Health inspection·December 18, 2023

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 identify and eliminate the risk for elopement for 1 of 2 sampled residents (1) when the facility placed a temporary fence against the permanent wall. As a result, Resident 1 used the temporary fence to elope from a secure unit, and Resident 1's safety was at risk. Findings: Resident 1 was admitted to the facility on [DATE] with diagnoses which included schizophrenia (mental disorder) and substance use disorder, per the facility's admission Record. A record review was conducted. Per the admission Data Collection and Baseline Care Plan Tool, dated 11/14/23, Resident 1 was at risk for elopement related to involuntary placement and history of elopement. Resident 1 was placed in a locked or secured facility. Per the MDS (Minimum Data Set- assessment tool that measures health status), dated 11/22/23, Resident 1 scored 10 out of 15 (meaning Resident 1 was moderately cognitively impaired). Per the Progress Notes, dated 12/2/23 at 2:30 P.M., Licensed Nurse (LN) 1 documented that Resident 1 was AWOL (absent without official leave) by jumping the fence on the back patio; the gardener and peer notified LN 1. On 12/5/23 at 1:20 P.M., an interview was conducted with the Administrator (ADM). The ADM stated Resident 1 used the temporary six-foot fence to climb the eight-foot fence and left the secure unit. Resident 1 ran toward the east side of the building, to the gasoline station, and got inside a car. Resident 1's whereabouts were unknown. The ADM further stated if the temporary fence was not there Resident 1 would not be able to elope. On 12/5/23 at 3 P.M., an interview was conducted with the Superintendent (Supt). The Supt stated they had to access the electrical panels, and they put a temporary fence to discourage residents from wandering around the electrical panels. The Supt stated he received a report that Resident 1 used the temporary fence to leave the secure unit unassisted. The Supt further stated that the temporary fence had been placed for two weeks, and they did not anticipate that Resident 1 would climb it. Per the facility's policy and procedure, dated 9/19/22, titled Elopement/Missing Resident, .Facilities are responsible for identifying and assessing a resident's risk for leaving the facility without (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 2 Event ID: 555887 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 555887 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeside Special Care Center 11962 Woodside Avenue Lakeside, CA 92040 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)