Health inspection·December 24, 2025

42 C.F.R. § 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. Cal. Code Regs., tit. 22, § 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: (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. Cal. Code Regs., tit. 22, § 72313. Nursing Service--Administration of Medications and Treatments. (a) Medications and treatments shall be administered as follows: (2) Medications and treatments shall be administered as prescribed. (6) Medications shall be administered as soon as possible, but no more than two hours after doses are prepared, and shall be administered by the same person who prepares the doses for administration. Doses shall be administered within one hour of the prescribed time unless otherwise indicated by the prescriber. (c) The time and dose of the drug or treatment administered to the patient shall be recorded in the patient's individual medication record by the person who administers the drug or treatment. Recording shall include the date, the time and the dosage of the medication or type of the treatment. Initials may be used, provided that the signature of the person administering the medication or treatment is also recorded on the medication or treatment record. Cal. Code Regs., tit. 22, § 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. (b) All policies and procedures required of these regulations shall be in writing, made available upon request to physicians and other involved health professionals, patients or their representatives, employees and the public shall be carried out as written. Policies and procedures shall be reviewed at least annually, revised as needed and approved in writing by the patient care policy committee. On 11/05/2025, the California Department of Public Health (CDPH) received a facility reported incident (FRI) indicating Resident 1 eloped from the facility on 11/04/2024 at approximately 8:30 p.m. On 11/06/2024, at 6:55 a.m., CDPH conducted an unannounced visit to the facility to investigate the FRI. Upon investigation, it was determined the facility failed to: 1. Provide a safe environment and adequate supervision since there is no system in place to monitor the facility's front door after 6:30 pm during times when the receptionist was not present to prevent residents from leaving the facility without staff knowledge. 2. Identify Resident 1's care needs and develop a care plan based upon an accurate elopement risk assessment when Resident 1 was incorrectly assessed as low risk for elopement due to being unable to ambulate (walk) and unable to self-propel a wheelchair. The general acute care hospital (GACH) 1, facility records, and interviews indicated that Resident 1 required minimal assistance with ambulation using a front wheel walker (FWW). 3. Provide adequate supervision for residents when facility staff prop open doors and do not respond to door alarms. CDPH observed an emergency exit door alarm, located at Station 3, ring for eight minutes on 11/7/2025 with no staff response to ensure the door was secure and no residents had eloped. 4. Follow the facility's policies and procedures for "Wandering and Elopement." 5. Ensure timely administration of medications as ordered by the physician for Resident 1. Resident 1 was admitted on 11/3/2025, but the physician's medication orders were not entered into the system until 11/4/2025, resulting in Resident 1 missing his scheduled morning medications on 11/4/2025. As a result of these deficient practices, Resident 1 eloped from the facility on 11/4/2025 at approximately 8:00 p.m. On 11/4/2025 Resident 1 was found at a local restaurant located approximately one mile away from the facility. While at the restaurant Resident 1 complained of shortness of breath, 911 was called and the resident was transported to GACH 2. Upon arrival at GACH 2 on the same day at 11:04 p.m., Resident 1 experienced a cardiac arrest and was pronounced dead on 11/4/2025 at 11:39 pm. A review of Resident 1's Admission Record, the Admission Record indicated Resident 1 was admitted from GACH 1 to the facility on 11/03/2025 with the diagnosis including acute myocardial infarction, presence of coronary angioplasty implant and graft, heart failure, chronic obstructive pulmonary disease (COPD) and psychosis. A review of GACH 1's Physical Therapy (PT) Assessment dated 10/31/2025, indicated Resident 1 was alert, able to ambulate 10 feet (ft) with FWW. The PT Assessment indicated Resident 1's gait was slow, and Resident 1 complained of fatigue. A review of Resident 1's Joint Mobility Screening dated 11/04/2025 indicated Resident 1 had full range of motion to bilateral upper extremities and bilateral lower extremities. A review of Resident 1's Occupational Therapy (OT) Evaluation dated 11/04/2025 indicated Resident 1 had excellent rehab potential as evidenced by the ability to follow multi-step directions, active participation in skilled treatment and a high prior level of function. A