Other·February 4, 2026

Code of Federal Regulations, Title 42, Section 483.25, Quality of Care (d) Accidents. The facility must ensure that- (1) The resident environment remains as free of accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. California Code of Regulations, Title 22, Section 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: (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. (C) Reviewing, evaluating and updating of the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient's condition. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. California Code of Regulations, Title 22, Section 72523, Patient Care Policies and Procedures (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. On 12/9/25 at 9:54 a.m., the California Department of Public Health (the Department) conducted an unannounced visit at the facility to investigate an entity reported incident regarding Patient 5's elopement (the act of leaving a facility unsupervised and without prior authorization) from the facility. The department determined the facility failed to prevent an elopement for one patient (Patient 5) of a census of 96, when Patient 5 was found by a family member walking down the street outside the facility and standing at a traffic light intersection. This failure decreased the facility's potential to maintain Patient 5's safety. A review of Patient 5's "Admission Record," indicated he was admitted to the facility in 2024 with diagnoses including moderate dementia (a decline in mental ability severe enough to interfere with daily life, involving memory loss and reasoning issues) with behavioral disturbance, post-traumatic stress disorder (PTSD-a mental health condition associated with experiencing an event that was traumatic, terrifying, or life-threatening), and difficulty in walking. The record further indicated Patient 5's spouse was his responsible party. A review of Patient 5's "Minimum Data Set (MDS - a federally mandated resident assessment tool)," dated 10/2/25, indicated Patient 5's Brief Interview for Mental Status (BIMS - an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score was four out of 15 with severe memory impairment. MDS further indicated a wander alarm device (a safety device designed to alert caregivers when an individual at risk of becoming lost or injured due to wandering) was not in use on Patient 5. A review of Patient 5's progress notes, dated 10/22/25 at 5:35 p.m., indicated Patient 5's family member notified a licensed nurse that she saw Patient 5 outside the facility walking down the street. The licensed nurse and an aide ran outside the facility to search for Patient 5. Patient 5 was found standing at the red light at an intersection and was escorted back to the facility. The facility's medical director was notified and a wander guard was placed on Patient 5's right foot. A review of Patient 5's "Care Plan Report," revised on 10/22/25, indicated Patient 5 had an episode of elopement on 10/22/25 and was at risk for elopement related to dementia, forgetfulness, and PTSD. A review of Patient 5's "Elopement and Wandering Risk Assessment," dated 4/7/25, indicated Patient 5 "... has exhibited unsafe wandering [and] has made one or more attempts to elope ... in the last year." The document further indicated a wander alarm was required for Patient 5. A review of the facility's "Order Summary Report," dated 4/8/25, indicated the facility's physician ordered a wander guard for Patient 5 due to "elopement risk." A review of Patient 5's nursing progress note, dated 4/19/25, indicated the wander guard order was discontinued and the device was removed. A review of Patient 5's "Care Plan Report," revised on 8/28/25, indicated Patient 5's elopement risk and need for a wander guard were resolved. During an interview on 12/9/25 at 1:56 p.m., the Director of Nursing (DON) stated on 10/22/25 Patient 5 left the premises until his family member spotted him on a road and alerted staff. During a concurrent interview and record review on 12/9/25 at 5:41 p.m. with the Administrator (ADM) and DON, Patient 5's care plan, elopement risk assessment, and MDS were reviewed. ADM and DON confirmed Patient 5 eloped from the facility on 10/22/25 and was at risk for elopement. DON stated Patient 5's care plan did not indicate the elopement risk between 8/28/25 and 10/22/25 and expected staff to prevent elopement incidents. ADM stated he did not know what time Patient 5 left the facility and for how long he was wandering outside the facility until a family member saw him. ADM and DON further stated Patient 5's elopement was a safety issue since he had dementia and PTSD which increased Patient 5's potential for injury if he fell or was hit by a vehicle. A review of the facility's policy and procedure (P&P) titled, "Wandering and Elopements," dated October 2024, indicated, "If identified as at risk for wandering or elopement, the resident's care plan will include strategies and interventions that will be provided to maintain the resident's safety." Therefore, the department determined the facility failed to prevent Patient 5's elopement. This failure decreased the facility's potential to maintain Patient 5's safety. This violation had a direct or immediate relationship to the health, safety, or security of Long Term Care patients or residents.