Health inspection·January 6, 2026

Title 42, Quality of care, Section 483.25 Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices, including but not limited to the following: (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 42, Comprehensive person-centered care planning, Section 483.21 (b) Comprehensive Care Plans (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. Title 22, Nursing Service-General, Section 72311 (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. Title 22, Patient Care Policies and Procedures, Section 72523 (a)Written patient care policies and procedures shall be established and implemented to ensure that patient-related goals and facility objectives are achieved. On 11/24/25, at 7:40 a.m., an unannounced visit was conducted at the facility to investigate a facility reported incident regarding an elopement of Patient 1 from the facility on 11/17/25 at approximately 4 a.m. The Department determined that the facility failed to provide adequate supervision to prevent patients from leaving the facility without staff knowledge. This failure led to Patient 1 leaving the facility undetected. The patient fell and sustained abrasions and scrapes to his hands and knee with additional exposure to the cold and rain and had the potential to cause major injury and possible death. Patient 1 was admitted to the facility in the fall of 2025 with diagnoses which included traumatic brain injury (an injury to the brain caused by a sudden bump, or jolt to the head, which can disrupt its normal function), muscle weakness, and difficulty walking. A review of Patient 1's Minimum Data Set (MDS, an assessment tool), dated 11/6/25, indicated Patient 1 had moderate impairment of his memory and was independent with most activities of daily living (ADLs). A review of Patient 1's document titled "FALL RISK EVAL [FRE, fall risk evaluation]," dated 10/30/25, indicated Patient 1 had intermittent confusion. A review of Patient 1's document titled "Wandering Risk Assessment [WRA]," dated 11/3/25, indicated "Resident [Patient] LACKS capacity to understand and make decisions...low to moderate risk of elopement..." A review of Patient 1's document titled "Progress Notes [PN]," dated 11/17/25, indicated "It was reported by [Licensed Nurse (LN) 1] at 4:30 a.m. while doing rounds the CNA [Certified Nurse's Assistant 1] identified [Patient 1] as missing...the last time she had a visual check on [Patient 1] was 3:30 a.m. Staff immediately following (sic) missing [patient] protocol...without success...[Patient 1] was located by staff members [family member] around 8:15 am...the charge [LN 1] did a body check on [patient] he has several abrasions...he stated he left the facility around 4am and headed to his home...he also stated he had several falls while he walked..." A review of Patient 1's facility "Discharge Instruction Form [DIF]," dated 11/17/25, indicated "[right] hand, scattered abrasions...Scrape to [right] knee, outside area of [right] foot, reddened area to [left] great toe..." During an interview on 11/24/25 at 8:34 a.m., CNA 2 indicated "[Patient 1] was more unsteady when he returned. I heard he left about three or four in the morning...He came back [11/17/25] around 8:45 a.m. [with a staff family member by car] soaking wet, was very cold...He was a little confused and a little unsteady. He had scratches on his right hand like he had fallen. They were fresh. There were scratches on his left knee, too...He never mentioned why he left. He mentioned he wanted to get keys for the church...The same day he left it was pouring [rain]..." During an interview on 11/24/25 at 12:04 p.m., the Director of Nurses (DON) said, "My expectation is to keep all our residents safe. [Patient 1's] long-term memory is good, but his short-term memory is bad. He thought the scratches were from an old motorcycle accident..." During an interview on 12/25/25 at 6:52 a.m., LN 1 said, "At 3:30 to 4 in the morning [11/17/25], [CNA 1] told me [Patient 1] was not in his room...He was found at the post office of [name of town]. It's about half an hour from here. He may have got a ride or walked there. We don't know..." During a review of the facility policy and procedure (P&P) titled "Safety and Supervision of [Patients]," dated 2001, the P&P indicated "[Patient] safety and supervision and assistance to prevent accidents are facility wide priorities." Therefore, the department determined that the facility failed to provide adequate supervision to prevent patients from leaving the facility without staff knowledge. This failure led to Patient 1 leaving the facility undetected. The patient fell and sustained abrasions and scrapes to his hands and knee with additional exposure to the cold and rain. This violation had a direct or immediate relationship to the health, safety, or security of a long-term facility patient.