Health inspection·February 20, 2026

California Code of 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. California Code of Regulations, Title 22, Section 72311(a)(1)(A)(B)(C)(2), Nursing Service - General (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include, but not be limited to, 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 i s a change in the patient's condition. (2) Implementing each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. 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 1/15/26 at 11:11 a.m., the California Department of Public Health (the Department) conducted an unannounced visit at the facility to investigate an entity reported incident regarding Resident 1's (Patient 1) elopement (the act of leaving a facility unsupervised and without prior authorization) from the facility. As a result of the investigation. the department determined the facility failed to ensure patient safety when the facility did not provide adequate monitoring and supervision of Patient 1. These failures led to Patient 1 eloping from the facility and reducing the facility's potential in keeping Patient 1 safe from harm. Review of Patient 1's "Admission Record," indicated Patient 1 was admitted in September of 2024 with diagnoses including unspecified dementia (memory loss), with anxiety (persistent, excessive fear or worry), and mood disturbance (intense, persistent, and disruptive changes in emotional state). Review of Patient 1's "Order Summary" dated 1/10/26 indicated, "Check placement of wander guard [an alarm system for wandering patients attached as a bracelet that triggers alarms and secure doors alerting staff to prevent elopement] located on left ankle every shift, monitor skin and notify MD [physician] as needed." Review of Patient 1's "Minimum Data Set" (MDS-a federally mandated resident assessment tool), dated 6/5/25 indicated Patient 1 had severe cognitive (memory) impairment. Review of Patient 1's "Care plan" (CP) initiated 9/19/24, indicated that Patient 1 had an elopement score of 14 (very high elopement risk), a goal: Patient will not leave the facility without a responsible party and an intervention: assure identification band or other form of identification is in place. During an interview on 1/15/26 at 11:18 a.m., the Director of Staff Development (DSD), stated she was not here the day Patient 1 eloped but did investigate this incident. DSD stated that Patient 1 walked out the back door, left the dining room and looked in offices and went out to the smoking area. DSD also stated, Resident 1 turned around and went out of the gate to the apartments behind the facility and got in a vehicle. DSD further stated, Resident 1 went to the next apartment building, and an apartment resident called 911 (emergency medical services), and Resident 1 was returned to the facility. During an interview on 1/15/26 at 12:17 p.m., Licensed Nurse (LN) 1 stated, Patient 1 would frequently try to elope and would take off the wander guard. During an interview on 1/15/26 at 12:46 p.m., LN 2, stated she was there the day Patient 1 eloped from the facility. LN 2 stated she did not hear an alarm go off. LN 2 stated that Patient 1 has tried to elope before and will wiggle out or cut off his wander guard. During a concurrent observation and interview on 1/15/26 at 2:19 p.m. in Patient 1's room with LN 1, Patient 1 was observed not wearing an identification band and LN 1 confirmed this finding. During an interview on 1/15/26 at 2:30 p.m., the Director of Nursing (DON) acknowledged that a wander guard is only effective when a resident is wearing it and that residents have the right to be safe in the facility. Review of the facility policy (P&P) titled, "Wandering and Elopements" dated March 2019, indicated, "The facility will identify residents [patients] who are at risk of unsafe wandering and strive to prevent harm..." Therefore, the department determined the facility failed to ensure patient safety when the facility did not provide adequate monitoring and supervision of Patient 1. These failures led to Patient 1 eloping from the facility and reducing the facility's potential in keeping Patient 1 safe from harm. This violation had a direct or immediate relationship to the health, safety, or security of Long-Term Care patients or residents.