Health inspection·July 18, 2025

Health and Safety Code Section 1424 (c)(1) Class "AA" violations are violations that meet the criteria for a class "A" violation and that the department determines to have been a substantial factor in the death of a resident of a long-term health care facility. (d)(1): Class "A" violations are violations which the state department determines present either (1) imminent danger that death or serious harm to the patients or residents of the long-term health care facility would result therefrom, or (2) substantial probability that death or serious physical harm to patients or residents of the long-term health care facility would result therefrom. Title 42, Federal Code of Regulations, Section 483.25(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. Title 42, Federal Code of Regulations, Section 483.20(g) Accuracy of Assessments. The assessment must accurately reflect the residents' status. Title 42, Federal Code of Regulations, Section 483.21(b)(1) Develop/Implement Comprehensive Care Plan. The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at Section 483.10(c)(2) and Section 483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following - (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under Section 483.24, Section 483.25 or Section 483.40. Title 22, California Code of Regulations, Section 72311 (a)(3) Nursing service shall include, but not be limited to, the following: (3) Notifying the attending licensed healthcare practitioner acting within the scope of his or her professional licensure promptly of: (B) Any sudden and/or marked adverse change in signs, symptoms or behavior exhibited by a patient. Title 22, California Code of Regulations, Section 72523 (a) Written patient care policies and procedures shall be established and implemented to ensure that patient-related goals and facility objectives are achieved. Title 22, California Code of Regulations, Section 72313 (a)(2) -Nursing Service--Administration of Medications and Treatments. (a) Medications and treatments shall be administered as follows: (2) Medications and treatments shall be administered as prescribed. On 2/18/25, the California Department of Public Health (Department) made an unannounced visit to the facility to investigate a Facility Reported Incident (FRI) and a complaint about quality of care. The Department determined during its investigation that the facility failed to: 1. Provide adequate supervision to prevent elopement (an unauthorized departure of a patient from an around-the-clock care setting). 2. Accurately assess Resident 1, who had behavioral issues with history of elopement, for further risk of elopement. 3. Develop and implement a care plan for elopement. 4. Identify safety factors that might arise, based on Resident 1's behavioral issues and history of elopement, when facility placed the resident in a room (65C) close to a fire exit door that opens up /lead to a busy traffic street. These failures resulted in Resident 1 exiting the facility through a fire exit door on 2/14/25 between 5:30 a.m. and 5:35 a.m., into a busy main street, where he was struck by a moving vehicle. Resident 1 was transported to an acute care hospital, where he succumbed to injuries sustained and was pronounced dead approximately one hour later. Record review on 2/18/25 of Resident 1's face sheet indicated, Resident 1 was a 79 year old male, admitted to the facility on 8/2/24 with diagnoses including: Unspecified Dementia (memory loss, impaired thinking), Psychotic Disturbance (a mental health condition characterized by a loss of touch with reality), Mood Disturbance (prolonged periods of sadness, irritability, or extreme highs), and Anxiety (feeling of fear, dread, and uneasiness). A review of Resident 1's care plan dated 8/6/24, indicated the resident had anxiety manifested by aggressiveness or wandering/pacing agitated behavior, and poor impulse control. The care plan goals were to reduce anxiety and keep Resident 1 and others safe. The facility's interventions included providing reassurance, redirection or diversion, administering anti-anxiety medication as ordered, referring to psychiatrist for possible medication adjustment and reassessing and evaluating the appropriateness of his current psychotropic medication regimen. The updated care plan for Resident 1 initiated on 10/28/2024, indicated on 10/18/2024, Resident 1 struck another resident using an empty coffee cup. Interventions included instructions to keep the residents away from each other when in a common area. The care plan further indicated on 12/19/2024, Resident 1 had episodes of physical aggression related to dementia and poor impulse control and hit another resident. Interventions included: to analyze the time of day, place, circumstances, what triggers Resident 1's behavior (initiated 12/15/2024); monitor the resident for behaviors of aggressiveness and document the behavior (initiated 12/15/2024); intervene when the resident becomes agitated (initiated 12/15/2024);and resident was to receive one-to-one staff supervision, pending an interdisciplinary team (IDT) review (initiated 12/19/2024). A review of the "IDT" (Interdisciplinary team) notes dated 1/14/25, indicated the IDT met following an incident where Resident 1 grabbed a fellow resident by the jacket and pushed the resident against a wall. Interventions mentioned included referring Resident 1 for Psychiatric evaluation to review medications for possible adjustment. During an interview on 2/28/25 at 1:45 p.m., a Certified Nurse Assistant (CNA2), stated there was an incident on 1/10/25, where Resident 1 followed a visitor departing the facility and exited through the South Station main entrance door with the visitor. A review of Resident 1's psychiatric practitioner's (PP) progress notes dated 2/5/25, indicated "Resident was seen for ongoing episodes of physical striking out at other residents, resident is "secured" in the facility's south wing due to the risk of elopement, self-harm or the need for extensive supervision. The PP did not mention the elopement incident witnessed by CNA2 in January 2025. A review of Resident 1's elopement assessment dated 1/10/25, indicated the resident had no elopement risk. During an interview on 3/7/25 at 11:50 a.m., a Nurse Supervisor (NS 3), confirmed doing the elopement risk assessment of Resident 1 on 1/10/25, after Resident 1 