Health inspection·December 1, 2025

Code of Federal Regulations, Title 42, 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. Code of Federal Regulations, Title 42, Section 483.10(g)(14) Notification of Changes (i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is- (B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); (C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment) (ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in §483.15(c)(2) is available and provided upon request to the physician Code of Federal Regulations, Title 42, Section 483.21(b) Comprehensive Care Plans (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 California Code of Regulations, Title 22, Section 72301. Required Services. (f) The facility shall ensure that all orders, written by a person lawfully authorized to prescribe, shall be carried out unless contraindicated. California Code of Regulations, Title 22, Section 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 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. (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. California Code of Regulations, Title 22, Section 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 10/6/25, the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to investigate a complaint regarding a resident elopement. The Department determined the facility failed to implement appropriate safety interventions including supervision to ensure a safe environment free of accidents and hazards for one of two sampled residents (Resident 1) when: 1. Resident 1 was not initially assessed (around the time of admission to the facility) accurately for an elopement risk (the potential for a vulnerable individual to leave a facility without staff awareness, leading to serious dangers like injury or even death) and Resident 1 was not reassessed for an elopement risk after Resident 1 became more confused, began to wander (aimless movement), and attempted to and expressed a desire to leave the facility on several occasions; 2. An elopement risk care plan (a comprehensive resident centered plan which includes interventions such as environmental modifications, supervision, and/or technology integration to prevent a resident from leaving a facility) was not created for Resident 1; and 3. A doctor's order to send Resident 1 to the hospital for a change in condition (any significant physical, cognitive, or mental deviation from a resident's baseline that requires an adjustment to their care plan) was not carried out by facility staff over multiple shifts. These failures resulted in Resident 1 eloping from the facility on the morning of 10/4/25 between 7:30 a.m. and 7:40 a.m. (during rush hour traffic near a busy road) and being found one mile away near a shopping center at 8:30 a.m. by a family friend (FF) looking pale, clammy, sweaty, and shaking. These failures had the potential to result in physical and emotional danger: including injury, exposure to the elements (extreme heat or cold), and/or death and the emotional toll could be severe, leading to feelings of loneliness, depression, and increased anxiety. Review of Resident 1's "ADMISSION RECORD," indicated, Resident 1 was admitted to the facility on 9/29/25 (Monday) with diagnoses which included hepatic encephalopathy (HE, when the liver is unable to properly filter toxins from the blood, leading to their accumulation in the brain which can cause confusion, disorientation, and personality changes among other symptoms) and hyponatremia (low levels of sodium (salt) in the blood which can cause restlessness, irritability, and dizziness when standing up among other symptoms). Review of Resident 1's "BRIEF INTERVIEW FOR MENTAL STATUS" (BIMS, an assessment tool that healthcare providers use to assess a person's cognitive function), dated 9/29/25, indicated, Resident 1 had a BIMS score of 5 on a scale of 0-15, which indicated severe cognitive impairment (Score of 0 to 7: severe problems with thinking and memory). During a phone interview on 10/6/25, at 4:02 p.m., Emergency Contact (EC) 1 stated Resident 1 was recently admitted to the facility after his family took him to the emergency room (ER) for increased confusion. EC 1 stated Resident 1 experienced a fall on 5/20/25 and broke his neck and required surgery. EC 1 stated Resident 1 had been in and out of the hospital seven times since then due to complications from surgery. EC 1 stated a nurse from the facility called her on 9/29/25 (Monday) because Resident 