Health inspection·March 4, 2026

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 483.21(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 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 1/6/26, the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to investigate a facility reported incident regarding a resident elopement. The Department determined the facility failed to ensure adequate supervision and a safe environment was provided to prevent an elopement (a resident leaves the facility or a secured area without staff permission or knowledge, putting them at severe risk of injury, getting lost, or death from exposure, traffic, or missed medical care) from occurring for one of two sampled residents (Resident 1) when, Resident 1, with severe cognitive impairment (a condition that affects a person's ability to think clearly, remember information, and make safe decisions) and known wandering risk, eloped from the facility during the night on 12/16/25 through an unlocked and unalarmed door located in the facility's laundry room. This failure resulted in Resident 1 leaving the facility without immediate staff knowledge of Resident 1's departure. Resident 1 remained missing for several hours during the night/early morning hours, until Resident 1 entered a private residence approximately 0.4 miles from the facility, and Resident 1 was subsequently brought to the hospital (due to the cold weather conditions, age, and diagnosis). Resident 1 was diagnosed at the hospital with an acute (new, sudden, and occurring over a short period of time) cardiac injury (damage to the heart). A review of Resident 1's "ADMISSION RECORD," indicated that Resident 1 was admitted to the facility with diagnoses including encephalopathy (a condition where the brain is not functioning normally), delirium (reduced awareness of surroundings, impaired ability to focus, disorganized thinking, and hallucination (seeing things that are not there)), abnormalities of gait and mobility (when a person's walk is different from what would be considered normal), need for assistance with personal care, and dementia (a condition that slowly affects memory, thinking, and the ability to make decisions), among other diagnoses. A review of Resident 1's care plan for wandering and elopement, initiated on 2/20/25, indicated, "Focus...Risk for wandering or elopement related to With [sic] exit seeking behavior, Focus on wanting to go home, Able to propel self around the facility, Dementia, Wanders aimlessly...Goal...Will have no episodes of elopement...Will maintain resident's safety...Will minimize episodes or [sic] wandering or elopement and possible injuries...Interventions/Tasks...Call the attention of the resident and redirect when seen going towards the exit door Date Initiated: 02/20/2025...Frequent check of resident's whereabouts Date Initiated: 02/20/2025...Assess for need of wander/elopement alarm Date Initiated: 02/20/2025...Apply wander guard [electronic monitoring device that alert staff if a resident tries to leave the building through an exit door] as ordered Date Initiated: 02/20/2025..." A review of an "Order Listing Report," dated 12/16/25, indicated, "...Resident Name...[Resident 1]...Wander guard placement secondary to: exit seeking behavior...[Order status] Active...[Revision Date] 09/25/2025..." A review of Resident 1's "Nurses Weekly Progress Notes...," dated 12/12/25, indicated, "...Cognitive Function...Confused [was selected]...Able to make needs known?...No [was selected]...ADL. ACTIVITIES OF DAILY LIVING...MOBILITY...Walk 10 feet...Supervision or touching assistance [was selected]...Walk 50 feet with 2 turns...Supervision or touching assistance [was selected]...Walk 150 feet...Not attempted due to medical condition or safety concerns [was selected]..." A review of Resident 1's "Progress Notes," dated 12/16/25, indicated that Licensed Nurse (LN) 3 documented, "...Resident was last seen by night shift CNA [Certified Nursing Assistant]...walking up and down the hallway...at approximately 0235 [2:35 AM] Resident's roommate came out inquiring about [Resident 1]...resident was not in the building... [LN 3] searched outside premises with no luck...DON [Director of Nursing] was notified around 0353 [3:53 AM]...Administrator [ADM] was also informed around 0400 [4 AM]...Administrator and DON came to building to try to locate patient. At approximately 0500 [5 AM] Administrator contacted [name of local police department]. Police department came and searched the building..." A review of Resident 1's "IDT [Interdisciplinary Team, a group of healthcare staff working together to plan and coordinate resident's care] Notes," dated 12/16/25, indicated, "...