Health inspection·December 15, 2025

Inspire Behavioral Health Provider Number: 05A277 Survey ID: 1D9B82-H1 Intake Number: 2653540 and 2652972 F689 §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. California Code of Regulations 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. (C) Reviewing, evaluating and updating 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. On 10/27/25, an unannounced visit was conducted at the facility for an annual federal recertification survey. During the survey an incident was reported to the state agency regarding Resident 48's elopement on 10/27/25. The facility failed to ensure the safety Resident 48 who was at risk for elopement (the unauthorized, unsupervised departure of a patient/resident from a healthcare facility when their condition puts them at risk of injury or death) and eloped from the facility when: The facility failed to provide appropriate and sufficient supervision to Resident 48, when Resident 48 who is deemed gravely disabled (legal term to describe a condition where a person, due to a mental health or substance use disorder, is unable to provide for their basic needs like food, clothing, or shelter) eloped from the locked facility on 10/27/25, when Houskeeper A (HA) failed to follow protocol of ensuring the location of her keys at all times. It was later identified Resident 48 had used HA's keys to exit the locked facility. Resident 48 remained missing until the afternoon of 10/30/25. These failures resulted in Resident 48 to be unaccounted for, causing the facility to fail in providing basic needs of food, medications, and shelter to Resident 48 for approximately three days. These failures had the potential for Resident 48 to be fatally injured, dehydrated (having lost a large amount of water from the body.), or withdraw from medications prescribed by his Physician causing medical and/or psychological deterioration (such as muscle stiffness, headache, dizziness, depression, anxiety, agitation or nausea) These failures required immediate correction to prevent similar occurrence of elopement due to inaccurate elopement risk assessments at the facility, and staff not accounting for their keys to the locked facility exit doors. On 10/28/25, at 5:40 p.m. an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified and declared, in the presence of the facility's Administrator and Director of Nursing related to the failure to provide adequate supervision, accurately assess Residents risk for elopement, and ensure facility staff kept their keys secured and accounted for at all times. On 10/31/25, at 4:17 p.m., the IJ was removed after the Administrator submitted an acceptable IJ Removal Plan (IJRP, a plan with interventions to immediately correct the deficient practices), and after the survey team verified and confirmed the corrective actions while onsite. Findings: 1. During an observation on 10/27/25 at 8:30 a.m., in Resident 48's room, Resident 48 was not present in his room. During an observation on 10/27/25 at 8:33 a.m., in Station 1 hallway, Resident 48 was not found in the hallway. Resident 62 who was in the hallway spoke loudly to no one in particular, "watch out everyone people are stealing keys around here". During an observation on 10/27/25 at 8:35 a.m., in Station 1 activity room, Resident 48 was not found in activity room. During a review of facility self-reported incident 2653540, dated 10/27/25, incident indicated, "At around 0710am, staff reported that [Resident 48] was not found in the facility during shift report. Per staff from noc [night] shift, [Resident 48] had his PRN [as needed] medication at around 5:30am and he was reassessed for the effectiveness of PRN medication at around 6:30am. During shift change report, staff were unable to find [Resident 48] Staff Initiated the search for resident in the facility and in the neighborhood... [Resident 48] is not found at this time". During a review of Resident 48's "Face sheet" (A face sheet is a summary document containing a Resident's personal and demographic information, including contact details and medical history) dated 10/27/25 indicated, Resident 48 had a diagnosis of "Schizoaffective Disorder, Bipolar Type" (a mental health condition that combines symptoms of schizophrenia and bipolar disorder, this condition is characterized by both psychotic symptoms (seeing things, hearing voices, disorganized thinking or speech) and mood swings (bipolar disorder) simultaneously.) since admission on 4/24/24. The Face sheet indicated, Resident 48 had a conservator (a person appointed by a court to manage the health care and financial affairs of an adult who is unable to do so themselves due to mental illness, dementia, or other incapacitating conditions) appointed to him. During a review of Resident 48's "Inpatient Psychiatry Admission Note" dated 4/5/24 indicated, "Pt [patient] is well known to [inpatient psychiatric facility] . . .given his history of non-compliance with medications in the community. However, when