Health inspection·July 23, 2025

§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. §483.21(b) Comprehensive Care Plans §483.21(b)(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 as required under §483.24, §483.25 or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). §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 (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. On 6/6/2025, the California Department of Public Health (CDPH) received a complaint alleging a confused elderly person (Resident 1) was found by a good Samaritan, walking alongside the side of the road without any shoes on with a piece of paper in his hand with the facility's address. 911 was called and the resident was taken back to the facility. On 6/9/2025 CDPH received a Facility Reported incident (FRI) indicating Resident 1 was found missing from the facility at approximately 5:32 p.m., and local police contacted them at approximately 5:55 p.m., to report Resident 1 was found near the facility (approximately 4.8 miles away) with a wander guard on (a bracelet worn by residents at risk for wandering/elopement that alerts caregivers when residents approach a monitored door by triggering an alarm). On 6/6/2025, CDPH conducted an unannounced visit to the facility to investigate the complaint allegation and FRI. During the investigation, CDPH determined Resident 1, who had a history of elopement (act of leaving a facility unsupervised and without prior authorization) and wandering (moving from place to place) behaviors eloped from the facility on 6/5/2025, was found by a good Samaritan approximately 4.8 miles from the facility and brought back to the facility the same day by the facility's Administrator (ADM). The facility failed to 1. Ensure Resident 1, who was assessed as an elopement risk due to wandering behavior and wore a wander guard, did not elope from the facility. 2. Ensure the facility followed the wander guard's "Product Document" titled, "System Installment Guide for Code Alert" dated 12/2017, that indicated the most reliable method of resident monitoring combines close personal surveillance with correct operation of monitoring equipment. 3. Ensure the facility followed their Policy and Procedure (P/P), titled, "Elopements" revised 2/21/2025, that indicated residents who exhibit wandering behavior and/or were at risk for elopement, receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. These deficient practices resulted in Resident 1 eloping from the facility on 6/5/2025 at approximately 5:32 p.m., unbeknownst to facility staff. Resident 1 was returned to the facility on the same day after being found by a Good Samaritan at approximately 5:55 p.m., with a wander guard in place. These deficient practices placed Resident 1 at risk for harm due to potential changes in climate/weather, motor vehicle accidents, falls, violence at the hands of others and death. A review of Resident 1's Admission Record (Face Sheet) indicated Resident 1, a 95 year old male, was admitted to the facility on 5/25/2025 with diagnoses including Parkinson's disease (a progressive disease of the nervous system marked by tremors, muscle rigidity and slow, imprecise movements), dementia (a progressive state of decline in mental abilities) and muscle weakness. A review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 5/27/2025, indicated Resident 1 was able to understand and be understood by others. The MDS indicated Resident 1's cognition (ability to register and recall information) was moderately impaired. A review of Resident 1's Nursing Documentation Evaluation form, dated 5/25/2025, indicated Resident 1 was alert and confused and had wandering (traveling aimlessly from place to place) behaviors. A review of Resident 1's untitled Care Plan, revised on 5/27/2025, indicated Resident 1 was at risk for wandering/elopement. The Care Plan's goal indicated Resident 1 would not leave the facility unattended and his safety would be maintained. The Care Plan's interventions included engaging Resident 1 in purposeful activity, identifying any triggers for wandering/eloping, identifying certain times of the day that wander/elopement attempts occur, identifying patterns and purpose of wandering, implementing wander/elopement de-escalation behaviors, and Resident 1 should be in a common area or attend activities of choice for close monitoring. A review of Resident 1's Change of Condition (COC) Evaluation, dated 5/27/2025, indicated Resident 1 was at risk for elopement due to wandering behavior (unsure what the behavior was). The COC Evaluation indicated Resident 1's physician was notified on 5/27/2025 at 12:20 p.m., and a wander guard bracelet was ordered to be applied. A review of Resident 1's Order Summary Report (Physician's Order) dated 5/27/2025, indicated a wander guard for Resident 1 and to check for placement of wander guard to Resident 1's left wrist every shift. A review of Resident 1's COC Evaluation, dated 6/5/2025, indicated Resident 1 was served dinner at approximately 