Health inspection·December 11, 2025

The Shores 2661963 The following reflects the findings of the California Department of Public Health during the investigation of Incident 2661963. Survey ID: 1DAEA9-H1 Class B Citation was written. 42 CFR § 483.25 (d) Accidents. The facility must ensure that - (d)(1) The patient environment remains as free of accident hazards as is possible; and (d)(2) Each patient receives adequate supervision and assistance devices to prevent accidents. 42 CFR §483.21. Comprehensive Person-Centered Care Planning. (a) Baseline Care Plans. (a)(1) The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must- (i) Be developed within 48 hours of a resident's admission. (ii) Include the minimum healthcare information necessary to properly care for a resident including but not limited to (A) Initial goals based on admission orders. Cal. Code Regs. Tit § 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. Cal. Code Regs. Tit. 22, § 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 11/6/25 at 1:47 P.M., an unannounced onsite visit to the facility was conducted related to an incident regarding quality of care and resident safety. Based on Department (Department=CDPH, California Department of Public Health) investigation, the facility failed to prevent a resident's successful elopement (when resident departs unsupervised and undetected) of a conserved (when a judge appoints another person to act or make decisions for the person who needs help) resident (Resident 1). This failure had a direct or immediate relationship to the health, safety, or security of long-term health care facility residents. Resident 1 was readmitted to the facility on 9/22/25, with diagnoses which included convulsions (uncontrollable muscle contraction), bipolar disorder (periods of extremely "up," elated, irritable, or energized behavior [known as manic episodes] and very "down," sad, indifferent, or hopeless periods [known as depressive episodes]), psychosis (a condition in which one is unable to distinguish between what is and is not real), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), among other diagnoses per the facility's Admission Record. Resident 1 was under conservatorship, was placed in a lock unit (a locked, secure area designed specifically for residents with a risk of wandering) in the skilled nursing facility (SNF) and was assessed as high risk for wandering. On 11/5/25, Resident 1 had an outpatient appointment and was escorted by a SNF staff member (Certified Nursing Assistant, CNA [1]) who fell asleep while waiting at the waiting area. Resident 1 eloped during the time SNF CNA was asleep. On 11/6/25, Resident 1 was located more than 11 miles away from the SNF location and was found in the streets intoxicated with alcohol. The facility failed to: 1.Provide adequate supervision and monitoring of Resident 1 who was under conservatorship to prevent elopement. When Resident 1 was located at the general acute care hospital (GACH), Resident 1 was found in the streets intoxicated with alcohol and was brought to GACH emergency department (ED), reported to have taken antipsychotic and antidepressant medications and found to have pneumonia (lung infection). 2.Develop and implement Resident 1's care plan based on her high-risk assessment of wandering. This includes but not limited to closely monitoring resident during an outpatient appointment. 3. Implement facility policies and procedures including "Wandering and Elopements" and "Care Plans, Baseline". A record review of Resident 1 was conducted on 11/6/25. Resident 1 was readmitted to the facility on 9/22/25 in the facility's lock unit, with diagnoses which included convulsions, bipolar disorder, psychosis, and major depressive disorder, among other diagnoses per the facility's Admission Record. A review of Resident 1's GACH 1 record was conducted. GACH 1 record prior to SNF admission, indicated Resident 1 had psychiatric evaluation and was admitted to GACH 1 on 9/10/25 due to "extreme agitation and unable to keep shelter endangering others". A review of Resident 1's History and Physical (H&P), dated 9/23/25, was conducted. The H&P indicated Resident 1 was admitted to the SNF for psychiatric care, and monitoring, did not have the capacity to make her own decisions and was under conservatorship. The H&P also indicated Resident 1 had a history of increased agitation and worsening auditory hallucinations (hearing voices that was not there) which included voices to harm herself. A review of Resident 1's wandering/elopement risk assessment dated 9/22/25 was conducted. The form wandering/ elopement risk assessment indicated Resident 1 had a history of wandering and was at high risk for wandering. A review of Resident 1's care plan was conducted. There was no care plan developed for Resident 1's high risk of wandering. A review