Ojai Health & Rehabilitation

F 0684

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

interview and record review, the facility failed to provide adequate supervision for one of two sampled residents (Resident 1), when Resident 1 was identified as at risk for elopement, left facility without knowledge of staff, and was found a block from the facility.Findings:During an interview on 9/25/25 at 1 p.m. with the director of nursing (DON), the DON stated, We didn't realize Resident 1 was missing until the fire department brought him back. He wasn't gone from the facility that long, so we didn't think reporting to CDPH was necessary. During an interview on 9/25/25 at approx. 1:30 p.m. with Certified Nursing Assistant 2 (CNA 2), CNA 2 verbalized, heard the wander guard alarm sound, checked the back door of the facility, did not see any residents, assumed it was a false alarm and did not realize a resident was missing until the fire department showed up.During an interview on 10/8/25 at 8 a.m. with [NAME] County Fire Captain (FC),

the FC stated, When we arrived on scene there was a gentleman lying just off the ramp into the road in front of a home approximately a block from the facility. He had a hospital bracelet on that had the name of

the facility and another bracelet on one of his legs (wander guard). After doing an assessment we helped him up, he was not talking, his blood pressure was pretty low. We stopped at the facility first.quickly ran inside and the staff did not know he was missing. The facility was able to pull up that he had medication around 9 a.m., the call went out about 10 a.m., so sometime in between he left the facility. He could have been missing from the facility for an hour and nobody would have noticed.During a review of Resident 1's Medication Administration Record (MAR), the MAR indicated, Resident 1 was given medication at approximately 9 a.m. and that was the time the resident was last noted in the facility.During a review of Resident 1's Minimum Data Set (MDS), a standardized assessment tool used in nursing homes to evaluate residents' health and functional status, dated 7/15/25, the MDS indicated, a Brief Interview for Mental Status (BIMS) score of 5 on admission (Scores of 0-7: indicate severe cognitive impairment). During a

review of Resident 1's Care Plan (CP), dated 7/8/25, the CP indicated, Resident is at risk for elopement, exit seeking/wandering related to communication deficits, difficult to redirect, exit seeking behaviors.During

a review of Resident 1's Order Summary Report (OSR), dated 11/10/25, the OSR indicated, Resident 1 was to wear a Wander Guard, a wearable device that tracks movement and triggers automated security responses when a resident nears a restricted area.

Residents Affected - Few

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

Event ID:

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/18/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Ojai Health & Rehabilitation

601 North Montgomery Street Ojai, CA 93023

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)

F 0836 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation, interview and record review, the facility failed to comply with the state requirement of unusual occurrence by not reporting to the Department (State Agency) for one of two sampled residents (Resident 1). When a Resident with a history of dementia left the care facility without knowledge to staff, fell and was transported to emergency department.This deficient practice resulted in a delayed investigation by the Department.Findings:During an interview on 9/25/25 at 1 p.m. with the director of nursing (DON), the DON stated, We didn't realize Resident 1 was missing until the fire department brought him back. He wasn't gone from the facility that long, so we didn't think reporting to CDPH was necessary. During an interview on 9/25/25 at approx. 1:30 p.m. with Certified Nursing Assistant 2 (CNA 2), CNA verbalized, they heard the wander guard alarm sound, checked the back door of the facility, did not see any residents, assumed it was

a false alarm and did not realize a resident was missing until the fire department showed up.During an

interview on 10/8/25 at 8 a.m. with [NAME] County Fire Captain (FC), the FC stated, When we arrived on scene there was a gentleman lying just off the ramp into the road in front of a home approximately a block from the facility. He had a hospital bracelet on that had the name of the facility and another bracelet on one of his legs (wander guard). After doing an assessment we helped him up, he was not talking, his blood pressure was pretty low. We stopped at the facility first.quickly ran inside and the staff did not know he was missing. The facility was able to pull up that he had medication around 9 a.m., the call went out about 10 a.m., so sometime in between he left the facility. He could have been missing from the facility for an hour and nobody would have noticed.During a review of Resident 1's Medication Administration Record (MAR),

the MAR indicated, Resident 1 was given medication at approximately 9 a.m. and that was the time the resident was last noted in the facility.During a review of Resident 1's Minimum Data Set (MDS) a standardized assessment tool used in nursing homes to evaluate residents' health and functional status, dated 7/15/25, the MDS indicated, a Brief Interview for Mental Status (BIMS) score of 5 on admission (Scores of 0-7: indicate severe cognitive impairment). During a review of Resident 1's Care Plan (CP), dated 7/8/25, the CP indicated, Resident is at risk for elopement, exit seeking/wandering related to communication deficits, difficult to redirect, exit seeking behaviors.During a review of Resident 1's Order Summary Report (OSR), dated 11/10/25, the OSR indicated, Resident 1 was to wear a Wander Guard, a wearable device that tracks movement and triggers automated security responses when a resident nears a restricted area.During a review of the facility's policy and procedure (P&P) titled, Unusual Occurrence Reporting, dated December 2007, the P&P indicated, As required by federal or state regulations, our facility reports unusual occurrences or other reportable events which affect the health, safety, or welfare of our residents, employees or visitors.

Event ID:

Facility ID:

If continuation sheet