review of Resident1's Transfer Reposition Assessment dated 11/04/2025, indicated Resident 1 was able to bear weight on both legs and Resident 1 was able to consistently perform a stand and pivot transfer with limited assistance. A review of Resident 1's Admission Assessment dated 11/04/2025, indicated Resident 1 was alert to person, had clear speech, was able to follow simple commands, and make his needs known, he was able to understand others. The Admission Assessment indicated Resident 1 was confused with poor safety judgement. The Admission Assessment indicated Resident 1 did not use any assistive devices for ambulation. A review of Resident1's Elopement Risk Assessment, dated 11/04/2025, indicated Resident 1 could not walk or self-propel wheelchair independently. A review of Resident 1's Order Summary Report dated 11/07/2025, indicated Resident 1 was prescribed the following medications on 11/04/2025: 1. Aspirin 81miligrams (mg) once a day for cerebral vascular accident (CVA-stroke, loss of blood flow to a part of the brain). 2. Atorvastatin 80 mg give at bedtime for hyperlipidemia ( high cholesterol). 3. Carvedilol 3.125 mg twice a day for hypertension (high blood pressure). 4. Clopidogrel 75 mg once a day for deep vein thrombosis (DVT- blood clot). 5. Levetiracetam 500 mg every 12 hours (hrs.) for seizure disorder (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness). 6. Olanzapine 10 mg at bedtime for psychotic behavior. 7. Pantoprazole 40 mg in the morning for gastroesophageal reflux disease (GERD- burning sensation in the chest heartburn). 8. Spironolactone 25 mg once a day for heart failure (heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen). There is no record that Resident 1 received the prescribed medication while at the facility. A review of Resident 1's Change of Condition (COC) Evaluation dated 11/04/2025, indicated Resident 1 was last seen at 7:20 p.m. on 11/04/2025 in his room. The COC also indicated that at 8:30 p.m. was when staff first noticed that Resident 1 had eloped from the facility. A review of Resident1's GACH 2's Emergency Room (ER) Record dated 11/4/2025, indicated Resident 1 was found at local restaurant located approximately one mile away from the facility. Resident 1 complained of shortness of breath while in the restaurant. 911 was called and Resident 1 was transported to GACH 2. The GACH 2's Emergency Room Record indicated Resident 1 arrived at GACH 2 at 11:04 p.m., experienced a cardiac arrest and was pronounced dead on 11/4/2025 at 11:39 pm. During a phone interview on 11/07/2025 at 11:18 a.m., Licensed Vocational Nurse (LVN) 4, stated she cared for Resident 1 on 11/03/2025 and first saw the resident around 11:30 p.m. in bed. LVN 4 stated she was unable to locate Resident 1's admission packet (hospital orders) and therefore did not enter any of the resident's medications into the electronic system. During an interview on 11/07/2025 at 1:59 p.m., with Registered Nurse Supervisor (RNS) 1, stated she began entering Resident 1's medication orders into the electronic system on 11/04/2025. RNS 1 stated Resident 1 arrived at the facility on 11/03/2025, but no arrival time was documented. RNS 1 stated the LVN should have entered the medication orders upon the resident's arrival, and the delay resulted in a delay in administration of Resident 1's medication. RNS 1 stated Resident 1 did not received his morning scheduled medication 11/4/2025. During an interview on 11/09/2025 at 12:27 p.m., the Administrator (ADM), stated that medications should be ordered immediately upon a resident's arrival to ensure timely care and meet the resident's medical needs. During a phone interview on 11/07/2025 at 11:32 a.m. CNA 4 stated she was responsible for Resident 1 on the night Resident 1 went missing. CNA 4 stated the last time she saw Resident 1 was around 7:30 p.m., at which time Resident 1 was in his bed. CNA 4 stated she believed Resident 1 exited through the front door. CNA 4 stated the front door locks from the outside but can easily be opened from the inside, as there was no alarm system in place. CNA 4 stated because staff were often busy, it was difficult to monitor the front door consistently. During a concurrent interview and record review on 11/7/2025 at 12:03 p.m. with the Physical Therapy Director (PTD), Resident1's Joint Mobility Screening dated 11/04/2025 was reviewed. The PTD stated she had completed the assessment and stated Resident 1 demonstrated full range of motion in both upper and lower extremities. PTD stated Resident 1 was able to walk to the bathroom using a FWW with minimal assistance but required frequent safety cues due to being impulsive while walking. During a concurrent interview and record review on 11/7/2025 at 1:59 p.m. with RNS 1, Resident 1's Elopement Risk Assessment dated 11/04/2025 and GACH 1's PT notes dated 10/31/2025 were reviewed. RNS 1 stated she had completed the Elopement Risk Assessment for Resident 1. RNS 1 stated