of Resident 1's SNF's interdisciplinary team (IDT, group of healthcare professionals and direct care staff that have primary responsibility for the development of a plan for the care and treatment of a resident) was conducted. The IDT notes dated 11/6/25 indicated the timeline as follows: - On 11/5/25 at 11:30 A.M., Resident 1 and her CNA escort (CNA 1) were picked up by an ambulance. - On 11/5/25 at 11:32 A.M., CNA 1 and Resident 1 checked in at the outpatient clinic and sat down in the waiting area. CNA 1 briefly fell asleep while waiting and woke up with the resident still beside him. - On 11/5/25 at 12:05 P.M., CNA 1 went to the bathroom. When CNA 1 returned from the bathroom, he noted that Resident 1 was not in sight, however, CNA 1 assumed Resident 1 was called in to her appointment. - About 10 -15 minutes later, CNA 1 heard clinic staff calling for Resident 1's name and this time CNA 1 realized Resident 1 left the clinic unnoticed. CNA 1 started to search around the building and notified the facility immediately. - On 11/5/25 at around 1:05 P.M., LN 1 received a call from CNA 1 stating Resident 1 left the clinic while CNA 1 was in the bathroom. CNA 1 searched around the area but did not find Resident 1. The IDT notes indicated Resident 1 was not found as of their IDT meeting on 11/6/25. When Resident 1 was located at the GACH on 11/6/25, Resident 1 was found more than 11 miles from the facility's location. The GACH record indicated Resident 1 was intoxicated with alcohol. A review of the GACH 2 record for Resident 1 was conducted on 11/13/25. Resident 1's GACH 2 ED physician notes on 11/6/25 at 11:51 A.M. indicated Resident 1 was brought in by ambulance to the ED reportedly coming from the streets and consumed "375 milliliter (ml) vodka in the morning with home medication olanzapine (Antipsychotic medication) and fluoxetine (Antidepressant medication). The ED notes from GACH 2 indicated Resident 1 had altered mental status, was "Hard to wake up" and reported eloped from the [name of the SNF]. The ED notes indicated two kinds of antibiotics (anti-infection medication) were prescribed for Resident 1 for left lower lobe pneumonia. The ED notes indicated Resident 1 was coded as homeless upon GACH admission and the disposition was to discharge the resident, and the resident declined discharge to shelters and destination details. Last documentation at GACH 2 ED was on 11/6/25 at 5:20 P.M. indicating Resident 1 was with GACH 2 ED security prior to departure at the ED to the waiting room. A review of Resident 1's GACH 3 record was conducted. Resident 1's GACH 3 records indicated Resident 1 was at the GACH 3 ED on 11/6/25 at 7:33 P.M., and presented at the ED with alcohol intoxication, potentially eloped from GACH 2 ED and was missing from her SNF. Resident 1's physician's assessment at the ED indicated Resident 1 was lethargic (having difficulty concentrating and doing simple tasks) but arousable and had slurred speech. Per the ED physician's notes, "This patient presents with a high risk highly complex clinical presentation involving agitation and altered mental status...considered multiple differential processes as noted above which may result in increased morbidity (having a disease or a symptom of disease), and/or mortality (the state of being mortal [destined to die]) for this patient during this visit. This presenting acute illness poses a threat to life and/or functionality which may significantly impact the patient's morbidity during this visit...discussed the evaluation, diagnostic findings, and return precautions with the patient and SNF staff, emphasizing the need for close monitoring for recurrent altered mental status, new neurologic symptoms, or behavioral changes..." On 11/6/25 at 2:12 P.M., an interview with CNA 2 was conducted. CNA 2 stated Resident 1 was alert, oriented and was ambulatory. CNA 2 stated Resident 1 was in a lock unit and would stroll in the patio when the patio was opened for smoking. CNA 2 stated for residents in the lock unit, the residents were closely monitored. CNA 2 stated the process was when a resident had an outpatient appointment, a staff member was assigned to escort the resident. CNA 2 stated, on 11/5/25, Resident 1 had an outpatient appointment, left at around 11:30 A.M. and was escorted by CNA 1. CNA 2 stated on 11/5/25 at around 1 P.M., CNA 1 called CNA 2 over the phone stating he lost Resident 1 while they were at Resident 1's outpatient appointment. On 11/6/25 at 2:47 P.M., an interview with CNA 3 was conducted. CNA 3 stated Resident 1 would walk around but could be redirected. CNA 3 stated the facility did not anticipate Resident 1 would elope because there was no indication that she would leave. CNA 3 further stated CNA 1 had been escorting residents out prior to the incident. CNA 3 stated, "If we escort, that is our