Health inspection·February 12, 2026

REGULATION VIOLATION: Title 42 of the Federal Code of Regulations: 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. Title 22 California Code of Regulations: 72311. Nursing Service - General. (a) Nursing service shall include, but not be limited to, the following: (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. Findings: On January 7, 2026, a complaint investigation was conducted during a federal recertification survey regarding an elopement incident involving Patient 175. On January 7, 2026, at 7:30 AM, video surveillance footage showed Patient 175 exiting his room without staff supervision, walking unassisted down the hallway, approaching an alarmed emergency exit door, opening the door, and exiting the facility without staff intervention. Facility leadership, including Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), and Director of Clinical Operations (DCO), acknowledged that the video surveillance did not show any staff responding to stop Patient 175, or following the patient to ensure his safety. Patient 175 was later found by local law enforcement approximately one mile from the facility and was transported to the hospital by ambulance. The facility failed to: 1. Provide adequate supervision for Patient 175, who was assessed to be at high risk for falls and required supervision due to Parkinson's disease ((a disorder that causes tremors, slowed movement, poor balance, and difficulty with walking and coordination, increasing fall and wandering risks)), history of cerebrovascular accident (stroke), impaired balance, and cognitive impairment. 2. Implement the facility's elopement prevention policy and procedure, as evidenced by staff not responding to an activated emergency exit alarm or intervening to prevent Patient 175 from exiting the facility. 3. Implement Patient 175's individualized care plan interventions related to supervision and safety. These failures resulted in Patient 175's elopement on January 6, 2025, which placed him at risk for serious injury including falls, traffic injury, environmental exposure and inability to seek assistance. Patient 175 was found by the local law enforcement approximately one mile from the facility. The hospital's emergency report for Patient 175 noted abrasions (injury to the surface of the skin caused by rubbing or impact) to bilateral (both) knees and bilateral feet, as well as bruising (bleeding under the skin caused by an injury, which can indicate tissue damage or internal bleeding) to left hip. A review of Patient 175's "Admission Record" (contains demographic and medical information), indicated Patient 175 was admitted to the facility on January 2, 2026, with diagnoses which included Parkinson's disease (a disorder that causes tremors, slowed movement, poor balance, and difficulty with walking and coordination, increasing fall and wandering risks) sequelae of cerebral infarction (a long term brain damage from prior stroke that can cause weakness, impaired judgment, confusion and poor safety awareness) and lack of coordination (difficulty controlling body movements ad balance, making walking unsafe and increasing risk for falls and injury). During a review of Patient 175's "MDS" (Minimum Data Set - a standardized assessment tool that measures health status in nursing home patients) Section C (Cognitive (involving conscious intellectual activity) patterns), dated January 6, 2026, indicated Patient 175 had a BIMS (brief Interview for Mental Status - tool used to screen how a patient is functioning cognitively) score of 12 (a BIMS score of 8-12 suggests patient is moderately impaired). During a continued review of Patient 175's "MDS, Section GG (Functional Abilities)" dated January 6, 2026, indicated: "...J. Walk 50 feet with two turns: Once standing, the ability to walk at least 50 feet (about 15 meters) and make two turns," coded "88" (Not attempted due to medical condition or safety concerns), "...K. Walk 150 feet: Once standing, the ability to walk at least 150 feet (about 46 meters) in a corridor or similar space," coded "88", "...L. Walking 10 feet on uneven surfaces: The ability to walk 10 feet on uneven or sloping surface (indoor or outdoor), such as turf or gravel," was coded "88", "...M. 1 step (curb): The ability to go up and down a curb and/or up and down one step," was coded "88". During a review of a document titled, "SOC 341" (a document used by mandated reporters to document and report suspected abuse (physical, financial, neglect, etc.) of elders (60+ years old) or dependent adults (18-59 years old)), dated January 7, 2026, the "SOC 341" indicated, "Patient (Pt - Patient 175), was brought in by ambulance and [name of local police department] (PD) after being found in the "The Wash"(a natural drainage channel or wash that runs through the city, used for flood control). Per PD, they received a call for service about Pt waking in a hospital gown and socks with blood on him. PD received a second call indicating Pt was seen in "the wash". PD confirmed to have located Pt in "the wash" a mile down from [name of the facility]. PD contacted the facility and drove to the facility to confirm Pt was from the facility. Per PD, Staff reported Pt was last seen 7-8 