patient restabilizes on his medications and is attempted to be placed in a lower-level care, he often AWOLs [Absence without official leave: leaving without approval from the facility] and relapses on methamphetamines [a powerful, highly addictive synthetic stimulant drug that affects the central nervous system] and stops taking his medications. [Resident 48] again presents for hospitalization due to his aggressive and threatening behavior at his residence and is no longer welcomed back and is unable to care for himself". During a review of Resident 48's "Reappointment Letters for Conservatorship" dated 8/12/25 indicated, "Powers of the conservator for a gravely disabled person under chapter 3 (commencing with section 5350), part 1 division 5, of the welfare and institutions code...it is hereby ordered that the conservatee [Resident 48] is still gravely disabled person within the meaning of the law, and the petition for reappointment is granted". Signed by County Superior Court on 7/22/25. During an interview on 10/27/25, at 2:09 p.m., with Certified Nursing Assistant (CNA) I, CNA I stated, she was clocked in for work this morning around 7:07 a.m. and was assigned to be the high risk CNA (she is tasked with monitoring the residents designated as high risk, whether it be a fall risk, or behaviors, she monitors them during her shift). CNA I stated, she did her head count after clocking in and noticed Resident 48 was missing. CNA I stated, she normally sees Resident 48 walking in the hallways in the morning, she then checked the bathroom, phone booth and showers and did not see Resident 48. CNA I stated she then notified the nurse who called the sheriff. CNA I stated, she heard one of the housekeepers lost her keys this morning. During a review of the Facility's head count sheet dated 10/27/25, sheet indicated staff wrote "HW [hallway]" for end of shift at 7:00 am, indicating Resident 48 was seen in the hallway around 7:00am from the NOC shift CNA. Facility head count sheet indicated, next shift CNA, CNA I charted at 7:00 am "AWOL" for Resident 48, indicating he was missing, signed by CNA I. During an interview on 10/27/25, at 2:17p.m., with the Director of Nursing (DON), the DON stated, "During our initial investigation it was reported to the housekeeping supervisor this morning that the AM housekeeper lost her keys". The DON stated housekeeper (Housekeeper A, HA) was suspended pending the investigation. During an interview on 10/27/25, at 3:35 p.m., the facility Administrator (ADM) stated, around 7:30 a.m., this morning she got a call that Resident 48 was missing. The ADM stated, she instructed staff to search for the nearby area around 8:30 a.m., and was informed staff came back and could not find Resident 48. The ADM also stated, she was also notified at the same time by the housekeeping supervisor (HS) that HA lost her keys. The ADM stated, her protocol for lost keys depends on where the staff loses the key, if they lost the key in the locked area, they are supposed to start a room-to-room search. ADM stated another resident (Resident 62) reported they saw Resident 48 with a set of keys. The ADM stated the missing keys were found outside the Station 1 exit door near the dining room shortly after. The ADM also stated that the housekeepers have lanyards on their keys, and it may have been possible the lanyard was hanging outside her apron and Resident 48 was able to grab it and take the keys. During an interview on 10/27/25, at 4:00 p.m., with the Program Director (PD), the PD stated, she spoke to HA at around 6:15 a.m., this morning. The PD stated, HA last remembered using her keys to open the middle classroom and she was cleaning the phone booth around 7:00 a.m. she was keeping her keys in her apron that morning and realized they were missing. The PD further stated, HA told her she reported to her supervisor (HS) around 6:50-7:00 a.m. that the keys were missing. The PD stated, HA was approached by Resident 48 earlier that morning around 5:40 a.m., when Resident 48 asked HA if her supervisor was going to be here today. The PD stated HA and Resident 48 had no other interactions according to HA. During an interview on 10/27/25, at 4:15 p.m., with the Housekeeping Supervisor (HS) HS stated, she was called around 7:05 a.m this morning by HA who stated she had lost her keys. The HS stated, HA told her she was cleaning, and she had put her keys in her front apron pocket, and she reached in to grab it, and could not find it. The HS stated, HA reported to her that Resident 48 came up to her early in the morning and asked her if HS was working today, and that is the only interaction they had. HS stated, it is her expectation that the housekeepers would keep the keys around their necks and know where the keys are at all times. The HS stated she had to write up the HA for her behavior two times in the past, when she had left open a door to the laundry room leading outside the facility. The HS further stated she gave the HA