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. Page 1 of 3 555838 555838 01/26/2024 Camden Postacute Care, Inc 1331 Camden Avenue Campbell, CA 95008

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident 1's minimum data set (MDS, an assessment tool) dated 8/31/23 indicated his brief interview for mental status (BIMS, cognition level) score was 6 (0 to 7 points suggests severe cognitive impairment). Further review of Resident 1's minimum data set (MDS, an assessment tool) dated 8/31/23 indicated that he needed supervision for a walk-in corridor, locomotion on unit (how the resident moves between locations in his room and adjacent corridor on the same floor), and locomotion off unit (how the resident moves to and returns from off-unit locations). Review of Resident 1's Elopement Risk assessment dated [DATE] indicated the provision of frequent monitoring. Review of Resident 1's care plan, initiated on 3/23/18, indicated Resident 1 was at risk for (Activities of daily living )ADL self-care performance deficit related to Alzheimer's disease and Dementia and required supervision with all areas of ADLs/mobility, ambulated unlimited distances without assistant device used. During an interview and concurrent record review with the Minimum Data Set Coordinator (MDSC) on 1/26 /24 at 5:12 p.m., the MDSC reviewed Resident 1's MDS assessment on 8/31/23 and the care plan on 8/23/23. The MDS stated that Resident 1 had Alzheimer's disease and needed supervision in all ADL areas, including mobility. During a phone interview with LVN A on 1/30/24 at 5:39 p.m., LVN A confirmed that the police officer found Resident 1 and sent him to the hospital ER (emergency room). Resident 1 returned to the facility the following day at 5:30 a.m. LVN A also confirmed that Resident 1 had an unwitnessed fall and a 3 cm laceration above the right eyebrow. Review of Resident 1's care plan updated post-event, dated 9/19/23, indicated Resident 1 returned to the facility via ambulance accompanied by EMTs from the hospital ER. Resident 1 was found in the Los Gatos area, where a resident had a fall incident and sustained a 3 cm laceration above the right eyebrow. During a phone interview with the Director of Nursing (DON) on 1/26 /2024 at 11:00 a.m., the DON confirmed that Resident 1 had Alzheimer's disease with severe cognitive impairment. the DON stated that the staff should have provided frequent supervision to prevent elopement. 2. Review of Resident 1's care plan, initiated on 9/19/23, indicated to monitor resident's whereabouts every 15 minutes. During a concurrent interview and record review with LVN B on 1/26/24 at 3:58 p.m., LVN B reviewed Resident 1's care plan initiated on 9/19/23. He stated that staff monitored Resident 1 every 15 minutes post-elopement for 72 hours. LVN B acknowledged that the licensed nurse should have updated the care plan to frequent monitoring after 72 hours. During a phone interview with the Director of Nursing (DON) on 1/31/24 at 11:05 a.m., the DON acknowledged that licensed nurses should have updated the care plan after monitoring every 15 minutes for 72 hours. Review of the facility's policy and procedure, dated January 2018, Elopement/Wandering Resident, 555838 Page 2 of 3 555838 01/26/2024 Camden Postacute Care, Inc 1331 Camden Avenue Campbell, CA 95008

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few indicated that The facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk for wandering. Review of the facility's undated policy and procedure, Care Plans, Comprehensive Person-Centered, indicated, .Assessments of residents are ongoing and care plans are revised as information about the residents and the residents ' conditions change . 555838 Page 3 of 3