Other·May 7, 2025

REGULATORY VIOLATIONS: Title 42 Code of Federal Regulations §483.25(d) Accidents. The facility must ensure that - (1) The resident environment remains as free of accident hazards as is possible; (2) Each resident receives adequate supervision and assistance devices to prevent accidents. Title 22 Code of California Regulations §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: ... (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. Title 22 Code of California Regulations§ 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 3/27/25, an unannounced visit was conducted at the facility to investigate regarding Quality of Care/Treatment. The facility failed to provide supervision for Resident 1 who was at risk for leaving (elopement) when Resident 1 went out of the facility premises without the facility's authorization on 3/25/25. This failure resulted in Resident 1 leaving the facility unattended and Resident 1 being found by a bystander face down and unresponsive at a bus stop. The bystander called 911 (universal emergency number) and EMS (Emergency Medical Services, a system that provides emergency medical care) responded and resuscitated Resident 1. Resident 1 was transferred to an acute care hospital where Resident 1 expired on 3/25/25. FINDINGS: Review of Resident 1's admission record indicated he was an elderly resident admitted to the facility on 10/18/24 with diagnoses including disorder of bone density and structure (occurs when bones become weak and brittle due to loss of bone mass), low back pain, bilateral primary osteoarthritis (breakdown of cartilage in the joints leading to pain, stiffness and reduced mobility) of hip, and generalized muscle weakness. Review of Resident 1's Minimum Data Set (MDS, an assessment tool) Section GG Functional Abilities, dated 10/24/24, indicated Resident 1 needed supervision or touching assistance to walk 150 feet once standing, and as well as to walk at least 150 feet in a corridor or similar space. Review of Resident 1's initial Elopement Evaluation, dated 10/19/24, did not indicate risk level for elopement. Review of Resident 1's Activity Care Plan, dated 11/13/24, indicated Resident 1 enjoyed independent activity such as walking around the facility or patio. The care plan further indicated interventions which included that it was important for Resident 1 to go outside when the weather was good, sit down and relax. The care plan also indicated that Resident 1 liked to use his walker to go around the building and sit at the patio. Review of Resident 1's Nursing Alert Note, dated 11/13/24, indicated "Resident 1 was seen walking towards the front door to the parking lot and was assisted back to the facility. Resident 1 expresses his desire of walking outside." During an interview on 3/27/25, at 3:04 p.m., with LVN B, she stated on 11/13/24, the previous Director of Staff Development (DSD) saw Resident 1 walk through the door, enter the parking lot and that the DSD brought Resident 1 back inside the facility. LVN B stated she accompanied Resident 1 back to his room and informed Resident 1 that if he would go outside, he had to inform staff and that he just cannot leave on his own. When LVN B was asked if she would do an elopement evaluation when a situation like this happened, LVN B stated she would not, because it was the first time Resident 1 went through the facility's door without informing staff. During an interview with the ADM on 3/27/25 at 3:20 p.m., the ADM stated the previous DSD who was working on 11/13/24 was no longer working in the facility. Surveyor was unable to interview the previous DSD. During an interview on 4/2/25, at 1:55 p.m., with the Minimum Data Set Coordinator (MDSC), the MDSC stated the MDS assessment on 10/24/24 indicated Resident 1 required supervision or touching assistance with most activities of daily living. The MDSC stated "supervision" means when somebody stands beside the resident and provides verbal or visual cues when the resident is doing tasks. The MDSC stated 'touching assistance' means to guide Resident 1 with no weight bearing from the staff. The MDSC stated Resident 1 was able to walk over 150 feet using the front wheel walker (FWW, a type of mobility aid with wheels on the front two legs). Review of Resident 1's Social Service Progress Note, dated 2/3/25, indicated Resident 1 left the facility again without informing the facility staff. The Social Service Progress Note further indicated that, the SSD interviewed Resident 1 due to the incident of leaving the facility. Resident 1 stated, "I just walked to the bus stop by firefighters and went home to pick up some items I needed." Review of Resident 1's MDS Section C dated 1/22/25, indicated Resident 1 had a brief interview for mental status (BIMS) score of 7 (a score of 0 to 7 indicates severe cognitive impairment [problems with how a person thinks, learn and use of judgment, and make decisions]). Review of Resident 1's MDS Section GG Functional Abilities, dated 1/22/25, indicated Resident 1 needed supervision or touching assistance to walk 150 feet once standing, and as well as to walk at least 150 feet in a corridor or similar