1 seemed more confused and the family requested blood work be done because he would get confused when he had a low blood sodium level (a mineral needed by the body to keep body fluids in balance). EC 1 stated on 9/30/25 (Tuesday) they were visiting Resident 1 and noticed he was more confused, did not know where he was, and was making up stories. EC 1 stated Resident 1 did not make sense, and she told staff he might be getting an infection, or his blood labs were off. EC 1 stated while at the facility Resident 1 could not get off his bed independently or walk because it was not safe and when she visited him on 10/2/25 (Thursday) she pushed him around in a wheelchair. EC 1 stated someone from the facility called on Thursday night and told them Resident 1 was resisting care and very confused. EC 1 stated Resident 1's responsible party (RP) went to the facility that night and when the RP arrived at the facility Resident 1 was at the entrance door and was trying to leave. EC 1 stated on 10/3/25 (Friday) she met Resident 1 at a medical appointment and when Resident 1 returned to facility after his doctor's appointment he refused to get out of the transport van and would not go inside the facility. EC 1 stated staff called the RP, and the RP was able to get Resident 1 to go back into the facility. EC 1 stated at 5 p.m. on 10/3/25 (Friday), staff called and asked when someone was coming to get him because he was resisting the wander guard (wearable device attached to a bracelet that is integrated with a security system to alert caregivers when residents are near or exit a door leading outside) staff was trying to place on him. EC 1 stated the staff member told her they would have to send him to the hospital because he was not listening and wanted to leave the facility. EC 1 stated she told the staff member she gave permission to send Resident 1 to the hospital if that was the safest place for him. EC 1 stated she did not hear back from the facility after that, so she thought everything was okay with Resident 1. EC 1 stated the next day, 10/4/25 (Saturday) the neighbor, who lived across the street from Resident 1's previous residence, found him disheveled and dirty, on a bench alone near a shopping center. EC 1 stated, just before 9 a.m., she called the facility to check if they knew Resident 1 was missing because she had not heard from them. EC 1 stated she was placed on hold for 25 minutes, so she used another phone line to call the facility back. EC 1 stated the person who answered the phone told her they were trying to locate Resident 1. EC 1 stated she told the staff member Resident 1 was already found by the shopping center. EC 1 stated Resident 1 had walked very little since his surgery in May and now he just walked about 2 miles outside of the facility, alone. EC 1 stated Resident 1 could have fallen and reinjured himself, or could have gotten hit by a car, or not been found at all. EC 1 stated they did not take Resident 1 to the doctor after finding him because they were tired of doctors not being able to help him. EC 1 stated nobody from the facility has called her since Resident 1's elopement nor have they spoken to the RP regarding medical updates or the elopement. Review of Resident 1's "[Hospital Name] HOSPITALIST DISCHARGE SUMMARY," dated 9/29/25, indicated, "...ADMIT DATE...9/26/25...DISCHARGE DATE...9/29/25...FINAL DISCHARGE DIAGNOSES...Encephalopathy acute [sudden]...Hyponatremia...HOSPITAL COURSE...brought in from home for generalized weakness worsening confusion unable to take care of self at home...Patient is currently orientated to his name [and] place could tell me the year but unable to give me history of what happened at home is complaining of back pain... sodium of 131 [normal blood sodium levels are 135-145]...ammonia 43 [normal blood ammonia levels are 11-32; high ammonia symptoms include confusion and disorientation]...initial labs showed elevated ammonia, which had trended down...mentation improving [less confusion]...9/28/25...NA [sodium] 126 (L) [low]...HPI [history of present illness]...recurrent admissions for hyponatremia..." A review of Resident 1's "Social Services/Case Management Initial Assessment Note," dated 9/30/25, indicated "...Patient had a fall at home prior to admission... Family also emphasized the Importance of monitoring the patient's...hyponatremia and requested close observation of lab values [blood tests]. They asked to be notified of any changes in the patient's condition..." Review