Health inspection·September 22, 2025

Title 42 Code of Federal Regulations §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 22 Code of California Regulations §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: (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. §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. The facility failed to ensure a resident received adequate supervision to prevent an elopement for one of three sampled residents (Resident 1) when Resident 1 eloped and was found on the street having sustained several injuries. FINDINGS: Review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 8/6/24, indicated Resident 1 had severe impairment in daily decision-making skills. Review of Resident 1's Nurse's Note, dated 6/22/25, at 2:43 p.m., indicated Resident 1 was alert with confusion, had an episode of going to another resident's room, and tried to awaken a resident by touching and shaking. Review of Resident 1's care plan, dated 6/22/25, indicated that staff were to monitor Resident 1's behavior of going to other residents' rooms, with an approach to redirect Resident 1 back to her room or activity room. On 6/24/25, a care plan was developed addressing that Resident 1 was at risk for elopement/wandering related to dementia (loss of memory, language, problem-solving and other thinking abilities severe enough to interfere with daily life) with an approach to monitor whereabouts frequently. However, the care plan did not specify how often to monitor. On 6/30/25, another care plan was developed indicating that a wander guard (device to put on a resident to prevent elopement) was placed on Resident 1's right wrist to alert staff whenever Resident 1 attempted to leave alarmed exits. Review of the Nurse's Note, dated 8/5/25, at 7:25 p.m., indicated that around 6:20 p.m., Resident 1 was missing greater than 15 minutes. Around 8:30 p.m., a staff member found Resident 1 on the ground in a parking lot across a bookstore and had sustained a bump on her forehead, abrasion on left knee, and bruise on left elbow. Review of the Interdisciplinary Team (IDT, members of health team that meet to discuss and plan resident care) Note, dated 8/6/25, at 1:59 p.m., indicated that Resident 1 was unable to recall the incident, ambulate by herself and had poor safety awareness. The IDT Note indicated that staff were to ensure that Resident 1 was wearing an active wander guard, and along with approaches to monitor hourly with frequent check. The IDT Note also indicated the change room near the nursing station. During an interview on 8/14/25, at 12:25 p.m., Resident 1 did not respond when she was asked about her elopement. During an interview on 8/18/25, at 1:20 p.m., the Director of Nurses (DON) who reviewed the record stated Resident 1 was not placed on hourly or more frequent monitoring until after the elopement (8/6/25) because she did not have the behavior of trying to leave and she did not think Resident 1 would elope despite Resident 1's June 2025 care plans. On 8/18/25, at 3 p.m., an interview and tour of the facility was conducted with the maintenance director (MD). The MD stated he reviewed the facility's cameras for about six hours to figure out how Resident 1 eloped and discovered that, she exited from the assisted living second floor (AL2) and walked along the building because she was found near a bookstore in that direction. The tour included the path from Resident 1's unit to the exit outside the facility (AL2); from St Dominic Unit to St Katherine Unit, to AL2, which had five turns in the facility. The MD then confirmed there were no alarms at St Dominic, St Katherine and AL2. The MD stated on 8/7/25 (day after elopement), a wander guard alarm was installed to the exit door of AL2. The path to where Resident 1 exited showed the final turn in AL2 was a long hallway where assisted living residents resided. The AL2 door led to a concrete stairway with a landing in the middle of stairs, at the bottom of the stairs to the left was a metal grate approximately three feet in height, and to the left was the ALS building in a forest like secluded setting with redwood trees that led to a side street. The MD stated Resident 1's elopement path in the building was about five blocks long. The path along the building from AL2 to the street was at least two city blocks in length. Resident 1's wander guard alarm did not sound during elopement because there were no installed alarms on the route where she walked. During an observation at the time of the tour on 8/18/25, at 3 p.m., the alarm to AL2 was activated and it took four minutes and 45 seconds for the assisted living supervisor (ALS) to respond. The MD then acknowledged the response time was long. During an interview on 8/18/25, at 3:19 p.m., the Assisted Living Supervisor stated some skilled nursing facility residents dine and attend activities in AL2, but she did not know which residents were confused, and if a confused resident asked for help they would call the nurse's station. Review of the facility and Assisted Living floor plan with the MD on 8/20/25, at 4 p.m., indicated there were eleven exits outside the facility, and five exits to the first floor of assisted living were not alarmed. During an interview on 8/20/25, at 4 p.m., the assistant director of nurses (ADON) stated any exit door for a confused resident was not safe and the nursing staff should have monitored the residents to prevent elopement. Review of the Elopement policy, revised April 2021, did not provide guidance for what to do to prevent elopement. The facility failed to ensure a resident received adequate supervision to prevent an elopement for one of three sampled residents (Resident 1) when Resident 1 eloped and was found on the street having sustained several injuries. These failures had direct relationship or immediate relationship to health, and safety of Resident 1.