Other·February 18, 2026

The following reflects the findings of the California Department of Public Health during an investigation of one facility reported incident 2692939 and two complaint numbers 2692910 and 2692922. Facility Reported Incident: 2692939 Complaint Numbers: 2692910 and 2692922 A deficiency was written for Facility Reported Incident 2692939 and complaint numbers 2692910 and 2692922 at F-tag 689-G. F689 §483.25(d) Accidents. The facility must ensure that - §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents. On 12/17/25, an unannounced visit was conducted at the facility to investigate a facility reported incident and complaints regarding a resident who eloped and was missing for 10 hours who sustained adverse health outcomes and required hospitalization. Resident 1 is a 60-year-old female who was admitted to the facility on 8/15/25 and has diagnoses of Schizophrenia (chronic brain disorder that disrupts how a person thinks, feels, and behaves, causing them to lose touch with reality through symptoms like hallucinations [hearing/seeing things] and delusions [false beliefs]. Based on interview and record review, the facility failed to monitor and document whereabouts (the place where someone is) every hour according to the care plan (CP) for one of two sampled residents (Resident 1) when Resident 1 was a known high risk for elopement (occurs when a resident leaves the facility without authorization and/or any necessary supervision). This failure resulted in staff being unaware of Resident 1 leaving the facility unaccompanied, missing for approximately 10 hours, exposing Resident 1 to environmental dangers, experiencing cold exposure, and requiring hospitalization. Findings: During a review of the "Admission Record" (AR) dated 12/18/25, the AR indicated Resident 1 was admitted to the facility on 2/7/24 with diagnoses of schizophrenia (chronic brain disorder that disrupts how a person thinks, feels, and behaves, causing them to lose touch with reality through symptoms like hallucinations [hearing/seeing things] delusions [false beliefs], anxiety disorder (mental condition characterized by excessive fear of or apprehension about real or perceived threats), and major depressive disorder (serious mood disorder causing persistent sadness and loss of interest, affecting feelings, thoughts, and behavior). During a review of the facility's "Investigation Follow Up" (IFU) dated 6/23/25 (history of elopement, approximately six months prior to the 12/13/25 incident), the IFU indicated, "Nurse on duty was notified by staff that Resident [1] is missing. Staff checked all the rooms at the facility and were still not found. At about 4 a.m. residents [Resident 1] were found by VPD [Police Department] next to the church." During a review of Resident 1's "Care Plan" (CP) dated 9/30/25, the CP indicated, "[Resident 1] is an elopement risk/wanderer r/t [related to] history of attempts to leave facility unattended, impaired safety awareness. Elopement Risk Score [a standardized assessment used to identify residents at risk of leaving the facility unsupervised (elopement) with the higher the score the higher the resident is at risk of eloping]: 14.0 High [risk]. Interventions: Monitor her whereabouts every hour. . .date initiated: 10/21/2025." During a review of the "Minimum Data Set" (MDS-resident assessment tool) dated 11/14/25, the MDS indicated Resident 1 had a BIMS (brief interview for mental status - cognitive screening [capacity to think, learn, reason, and solve problems] which has a scale with scores ranging from 0 to 15) Summary Score of 9 (score of 8 - 12 means moderate impairment in cognitive ability) and functional abilities: able to walk. During a review of Resident 1's "POC (Point of Care) Response History" (POCRH - used by staff to document Resident 1's monitoring and whereabouts), dated 12/13/25, the POCRH indicated "Task: Monitor resident whereabouts every 1 hour." The POCRH indicated check marks (indicating the resident's whereabouts were monitored) on the following dates and times: a) On 12/13/25 at 5 a.m., 8:34 a.m., 11:31 a.m., 2:38 p.m., 5:48 p.m., and 7:04 p.m. (7:04 p.m. was the last documented time Resident 1 was checked before Resident 1 was discovered missing at 9:30 p.m.) b) On 12/12/25 at 5:09 a.m., 8:21 a.m., 1:02 p.m., 8:34 p.m., 9:03 p.m., and 11:51 p.m. c) On 12/11/25 at 5:01 a.m., 8:57 a.m., 10:47 a.m., 1:02 p.m., and 5:06 p.m. The document showed Resident 1's whereabouts were not monitored every hour. During a review of Resident 1's "Progress Notes" (PN) dated 12/14/25 at 2:34 a.m., the PN indicated, "Resident [1] last seen at facility (12/13/24) around 8:40 p.m. by CNA [Certified Nursing Assistant]. They were [sic] [Resident 1] in room sleeping covered by blanket. Resident [1] was noticed missing around 9:30 p.m. CNA reported it to nurse at that time. All the facility was