that prior to completing the assessment, she interviewed Resident 1 and reviewed Resident 1's GACH 1's record. RNS 1 stated she observed Resident 1 was unresponsive, only answering questions selectively. RNS 1 stated she observed Resident 1's arms were moving erratically, and when asked if he could walk, Resident 1 did not provide a clear yes or no response. RNS 1 stated based on her observations, Resident 1 was non-ambulatory (not walking) and unable to self-propel in a wheelchair. RNS 1 stated that "in her assessment, he looked like he could not walk." RNS 1 stated she did not review the PT's notes from GACH 1's, which indicated that Resident 1 was able to ambulate with a FWW with minimal assistance. RNS 1 stated that had she known Resident 1 was ambulatory, she would have assessed Resident 1 as high risk for elopement and implemented appropriate interventions to alert staff. RNS 1 stated Resident 1's elopement was avoidable and that staff should have been more attentive to his condition and risk level. During a concurrent interview and record review on 11/8/2025 at 8:22 a.m. with RNS 2 Resident 1's Elopement Risk Assessment dated 11/04/2025 and GACH 1's PT notes dated 10/31/2025 were reviewed. RNS 2 stated that RNS 1 inaccurately assessed Resident 1 on 11/4/2025 as not being at risk for elopement. RNS 2 stated based on the available information, Resident 1 should have been assessed as high risk for elopement. RNS 2 stated when a resident was identified as high risk for elopement, the facility was expected to implement specific interventions, including placement of an elopement bracelet on the resident, room assignment near the nurses' station, facility-wide staff notification regarding the resident's elopement risk and frequent visual checks, typically every 15 minutes. RNS 2 stated the facility failed Resident 1 by not identifying and addressing his elopement risk appropriately. RNS 2 stated concern about the front door security, stating that when the lobby was closed, the facility relies on Station 1 staff to monitor the front door, even though there was no alarm system to alert staff if someone exits. RNS 2 stated any resident can simply push the door open, and that staff are often too busy providing care to continuously monitor the front entrance. During an interview on 11 /09/2025 at 12:27 p.m., the ADM stated that she believed Resident 1 eloped through the front door. The ADM stated the front door was not equipped with an alarm system, and the facility relies on staff at Station 1 to monitor the door. The ADM stated Resident 1's elopement was avoidable, if staff had been more vigilant in monitoring the front door, and if the elopement risk assessment had been completed accurately, appropriate interventions could have been implemented to better monitor Resident 1. The ADM stated, "I'm sure the outcome would have been different." During an observation on 11/07/2025 at 6:55 a.m. at the facility entrance, the front door was observed propped open with a box of gloves, and the lobby area was unsupervised, with no staff present to monitor the entrance. During a concurrent observation and interview on 11/07/2025 at 7:02 a.m. at the facility's front entrance, Certified Nursing Assistant (CNA) 1 stated the front door should remain closed, as it locks from the outside and was equipped with a doorbell. CNA 1 stated Station 1 staff were responsible for opening the door for staff entering the facility. CNA 1 stated a box of gloves had been used to prop the door open so that staff would not have to repeatedly open it for incoming facility staff. CNA 2 further stated leaving the door open without supervision posed a risk, as residents could potentially exit the facility unsupervised, and unauthorized individuals could enter, creating significant safety concern. During an observation on 11/07/2025 at 7:10 a.m., the emergency exit door located in Station 3 was observed alarming. The alarm continued to sound until 7:18 a.m., when CNA 2 arrived and turned off the alarm and secured the door. During an observation on 11/07/2025 at 7:17 a.m. at Nursing Station 3, CNA 2, CNA 3, and Licensed Vocational Nurse (LVN) 1 were observed sitting at the nursing station and conversing with one another, while the emergency exit door alarm on Nursing Station 3 continued to sound. During an interview on 11/07/2025 at 7:20 a.m., CNA 2 stated he did not have the key to turn off the emergency door alarm and only LVNs were authorized to do so. CNA 2 stated CNAs were not permitted to touch the alarms. CNA 2 stated a resident could have pushed the door open and exited the facility, as the door locks from the outside and alarms when opened from the inside. During an interview on 11/07/2025 at 7:25 a.m., CNA 3 stated LVNs were responsible for silencing the emergency exit door alarms because they have the keys. CNA 3 stated she could not locate the LVN to inform her about the alarm sounding. CNA 3 stated she should have che