a warning the first time, then the second time she was found to leave the door open she was suspended for a period of time. During an interview on 10/27/25, at 4:40 p.m., with CNA J, CNA J stated she last saw Resident 48 this morning around 6:30 a.m., walking in the hallway. During an interview on 10/27/25, at 5:05 p.m. with Resident 62, in Residents room. Resident 62 stated he saw Resident 48 with a set of keys that were not his. Resident 62 stated the keys had a black string on them, and he saw Resident 48 put them in his pocket and walk toward the dining room. Resident 62 stated he did not see where Resident 48 got the keys, but he was standing next to the phone room leaning against the wall. During a review of Resident 62's Brief Interview for Mental Status (BIMS- a standardized cognitive screening tool used primarily in long-term care facilities to assess a resident's cognitive function) dated 7/31/25, indicated a score of 14. A score of 13-15 indicates being cognitively intact. During an interview on 10/27/25, at 7:00p.m., with CNA K, CNA K stated he was the CNA for the NOC shift prior to when Resident 48 went missing. CNA K stated he last saw Resident 48 around 6:30 in the hallway. During a review of Resident 48's care plan dated 8/9/25, care plan indicated, "Resident is an elopement risk AEB [as evidenced by] resident may leave the facility without permission. Noted with a long history of AWOL from previous placements and substance abuse...". The care plan had a goal, "Resident will have 0 (zero) episode of attempting AWOL q (every) day". It included interventions such as: "Resident will be redirected away from the exit doors when observed standing by the exit doors, Nursing or Program staff will observe for exit seeking behaviors, if observed res (resident) to placed on high risk monitoring and counselling". During a review of Resident 48's "Psychiatrist Progress Note" dated 8/23/25 indicated, "Staff reports 8/21/25 patient attempted to elope from the facility by following staff an [sic] pushing past them through station exit door to main lobby. . .Patient was seen by me for evaluation. . .Continue treatment plan". Signed by Medical Doctor (MD) L. During an interview on 10/29/25 at 3:56 p.m., with the Medical Director (MD), the MD stated, it is his expectation that the facility staff supervise all residents in order to prevent elopements. The MD stated staff are taught to be cautious. During an interview on 10/30/25, at 3:19 p.m., with the Conservator (CON), he stated he was the appointed conservator for Resident 48 who makes decisions on his behalf. The CON stated, he was concerned that Resident 48 was missing for so long, because he is considered gravely disabled and he cannot provide food or safety for himself. During an interview on 10/30/25 at 9:44 a.m., with MD L, MD L stated, he is Resident 48's psychiatrist and manages his psychiatric medications. MD L stated it is his expectation that staff supervise the residents in order to prevent elopements from the facility. During a review of Resident 48's Physician Orders dated active on 10/27/25, orders indicated Resident 48 was ordered Divalproex Sodium (a medication used to treat manic phases of bipolar disorder) DR (delayed release) 250 mg. give three tablets by mouth two times per day, Lorazepam (a drug of the benzodiazepine group, used especially to treat anxiety) two mg. 1 tablet by mouth two times a day for agitation, and Zyprexa (atypical antipsychotic medication primarily used to treat schizophrenia and bipolar disorder) 20 mg. q HS (every bedtime), Propranolol HCL (hydrochloride, medication to lower blood pressure) 10 mg 1 tablet by mouth two times a day, hold if BP (blood pressure) < (below) 100/60, PR (pulse rate) < 60". During a review of "Medication Guide" for Divalproex Sodium by the National Institute for Health (NIH), dated 2022, guide indicated, "Do not stop taking Depakote [divalproex sodium] without first talking to your healthcare provider. Stopping Depakote suddenly can cause serious problems [such as anxiety, nausea, vomiting, irritability, depression and insomnia]". During a review of "Medication Guide" for Zyprexa by the National Institute for Health (NIH), dated 2009, guide indicated, "To prevent serious side effects [such as headaches, nausea, brain zaps [electrical like pain sensation] anxiety, mood swings], do not stop taking ZYPREXA suddenly. If you need to stop taking ZYPREXA, your doctor can tell you how to safely stop taking it". During a review of "Medication Guide" for Lorazepam by the National Institute for Health (NIH), dated 2024, guide indicated, "Withdrawal symptoms [such as cramping, anxiety, dizziness, depression, panic attacks, vomiting, weight loss, ringing of the ears] if abruptly discontinued after long-term use". During a review of "5 day Follow up" dated 10/31/25 indicated, Resident 48 was found on 10/30/25 at a family members home. Document indicated, "Upon investigation, it is determined that [Resident 48] took away