searched each bathroom and room, no sign of resident present inside. DON [Director of Nursing] . . .called at 9:53 p.m. to report that resident was unable to be found. Staff then continued to search outside and drive around neighborhood to see if they can find resident. Police were called around @ [at] 10:40 p.m. and report was filed. Police arrived to facility and took report from charge nurse and staff to get accurate description of resident [1]. Each staff member wrote statements. They [staff] then searched facility for possible exits resident may have taken. Police stated to charge nurse that door near resident's room was tested x3 [times three] and no alarm went off. Rp [responsible party] public guardian left message and Dr [doctor] made aware." During a review of the Ambulance Documentation (AD) dated 12/14/25 at 7:09 a.m., the AD indicated, Patient Condition "hypothermia[dangerous medical condition where the body's core temperature drops below 95 degrees Fahrenheit often from prolonged cold exposure, wetness, or inadequate clothing]/cold injury. . .complaint. . .skin numbness. . .Per [name of town] PD [police department] the patient has been missing since approximately [8:00 p.m.] last night. . .the patient was cold to the touch. EMS [emergency medical services] removed the patients wet socks once she was on the gurney and placed hot packs on her feet. EMS also gave the patient hot packs for her hands and armpits. . .Patient positive: cold exposure. . .EMS noted that the patient's heart rate was elevated at 142 sinus tachycardia [heart rate faster than normal, normal heart rate is 60-100]." During a review of Resident 1's PN dated 12/14/25 at 9:28 a.m., the PN indicated, "Investigator informed staff of resident being found around 7:00 a.m. and transferred to [hospital], writer spoke with ER [emergency room] nurse. . .he updated, resident has hypothermia, resident alert and conscious, vital heart rate fast/tachycardia [fast heart rate], right now she is on the warmer, resident is still under evaluation, MD [Medical Doctor] notified, family made aware." During a review of Resident 1's hospital's "History and Physical" (H&P) dated 12/14/25 at 2:29 p.m., the H&P indicated, "Chief Complaint. . .Found down after eloping from facility. . .This is a 60-year-old female with past medical history of schizophrenia and major depression who presents to the Emergency Department for evaluation following eloping from [facility name]. The patient [Resident 1] was found this morning approximately 1 mile from her facility in a field after having eloped overnight. EMS reports that efforts were made to rewarm patient after she was found. . .Assessment and Plan 1. Exposure/Hypothermia. . .Elevated lactate [made in your muscles and red blood cells when they break down food for energy] and abnormal blood gas [shows how well your lungs are oxygenating blood] findings consistent with cold exposure. . .2. Leukocytosis with left shift. . .Assessment: Markedly elevated WBC [increased white blood cells] at 21.83 [normal range is 4,500-11,000 cells per microliter] with neutrophils [body's first responders to infection] at 91.5% [very high proportion of these infection-fighting white blood cells] and lymphopenia [too few lymphocytes- a type of white blood cell] in your blood, weakening your immune system and increasing infections risk). Concerning for infectious process versus stress response from exposure. . .3. Metabolic Acidosis. . .Assessment: Venous [vein] pH [a scale from 0 to 14 that measures how acidic or basic a substance is] 7.29 with elevated lactate at 3.8 [normal range is below 2 mmol/L [millimoles per liter-a unit of measurement], elevated anion gap [blood test calculation used to diagnose acid-base imbalances] at 21.3 [normal range is 10-18 mmol/L]. Likely secondary to cold exposure and possible tissue hypoperfusion [not enough oxygenated blood flowing to the body's tissues] . . .4. Facility elopement/neglect concern. . .Assessment: Second time patient has eloped from facility. Report filed for abuse and neglect per resident physician documentation." During an interview on 12/17/25 at 2 p.m. with DON, DON stated on 12/13/25 at approximately 9:52 p.m. the nurse called and reported Resident 1 was missing. DON stated Resident 1 was last seen by CNA 1 at approximately 8:45 p.m. DON stated the police were called and all staff were out looking for Resident 1. DON stated Resident 1 was found alive on 12/14/25 at approximately 7 a.m. a mile away in an empty lot. DON stated Resident 1 was found lying down and taken to the hospital and diagnosed with hypothermia. During an interview on 12/17/25 at 2:32 p.m. with Administrator, Administrator stated Resident 1 was reported missing on 12/13/25 at 9:15 p.m. Administrator stated Resident 1 was last seen by staff sitting on the edge of the bed at approximately 8:45 p.m. Administrator stated