space. Review of Resident 1's clinical record indicated there was no SBAR (Situation, Background, Assessment, Recommendation; a communication tool) for the incident on 2/3/25 when Resident 1 left the facility a second time and went to his old apartment to get a jacket without informing facility staff. During a concurrent interview and record review on 4/1/25 at 2:29 p.m., with the DON, she reviewed Resident 1's clinical record and confirmed there was no SBAR done on 2/3/25. Review of Resident 1's Elopement Evaluation, dated 2/3/25, did not indicate Resident 1's elopement risk level. Review of Resident 1's care plans indicated there was no care plan initiated to address Resident 1's incident on 2/3/25 when Resident 1 left the facility without informing facility staff. During an interview on 3/27/25, at 3:28 p.m., the SSD stated on 2/3/25 Resident 1 left the facility and went to his old apartment and was gone for about an hour. The SSD stated she was made aware by a CNA that Resident 1 was not in the facility. The SSD stated she could not remember the time or who was the CNA at that time. During a concurrent interview and record review on 4/1/25, at 2:29 p.m., with the DON, she stated that the incident on 2/3/25 when Resident 1 left the facility and went to his old apartment was not considered an elopement because Resident 1 came back to the facility. The DON stated she did the elopement reevaluation and based on the evaluation Resident 1 was not at risk for elopement. The DON further stated that a care plan was not initiated for Resident 1, and it could have been the best practice to initiate a care plan for elopement when Resident 1 left the facility. When the DON was asked what was considered as an elopement, the DON stated elopement was when a resident leaves the facility without authorization. The DON further stated that when Resident 1 left the facility on 2/3/25, it was not considered as an elopement because he had a purpose to go to his apartment and came back to the facility. During an interview on 4/1/25, at 3:07 p.m., with CNA C, she stated there was an episode when Resident 1 was in the hallway and asked where the bus stop and taxi was. CNA C stated Resident 1 verbalized "he wants to go to the bus stop." CNA C stated another CNA, and a nurse heard the resident but could not remember who the CNA and the nurse were. CNA C could not remember the date when Resident 1 was asking where to find the bus stop and taxi. During an interview on 4/2/25, at 12:46 p.m., the DON stated the IDT (Interdisciplinary Team, a group of healthcare professionals from different fields that work together towards a common goal for a patient) decides if a resident was high risk of elopement or not. The DON stated the incident on 2/3/25 when Resident 1 left the facility and went to his old apartment was discussed by the IDT but determined Resident 1 was not a high risk for elopement. The DON acknowledged that the IDT discussion was not documented. Review of Resident 1's clinical record indicated there was no IDT (Interdisciplinary Team) note documented for the incident of 2/3/25 when Resident 1 went to his apartment to get a jacket. During a telephone interview on 4/2/25, at 1:01 p.m., with LVN E, the nurse assigned to Resident 1 on 2/3/25, LVN E stated that around 7:15 a.m. he saw Resident 1 in his room and the CNA informed LVN E around 9 a.m. that Resident 1 was not in the room. LVN E stated Resident 1 came back around 11 a.m. to the facility. LVN E stated Resident 1 mentioned he took the bus to go to his house to get his jacket. LVN E stated management team were informed because they had to search for Resident 1. LVN E stated he did not think he did an elopement evaluation after the incident. Review of Resident 1's Nurses Progress Note, dated 3/25/25, indicated "Resident was seen in his room, at the start of the shift around 0720 [7:20 a.m.]. Resident was laying in bed, resting ...Resident was seen by other staff during the morning rounds. Resident's walker noted in the from [front] by reception, however, resident was not in the building." During an interview on 3/27/25, at 1:12 p.m., with LVN A, she stated on 3/25/25, around 7:20 a.m., Resident 1 was lying in bed. LVN A stated she saw Resident 1 an hour after when she gave the medications to Resident 1's roommate. LVN A stated around 8:30 a.m. is when she last saw Resident 1. LVN A stated she realized Resident 1 was not in the facility around lunch time between 12:00 noon to 12:30 p.m. when a CNA informed her that Resident 1 was not in the dining room. LVN A went to Resident 1's room and bathroom and checked the sign out binder. LVN A instructed the CNA to look at the rest of the facility's bathrooms. LVN A added, "someone" called the Code Orange (a code for a resident missing in the facility). During a concurrent interview on 4/2/25, at 11:05 a.m., with CNA D, she stated she was the assigned CNA to Resident 1 on 3/25/25. CNA D stated, she saw Resident 1 around 8:35 a.m. walking around the facility after breakfast. CNA D stated a CNA informed her around 12 p.m. that Resident 1 was not in the dining room. CNA D went to Resident 1's room and restroom and did not