hours prior to being found. Per PD, staff was unable to inform PD when and how Pt was able to leave the facility. Per PD, staff reported Pt has history of Parkinson's, Dementia (decline in mental abilities), and is a fall risk." During an interview on January 7, 2026, at 2:26 PM, with the Administrator (ADMIN), in her office, the ADMIN stated, Patient 175 was admitted to the facility on January 2, 2026, with medical diagnoses of Parkinson's disease and dysphagia (difficulty swallowing). The ADMIN further stated in the morning of January 7, 2026, Patient 175 informed his nurse that he wanted to go out to "get some fresh air." ADMIN further stated she was made aware of Patient 175 being transported to the hospital at approximately 9:30 AM after the local police arrived at the facility. During an interview on January 7, 2026, at 2:34 PM, with the Licensed Vocational Nurse / Treatment Nurse (LVN 1), the LVN 1 stated Patient 175 was admitted on "January 1 or 2, of 2026". LVN 1 stated the last time she saw Patient 175 was in the hallway "walking with his wheelchair." LVN 1 stated Patient 175 appeared to be thinking about what he was going to do but not headed in any specific direction. LVN 1 stated Patient 175 was alert, oriented (a person who is aware of their identity, surroundings, and the current time), and ambulatory (a person who can walk or move independently). LVN 1 stated she was not aware of any behavioral issues, or special safety precautions in place for Patient 175. LVN 1 stated Patient 175 had a history of homelessness and had not observed any elopement behavior. During a further interview on January 7, 2026, at 2:36 PM, with LVN 1, LVN 1 stated Patient 175 had told his nurse (LVN 3) he wanted to go outside "to get some fresh air" and an "Out on pass" (OOP - a formal physician's authorization for patients to temporarily leave for a set period of time) physician's order was obtained, and she was the nurse who obtained the order. Subsequently, during a concurrent interview and record review conducted on January 7, 2026, at 2:38 PM, with LVN 1, Patient 175's OOP order dated January 7, 2026, at 10:21 AM (at approximately 3 hours after Patient 175 left the building), was reviewed. The OOP order indicated, "May go out on pass for 4 hours." LVN 1 stated the OOP order was entered after Patient 175 had already exited the facility and there was no previous order for Patient 175 to be on out on pass. During an interview on January 7, 2026, at 4:07 PM, with the acute hospital Social Worker (SW). The SW stated Patient 175 arrived at the hospital at approximately 9:15 AM, on January 7, 2026. The SW stated the Police Department received a call reporting that an individual was walking down the street on a hospital gown and socks, with blood on them, which caused concern. The SW stated two vehicles were sent to search for the individual. The SW further stated that law enforcement initially searched for the individual but did not locate him. Later, PD received a second call reporting that (Patient 175) was in "the wash." The SW further stated PD found Patient 175 with lacerations on his feet and on his knees. He also had a large bruise on his left hip. The SW stated Patient 175 was found approximately one mile away from the facility. The law enforcement went to the facility and confirmed Patient 175 "belonged to them." The facility informed PD Patient 175 had Parkinson's disease, dementia, and was at risk for falls. During an interview on January 7, 2026, at 4:25 PM, with the Director of Nursing (DON), the DON confirmed Patient 175 was admitted to the facility on January 2, 2026, with medical diagnoses of Parkinson's disease and dysphagia, and that he was "ambulatory with assistance (capable of walking or moving around but requires help from another person or a device such as a walker or cane)." The DON confirmed that the admission assessment was completed upon admission. During a concurrent interview and record review on January 7, 2026, at 4:38 PM, with the DON, DON reviewed Patient 175's "Nursing - Fall Risk Evaluation," dated January 2, 2026, at 10:41 PM. The evaluation indicated Patient 175 fall score was "14, ... Category: high fall risk... 1. Mental status: 2. disoriented x 3 (person, place, and time) ... 2. History of Falls: 3 or more falls in the past 90 days... 3. Ambulatory/Continence: 2. Wheelchair/bed bound (assist with elimination) ..." The "Fall Risk Evaluation" also indicated Patient 175 had diagnoses that could contribute to falls, and was taking 1 or 2 medications within the last seven days that could increase the risk of fall. The DON confirmed the evaluation indicated that Patient 175 was disoriented, had a history of multiple falls, and required assistance for mobility. During a review of Patient 175's "Change in Condition Evaluation," dated January 7, 2026, at 9:27 AM, it indicated "1. Signs and Symptoms identified... 31. Other change in condition, ...1a. List the other change: resident (Patient 175) had a fall outside, ... 3. Review Findings and Provider Notifications... 