1:1 on him at the time when staff couldn't find him. CNA 2 stated she did not see Resident 1 leave the facility. CNA 2 stated the practice was that the CNA assigned to Resident 1's run was the CNA who would do the 1:1 monitoring from 9:00 to 10:00 p.m. CNA 2 stated it was CNA 1 who was doing the 1:1 monitoring on Resident 1 at that time. CNA 2 stated CNA 1 was sitting outside Resident 1's room and he was the one who asked where Resident 1 was. On November 5, 2024, at 2:25 p.m., during an interview with Registered Nurse (RN) 1, RN 1 stated residents are identified for elopement by conducting an elopement assessment, which is included in the admission assessment. RN 1 stated when a resident is identified as at risk for elopement, they monitored the resident's whereabouts and initiate a care plan. RN 1 stated Resident 1 wandered around the facility, but she was not aware if he had exit seeking behavior or verbalized he didn't want to be in the facility. RN 1 stated the nurses should be educated on when to use 1:1 monitoring or line of sight. RN 1 stated Resident 1 was on line of sight. RN 1 stated 1:1 monitoring is when a CNA is watching over a resident in close proximity and line of sight was when a CNA is watching over multiple residents and maintaining visual on the residents. RN 1 stated Resident 1 was out of the facility for 29 hours and he could have had an injury, pass out, or get into an accident. RN 1 stated the expectation for staff was to ensure they are watching the residents, most specifically those that are at risk for elopement and falls. On November 5, 2024, at 3:05 p.m., during an interview with the Social Service Director (SSD), the SSD stated Resident 1 would go outside looking for an opportunity to leave or to see if a door was open. The SSD stated she observed Resident 1 doing this on his second day of stay at the facility and she asked him to back inside. On November 8, 2024, at 3:18 p.m., during an interview with the Director of Staff Development (DSD), the DSD stated 1:1 monitoring was when staff goes wherever the resident goes. The SSD stated line of sight was when a resident should be within staff's vision and if the resident is no longer within (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555711 If continuation sheet Page 2 of 3 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 555711 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Community Care on Palm 4768 Palm Avenue Riverside, CA 92501 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 Residents Affected - Few staff's sight then the staff will have to follow the resident and maintain a visual on the resident. The SSD stated at the time Resident 1 eloped, he was on line of sight. The SSD stated there was no excuse for when Resident 1 eloped and that no one was really paying attention when Resident 1 was on line of sight. The SSD stated when residents are on line of sight, staff should know where the residents are at all times. On November 5, 2024, at 4:11 p.m., during an interview with the Director of Nursing (DON), the DON stated Resident 1 was on line of sight since admission because they do not know what his behaviors were, and to prevent falls. The DON stated the expectation for when a resident is on line of sight is for staff to alert another staff when the resident is going or coming out of an area of supervision. The DON stated it caught them by surprise when Resident 1 eloped. The DON stated she did not have an answer when she was asked how Resident 1 could have eloped if he was on line of sight. A review of the facility's policy and procedure titled, Wandering and Elopements dated 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 .If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. A review of the facility's policy and procedure titled, Safety and Supervision of Residents dated July 2017 indicated .Resident safety and supervision and assistance to prevent accidents are facility wide priorities .Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determine by the individual resident's assessed needs . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555711 If continuation sheet Page 3 of 3