Health inspection·January 26, 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 provide supervision to prevent one out of three residents (Resident 1) from leaving the facility without staff's knowledge and permission. 1. The facility did not implement the care plan to provide enough supervision for Resident 1's mobility; 2. The facility did not update Resident 1's care plan to provide adequate supervision post-event. These failures compromised Resident 1's health and safety, as he was found by the police and, was admitted to the acute hospital for treatment and evaluation on 9/20/23, and had a potential risk for Resident 1's elopement in the future. Findings: 1. Review of Resident 1's medical record indicated he was admitted to the facility on [DATE] with diagnoses including unspecified Alzheimer ' s disease (a brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest tasks) and unspecified Dementia (impaired ability to remember, think, or make decisions that interfere with doing everyday activities). During an interview with the Licensed Vocational Nurse (LVN) A on 9/21/23 at 2:53 p.m., LVN A stated that Certified Nursing Assistant (CNA) C reported that Resident 1 was not in his room around 10:30 p.m. on 9/19/23. Staff searched inside and outside the facility and reported to police around 11:05 p.m. During a phone interview with CNA C on 1/30/24 at 10:57 p.m., CNA C stated she found Resident 1 was not in his room around 10:30 p.m. on 9/19/24. She searched the rehabilitation and activity rooms and did not find Resident 1, so she reported this to LVN A. CNA C further stated that Resident 1 had Alzheimer ' s disease and was confused. Sometimes, Resident 1 got up at midnight because he thought it was morning and she needed to redirect him for time disorientation. Review of Resident 1's IDT post-event notes dated 9/20/23 indicated that Resident 1 was post-elopement and returned to the facility at 5:30 a.m., with an unwitnessed fall per EMTs( Emergency Medical Services ) and a 3 cm (Centimeters are metric units of measurement ) laceration (cut) above the right eyebrow. (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: 555838 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 555838 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Camden Postacute Care, Inc 1331 Camden Avenue Campbell, CA 95008 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)