Health inspection·December 31, 2025

Title 42, Section 483.25, Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. 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 resident's choices, including but not limited to the following: 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. 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 Section 483.10(c)(2) and Section 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 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. 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. 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 11/24/25 at 11 a.m., an unannounced visit was conducted at the facility to investigate a facility reported incident regarding patient safety when the facility reported that Patient 1 had gone missing from the facility on 11/15/25 at 5:45 p.m. The department determined the facility failed to provide appropriate supervision when they did not ensure Patient 1 was wearing a wandering device (a wearable device, commonly referred to as a wander guard, with sensors that trigger alarms, used to prevent patients at risk of wandering from leaving a safe area unsupervised) according to Patient 1's physician orders (PO) and care plan (CP). These failures led to Patient 1 walking out of the facility unsupervised and without the facility's knowledge, which exposed the patient to cold temperatures, nightfall, and traffic, which could have resulted in serious injury, medical complications, and/or death. Patient 1 was admitted to the facility in September 2025 with multiple medical diagnoses which included dementia (a progressive state of decline in mental abilities), a history of falling, and a spinal fracture (a break or crack in one or more of the bones in the spinal column). Patient 1 had a Brief Interview Mental Status (BIMS-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the patient) score of 4 out of 15 which indicated Patient 1's cognitive function was severely impaired. A review of Patient 1's Wandering Risk Assessment (WRA), dated 9/29/25, indicated, "Score of 3 or more = High risk for elopement...[Patient 1] Score: 8...Has the resident [Patient 1] wandered before? Yes...Does the wandering place the [Patient 1] at significant risk of getting to a potentially dangerous place (stairs, outside the facility)? Yes." A review of Patient 1's CP, dated 10/1/25, indicated, "[Patient 1] is an elopement risk/wanderer r/t (related to) History of attempts to leave facility unattended, [Patient 1] wanders aimlessly at a risk for elopement assessment done with the score 8.0...Monitor [Patient 1] whereabouts." A review of Patient 1's CP, dated 10/8/25, indicated, "[Patient 1] have wander guard on left ankle r/t (related to) high risk of elopement and wandering...Ensure the [wander guard] device is functioning properly and securely attached to [Patient 1]." A review of Patient 1's PO, dated 10/8/25, indicated, "Make sure Pt [Patient 1] have wander guard on left ankle # 9000-0138J exp 05/15/2026 every shift." A review of Patient 1's Interdisciplinary Team (IDT) note, dated 11/17/25, indicated, "ELOPEMENT November 15, 2025, at 5:45 PM...[Patient 1] was missing...the PD (Police Department)...reported that [Patient 1] had been located at...7:00 PM...At 8:35 PM, [Patient 1] was returned to the facility by law enforcement...[wander guard] was missing." During an interview on 11/24/25 at 11:30 a.m., Certified Nursing Assistant (CNA) 1 stated Patient 1 was a known wanderer who frequently walked up and down the hallways, exhibited exit-seeking behavior, and often needed re-direction. During an interview on 11/24/25 at 11:46 a.m., Licensed Nurse (LN) 1 stated Patient 1 was confused and would frequently wander down the hallways and into other patients' rooms, requiring re-direction. LN 1 further stated Patient 1 was supposed to wear a wandering device on his left ankle; the wandering device would activate an alarm when Patient 1 neared the exit to signal staff. During an observation on 11/24/25 at 12:27 p.m. near the elevators, Patient 1 and their Responsible Party (RP) walked into the facility through the elevators. An alarm sounded upon the elevator doors opening. During an interview on 11/24/25 at 12:30 p.m., RP stated the facility notified him on 11/15/25 that Patient 1 had gone missing from the facility and "they didn't know how he got out." RP stated the facility was aware Patient 1 had a history of wandering and elopement. RP further stated Patient 1 was very confused and "like a little kid." RP, who stated he regularly visited Patient 1 twice weekly, had no recollection of Patient 1 wearing a wandering device prior to his elopement on 11/15/25. During an interview on 11/24/25 at 1:22 p.m., LN 2 stated Patient 1 was a known wanderer and would attempt to walk out of the facility through the elevators. LN 2 further stated Patient 1 had an order to wear a wandering device and nurses were supposed to "check off" in the electronic Medication Administration Record (MAR) that Patient 1 wore it each shift. During a review of Patient 1's MAR, dated November 2025, the MAR indicated, "Make sure Pt [Patient 1] have wander guard on left ankle...every shift...start date 10/08/2025." The MAR further indicated, "n/N [no]," on the following dates and shifts: 11/13/25 evening shift, 11/13/25 night shift, 11/14/25 day shift, 11/14/25 evening shift, 11/14/25 night shift, and 11/15/25 day shift. During a concurrent interview and record review on 11/24/25 at 2:22 p.m. with Director of Nursing (DON), Patient 1's MAR for November 2025 was reviewed. DON verified there was no documentation indicating Patient 1 was wearing a wandering device from 11/13/25 evening shift through the time of elopement on 11/15/25 and there should have been. DON acknowledged Patient 1 had PO, initiated on 10/8/25, to wear a wandering device, which should have been followed. DON stated it was the expectation for nurses to indicate yes or no in the MAR that Resident 1 was wearing his wandering device. If a resident was found without a wandering device on, it was expected for nurses to replace the wandering device immediately. DON stated without wearing a wandering device, the risk was that a patient might elope. DON verified nursing staff had marked "n" which indicated Patient 1 was not wearing his wandering device for six shifts prior to elopement. DON stated Patient 1 eloped from the facility on 11/15/25. Police found Patient 1 walking around outside, more than two miles from the facility. DON stated she observed Patient 1 was not wearing a wandering device when he returned to the facility. During a review of the facility's policy and procedure titled, "Wandering and Elopements," dated March 2019, indicated, "The facility will identify residents who are at risk of unsafe wandering...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." During a review of the facility's policy and procedure titled, "Care Plans, Comprehensive Person-Centered," dated March 2022, "A comprehensive, person-centered care plan...is developed and implemented." Therefore, the department determined the facility failed to provide appropriate supervision when they did not ensure Patient 1 was wearing a wandering device according to Patient 1's PO and CP. These failures led to Patient 1 walking out of the facility unsupervised and without the facility's knowledge, which exposed the patient to cold temperatures, nightfall, and traffic, which could have resulted in serious injury, medical complications, and/or death. These violations had a direct or immediate relationship to the health, safety, or security of long-term care facility patients or residents.