Health inspection·February 25, 2026

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 should 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 1/13/2026, the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to investigate allegations regarding a resident (Resident 1) who sustained facial injuries and was sent to a general acute care hospital (GACH). Based on observation, interview and record review, the facility failed to ensure Resident 1, who was assessed at risk for eloping (leaving the facility unsupervised) from the facility and was at high risk for falls, was monitored for safety and was regularly checked on to determine location. The facility failed to: 1.Ensure the Registered Nurse (RN) 1 did not leave the facility's lobby, which was unmonitored while the receptionist was on break, to provide appropriate supervision of the lobby area for residents and visitors. 2.Implement and update Resident 1's fall care plan interventions to provide incremental (increase) monitoring to address resident safety precautions by creating clear plans for monitoring Resident 1's risk of wandering and eloping from the facility. 3.Implement Resident 1's behavioral care plan interventions to check Resident 1's whereabouts (location) and redirect Resident 1 back to a supervised area, in order to prevent Resident 1 from eloping from the facility. 4.Implement its facility's policy and procedure (P&P) titled "Safety Supervision of Residents" which indicated resident safety and supervision are company-wide priorities to prevent accidents, including eloping from the facility. As a result, Resident 1 wandered out from the facility on 1/9/2026 at 9 a.m., without the facility's knowledge and supervision, leading to the resident's fall, sustained left hand fourth (4th) and fifth (5th) fingers fracture (broken bone), left frontal scalp hematoma (a collection or pool of blood that forms outside of blood vessels) and intracranial (within the cranium [skull] the bony dome that houses and protects the brain) hemorrhage (bleeding). Resident 1 was transferred to GACH 1 on 1/10/2026 for further evaluation and treatment. Resident 1 was a 90-year-old female, originally admitted to the facility on 1/20/2023 and readmitted to the facility from GACH 1 on 1/10/2026, after the elopement from the facility. Resident 1's diagnoses included closed head injury (a type of brain injury where the brain sustained damage due to external forces, but the skull remains intact), left hand 4th and 5th fingers fractures, dementia (a progressive state of decline in mental abilities), Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), and generalized muscle weakness. A review of Resident 1's care plan titled, "Category: CAA9 Behavioral Symptoms," dated 1/18/2024, indicated Resident 1 was identified as being at risk for elopement and wandering out of the facility, wandering without purpose, exit-seeking behavior (a resident's attempts to leave a safe environment without regard of their safety or consequences of the actions) and searching behavior (a behavior that is goal-oriented, an expression of need, manifested as wandering, exit-seeking). The care plan goal was to decrease resident's risk of elopement and wandering out of the facility. The care plan interventions included allowing the resident to move around the hallways safely, gently redirecting the resident back to the supervised areas and checking resident's whereabouts. The care plan's additional intervention dated 3/11/2024 included to use wander guard bracelet (a safety device designed to monitor and manage residents who wander away from the care environment) on left wrist for elopement precautions, check alarm for functioning, monitor for proper placement and battery function every shift. A review of Resident 1's care plan titled "Category: CAA11 Falls," indicating problem start date of 1/18/2024, indicated Resident 1 had increased susceptibility (likelihood) to falling that may cause physical harm due to history of falls, balance problem, loss of muscle strength and wandering. The care plan indicated Resident 1 had a fall risk assessment score of 16 (indicating a high risk for fall). The care plan included documentation indicating Resident 1 had fallen on 12/13/2024, 6/12/2025, and 11/17/2025 without injuries. The interventions to achieve care plan goals in preventing Resident 1 from falling and sustaining injuries included: on 12/13/2024, educating resident and staff on safety precautions; on 1/18/2024, checking resident's whereabouts; and on 6/12/2025, incremental monitoring (unspecified) to address resident's needs and safety precautions. A review of Resident 1's History and Physical (H&P), dated 6/7/2025, indicated Resident 1 could not make medical decisions and had the fluctuating capacity (unstable) to understand and make decisions due to dementia. A review of Resident 1's Physical Therapy (PT) Discharge Summary, dated 10/10/2025, indicated Resident 1 had history of falling and lacking insight (understanding) into her condition and risk factors (hazards). The summary indicated Resident 1 required supervision/touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as the resident completes the activity) in transferring from sitting to standing position and when walking 150 feet. The summary indicated walking ten feet on uneven surfaces and taking one step on curb (taking a step down) was not attempted due to Resident 1's medical condition or safety concerns. The summary indicated Resident 1 required 24-hour staff assistance with mobility and daily care tasks. A review of Resident 1's Elopement Risk Assessment, dated 10/24/2025, indicated Resident 1 was at risk of elopement. The assessment indicated Resident 1 was able to propel (drive) her wheelchair and ambulate (walk). The assessment indicated Resident 1 was oblivious to her needs or safety and wandered without purpose. A review of Resident 1's Fall Risk Data Collection form, dated 10/24/2025, indicated Resident 1 was at high risk for falling due to poor decision making, incontinence (no control of bowel and bladder elimination), gait/balance (manner of walking) problem, multiple medications, and multiple medical conditions. A review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 10/29/2025, indicated Resident 1 had severe cognitive impairment for daily decision making. The MDS indicated Resident 1 wandered four to six days within the previous week (unspecified). The MDS indicated Resident 1 was independent with sitting to standing position (the ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed), walking 10 feet, walking 50 feet with two turns. The MDS indicated Resident 1 used a manual wheelchair independently for mobility. A review of Resident 1's care plan titled "CAA11 Falls," dated 11/18/2025, indicated to provide with bed alarm and wheelchair alarm (devices to notify staff when a resident attempts to get out of bed or wheelchair unassisted) to remind Resident 1 not to get up unassisted and alert staff of resident's attempts to get up unassisted, place the resident in a visible area (area where staff can view) after group activities, provide individualized activity to keep the resident engaged (occupied) and distracted from attempting to get up unassisted, encourage/ remind resident to ask for help when needed, if able and provide assistance as identified in transfer and mobility and keep environment free of hazards. Resident 1's care plan goal indicated to decrease resident's risk of fall and injury with the interventions, reduce risk of serious injury from falls and resident will relate the intent (purpose) to use safety measures to decrease risk of fall. A review of Resident 1's Functional Abilities Assessment (an assessment to determine an individual's physical, cognitive and emotional capabilities in relation to their ability to perform work-related tasks), dated 1/7/2026, indicated Resident 1 required supervision or touching assistance to transfer from sitting to standing. The assessment indicated Resident 1's walking ten feet was not attempted due to medical condition or safety concerns. A review of Resident 1's Physician Orders, dated 1/8/2026, indicated Resident 1 to wear a wanderguard bracelet on the left wrist for elopement precautions. A review of Resident 1's Situation, Background, Assessment, Recommendation (SBAR-a communication tool used by healthcare workers when there is a change of condition among the residents), dated 1/9/2026, indicated at 8:50 a.m., Resident 1 had an unwitnessed fall outside the facility. The SBAR indicated Resident 1 was confused following the fall. The SBAR indicated Resident 1 complained of mild pain and sustained abrasion ([scratch] body part not indicated). The SBAR indicated radiology was ordered by the physician. A review of Resident 1's Radiology Report dated 1/10/2026 at 10:40 a.m., indicated Resident 1 had an acute fracture of the left-hand 4th and 5th fingers with minimal angulation (a fracture where the broken ends of a bone are tilted or bent at an angle, deviating from the bone's normal alignment) and displacement (moved out of their normal alignment). A review of Resident 1's Progress Notes dated 1/10/2026 at 12:33 p.m., indicated the abnormal diagnostic results (unspecified) were reviewed and new orders (unspecified) were obtained. The Progress Notes indicated Resident 1 was transferred to a GACH 1 for evaluation and treatment. A review of Resident 1's GACH 1 Emergency Department (ED) Physician Documentation, dated 1/10/2026 at 7:19 p.m., indicated Resident 1 presented to