Health inspection·May 1, 2025

The following reflects the findings of the California Department of Public Health during the investigation of a Facility Reported Event #: CA00946270. Survey Event ID: XB3P11. Representing the Department, HFEN # 50146. State Citation B was written. F 689 Free of Accidents Hazards/Supervision/Devices §483.25(d) Accidents. The facility must ensure that - §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents. Title 22 72311 Nursing Service - General (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. (B) Development of an individual, written patient care plan which indicates the care to be given, the objectives to be accomplished and the professional discipline responsible for each element of care. Objectives shall be measurable and time limited. On 2/13/25 at 9:00 a.m., the California Department of Public Health conducted an unannounced visit at the facility to investigate a facility reported event regarding an elopement by Resident 1. The facility failed to ensure residents received one-to-one supervision to prevent accidents for four of four sampled residents (Residents 1, 6, 8, and 9). Resident 1 was roomed within nine feet from an exit door with no one-to-one supervision, Residents 6 and 8 were roomed within 18 feet of an exit door with no one-to-one supervision, and Resident 9 was roomed within nine feet of an exit door with no one-to-one supervision. This failure resulted in Resident 1 leaving the facility and becoming a missing person who has not been located by police, and placed Residents 6, 8, and 9 at risk of leaving the facility, at risk for wandering into oncoming traffic, and at risk of being struck by oncoming traffic. It was determined to constitute an Immediate Jeopardy (IJ) situation. An Immediate Jeopardy situation (IJ, a situation in which a facility's actions places one or more residents/patients in jeopardy of being significantly harmed up to the point of possible death if not immediately corrected) was identified and called due to the failure of the facility to provide one-to-one supervision for Residents 1, 6, 8, and 9 who were at risk of elopement (leaving a facility without staff or responsible parties being aware). The Director of Nursing (DON) was verbally notified of the IJ situation on 02/13/2025 at 5:25 p.m. The facility submitted an acceptable removal plan for the IJ, which was verified through observation, interview, and record review. The IJ was lifted on 02/19/2025 at 1:20 p.m. As of this time, Resident 1 has not been located and remains a missing person. Findings: A review of Resident 1's Face Sheet (a document used to communicate basic information about a resident), undated, indicated Resident 1 was admitted to the facility in October 2024 with unspecified dementia (a loss of brain function that occurs with certain diseases, affecting one or more brain functions such as memory, thinking, language, judgment, or behavior.) A review of the document titled "Internal Medicine History & Physical," dated 8/22/24 at 7:27 p.m., indicated Resident 1 had a prior medical history of "dementia (unclear etiology, suspect severe)" who had previously been "missing for the past 2 years" and had been reported as a missing person. Resident 1 also "was seen in the ED (Emergency Department) on 08/05/2024 for altered mental status but eloped...." A review of Resident 1's "Minimum Data Set" (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan), dated 01/23/25, indicated Resident 1 had a score of 12 on the "Brief Interview for Mental Status" (BIMS, a scoring system used to determine the resident's cognitive status in regard to attention, orientation, and ability to register and recall information. A BIMS score of eight to twelve indicates moderate impairment in cognition.) The MDS further indicated Resident 1 was independently able to walk up to 150 feet with no impairment or need for supervision. A review of the document titled "Wander-Elopement Risk Evaluation," dated 1/21/25, indicated Resident 1 had two out of five assessed risk factors present for elopement. The document indicated that Resident 1 was not an elopement risk, and "if answered 'Yes' to any of questions 1-5 and resident is evaluated NOT at risk for wandering/elopement, check reasons that apply below." The document did not have any reasoning checked in the area below. A review of Resident 6's "Face Sheet," undated, indicated Resident 6 admitted to the facility in October 2024 with dementia. A review of Resident 6's "MDS," dated 1/20/25, indicated Resident 6 had a BIMS score of seven and was able to walk up to 50 feet with no assistance or supervision. A review of Resident 8's "Face