Rosewood Post Acute

During a review of Resident 1's Departmental Notes indicated that the resident was discovered missing on 5/25/26 at approximately 5:00 a.m. and was later located at the 7-Eleven store across the street from the nursing home at 5:30 a.m.

During an interview on 5/28/26 at 1:44 p.m. with Registered Nurse (RN) 1, RN1 stated on 5/25/26 at 5:00 a.m., the facility staff was unaware that the resident had left the building and explained that the front lobby door automatically allowed anyone inside to exit. RN1 also added, the resident was found at 5:30 a.m. by Certified Nursing Assistant (CNA 1) in the 7-eleven store across the street and when he assessed the resident, the resident had a left knee skin laceration and was unable to explain how he obtained the laceration.A review of Resident 1's Face sheet indicated that the resident was admitted to the facility on [DATE] with diagnoses that included cerebral infarction, muscle weakness and cognitive communication deficit (cerebral infarction is medical term for stroke meaning when blood flow to the brain is stopped causing brain injury, cognitive communication deficit means someone struggles to communicate effectively, because their brain has trouble processing or organizing information. It affects a person's ability to pay attention, remember details, reason, and understand social cues).During a review of Resident 1's MDS (an assessment tool) dated 5/8/26 under Section C, it indicated Resident 1's cognition was severely impaired.

During an interview on 5/28/26 at 4:07 p.m. with the Director of Nursing (DON), the DON stated that Resident 1's elopement incident should have been reported to the department.

During an interview on 5/28/26 at 4:43 p.m. with the Administrator (Adm), ADM stated Resident 1 eloped on 5/25/26 and stated the incident of elopement was not reported to the department.During a review of the facility's policy and procedure (P&P) titled, Accidents and incidents investigating and reporting, dated 2001, the P&P indicated, Policy Statement: All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the Administrator.S483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures.

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 TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE

056476 05/28/2026

Rosewood Post Acute 1911 Oak Park Boulevard Pleasant Hill, CA 94523