of Resident 1's "Care Plan Report," initiated 9/30/25, indicated, "...Skilled PT [Physical Therapy] needed for impaired gait [walking], impaired balance...decreased endurance [strength], and decreased functional level [the loss of ability to perform usual activities due to a decline in physical or cognitive function]..." Review of Resident 1's "Care Plan Report," initiated 9/30/25, indicated, "...Falls: Resident is at risk for falls with or without injury related to altered mental status...Goal...Will be compliant with fall interventions...Interventions...Anticipate and meet needs...Education/remind resident to call for assistance with all transfers..." Review of Resident 1's "Care Plan Report," initiated 10/1/25, indicated, "... Not alert to surroundings at eval [evaluation], thinks he is at [name of high school] in the gym...Pt [patient] will be orientated to place/time/circumstances/new deficits and safety precautions...Skilled ST [speech therapy ] 5x wk [times per week] x 4 wks to address Cognitive Communication Deficit..." Review of Resident 1's "Care Plan Report," initiated 10/3/25, indicated, "... Cognitive Impairment...exhibits cognitive loss related to altered cognitive performance with BIMS score of 5...indicating severe impairment...Goal...Will avoid complications...Interventions...Anticipate needs and meet promptly...Monitor for changes in cognitive status. Notify physician if observed...Observe for indicators of clinical changes...behavior changes...Notify physician if occurs..." Review of Resident 1's "Care Plan Report," initiated 10/3/25, indicated, "...[Resident 1] has an alteration in neurological status [mental status] r/t [related to]...Encephalopathy... Intervention...Cueing, reorientation as needed...Obtain and monitor lab/diagnostic work as ordered. Report result to MD [Medical Doctor] and follow up as indicated... Review of Resident 1's "Physical Therapy Medicare PT Evaluation & Plan of Treatment," dated 9/30/25, indicated, "...Patient exhibits new onset of decrease in strength, decrease in functional mobility, decrease in transfers, reduced ability to safely ambulate and reduced functional activity tolerance... Pt is confused...Fall risk, confusion, poor endurance...Safety Awareness...Poor...the patient is at risk for: falls and further decline in function... Pt unable to take a step on first attempt of gait training [walking]. Pt instructed on side stepping on second attempt but only able to take 2 side steps. On third attempt, pt able to take 3 steps but drags R [right] foot d/t [due to] c/o [complaints of] pain on B [both] ankles and feet..." Review of Resident 1's "Physical Therapy Medicare PT Evaluation & Plan of Treatment", dated 10/3/25, indicated "...Pt educated and instructed on gait training...utilizing FWW [front wheeled walker]...Pt completed 200ft...Pt demonstrates increase in confusion requiring frequent redirecting back to therapy tasks. Nursing staff aware..." A review of Resident 1's physician order, dated 9/29/25, indicated "...CMP [Comprehensive Metabolic Panel - a blood test that includes a sodium level]..." A review of Resident 1's CMP results, dated 9/30/25, indicated "...sodium...127..." A review of Resident 1's physician order, dated 10/2/25, indicated "...CMP in one week one time only for sodium..." Review of Resident 1's "PERSONAL HISTORY AND PHYSICAL EXAMINATION," dated 10/2/25, hand-written by Resident 1's Medical Doctor, indicated, "...INITIAL EXAM watch mental [observe for mood/behavior changes], Repeat Lab...Na...NH3 [ammonia]..." A review of Resident 1's physician order, dated 10/3/25, indicated "...NH3 one time only for confusion for 1 Day..." Review of Resident 1's "SBAR [Situation, Background, Assessment, and Recommendation]" change in condition form," written by Licensed Nurse (LN) 1, dated 10/3/25 at 12:40 p.m., indicated, "...Resident seems very confused...Increased confusion...This started on...10/03/2025...MD notified...if family wants, and condition not better...go back to ER [emergency room]..." Review of Resident 1's "Nurse's Note," written by the Director of Nursing (DON), dated 10/3/25 at 2:01 p.m., indicated, "...Resident noted with aggressive, restlessness behavior concerned about safety/high fall risk..." Review of Resident 1's "Order Details," created by the DON on 10/3/25 at 2:01 p.m., indicated, "...Order Summary...OK to transfer the resident to ER for safety concerns...every shift for 2 days..." Review of Resident 1's "Nurse's Note," written