Sheet," undated, indicated Resident 8 admitted to the facility in November 2024 with schizophrenia (a mental condition which makes it difficult to think clearly, have normal emotional responses, act normally in social situations, and tell the difference between what is real and what is not real). A review of the document titled "Wander-Elopement Risk Evaluation," dated 11/21/24, indicated Resident 8 had three of five assessed risk factors present for elopement. A review of Resident 8's "MDS," dated 11/28/24, indicated Resident 8 had a BIMS score of twelve and was able to walk 150 feet with no assistance or supervision. A review of Resident 9's "Face Sheet," undated, indicated Resident 9 was admitted to the facility in October 2024 with dementia. A review of Resident 9's "Wander-Elopement Risk Evaluation," dated 1/20/25, indicated Resident 9 had two out of five assessed risk factors present for elopement. A review of Resident 9'ss "MDS," dated 1/31/25, indicated Resident 9 had a BIMS score of seven. The MDS indicated Resident 9 needed supervision or touching assistance when using a wheelchair. During an interview on 02/13/25 at 09:50 a.m. with the Certified Nursing Assistant (CNA 1), CNA 1 stated Resident 1 was able to walk independently and normally wandered around the facility every day. CNA 1 stated Resident 1 was roomed at the end of the hallway in room [room number], next to an exit door which led directly to a public sidewalk and street. The exit door was measured to be approximately 100 inches, or eight feet and eight inches, away from Resident 1's room. During an observation on 02/13/25 at 09:55 a.m., the exit door next to room [room number] was observed to be unlocked and able to be opened. No staff were observed monitoring the exit door. A review of the document titled " [Resident 1] Initial Change of Condition/SBAR", dated 02/09/25 and written by LVN 2, indicated "Resident [1] unable to find in the building...made rounds @ 1500...called DON...police called speaked with [badge number] to file a report for missing patient." During an interview on 02/13/25 at 12:30 p.m. with the Licensed Vocational Nurse (LVN 1), LVN 1 stated he assessed Resident 1 for elopement risk. LVN stated elopement risk for residents is determined using the "Wander-Elopement Risk Evaluation" form to assess elopement risk for residents. LVN 1 verified the "Wander-Elopement Risk Evaluation" form for Resident 1 was not completed. LVN 1 stated Resident 1 should have been a "high elopement risk" based on Resident 1's history of elopement prior to admission and Resident 1's prior missing person status. During an interview on 02/13/25 at 1:47 p.m. with the Director of Nursing (DON), DON stated room placement can contribute to elopement risk, and elopement risk residents should not be roomed near exit doors. DON stated Resident 1 did not receive any one-to-one (1:1) monitoring during his time at the facility and was not evaluated for placement in a different room. The DON was unable to state if Resident 1 required 1:1 monitoring or should have received. The DON was unable to state why Resident 1 was roomed near an exit door or why Resident 1 was not moved away from the exit door. DON also stated that Resident 9 was able to independently wheel herself around the facility. The DON declined to answer whether or not the Wander-Elopement Risk Evaluation forms for Residents 1, 6, 8, and 9 were filled out completely and accurately, and abruptly ended the interview. During an observation on 02/13/25 at 5:35 p.m., Residents 6 and 8 were observed in their bedroom, [room number], which was approximately 17 feet and 11 inches from an exit door that led directly to a public sidewalk and street. During an observation on 02/13/25 at 5:38 p.m., Resident 9's room was observed to be approximately eight feet and 8 inches from an exit door that led directly to a public sidewalk and street. A review of the facility's policy and procedure (P&P) titled "Policy and Procedures on Elopement," dated 10/14/19, indicated "2. Residents who are assessed and evaluated to be at high risk for wandering/elopement will be provided 1:1 monitoring, and Social Services Designee will evaluate resident within 72 hours for appropriate placement." The facility failed to supervise Resident 1 resulting in Resident 1 leaving the facility and becoming a missing person who has not been located by police, and placed Residents 6, 8, and 9 at risk of leaving the facility, at risk for wandering into oncoming traffic, and at risk of being struck by oncoming traffic. This violation had a direct or immediate relationship to the health, safety, or security of patients or residents.