Health inspection·June 5, 2024

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide adequate/ necessary supervision to prevent elopement (when a resident leaves the premises or safe area without the facility's knowledge and supervision) with injury for one of three sampled residents (Resident 1), when the facility staff failed to assess level of supervision required for safety for Resident 1, who was cognitively impaired, for elopement risk when he attempted to leave the facility and fell at the facility's back gate on 6/5/2023. In addition, the facility staff did not follow the facility expectation as directed to visualize the resident every two hours. Resident 1 eloped and fell approximately one mile from the facility, and was missing for approximately 9 hours, on 1/24/2024. These failures resulted in a two-centimeter forehead laceration that required five sutures for Resident 1 and had the potential to result in serious impairment and death. Findings: During a review of the Minimum Data Set (MDS- assessment tool that measures health status in nursing home residents), dated 12/10/2023, the MDS indicated Resident 1 had a BIMS (Brief Interview for Mental Status- a tool to measure and track a resident's cognitive decline or improvement) score of 9 out of 15 (a score of 8 to 12 suggests moderate cognitive decline). During a review of the Physician Order (PO), dated 9/29/2023, indicated Resident 1 may go out of the facility on pass with a responsible party. During a review of the History and Physical (H&P), dated 5/22/2023, the H&P indicated Resident 1 was readmitted to the facility on [DATE]. Resident 1's diagnoses included dementia (the loss of cognitive function-thinking, remembering, and reasoning, which interferes with a person's daily life) and paranoid schizophrenia (serious mental illness that causes disorganized thinking). During an interview with the Facility Administrator (FM) on 1/26/2024 at 10 AM, the FM stated the facility's staff did not know Resident 1's whereabouts on 1/24/2024 after 9:12 AM until he was returned to the facility via ambulance from the hospital at 6:40 PM. (Resident 1 was missing for approximately 9 hours). During a concurrent observation and interview on 1/26/2024 at 10:19 AM, in the facility's Activity Room, Resident 1 was observed with a bandage on his forehead, dark purple discoloration on the skin under both eyes, and an abrasion/scab along the entire length of his nose. Resident 1 was ambulatory with a walker. He had on a red color-coded identification (ID) badge. Resident 1 was alert and oriented. (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 3 Event ID: 555795 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 555795 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Veterans Home of California - Chula Vista 700 East Naples Court Chula Vista, CA 91911 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)