Health inspection·December 23, 2025

Health and Safety Code Section 1424 (d): 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, Subdivision (d) Quality of care is a fundamental principle that applies to all treatment and care provided to facility patients. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices, including but not limited to the following: (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. 22 Cal. Code Reg., §72523. Patient Care Policies and Procedures. (a)Written patient care policies and procedures shall be implemented to ensure that patient-related goals and facility objectives are achieved. §483.21(b) Comprehensive Care Plans §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §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 §483.24, §483.25 or §483.40; 22 Cal. Code Reg., §72311 - Nursing Service General Requirements. (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. (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. On 9/25/25 at 12:50 p.m. an unannounced visit was conducted at the facility to investigate a complaint regarding a resident elopement. During the investigation the Department determined the facility failed to: 1. Provide adequate supervision when a resident (Resident 1) with dementia left the facility and was found approximately a block from the facility without knowledge of facility staff. 2. Implement their policy and procedure, "Emergency Procedure - Missing Resident," dated August 2018, which indicated, "Residents at risk for wandering and/or elopement will be monitored, and staff will take necessary precautions to ensure their safety." 3. Implement Resident 1's Care Plan for the intervention," Allow wandering in safe areas within the facility". As a result, Resident 1 was found alone lying near the road approximately one block away from the facility. Resident 1 was brought back to the facility by the fire department. This deficient practice put Resident 1 at risk of harm and injuries due to potential falls, accidents, and/or being struck by motor vehicles. During a review of Resident 1's "Interdisciplinary Team (IDT)," meeting notes dated 9/23/25, the "IDT" meeting notes indicated, Resident 1 was a 65-year-old male patient admitted to the facility on 7/8/25 with the following diagnoses: Cerebral Infarction due to Embolism (a condition where a blood clot travels to the brain and blocks a blood vessel, causing brain tissue to die), Encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition), Lack of Coordination, Difficulty in Walking, Cognitive Communication Deficit (a group of disorders that affect a person's ability to understand, use, and produce language due to underlying cognitive impairments), Weakness, Dementia (progressive or persistent loss of intellectual functioning, impairment of memory and abstract thinking, and often with personality change), Anxiety Disorder (excessive and persistent worry, fear, and nervousness). Resident 1 had episodes of being coherent at times with intermittent forgetfulness and confusion. Resident 1 ambulates unsteadily due to problems with gait and balance and most of the time would grab or hold on to the wood bars installed in the facility. During a review of Resident 1's Minimum Data Set (MDS) a standardized assessment tool used in nursing homes to evaluate residents' health and functional status, dated 7/15/25, the MDS indicated, a Brief Interview for Mental Status (BIMS) score of 5 on admission (Scores of 0-7 indicate severe cognitive impairment). During a review of Resident 1's "Care Plan (CP)," dated 7/8/25, the "CP" indicated, "Resident is at risk for elopement, exit seeking/wandering related to communication deficits, difficult to redirect, exit seeking behaviors. Interventions included, Administer medications as ordered, monitor for side effects, Allow wandering in safe areas within the facility, Approach in calm, non-threatening manner, and Check placement of wander alarm every shift." During a review of Resident 1's "Order Summary Report (OSR)," dated 11/10/25, the "OSR" indicated, Resident 1 was to wear a Wander Guard, a wearable device that tracks movement and triggers automated security responses when a resident nears a restricted area. During a review of the facility's policy and procedures (P&P) titled, "Emergency Procedure - Missing Resident," dated August 2018, the P&P indicated, Policy Interpretation and Implementation 1. Residents at risk for wandering and/or elopement will be monitored, and staff will take necessary precautions to ensure their safety." During an interview on 9/25/25 at 1 p.m. with the Director of Nursing (DON), the DON stated, "We didn't realize Resident 1 was missing until the fire department brought him back. He wasn't gone from the facility that long, so we didn't think reporting to CDPH was necessary." During an interview on 9/25/25 at 1:30 pm. with Certified Nursing Assistant (CNA 2), CNA 2 verbalized, heard the wander guard alarm sound, checked the back door of the facility, did not see any residents, assumed it was a false alarm. CNA 2 was not aware a resident was missing until the fire department arrived with the resident. During an interview on 10/8/25 at 8 a.m. with the Ventura County Fire Captain (FC), the FC stated, "When we arrived on scene there was a gentleman lying just off the ramp into the road in front of a home approximately a block from the facility. He had a hospital bracelet on that had the name of the facility and another bracelet on one of his legs (wander guard). After doing an assessment we helped him up, he was not talking, his blood pressure was pretty low. We stopped at the facility first...quickly ran inside and the staff did not know he was missing. The facility was able to pull up that he had medication around 9 a.m., the call went out about 10 a.m., so sometime in between he left the facility. He could have been missing from the facility for an hour and nobody would have noticed." In summary, the facility failed to: 1. Provide adequate supervision when a resident (Resident 1) with dementia left the facility and was found approximately a block from the facility without knowledge of facility staff. 2. Implement their policy and procedure, "Emergency Procedure - Missing Resident," dated August 2018, which indicated, "Residents at risk for wandering and/or elopement will be monitored, and staff will take necessary precautions to ensure their safety." 3. Implement Resident 1's Care Plan for the intervention," Allow wandering in safe areas within the facility". As a result, Resident 1 was found alone lying near the road approximately one block away from the facility. Resident 1 was brought back to the facility by the fire department. This deficient practice put Resident 1 at risk of harm and injuries due to potential falls, accidents, and/or being struck by motor vehicles. This violation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result therefrom.