Health inspection·November 18, 2025

42 CFR §483.25 Accidents. The facility must ensure that - (d)(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. 22 CCR 72311- Nursing Service - General (a) Nursing service shall include, but not be limited to, the following: (2) Implementing each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. 22 CCR 72523 - Patient Care Policies and Procedures (a) Written patient care policies and procedures shall be implemented to ensure that patient related goals and facility objectives are achieved. On 10/8/2025 at 12:50 p.m., the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to investigate an allegation involving a resident elopement. The facility failed to: 1). Ensure Resident 1's elopement risk assessment included the resident's cognition (ability to think and process information) and poor judgement (inability to make decisions that prioritize safety) as indicated in the facility's Nursing Procedures titled, "Wandering (aimlessly walking around) & Elopement (likelihood of resident leaving the facility supervised) Risk Assessment. 2). Follow its Policy and Procedure (P&P) titled, "Elopement Behavior Management," which indicated the facility will ensure each resident at risk for elopement was identified, assessed and provided appropriate interventions and supervision. 3). Ensure Resident 1 was reassessed for wandering and elopement risk on 9/24/2025 after Resident 1 had a Change of Condition ([COC] a clinical deviation from a resident's baseline). 4). Ensure Resident 1's physician's recommendation to the Director of Nursing (DON) to initiate a 5150 hold (a hold that allows a qualified person to involuntarily detain a patient for up to 72 hours for psychiatric evaluation if danger to self, others, or gravely disabled [unable to provide for their basic needs] due to a mental disorder), to allow for immediate psychiatric evaluation (a comprehensive assessment conducted by a mental health professional to understand a patient's mental health condition) and stabilization (a short-term care provided for patients struggling with a mental health crisis) was followed. As a result, on 9/25/2025 at 2:40 a.m., Resident 1 eloped from the facility. Resident 1 was found on 10/30/2025 (35 days later) sleeping on a bench somewhere in Glendora. Resident 1 was a 46-year-old male, initially admitted to the facility on 8/15/2025 and readmitted on 9/11/2025. Resident 1's diagnoses included schizophrenia (a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions), suicidal ideations (thoughts, wishes, or preoccupations with death or self-harm), bipolar disorder (a mental condition marked by alternating periods of elation and depression), major depressive disorder (mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest or pleasure in activities) and diabetes mellitus (DM, abnormal blood sugar level). A review of Resident 1's History and Physical (H&P) dated 9/11/2025 indicated Resident 1 did not have the capacity (ability) to consent (unspecified) due to diagnosis of schizophrenia. A review of Resident 1's Multidisciplinary Care Conference (also known as IDT) notes dated 9/11/2025 timed 4:00 p.m., indicated Resident 1 presented with multiple chronic (persistent or long lasting) medical and psychiatric conditions including schizoaffective disorder, bipolar type, hypertension (high blood pressure), DM with complications, obesity and neuropathy (nerve disorder). The IDT notes indicated Resident 1 required ongoing support for mood stabilization, pain management, blood pressure and glucose (blood sugar) control. The IDT notes indicated Resident 1 had a history of depressive disorder and suicidal ideations that required monitoring. The IDT notes indicated Resident 1 was recently readmitted to the facility (unspecified date) and had spent a lot of time walking around the facility and out of the patio. The IDT notes indicated Resident 1 had a very short-term attention span (concentration), talked to himself often and was hard to be redirected. A review of Resident 1's Wandering & Elopement Risk Assessment dated 9/12/2025 timed 10:00 a.m., indicated Resident 1 was not an elopement risk. The wandering and elopement risk assessment did not indicate Resident 1's cognitive level or history of elopement. A review of Resident 1's Minimum Data Set (MDS, a resident assessment tool) dated 9/15/2025 indicated Resident 1 had moderate cognitive impairment (loss). The MDS indicated Resident 1 required supervision or touching assistance (helper provides verbal cues) with activities of daily living (ADLs) such as eating, oral hygiene, toilet use, personal hygiene, showering, upper/lower body dressing and putting off footwear, transfer and mobility. A review of Resident 1's Order Summary Report dated 9/24/2025 (no time indicated) indicated to transfer Resident 1 to a GACH on 9/24/2025 due to agitation (a state of anxiety or nervous excitement) and unsafe behavior. A review of Resident 1's behavior progress notes dated 9/24/2025 at 4:38 p.m., indicated Resident 1 was observed with a notable increase in agitation and unsafe behavior. The progress notes indicated Resident 1 was witnessed by a staff earlier (time unspecified) obtained a cup, walked to the wall-mounted hand sanitizer (a liquid, gel or foam used to kill viruses, bacteria, and other microorganisms on the hands) dispenser (equipment to release hand sanitizer), and intentionally dispensed (released) the sanitizer into the cup and attempted to drink it. The progress notes indicated Resident 1 demonstrated poor judgment, impulsiveness (doing things suddenly without considering the effects), increased agitation and was at risk of self-harm. The progress notes indicated because of Resident 1's impaired judgment, unsafe actions, and ongoing agitation, Resident 1's physician strongly recommended that a 5150 hold be initiated due to danger to himself (Resident 1), to protect the resident's health and safety and to allow for immediate psychiatric evaluation and stabilization. A review of Resident 1's Care Plan titled "Resident exhibits acute agitation and impaired judgment, as evidenced by attempt to ingest hand sanitizer," dated 9/24/2025 indicated interventions including to document Resident 1's mental status, behavior, interventions, and response on the Close Monitoring Form (form used by the facility to document hourly assessments of the resident), immediately notify the physician (MD) for unsafe behaviors and escalating agitation, if the resident attempted self-harm or his condition worsened and monitor the resident and document every one (1) hour using the Close Monitoring Form. A review of Resident 1's Close Monitoring Form dated 9/24/2025 indicated on 9/25/2025 at 1:40 a.m., Resident 1 was observed talking to himself while walking down hallways. A review of Resident 1's progress notes dated 9/25/2025 at 4:40 a.m., indicated on 9/25/2025, at 2:40 a.m., while Licensed Vocational Nurse (LVN) 2 was making rounds, Resident 1 was not in his room or bed. The progress notes indicated Resident 1 was last seen at 1:40 a.m. in the hallway asking for towels. The progress notes indicated staff searched for Resident 1 in the unit and the surrounding areas, but Resident 1 was missing. A review of Resident 1's IDT notes with a focus on the elopement incident, dated 9/25/2025 (untimed, after Resident 1had eloped) indicated Resident 1 was identified as high risk for elopement due to the resident's history of unsafe behaviors and psychiatric diagnosis (schizoaffective disorder, bipolar disorder, depression and suicidal ideation). The IDT notes indicated Resident 1's psychiatric history and impulsiveness contributed to the high elopement risk. During an interview on 10/8/2025 at 4:40 p.m., with Resident 1's Nurse Practitioner (NP), the NP stated Resident 1 was placed on 5150 hold on 9/25/2025 because Resident 1 was a danger to himself and needed to be closely monitored. The NP stated he recommended to the DON a 5150 Psychiatric Emergency Team (PET- are specialized units designed to provide immediate care and support for individuals experiencing severe mental health crises) to conduct a psychiatric evaluation and transfer Resident 1 to the GACH. The NP stated, during 5150 hold, nurses were expected to monitor Resident 1 every 15 minutes. The NP stated if a resident had suicidal ideation, the resident was placed on one-to-one (1:1) supervision (when a staff member is assigned to directly supervise no more than one resident) and the staff stayed close to ensure constant supervision and immediate intervention for safety reasons, if needed). During a concurrent interview and record review on 10/9/2025 at 1:48 p.m., with LVN 3, the facility's Elopement Behavior Management P&P dated 12/2016, the Wandering & Elopement Risk Assessment dated 9/12/2025 and Resident 1's COC dated 9/24/2025 were reviewed. LVN 3 stated the P&P indicated elopement was a situation where a resident with impaired cognition or poor safety judgement left the