[Resident 1]...alert and awake, ambulatory [able to walk]...at the time of exiting the facility, resident wander guard did not alarm d/t [due to] resident exited through a door that did not have an alarm and is out of the patient care area...resident was found by Police...and was transferred to [name of local hospital]..." During an interview on 1/7/26 at 1:04 PM, the ADM stated that Resident 1 exited through the laundry door, which did not have an alarm and was left unlocked on 12/16/25. During an interview and record review with the Maintenance Director , Administrator-in-Training, and the ADM on 1/7/26 at 1:42 PM, the ADM stated that at the time of the interview, all exit doors were alarmed. However, the ADM stated that prior to the elopement, there was one door located in the laundry area that was not alarmed, and that Resident 1 eloped through that door. The ADM stated that the laundry area has two doors, with a second door located beyond the first door in the hallway. The ADM further stated that the laundry door through which Resident 1 exited did not have an alarm at the time of elopement and that although the second door is usually kept locked, it was not locked on the day of the elopement because staff forgot to lock it. The ADM added that on the day of the elopement (12/16/25), the facility's exit safety systems included a Wander Guard system and door alarm system, and that all other exit alarms were operational that night. The ADM further stated that after the incident, the facility added a door alarm to the laundry door, tested all wandering and door alarm systems, and reassessed residents for elopement risk. During a concurrent interview and record review with the DON and the ADM, on 1/7/26, at 2:58 PM, the DON stated Resident 1's BIMS (Brief Interview for Mental Status, an assessment tool) score on 11/12/25 was 1 on a scale of 0-15 indicating severe impairment in cognition . The ADM stated that per facility policy, residents were assessed for elopement risk upon admission and monitored for exit-seeking behaviors throughout their stay, and that prior to the elopement, Resident 1 did not exhibit exit-seeking behaviors. The DON stated that the facility provided adequate supervision but acknowledged that communication among staff could have been better. The ADM further stated that, during the facility's investigation, between 1:50 AM and 2:30 AM, Resident 1 was redirected and left in the activities room because she did not want to remain in bed. The ADM stated that after assisting another resident, the CNA returned and observed that Resident 1 was no longer in the activities room or in her bedroom, at which time staff initiated a search of the building. The ADM identified the laundry room exit being left unlocked as a contributing factor to Resident 1's elopement. During a concurrent observation and interview with the ADM on 1/7/26 at 3:41 PM, in the laundry room, the ADM showed the laundry area, checked the doors, and demonstrated that the newly installed red alarm on the laundry door was functioning. The ADM stated that the first laundry door was routinely unlocked because it was used by staff to sort laundry. The ADM stated that the second laundry door was required to be locked from the inside when staff leave the area and that the alarm was added to that door as an additional safeguard. It was observed upon entering the second door of the laundry area that there was a third door to the left, which was easily opened and appeared to lead to the street. During a phone interview on 1/7/26, at 4:25 PM, LN 3 confirmed that she was the nurse assigned to Resident 1 on the night of 12/16/25, when Resident 1 eloped, and stated she was responsible for 30 residents during that shift. LN 3 stated that at approximately 1:50 AM, she accompanied an x-ray technician (a healthcare professional who operates imaging equipment that takes pictures of the inside of the body) to assist with other residents and left Resident 1 under the supervision of the assigned CNA. LN 3 stated she remained with the x-ray technician until approximately 2:30 AM, then took her scheduled lunch break, assuming Resident 1 remained under the CNA's supervision. LN 3 stated she became aware Resident 1 was missing when the resident's roommate approached staff asking about her whereabouts. LN 3 stated she believed Resident 1 remained in the building because no door alarm had sounded. LN 3 identified a communication barrier with the assigned CNA, stating