responsibility, we should not let our eyes away because we don't know what is in their minds. It is for their safety; it is our responsibility to make sure they are safe." CNA 1 was no longer employed at the facility and was not available for interview. On 11/6/25 at 3:03 P.M., a joint review of Resident 1's wandering assessment, and care plan and an interview with Licensed Nurse (LN) 1 was conducted. LN 1 stated she was familiar with Resident 1 and had worked with the resident since her admission to SNF. LN 1 stated Resident 1 was alert and oriented with forgetfulness. LN 1 stated Resident 1's wandering assessment was coded as high but there was no care plan related to Resident 1's high risk of wandering. LN 1 stated she received a call on 11/5/25 at 1 P.M. from CNA 1 and was informed Resident 1 eloped while at Resident 1's outpatient appointment. On 11/6/25 at 3:43 P.M., a joint record review of Resident 1's clinical record and an interview was conducted with the Director of Nursing (DON). The DON stated the expectation was never to leave the residents unattended and if they needed to use the bathroom, the staff was to notify someone else for the resident's safety. The DON stated, "That is the purpose of having an escort." The DON further stated the LNs were to develop a care plan to meet the expectation and to evaluate the intervention provided to the residents for their care and needs for resident's safety. On 11/17/25 at 5:22 P.M., an observation and an interview with Resident 1 was conducted in her room. Resident 1 was sitting up in bed, ready to eat her dinner. Resident 1 stated it was okay to talk to her. Resident 1 stated she remembered what happened on 11/5/25. Resident 1 stated she and CNA 1 were picked up for her outpatient appointment, checked in at the clinic and waited at the waiting area. Resident 1 stated, "He (CNA 1) fell asleep and so I left." Resident 1 stated she got on the bus and went downtown, got her money and went shopping across the street in the downtown area. Resident 1 stated she took her home (antipsychotic and antidepressant) medications, took the trolley and the bus and went to the beach. At the beach, Resident 1 stated she had a couple of alcohol drinks, also bought a bottle of vodka and drank the vodka. Resident 1 stated, "I enjoyed that." Resident 1 stated she felt like having shortness of breath and had some coughing and had walked from the ocean to GACH 2. Resident 1 stated she walked at the beach and ended up in GACH 2 ED. At GACH 2 ED, Resident 1 stated, she was told to leave, and a security guard took her to the trolley station. At the trolley station, Resident 1 stated, "I feel effy because I did not have proper sleep" and so she asked two strangers to call 911 for her to take her to the emergency room. Resident 1 stated she ended up in GACH 3 and from there she was transferred back to the facility. Resident 1 stated, "I guess they called here so here I am." A review of the facility's policy titled, Wandering and Elopements, revised March 2019, indicated, "The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents... If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety..." A review of the facility's policy titled, Care Plans, Baseline, revised March 2022, indicated, "A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission... The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care..." The facility failed to: Provide adequate supervision and monitoring of Resident 1 who was under conservatorship to prevent elopement. When Resident 1 was located at the GACH, Resident 1 was found in the streets intoxicated with alcohol and was brought to GACH ED, reported to have taken an antipsychotic and antidepressant medications and found to have pneumonia. Develop and implement Resident 1's care plan based on her high-risk assessment of wandering. This includes but not limited to closely monitoring resident during an outpatient appointment. Implement facility policies and procedures including "Wandering and Elopements" and "Care Plans, Baseline". Resident 1 was readmitted to the facility on 9/22/25, with diagnoses which included convulsions, bipolar disorder, psychosis, and major depressive disorder, among other diagnoses per the facility's Admission Record. Resident 1 was under conservatorship, was placed in a lock unit in the SNF and was assessed as high risk for wandering. On 11/5/25, Resident 1 had an outpatient appointment and was escorted by a SNF staff member, (CNA 1) who fell asleep while waiting at the waiting area. Resident 1 eloped during the time SNF CNA was asleep. On 11/6/25, Resident 1 was located more than 11 miles away from the SNF location and was found in the streets intoxicated with alcohol. These failures had a direct or immediate relationship to the health, safety, or security of long-term health care facility residents.