facility unsupervised. LVN 3 stated Resident 1's wandering & elopement risk assessment dated 9/12/2025 was done incorrectly. LVN 3 stated the nurses should have conducted Resident 1's elopement risk re-assessment after the COC on 9/24/2025 and placed Resident 1 on a 1:1 supervision because the resident was at risk for elopement. LVN 3 stated the PET should have been called immediately to assess Resident 1. LVN 3 stated if the PET was called immediately and had transferred Resident 1 to a GACH, it could have prevented Resident 1 from eloping from the facility. LVN 3 stated on 9/24/2025, the nurses should have called 911 and sent Resident 1 to a GACH. LVN 3 stated the facility failed to place Resident 1 on a 1:1 supervision to prevent the elopement while waiting for Resident 1 to be transferred to the GACH. During a concurrent interview and record review on 10/9/2025 at 2:00 p.m., with the Assistant Administrator (AADM), the facility's Elopement Behavior Management policy dated 12/2016 was reviewed, which indicated the facility will ensure each resident who was an elopement risk be identified, assessed and provided appropriate intervention, adequate supervision and assistive devices. The AADM stated the definition of elopement in the policy, reflected Resident 1 was cognitively impaired. The AADM stated Resident 1 was only oriented to self, was confused, and verbalized words that did not make sense. The AADM stated Resident 1 demonstrated poor judgment when he tried to ingest hand sanitizer on 9/24/2025. The AADM stated Resident 1's cognitive level was not assessed during the elopement risk assessment on 9/12/2025. The AADM stated after Resident 1 eloped on 9/25/2025, Resident 1's family member (FM 1) stated Resident 1 had a history of elopement (unspecified). The AADM stated if the facility had obtained Resident 1's prior elopement history from the family or conservator, Resident 1's wandering and elopement risk assessment would have been done accurately. The AADM stated the facility did not re-assess Resident 1's elopement risk assessment after the COC on 9/24/2025. The AADM stated "if Resident 1 was reassessed for elopement, proper interventions could have been provided, and the resident would still be at the facility." The AADM stated Resident 1's elopement risk assessment on 9/12/2025 did not address Resident 1's cognitive level. The AADM stated Resident 1 did not have enough monitoring and supervision while waiting for the 5150 transfer orders on 9/24/2025. A review of the facility's P&P titled, "Elopement Behavior Management," dated 12/2016 indicated it is the facility's policy to ensure that each resident who was an elopement risk be identified, assessed and provided appropriate intervention, adequate supervision and assistive devices. The P&P defined elopement as a situation in which a resident with impaired cognition or poor safety awareness or judgment successfully left the facility or a secure area undetected or unsupervised by staff. The P&P defined hazardous wandering as any behavior initiated by a cognitive impaired individual that is characterized by ambulation that may lead to safety problems or elopement. The P&P indicated the DON and/ or its designee should be responsible for the implementation and enforcement of policy and to monitor compliance through staff participation in quarterly elopement drills. The P&P indicated the assessment should be completed every quarter and with significant change of condition. The facility failed to: 1. Ensure Resident 1's elopement risk assessment included the resident's cognition and poor judgement as indicated in the facility's Nursing Procedures titled, "Wandering & Elopement Risk Assessment. 2. Follow its P&P titled, "Elopement Behavior Management," which indicated the facility will ensure each resident at risk for elopement was identified, assessed and provided appropriate interventions and supervision. 3. Ensure Resident 1 was reassessed for wandering and elopement risk on 9/24/2025 after Resident 1 had a COC. 4. Ensure Resident 1's physician's recommendation to DON to initiate a 5150 hold, to allow for immediate psychiatric evaluation and stabilization was followed. As a result, on 9/25/2025 at 2:40 a.m., Resident 1 eloped from the facility. Resident 1 was found on 10/30/2025 (35 days later) sleeping on a bench somewhere in Glendora. The above violations jointly, separately, or in any combination, presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result for Resident 1.