the CNA did not speak English fluently and required a translator. LN 3 stated she specifically instructed the CNA to keep an eye on Resident 1, as the resident did not want to go to bed yet, and that it was okay to keep her in the activities room since she was not bothering anyone. LN 3 stated she believed that while she was assisting the x-ray technician, the CNA attempted to place Resident 1 in bed despite the resident refusing, and that the resident likely got up and wandered off independently. LN 3 acknowledged Resident 1 had dementia, was frequently confused, and was a known wandering risk, stating the resident often stayed near the nursing station and required redirection and staff supervision. LN 3 stated that prior to the incident, staff interventions included keeping the resident near the nursing station and use of a wander guard. LN 3 confirmed the facility had exit alarms in place except for the laundry room exit and later learned Resident 1 had exited the facility through the unalarmed laundry room door. A review of the Police Department record titled, "Missing Persons - 1 Report," dated 12/17/25, indicated, "...On 12/16/2025 at approximately 0529 hours [5:29 AM], I responded to a missing person call at [name of facility]...I contacted the nurse that had last seen [Resident 1]...[LN 3] said that [Resident 1] typically walked around the nursing home but always returned to her room...[LN 3] said that the last time she saw [Resident 1] was at approximately 0219 hours [2:19 AM]. [LN 3] remembered the time specifically because she had looked at her watch to remember the time and take her lunch at 0230 hours [2:30 AM]...It should be noted that while I spoke to the staff members at the facility, multiple...officers were searching in the neighboring area for [Resident 1]. A description of [Resident 1] was put out over the radio: yellow gown, yellow socks, she was not wearing any shoes...A drone was also dispatched to further assist. At approximately 0618 hours [6:18 AM]...dispatch advised they had located a subject possibly matching the description of [Resident 1]....a subject in what appeared to be a light-colored gown at the intersection of Grante Line Rd. and Holly Dr. [an online direction's map showed the intersection was 0.7 to 0.8 miles away from the facility, dependent on the route walked]...At approximately 0719 hours [7:19 AM]...[name of caller from the community] called [name of police department] advising that there was a female in her house with a yellow gown. [Name of caller] provided the address to her home to be [address redacted; an online directions map showed the address was 0.4 miles away from facility]...officers arrived shortly afterwards and positively identified [Resident 1]...[name of caller] said that when she walked into her living room, she saw [Resident 1] wearing a yellow gown and sitting on the couch and called 911 as she did not recognize who the female was...Due to the extreme cold weather, [Resident 1's] age and health conditions, [name of ambulance company] was requested to respond to the scene to examine [Resident 1]. Ultimately, [name of ambulance company] transported [Resident 1] to [name of local hospital] for further evaluation..." A review of Resident 1's hospital record titled "Discharge Summary," dated 12/18/25, at 8:33 AM, indicated, "...FINAL DIAGNOSES: Acute altered mental status...NSTEMI [Non- ST Elevation Myocardial Infarction, a type of heart attack]...REASON FOR ADMISSION: ...[Resident 1] was found by police...brought into ED [Emergency Department]... has severe dementia...found to have elevated serum troponin [a blood test. Levels above the normal range suggest heart muscle injury]...admitted to the hospital for further evaluation...HOSPITAL COURSE: [Resident 1] was admitted with acute NSTEMI, evidenced by elevated troponin [indicates injury to the heart muscle, often resulting from acute myocardial infarction (heart attack) but also caused by various non-cardiac conditions], and was started with heparin [a medicine that helps stop blood clots, especially during heart problems]...she experienced a brief episode of SVT [Supraventricular Tachycardia, an episode where the heart beats very fast] on telemetry [a way of monitoring your heart while you are in the hospital to watch the pattern of your heartbeats and find any heart problems you may have with your heartbeat]...START taking these medications...aspirin [used to help prevent certain health problems, such as a heart attack or stroke] 81mg [milligrams; a unit of measurement]...atorvastatin [used to lower cholestero