exited the facility alongside a visitor. NS 3 verbally confirmed doing Resident 1's elopement assessment, but indicated not reviewing the resident's records, past evaluations, history and other pertinent information regarding elopement incidents which resulted in the assessment of no risk for elopement. Further review of Resident 1's clinical record indicated no rationale why Resident 1 was placed in Room 65, at the South Wing of the facility, which was noted to be a short distance from a fire exit door that /opens to a busy side street that leads to a busy main street. During a review of Resident 1's Medication Administration Record (MAR) dated 2/2025, from 2/12/25 and 2/13/25, from morning to evening shifts, approximately 33 episodes of psychological disturbance by Resident 1 were documented, including suspiciousness, restlessness, and anxiety. No pharmacological interventions were recorded during this period (2/12/25 to 2/13/25). Administrations of Lorazepam 0.5mg, ordered by Resident 1's physician to be administered as needed for anxiety, were not noted as administered or documented as administered. During an interview on 3/8/25 at 12:15 a.m., CNA1 stated, on 2/14/25 between the hours of 5:30 a.m. and 5:35 a.m., Resident 1 dashed out of Room 65, and headed towards the fire exit door, setting the alarm off and walked into a busy side street. CNA1 claimed to have followed the resident from behind but was not able to redirect Resident 1 back to the facility. CNA called for backup help from the facility and at the same time called for 911. Resident 1 continued walking on to a busy main street followed by CNA1 from behind, when without warning the resident walked straight to the middle of the busy street into the path of a moving vehicle. Resident 1 was directly hit/ struck down by the moving vehicle and got thrown into the middle of the street. This is when 911 and the law enforcement came, Resident 1 was then transported to a local hospital in full cardiac arrest after auto vs pedestrian trauma. Resident 1 was pronounced dead at the hospital's trauma bay at 6:40 am. During an interview on 3/12/25 at 2:50 p.m., a Licensed Nurse (LN 3), indicated on 1/2/25, Resident 1 was noted as being restless, and observed pacing back and forth. LN3 indicated that on1/6/25, Resident 1 experienced an episode where he was observed to be suspicious that someone will steal from him. During an interview on 3/12/25 at 3:05 p.m., LN 4 stated, on 1/4/25, Resident 1 was observed to have restlessness manifested by pacing back and forth. During an interview on 3/14/25 at 3:55 p.m. LN 5 indicated, on 2/12/25-2/13/25, during the 3pm to 11pm shift, LN5 observed Resident 1 repeatedly stating, "I want to go home, someone was out to get me". LN 5 indicated documenting the behavior in the Medication Administration Record (MAR) but did not report the behavior to the resident's attending physician. During an interview on 3/15/25 at 5:22 a.m., a Nursing Supervisor (NS 2), stated during the night shift (11 pm to 7 am) on 2/13/25, NS 2, with Charge Nurse (CN 1), entered a behavior monitoring observation for Resident 1 in the Medication Administration Record (MAR) dated 2/12 and 2/13 indicating Resident 1 was observed showing restless behavior manifested by pacing back and forth, and a belief that someone "will get him." During an interview on 3/15/25 at 4:15 p.m., LN 2 stated during her morning shifts (7 am to 3 pm) on 2/12/25 and 2/13/25, LN2 did not administer antianxiety medication to Resident 1 because it appeared Resident 1 had already calmed down. No nonpharmacological interventions were done, and the physician was not informed of the resident's restlessness, pacing back and forth, and suspicious thoughts of someone out to get him. Further review of the clinical record for Resident 1 indicated, no documentation that the attending physician or psychiatric practitioner (PP) were informed of the resident's escalation of behaviors on 2/12/25 and 2/13/25. On 3/18/25 at 1:00 p.m., the PP indicated receiving no calls from facility staff on 2/12/25 or 2/13/25 regarding Resident 1's escalation of behavior. The PP stated, "I could have ordered medication for the increased episodes in Resident 1's behavior." A review of the facility's P&P titled Elopement and Missing Resident dated 12/17 indicated, "It is policy to monitor and evaluate residents at risk for wandering and elopement. The Interdisciplinary Team (IDT) is responsible for identifying residents at risk for elopement, implementing preventative measures to reduce risk, and provide a process for action if an incident of elopement occurs..." A review of the facility's policy and procedure (P&P) titled "Resident Assessment", dated 2006, P&P under Care Plan Documentation Guidelines indicated, "Nursing service has the overall responsibility to coordinate care among all disciplines to achieve the established goals." A review of the facility's P&P titled Behavioral Health Services, dated 10/22, this indicated, "It is the policy of this facility to ensure all residents receive necessary behavioral health services to assist them in reaching and maintaining their highest level of mental and psychosocial functioning...." Review of the hospital's trauma progress notes dated 2/14/25, indicated ... Patient in full arrest after auto vs pedestrian trauma. Patient pronounced dead in trauma bay at 6:40 am. The facility failed to: 1. provide adequate supervision to prevent accidents, 2. accurately assess Resident 1's risk for elopement, 3. implement interventions for administration of anti-anxiety medications, 4. call the physician/practitioner for change in condition (increased agitation) to seek appropriate care intervention for Resident 1 and identify safety factors when the facility placed Resident 1 in a room (65C) close to a fire exit door that opens up /leads to a busy traffic street. As a result of these failures, Resident 1 run out of the facility through a fire exit door on 2/14/25 between 5:30 a.m. and 5:35 a.m., into a busy main street and was hit by a moving vehicle. Resident 1 was transported to an acute care hospital, where he was pronounced dead in approximately one hour. These violations presented imminent danger that death or serious harm would result or substantial probability that death or serious physical harm would result and was a substantial factor in the death of Resident 1.