5.25 p.m., on 6/5/2025, and at approximately 5:32 p.m., Certified Nurse Assistant (CNA) 1, noticed Resident 1 was not in his room and she (CNA 1) alerted Licensed Vocational Nurse (LVN) 1. The COC Evaluation indicated staff searched throughout the building, the surrounding premises and streets by foot and car. The COC Evaluation indicated Resident 1 was found by a Good Samaritan at approximately 5:50 p.m., (6/5/2025), the Good Samaritan called the Fire Department who contacted the facility. The COC Evaluation indicated the ADM picked Resident 1 up and returned Resident 1 to the facility at 6:20 p.m., on 6/5/2025. A review of the facility's Unusual Occurrence letter dated 6/6/2025, indicated on 6/5/2025 at approximately 5.25 pm., Resident 1 was served dinner in the hallway and at 5:32 p.m., Resident 1 was not in the hallway eating dinner. The Unusual Occurrence letter indicated facility staff immediately initiated a search of the facility premises and nearby areas. The Unusual Occurrence letter indicated at approximately 5:55 p.m., the facility received a call from the local police department reporting that Resident 1 had been located. The Unusual Occurrence letter indicated the ADM drove to Resident 1's location picked him up and returned him to the facility. During an interview on 6/6/2025 at 11:40 a.m., Resident 1 stated he walked out of the facility's door, but he did not remember which door. Resident 1 stated he left because he wanted to leave. During an interview on 6/6/2025 at 3:08 p.m., CNA 1 stated at approximately 5:20 p.m., on 6/5/2025, she directed Resident 1 to sit in his wheelchair in the hallway, to eat dinner while she passed dinner trays to other residents. CNA 1 stated she did not have visual confirmation of Resident 1's location while she was passing dinner trays, nor did she inform other staff members that she would be unable to maintain a direct line of sight of Resident 1's whereabouts. CNA 1 stated at approximately 5:35 pm., she did not see Resident 1 in his wheelchair and immediately notified LVN 1 along with other staff members to search for Resident 1. CNA 1 did not hear a wander guard alarm alerting her that Resident 1 had left the building. During an interview on 6/6/2025 at 3:26 p.m., the Director of Staff Development (DSD) stated on 6/5/2025 at approximately 5:50 p.m., she and the ADM received a phone call from the police that Resident 1 had been located on the street about a four minute drive from the facility. During an interview on 6/6/2025, at 4:30 p.m., the DON stated wander guard bracelets are worn by residents who are at risk for elopement, but it does not prevent a resident from eloping, it is only a monitoring system. The DON stated it was the responsibility of the facility staff to supervise, monitor and redirect residents to prevent them from eloping. The DON stated Resident 1 eloping from the facility placed him at risk for injury from falls, car accidents or violence. During an interview on 6/6/2025, at 4:40 p.m., the ADM stated the wander guard was a reactive monitoring system that enhanced interventions staff should have been providing such as monitoring Resident 1's. A review of the facility's "Product Document" for the wander guard, titled "System Installment Guide for Code Alert" dated 12/2017, indicated the most reliable method of resident monitoring combines close personal surveillance with correct operation of monitoring equipment. A review of the facility's P&P titled, "Elopements" revised 2/21/2025, indicated residents who exhibit wandering behavior and/or were at risk for elopement, receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. The facility failed to 1. Ensure Resident 1, who was assessed as an elopement risk due to wandering behavior and wore a wander guard, did not elope from the facility. 2. Ensure the facility followed the wander guard's "Product Document" titled, "System Installment Guide for Code Alert" dated 12/2017, that indicated the most reliable method of resident monitoring combines close personal surveillance with correct operation of monitoring equipment. 3. Ensure the facility followed their P/P, titled, "Elopements" revised 2/21/2025, that indicated residents who exhibit wandering behavior and/or were at risk for elopement, receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. These deficient practices resulted in Resident 1 eloping from the facility on 6/5/2025 at approximately 5:32 p.m., unbeknownst to facility staff. Resident 1 was returned to the facility on the same day after being found by a Good Samaritan at approximately 5:55 p.m., with a wander guard in place. These deficient practices placed Resident 1 at risk for harm due to potential changes in climate/weather, motor vehicle accidents, falls, violence at the hands of others and death. These violations jointly, separately, or in any combination, presented either imminent danger that death or serious harm would result or substantial probably that death or serious physical harm would result to Resident 1.