Health inspection·February 23, 2024

F 0576 Ensure residents have reasonable access to and privacy in their use of communication methods. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure access to a telephone for one resident (Resident 1). Residents Affected - Few This failure prevented Resident 1 from calling his mother. Findings: A review of Resident 1 ' s admission record indicated diagnoses that included schizoaffective disorder bipolar type (a mental health disorder that includes increased risk taking behavior and mood swings) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness). An observation and interview of Resident 1 was conducted on 1/25/24 at 11:30 A.M. Resident 1 stated that he had been very sad because he could not speak with his mother on the phone or visit her. Resident 1 stated They don ' t let me use a phone. A joint observation and interview with the Director of Nursing (DON) was conducted on 1/25/24 at 11:40 A.M. Resident 1 asked the DON if he could call his mother. The DON stated, There is no phone for you to use. An observation of common areas indicated there were no pay phones. An observation of resident rooms indicated there were no facility phones in the rooms. Resident 1 stated he did not own a cellular phone. A review of the facility policy titled Telephones, Resident Use of dated May 2017 indicated Designated telephones are available to residents to make and receive private telephone calls. The telephones at the nursing stations should ordinarily be reserved for staff use, unless no other alternative is available. Residents should use telephones at the nursing stations for as brief a period as possible.Resident telephones are located in the following areas: main office. Page 1 of 2 555919 555919 02/23/2024 Imperial Manor 100 East 2nd Street Imperial, CA 92251

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. Based on observation, interview and record review, the facility failed to supervise Resident 1. As a result, Resident 1 eloped from a secured mental health facility and suffered a laceration (cut) on his right hand and abrasions on his legs when he climbed over the facility gate to leave the facility. Findings: A review of Resident 1 ' s admission record indicated diagnoses that included schizoaffective disorder bipolar type (a mental health disorder that includes increased risk-taking behavior and mood swings) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness). An interview was conducted with the Director of Nursing (DON) on 1/25/24 at 11:12 A.M. The DON stated staff became aware that Resident 1 was missing at 6 P.M. on 1/12/24. The DON stated surveillance footage was reviewed which showed Resident 1 climbed over a gate at 5:30 P.M. The DON stated Resident 1 was located by the local police department on 1/12/24 at approximately 10:00 P.M. after four- and one-half hours outside of the facility. Resident 1 was brought to the local emergency department by the police, where he was treated for a laceration on his right hand. A review of the nursing progress note dated 1/13/24 at 1:39 P.M. indicated, Patient arrived at 8:57 A.M. from (local hospital) via (name of facility) transportation.upon skin assessment patient was found with scattered abrasions to bilateral knees and a skin tear to left hand. An observation and interview of Resident 1 was conducted on 1/25/24 at 11:30 A.M. Resident 1 stated he was worried about his mother who was in the hospital and wanted to go see her. Resident 1 stated, I need to know how she is, so I went over the gate to go to her. I am so sad worrying about her. An observation of the secured mental health facility premises was conducted with the DON on 1/25/24 at 12:00 P.M. The door between the interior of the facility and the exterior yard was unlocked and unalarmed. The DON stated, The door is never locked and there is no alarm, even at night. Residents can go out whenever they want to. No staff member goes with them unless they are smoking. (Resident 1) doesn ' t smoke, so no one is required to go outside with him. A main road was noted on the other side of a facility fence. The DON stated, The road on the other side of the fence has fast traffic. A gate was noted in the perimeter fence. The DON stated a different resident eloped twice in 2023 by climbing over the same gate. A review of the facility policy titled Elopement Prevention dated July 2008 indicated It is the policy of SnF Healthcare to provide a safe and secure environment and ensure the safety of any resident attempting to elope from the facility. 555919 Page 2 of 2