the police department found Resident 1 the next morning at 7:15 a.m. in a ravine hidden away approximately a mile from the facility. Administrator stated Resident 1 was missing approximately 10 hours and was admitted to the hospital for hypothermia. Administrator stated Resident 1 had a prior elopement attempt in June 2025. During an interview on 12/17/25 at 3 p.m. with DON, DON stated she did not know where Resident 1 exited the facility at but her best guess was the exit door closest to her room. DON stated Resident 1 was wearing a gray shirt, knit shawl and socks. DON stated when Resident 1 was found she was wearing socks and had no shoes. DON stated the temperature was in the 40's (Fahrenheit, cold) the night Resident 1 went missing. During an interview on 12/17/25 at 3:19 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated she was assigned to Resident 1 at the time the resident went missing. LVN 1 stated she was informed around 9 p.m. that Resident 1 was missing. LVN 1 stated staff looked for Resident 1 throughout the facility and were unable to locate her. LVN 1 stated she notified the DON and the police. LVN 1 stated she had last seen Resident 1 at approximately 6 p.m. walking in the hall towards the shower and Resident 1 was redirected back to her room. LVN 1 stated she did not know where Resident 1 exited the facility. During an interview on 12/17/25 at 4:01 p.m. with CNA 2, CNA 2 stated she was assigned to Resident 1 at the time she was discovered missing. CNA 2 stated she last seen Resident 1 during last rounds at approximately 8:45 p.m. CNA 2 stated she had seen Resident 1's feet and she had a blanket over her sitting on the bed. CNA 2 stated shortly after that, CNA 1 and her, went to Resident 1's room and noticed she was not there and immediately started looking for her. CNA 2 stated she did not know where Resident 1 exited the facility. During an interview on 12/18/25 at 1:48 p.m. with LVN 2, LVN 2 stated at times Resident 1 would peek out of her room to see who was in the hallway and wander in the facility looking at the doors. Resident 1 displayed exit seeking (attempt to leave) behavior. LVN 2 stated four days prior to 12/13/25 she last saw Resident 1 seeking to exit the facility. During an interview on 12/22/25 at 4:46 p.m. with CNA 1, CNA 1 stated she was assigned to Resident 1 on the night she went missing. CNA 1 stated she last saw Resident 1 sitting on her bed with her feet on the floor around 7 p.m. CNA 1 stated she went to break around 8:40 p.m. and when she returned, she helped another CNA with her rounds and then went to check on her residents. CNA 1 stated when she noticed Resident 1 was missing, she notified the other staff and began looking for her. CNA 1 stated she did not know where Resident 1 exited the facility. During an interview on 1/9/26 at 9:11 a.m. with Administrator, Administrator stated every hour on the POCRH, the task would appear for the staff to document the hourly monitoring that was to be completed for Resident 1. Administrator stated in the POCRH, the time in the monitoring was done but there was no ability to enter the physical whereabouts of Resident 1. Administrator stated he expected staff to complete the task and document it (monitoring and whereabouts) every one hour. During a review of the facility's policy and procedure (P&P) titled, "Elopements and Wandering Residents" dated 3/2025, the P&P indicated, "Wandering is random or repetitive locomotion that may be goal-directed (e.g., the person appears to be searching for something such as an exit) or non-goal directed or aimless. The facility shall establish and utilize systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. Monitoring and managing residents at risk for elopement or unsafe wandering. . .residents will be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the interdisciplinary care plan team. . .the interdisciplinary team will evaluate the unique factors contributing to risk in order to develop a person-centered care plan. . .interventions to increase staff awareness of the resident's risk associated with hazards will be added to the resident's care plan and communicated to appropriate staff. . .adequate supervision will be provided to help prevent accidents or elopements. . .charge nurses and unit managers will monitor the implementation of interventions, response to interventions, and document accordingly. . .the effectiveness of interventions will be evaluated, and changes will be made as needed." In violation of the above cited standards, the facility failed to ensure Resident 1's whereabouts were monitored. This failure resulted in staff being unaware of Resident 1 leaving the facility unaccompanied, missing for approximately 10 hours, exposing Resident 1 to environmental dangers, cold exposure and requiring hospitalization. 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.