find the resident. CNA D stated she informed the nurse and checked other rooms and outside the facility. Review of the facility's report to the department (CDPH, California Department of Public Health), received on 3/26/25, indicated Resident 1 was last seen around 9:00 a.m. on 3/25/25. The report further indicated that a CNA noticed that Resident 1 was not in his room. The facility was made aware that Resident 1 was not in the facility around 12:40 p.m. that prompted the search for Resident 1. The report also indicated the facility received a call at 12:58 p.m. informing the facility that Resident 1 was at the acute care hospital's Emergency Department (specific area within a hospital that provides immediate medical care). During an interview on 4/2/25, at 12:17 p.m., with the Maintenance Director (MTD), he stated the patio gate was wide open before the "breakable lock" was placed about two weeks ago. The MTD stated residents could go through the gate at the patio before 3/25/25. The MTD further stated the "breakable lock" was a lock that could be broken in case of emergency and does not need a key to unlock. During an interview on 4/2/25, at 1:40 p.m., with the Receptionist (RECPST), she stated she was working at the front desk on 3/25/25. The RECPST stated she was at the reception desk all day and did not see Resident 1 leave the facility. The RECPST stated she paged the Code Orange which means missing resident. The RECPST stated she checked residents sign out book (a record keeping tool) and found out neither Resident 1 nor Resident 1's family member signed him out. During an interview on 4/2/25, at 2:21 p.m., with the Physical Therapist Assistant (PTA), the PTA stated Resident 1 was able to walk on his own independently using the FWW. During an interview on 4/2/25 at 4:55 p.m., with the Administrator (ADM), the ADM stated there was nothing that could have been done differently to prevent the incident. Review of Resident 1's ambulance provider record, dated 3/25/25, indicated EMS (Emergency Medical Services, a system that provides emergency medical care) was dispatched (send off to a destination) at 9:26 a.m. and was on scene at 9:30 a.m. at North Main Street/Iris Drive. At 9:52 a.m., Resident 1 was transferred to the acute care hospital. According to googlemaps.com, the facility's distance from the nearest bus stop located at North Main Street/iris Drive was approximately 0.4 miles by foot or walking. According to weather.com. on 3/25/25 the weather forecast in Salinas, CA, indicated that the temperature record high was 80 degrees Fahrenheit (temperature scale) and the record low was 25 F. Review of Resident 1's "History and Physical" from the acute care hospital, dated 3/25/25, indicated "he was found down from an unwitnessed fall while at a bus stop. He was found in prone [face down] position by a bystander who then called 911 at 9:30. EMS expressed concern for assault [a violent or sudden attack] given patient's abrasion on forehead and cracked rib prior to starting CPR [Cardiopulmonary Resuscitation, an emergency lifesaving procedure performed when the heart stops beating}. Patient was in ventricular fibrillation [a serious heart rhythm problem where the heart's lower chambers (ventricles) beat too fast, often over 100 beats per minute] and started CPR at 9:32. He was shocked twice with 3 rounds of epinephrine [a medication to treat many life-threatening conditions] along with amiodarone [a medication to keep the heart rhythm normal.]. He was transferred to the ED [Emergency Department] ...CPR was continued in the ED starting 9:51 and stopped at 9:54 after ROSC [return of spontaneous circulation, return of heartbeat and breathing without needing external assistance] was achieved. He was admitted to the ICU [Intensive Care Unit, a specialized hospital department providing critical care to severely ill or injured patients]." Review of Resident 1's Death Summary from acute hospital dated 3/25/25, indicated Resident 1 passed away at 5:36 p.m. Review of the facility's policy and procedure (P&P), titled "Elopements Resident Behavior and Facility Practices", dated 3/22/22, indicated "Elopement occurs when a resident leaves the premises or a safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so. The interdisciplinary team will further evaluate the unique factors contributing to risk in order to develop a person-centered care plan. Documentation in the medical record will include findings from nursing and social service assessments, physician/family notification, and care plan discussions, as applicable." Review of Resident 1's Certificate of Death, issued on 4/14/25, indicated the cause of death was ventricular fibrillation (fast and irregular heartbeat), undifferentiated shock (unknown cause of the body not getting enough oxygen), and respiratory failure (a serious condition that makes it difficult to breathe on our own). The Certificate of Death further indicated the date of death was 3/25/25. The facility failed to provide supervision for Resident 1 who was at risk for leaving (elopement) when Resident 1 went out of the facility premises without the facility's authorization on 3/25/25