Santa Fe Post-acute

cognitive (pertaining to memory, judgement and reasoning ability) deficits. On 8/20/25 11:47 A.M., an

[DATE] did not specify if Resident 3 had a pressure ulcer because it was un-marked and noted as an

had not seen Resident 3 the following day (8/2/25). LN 1 stated the wound NP's first visit with Resident 3 was on 8/18/25 (17 days after Resident 3's admission) and observed Resident 3's R hip wound as a stage III pressure ulcer with measurements of 1.4cm (length)x 1cm (width)x0.2cm (depth).

LN 1 stated it was important to stage pressure ulcers on admission and get wound measurements to prevent the delay of necessary treatments that could cause harm (increased size, infection, delayed in healing) if not treated immediately.On 8/20/25 at 1:19 P.M., an interview and observation was conducted with Resident 3, in Resident 3's room. Resident 3 stated he had a (R) hip pressure ulcer prior to admission to the facility in the hospital and did not get the pressure ulcer at the facility. Resident 3 was sitting in his wheelchair and showed his R hip wound dressing. Resident 3 did not have a specialty pressure relieving device on his bed and had below the knee amputations to both legs. Resident 2 stated he was not turned while in bed by the nursing staff.A record review of Resident 3's MDS was conducted.

The MDS dated [DATE] Section GG indicated, Resident 3 required partial/moderate assistance to roll left and right (Helper does less than half the effort.

Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort).On 8/22/25 at 5:54 P.M., an interview and record review was conducted with LN 3. LN 3 stated she was the admission nurse that conducted Resident 3's initial admission assessment on 8/1/25. LN 3 stated that she was told in the past (LN 3 worked at facility for over 10 years) not to stage pressure ulcers because the wound NP did the staging of pressure ulcers for new admissions. LN 3 stated she was a Registered Nurse (RN) and was responsible for conducting skin assessments with new residents who were admitted . LN 3 stated she noted Resident 2's R hip as an open wound and described it but was unable to confirm if it was a stage III pressure ulcer. LN 3 stated Resident 3 is at high risk for poor wound healing because of his history of DM which affected his circulation to cause problems with wound healing. LN 3 stated the wound NP assessed Resident 3's (R) hip stage III pressure ulcer late on 8/18/25 and was unsure why the wound NP assessed Resident 3's pressure ulcer late.On 8/26/25 at 11 A.M., an interview was conducted with the Director of Nursing (DON).

The DON stated her expectations were for the LN's conducting the initial admission skin assessments to be completed by an RN accurately as to prevent pressure ulcers and to prevent a delay of care.

The DON stated it was important for the admission LN's to check hospital orders for wound treatments and if there are no orders, to contact the wound NP.

The DON stated residents with pressure ulcers should be assessed properly upon admission to avoid a delay in necessary treatments, worsening of the wounds and possible infections.A review of the facility's policy and procedure titled, Pressure Ulcers/Skin Breakdown - Clinical Protocol revised April 2018, indicated .The staff and practitioner will examine the skin of newly admitted residents for evidence of existing pressure ulcers or other skin conditions

555723 09/04/2025

Santa Fe Post-Acute 247 E.

Bobier Drive Vista, CA 92084

prevent accidents.

observation, interview, and record review, the facility failed to provide adequate supervision and

three sampled residents (Resident 1) reviewed during a complaint investigation.This deficient practice placed Resident 1 at risk for serious injury, harm or death due to unsafe wandering, potential exposure to traffic-related injuries, falls, or becoming lost in the community.

Findings:A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses which included a history of non-traumatic intracerebral hemorrhage (a type of stroke [brain attack] where bleeding occurs within the brain's tissue not caused by head injury).A record review of Resident 1's minimum data set (MDS - a federally mandated resident assessment tool) dated 8/8/25 indicated, a Brief Interview for Mental Status (BIMS- developed by reviewing the resident's status during the prior seven-day period) score of three points out of 15 possible points which indicated Resident 1 had severe cognitive (pertaining to memory, judgement and reasoning ability) deficits. On 8/19/25 at 2:10 P.M., an interview was conducted with Resident 1, in Resident 1's room. Resident 1 stated he left the facility alone just recently but unable to remember the date and stated he walked up and down the street to go to the store but had no money. Resident 1 stated a male staff that he did not remember followed him and brought him back to the facility.On 8/20/25 at 4:17 P.M., an interview and record review was conducted with the Social Service Assistant (SSA).

The SSA stated that the former Social Service Director (SSD) had told her that Resident 1 was trying to go to a restaurant to get something to eat.

The SSA stated they did not report Resident 1's elopement incident to law enforcement, ombudsman and California Department of Public Health (CDPH) because Resident 1 did not disappear.

The SSA stated the Mental Health Worker (MHW) had followed Resident 1 out of the facility then brought Resident 1 back to the facility.On 8/20/25 4:59 P.M., an interview was conducted with the MHW.

The MHW stated he was on break at [Fast-Food Place Name] when he saw Resident 1 wandering the area alone.

The MHW stated he did not see any staff members following Resident 1 and Resident 1 was unsupervised at the time of the incident.

The MHW stated when he tried to catch up to Resident 1 he tried to grab Resident 1 but he had already crossed the street.

The MHW stated Resident 1 could have gotten hit by ongoing traffic.

The MHW stated once he caught up to Resident 1 on the other side of the street he had called the facility to notify them of the incident. On 8/22/25 at 11:53 A.M., an interview was conducted with Certified Nursing Assistant (CNA) 2. CNA 2 stated Resident 1 was assigned to her the day of the elopement incident (8/3/25). CNA 2 stated she last saw Resident 1 at around 9AM in the facility patio eating breakfast. CNA 2 stated she went on break at 10AM and heard about the incident after her lunch break. CNA 2 stated she was informed that Resident 1 had eloped and that MHW brought Resident 1 back to the facility.On 8/26/25 10:26 A.M., an interview was conducted with the Director of Nursing (DON).

The DON stated Resident 1 did not have an out of facility pass due to his cognitive capacity with brain trauma to be unsupervised and leave the facility.

The DON stated Resident 1 was vulnerable to injuries during the elopement episode which could have impacted the welfare, safety, and well being of Resident 1.

The DON stated her expectation was for the facility to report Resident's 1's elopement episode to the proper entities (law enforcement, ombudsman and CDPH) because this exposed Resident 1's safety to ongoing traffic accidents and injuries during the elopement episode.A review of the facility's policy and procedure titled, Unusual Occurrence Reporting (undated), 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 .Unusual occurrences shall be reported via telephone to appropriate agencies as required by current law and/or regulations within twenty-four (24) hours of such incident or as otherwise required by federal and state regulations.