Health inspection·November 25, 2025

The following reflects the findings of the California Department of Public Health during an investigation of facility reported incident 2647062. Facility Reported Incident: 2647062 State Citation A was written at Title 22 §72311(a)(1)(B)(C)(2). 22 CCR § 72311 § 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. 22 CCR § 72523 § 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 10/23/25, an unannounced visit was conducted at the facility to investigate a facility reported incident regarding Resident 1's elopement incident. Resident 1 was a 75-year-old male resident who was admitted to the facility on 7/1/25 with diagnoses including dementia (progressive or persistent loss of memory), diabetes (inability of the body to control blood sugars), difficulty walking, unsteadiness on feet, lack of coordination, muscle weakness, and need for assistance with personal care. Based on interview and record review, the facility failed to provide nursing services for one sampled resident (1) when there was a failure to: 1. Update and revise the care plan (a personalized document used to guide the management of a patient's care needs by prioritizing concerns/problems, goals and planned interventions) after two elopement attempts (leaving the facility without authorization or notification). 2. Ensure a physician's order was obtained for the use of a Wander Guard (a bracelet worn by the resident with a sensor that triggers an audible alarm to alert staff when the resident attempts to leave the facility) and the elopement risk care plan included the Wander Guard as a safety intervention when applied. 3. Accurately assess the resident's elopement risk upon admission. These failures resulted in Resident 1 eloping from the facility and remaining missing for over eight hours. This placed Resident 1 at risk for accidents and harm while being unsupervised outside of the facility; Resident 1 missing his scheduled medications, including two doses of Insulin (a medication to control blood sugar levels) placing Resident 1 at risk for hyperglycemia (elevated blood sugar), and one dose of Eliquis (a medication to prevent blood clots), increasing the risk of blood clots which could lead to stroke (serious medical condition when the blood supply to part of the brain is interrupted or reduced preventing brain tissue from getting oxygen) and heart attack (life threatening medical emergency when blood flow to the heart is suddenly blocked). Findings: 1. During a review of Resident 1's "Admission Record (AR)," undated, the AR indicated Resident 1 was admitted to the facility on 7/1/25 with diagnoses including Dementia (progressive or persistent loss of memory), diabetes (medical condition characterized by elevated blood sugar levels), difficulty walking, unsteadiness on feet, lack of coordination, muscle weakness, and need for assistance with personal care. During a review of Resident 1's Minimum Data Set (MDS - a comprehensive assessment tool) dated 7/8/25, the MDS indicated Resident 1 had a Brief Interview for Mental Status (BIMS - a cognitive test with scores ranging from 0 to 15, with higher scores reflecting more intact cognitive status [mental process involved in knowing, learning and understanding]) score of 10 (score of 8 to 12 means moderate cognitive impairment). During a review of Resident 1's "Progress Note (PN)," dated 7/13/25 at 1:47 p.m., the PN indicated an elopement attempt. The PN indicated, "[Resident 1]. . .tried to leave the facility to go to the bank to withdraw some money." During a review of Resident 1's "Care Plan Report (CPR)," dated 7/21/25, the CPR indicated, "[Resident 1] has some forgetfulness cognitive function/dementia or impaired thought processes. . .At risk for elopement." During a review of Resident 1's PN dated 8/9/25 at 2:48 p.m., the PN indicated a second elopement attempt. The PN indicated, "[Resident 1] so agitated started walking out of the door to go to the bank. . .Charge nurse told [Resident 1] to wait. . .But [Resident1] kept walking no way to stop him. . .Police brought [Resident 1] back to the facility. . ." During a review of Resident 1's "Care Plan Report (CPR)," dated 7/21/25, there was no revision to include interventions after the 8/9/25 elopement attempt. No changes to the care plan to prevent future elopements and no care plans developed for the attempted elopement. During a review of Resident 1's PN dated 10/18/25 at 1:02 p.m., the PN indicated, "[Resident 1] last observed in the facility at approximately [1 p.m.] ... Code for elopement was immediately activated. . . All resident rooms and common areas within the facility were systematically searched... This nurse conducted an external search of the facility premises and surrounding neighborhood streets. . .[Resident 1] was not located during this search... [Resident 1]'s Wander Guard was discovered at bedside, indicating [Resident 1] had exited without the tracking device [Wander Guard] in place. . .A non-emergent report was made to the [police]." During a review of Resident 1's PN dated 10/18/25 at 4:24 p.m. titled "[Medication] Administration Note", the PN indicated Resident 1 missed the following medications when he was missing for approximately eight hours: a. "Insulin Lispro [medication for diabetes] Subcutaneous Solution Pen-injector 100 UNIT/ML [milliliter] Inject [injection under the skin] as per sliding scale [is a dosing regimen where the amount of rapid- or short-acting insulin administered to a patient is adjusted (or "slides") up or down based on their current blood glucose level. The higher the blood sugar reading, the more insulin is given]. . .Resident out of facility." b. "Humalog Kwik Pen [medication for diabetes] Subcutaneous Solution Pen-injector 100 UNIT/ML Inject 6 units subcutaneous [injection applied under the skin] before meals... Resident out of facility." c. "Ferrous Sulfate Oral Tablet [vitamin supplement] 325 MG [milligrams] Give 1 tablet by mouth two times a day for low hemoglobin level... Resident out of facility." d. "Pro-Stat Oral Liquid [supplement] Give 30 ml by mouth two times a day for wound healing... Resident out of facility." e. "Eliquis Oral Tablet 5 MG Give 5 mg by mouth two times a day for blood clots... Resident out of facility." f. "Gabapentin Oral Capsule 100 MG Give 1 capsule by mouth three times a day for Diabetic Neuropathy [a complication of diabetes that damages the nerves, typically in the hands, feet, legs, and arms] ... Resident out of facility." During a review of Resident 1's "Progress Notes (PN)" dated 10/18/25 at 8:56 p.m., the PN indicated, "At 8:51 p.m. [almost nine hours from time of elopement] [Resident 1] independently walked into the facility." During a review of the facility investigative report titled, "5 Day Investigative Report (IR)," dated 10/22/25, the IR indicated, "[Resident 1] eloped around 1300 [1 p.m.] Saturday afternoon on 10/18/2025. [Resident 1] has a diagnosis of dementia and has a history of eloping at previous facility before being admitted to the facility... [Resident 1] arrived safely and unharmed accompanied by [Police Department] at 2045 [8:45 p.m.]