Forest Hill Manor Health Center

F 0689 Level of Harm - Actual harm Residents Affected - Few

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

8 a.m. to 2 p.m.,6/18/25 from 4 p.m. to 11 p.m., 6/19/25 and 6/20/25 from 4 p.m. to 11 p.m., 6/21/25 from 7 a.m. to 11 p.m., 6/23/25 from midnight to 7 a.m., 6/24/25 from 1 p.m. to 11 p.m., 6/25/25 from 4 p.m. to 11 p.m., and 6/26/25 from 4 p.m. to 11 p.m. with no explanation for no documentation. Also, the fall monitoring log dated 6/27/25 during the times Resident 1 was missing from 5 p.m. to 11 p.m., indicated Resident 1 was monitored for falls in the facility.During an interview on 9/3/26 at 2:40 p.m., the DON who reviewed the monitoring log acknowledged the monitoring entries were not complete.During an interview on 9/18/25 at 3:10 p.m., the certified nurse assistant (CNA) confirmed he initialed Resident 1's Monitoring Log on 6/27/25 from 4 p.m. to 11 p.m. The CNA stated Resident 1 was missing and he made a mistake in documentation in

the fall monitoring log.During an interview on 9/25/25 at 11:07 a.m. the DON stated the facility did not have

a wander guard (system with bracelets and sensors at doorway and a central platform that sends alerts to staff when a person approached a restricted area) and no alarm system.During an interview on 10/1/25 at 3:15 p.m., the social services director (SSD) stated Resident 1 had a sitter paid by the family on 6/6/25 from 7 a.m. to 7 p.m. The sitter service was discontinued on 6/10/25 after she discussed with a family member the resident did not need a sitter.Review of the Pacific Grove Police Department (PGPD) report, dated 6/27/25 at 9:29 p.m., indicated the California Highway Patrol activated a Silver Alert (pubic notification issued by law enforcement for a missing adult who is 65 or older and is considered at risk of harm due to their condition or the circumstance of their disappearance) for Resident 1 within a 3-mile radius of the area, a missing person flyer was posted on the PGPD's social media accounts for citizens to be on the lookout and volunteers were prompted to respond and conduct a systemized search for the resident. It indicated on 6/28/2025, at approximately 3:44 p.m., dispatch advised officers that a citizen reported that they located Resident 1. Resident 1 was not in a clear state of mind, the resident was talking and pointing about a dog but there was no dog in sight and when asked if she slept she stated Yes.Review of Resident 1's acute hospital emergency department (ED) note, dated 6/28/25 at 8:39 p.m., indicated the patient had multiple bodily scratches/abrasions including a gaping scalp wound requiring repair and possible fall and was likely out all night. It indicated a [NAME] (medical device used to raise a person's body temperature) was started given significant hypothermia. The ED Clinical Impressions included altered mental status, hypothermia, rhabdomyolysis (breakdown of muscle tissue that releases a damaging protein into the blood), forehead laceration and urinary tract infection.Review of the Care Planning Interdisciplinary Team (IDT, members of the health team who meet to discuss and plan residents' care) policy, revised September 2013, indicated the IDT was responsible for the development of an individualized comprehensive care plan for each resident.Review of the Wandering and Elopements policy, revised March 2019, did not address preventative measures to prevent elopement.During an interview on 9/3/25 at 1:51 p.m., the DON who provided the elopement policy stated policy addressed preventative measures.

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