4. Summarize your observations evaluation and recommendations: resident had stated to staff that (he) wanted to go outside for some fresh air. Upon this walk he fell into the driveway of the facility. A police car was pass by and assisted the resident. They (the police) decided to all (call) the 911 and send the resident to the hospital despite us advising them we had the means to care for the resident in house." Patient 175's "Change in Condition Evaluation," indicated vital signs (blood pressure, temperature, respiration, heart rate) were taken at the facility at 9:35 AM and the physician was notified on January 7, 2026, at 00:00 (midnight), the evaluation was signed by LVN 1. During a review of Patient 175's "Nursing Admit/Readmit Data Collection and Baseline," dated January 2, 2026, at 10:38 PM, it indicated, "A. Admission Information... N. Pertinent diagnosis (es): CVA (Cerebral Vascular Accident - stroke) with mild right-side weakness, ... 2. LOC (Level of Consciousness)/Orientation A. LOC... 1. Alert... B. Orientation, 1. Person (Self), 2. Place (location)... 4. Skin condition, ...40) left knee (rear): scattered (different areas) scabs, no open areas, ... 41) Right lower leg (front): scattered scabs no open areas..., 5. Pain/Fall Risk... Fall Risk... A. Is the Patient at risk for falls? 1. Yes... A1. Fall Care Plan... Goal: The resident's risk for injury will be minimized through the review date... Interventions: Ensure that the patient is wearing appropriate footwear when ambulation or mobilizing in w/c (wheelchair)." During a concurrent interview and record review on January 7, 2026, at 4:35 PM, with the DON, the DON confirmed that the SBAR (Situation, Background, Assessment, Recommendation - used to standardize and improve the clarity of information exchange between healthcare professionals), dated January 7, 2026, was completed by LVN 1 after the facility was contacted by law enforcement. The DON further confirmed there was no prior SBAR documentation indicating Patient 175's ability to leave the facility safely nor being assessed or approved by a physician. During a review of Patient 175's hospitals record provided by the facility, titled, "Fall Risk Assessment" (Morse Fall Scale - a tool healthcare providers use to predict a patient's likelihood of falling), dated January 7, 2026, at 09:16 AM, the record indicted Patient 175's Morse Fall Risk Score was assessed as "55" (High fall risk) During a review of Patient175's facility provided hospital records, the "ED (Emergency Department) provider Notes," dated January 7, 2026, at 9:38 AM, indicated, Patient 175 had "a past medical history of stroke, COPD, (chronic obstructive pulmonary disease, a long - term lung disease that makes it hard to breath), Parkinson's, type 2 DM (Type 2 diabetes mellitus, a chronic condition where the body does not properly use insulin, causing high blood sugar), chronic anemia (a long term condition where the blood does not carry enough oxygen), CKD, (Chronic Kidney Disease - a long term condition where the kidneys do not work properly), paroxysmal A-fib (atrial fibrillation - an irregular heart rhythm that comes and goes, which causes dizziness) and hypertension (high blood pressure) is brought in by ambulance after law enforcement found patient walking outside in the cold this morning... Patient (Patient 175) has abrasions (injury to the surface of the skin cause by rubbing or impact) to bilateral (both) knees and bilateral feet, as well as bruising (bleeding under the skin caused by an injury, which can indicate tissue damage or internal bleeding) to left hip... Social history, alcohol use: Comment: patient confused no family at bedside..." Physical Exam indicated, "Skin... abrasions are present to bilateral knees and feet... There is bruising to the left hip (pictures were included in the ED report)". During an observation on January 7, 2026, at 6:38 PM, with the ADMIN, in the presence of the DON, Assistant Director of Nursing (ADON), and Director of Clinical Operations (DCO), the facility 's video surveillance system footage was reviewed. The surveillance system video showed on January 7, 2026, at approximately 7:30 AM, Patient 175 exited his room wearing a white T-shirt, blue hospital-like pajama pants, and socks. Patient 175 began walking down the hallway toward the rear emergency exit. Two nursing staff were standing near nurses' station by the hallway where Patient 175 was walking. The video showed Patient 175 walking directly past the two-nursing staff without any staff approaching, speaking to, re-directing or accompanying the patient. The video then showed Patient 175 approached the rear emergency exit door, which was marked with a "STOP" and "Emergency Exit Only" signage, equipped with a push-bar exit mechanism, and an audible alarm system that requires a key to silence. Patient 175 removed the elastic band that had been placed across the door, pushed the alarmed exit door open, and exited the building without staff assistance or supervision. After exiting the building, Patient 175 was observed on video walking outside the facility toward the front of the building (by the main street), with an unsteady gait (a manner of walking or moving on foot) appearing off balance, but continued walking away from the facility. The video showed: i. 7:30 AM Patient 175 exited his room ii. 7:32 AM Patient 175 passed through the front parking lot iii. 7:34 AM Patient 175 cont