." During an interview on 10/23/25 at 2:30 p.m. with DON, DON stated the care plan was not updated with elopement prevention interventions for Resident 1 after the 8/9/25 elopement attempt and prior to his elopement on 10/18/25. DON stated Resident 1 was at risk of elopement on admission and although there should have been an elopement care plan developed, no elopement care plan was developed. During a review of facility policy and procedure (P&P) titled, "Care Planning", dated November 1, 2017, the P&P indicated, "A comprehensive person-centered Care Plan will be developed for each resident. The Care Plan will include measurable objectives and timetables to meet a resident's medical, nursing, mental and psychological needs. . .Each resident's Care Plan will describe the following. . .Services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. . ." 2. During a review of Resident 1's PN dated 10/18/25 at 1:02 p.m., the PN indicated, "[Resident 1] was not located during this search... [Resident 1]'s Wander Guard was discovered at bedside, indicating [Resident 1] had exited without the tracking device [Wander Guard] in place." During an interview on 10/23/25 at 10:05 a.m. with Director of Nursing (DON), DON stated Resident 1 was out of the facility for about eight hours and was brought back by the police department. DON stated Resident 1 was found near the mall (about 10 miles from the facility). DON stated Resident 1 had a history of elopement having eloped before from another facility and was at risk for elopement. DON stated Resident 1 had been provided a Wander Guard bracelet but Resident 1's Wander Guard was found cut on the floor next to his bed, which allowed Resident 1 to leave the facility undetected. During an interview on 10/23/25 at 10:15 a.m. with Resident 1, Resident 1 was alert and stated he left the facility to go to the [medical] clinic. Resident 1 stated he left the facility on foot, took a bus to the clinic, and from there, walked to the mall. During an interview on 10/23/25 at 2:30 p.m. with DON, DON stated the care plan addressing elopement risk should have specified that Resident 1 was to wear a Wander Guard, and that should staff should monitor to ensure Resident 1 had the Wander Guard on at all times. During an interview on 11/5/25 at 2:53 p.m. with DON, DON stated she was unable to determine which staff applied the Wander Guard bracelet and when it was applied on Resident 1. DON stated there should have been a physician's order, monitoring of the placement, and a care plan for the use of the Wander Guard. DON stated the facility has no policy on Wander Guard use. 3. During a review of Resident 1's "Elopement/Wandering Risk Worksheet (EWRW-assessment to identify residents at risk of elopement based on ambulation status, mental status, cognitive processes, and history of elopement)," dated 7/1/25 (date of admission), the EWRW indicated, "History of elopement episodes for last 6 months: No history. At risk for elopement? No." The final score was 7. The document indicates if the score is 10 or higher it may indicate the resident is at risk of elopement. During a review of Resident 1's "Nursing Admission Screening/History (NASH)," dated 7/1/25, the NASH indicated, "Per report from [hospital] resident [1] is pleasantly confused, poor historian, however, has a history of trying to "get out" of his family's homes." During an interview on 11/5/25 at 2:53 p.m. with DON, DON stated the hospital informed the facility upon admission that Resident 1 had a history of elopement, but that this information was not indicated in the EWRW. DON stated the admission EWRW was inaccurate and should have indicated Resident 1 was at risk for elopement. If the EWRW had been completed accurately to include the resident's history of eloping as indicated by the hospital on admission, the nurse would have calculated the score of 10, which places the resident at risk of elopement. During a review of the facility's P&P titled, "Wandering & Elopement", dated 11/117, the P&P indicated, "To enhance the safety of residents of the Facility. . .The Facility will identify residents at risk for elopement and minimize any possible injury because of elopement. . .Procedure. . .The Licensed Nurse, in collaboration. . .will assess residents upon admission, readmission, quarterly, and upon identification of significant change in condition. . .The resident's risk for elopement and preventative interventions will be documented in the resident's medical record, and will be reviewed and re-evaluated. . .The resident's risk for elopement and preventative interventions will be documented in the resident's medical record. . ." During a review of the facility's P&P titled, "Elopement Risk Reduction Approaches", dated 11/1/17, the P&P indicated, "Ensure that residents. . .are monitored and remain safe. . . develop a care plan. . .to promote choice, mobility and safety. Base care plan on assessments and family and caregiver involvement. . .Install non-intrusive alarm systems that alert staff to resident exiting." In violation of the above cited, the facility failed to update and revise the care plan after two elopement attempts, ensure a physician's order was obtained for the use of a Wander Guard and accurately assess the resident's elopement risk upon admission. These failures resulted in Resident 1 eloping from the facility and remaining missing for over eight hours placing Resident 1 at risk of accidents and harm while being unsupervised outside of the facility and missing his scheduled medications. This violation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result and represents a class "A" citation.