the ED due to a mechanical fall (a type of fall that occur due to an external force or interaction with a physical object or condition in the environment, not by an acute medical event) on 1/9/2026. The ED Physician Documentation indicated Resident 1 reported a swollen left hand but was unable to recall the fall. The ED Physician Documentation indicated Resident 1 was mildly distressed with raccoon's sign (dark bruising and swelling) on head/ eyes. The ED Physician Documentation indicated Resident 1's radiology report showed acute and minimally displaced fractures of the left 4th and 5th fingers and left frontal scalp hematoma (a collection or pool of blood that forms outside of blood vessels). The ED Physician Documentation indicated Resident 1's differential diagnoses (list of possible conditions or diseases) included intracranial hemorrhage, fracture, dislocation (a medical condition where the bones in a joint are pushed out of their usual place) and electrolyte abnormalities (occur when too much or not enough minerals are in the body). The GACH 1 diagnostic impression indicated Resident 1 had closed head injury and left-hand fingers fractures. During an interview on 1/13/2026 at 8:45 a.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 1 had unsteady gait and weakness prior to the fall on 1/9/2026 and required touching assistance in transferring in and out of wheelchair and walking to prevent falls. CNA 1 stated Resident 1 was not allowed to leave the building without staff supervision and assistance prior to, and since the fall on 1/9/2026. During a concurrent observation and interview on 1/13/2026 at 8:50 a.m., with Resident 1, in Resident 1's room, Resident 1 cried, stating she was angry and mad about her pain. Resident 1 could not remember leaving the facility or falling. During a concurrent interview and record review on 1/13/2026 at 11:22 a.m., with Licensed Vocational Nurse (LVN 1), Resident 1's Elopement Risk Assessment, dated 10/24/2025, Fall Risk Data Collection form, dated 10/24/2025, MAR for the month of January 2026, Resident 1's SBAR dated 1/9/2026, and Resident 1's Progress Notes dated 1/9/2026 to 1/11/2026, were reviewed. LVN 1 stated the Fall Risk Data Collection form indicated Resident 1 had an unsteady gait and frequently stood up from her wheelchair without asking for staff assistance and had a wheelchair alarm in place to alert staff when Resident 1 was trying to stand without assistance. LVN 1 stated prior to Resident 1's fall on 1/9/2026, Resident 1 used her wheelchair to go around the unit. LVN 1 stated on 1/9/2026, she did not hear the wheelchair alarm turned on. LVN 1 stated Resident 1's progress notes indicated the resident exited the facility unsupervised and fell on the sidewalk outside the facility. Resident 1 sustained abrasion on the forehead, mild pain and the left hand was red and mildly swollen after the fall. LVN 1 stated Resident 1 should have been continuously supervised when not in her room to avoid falls and elopements. During a concurrent interview and record review on 1/13/2026 at 1:17 p.m., with the Director of Rehabilitation (DOR), Resident 1's Physical Therapy (PT) Discharge Summary dated 10/10/2025, Resident 1's Functional Abilities Assessment dated 1/7/2026, were reviewed. The DOR stated the discharge summary indicated Resident 1 required 24-hour staff assistance with mobility and daily care tasks. The DOR stated Functional Abilities Assessment dated 1/7/2026, indicated walking ten feet was not attempted due to Resident 1's medical condition or safety concerns. The DOR stated Resident 1 required supervision/touching assistance in transferring from sitting to standing position and when walking 150 feet. The DOR stated walking ten feet on uneven surfaces and taking one step on curb were not attempted for Resident 1 due to medical condition or safety concerns. The DOR stated the Rehabilitation Department performed Resident 1's quarterly screening on 10/13/2025 and there were no changes in her functional abilities. The DOR stated the Rehabilitation Department was not notified about Resident 1's change (unspecified) in walking abilities. During a concurrent interview and record review on 1/13/2026 at 1:50 p.m., with Registered Nurse (RN 1), Resident 1's care plan titled "Category: CAA11 Falls" dated 1/18/2024, care plan titled "Category: CAA9: Behavioral Symptoms at risk for elopement and wandering out of the facility- wandering without purpose, searching behavior, and exit seeking behavior" dated 1/18/2024, and Resident 1's Radiology Report, dated 1/9/2026, were reviewed. RN 1 stated Resident 1's fall care plan dated 1/18/2024 did not indicate required interventions to prevent falls and injury. RN 1 stated Resident 1's care plan for fall prevention was not followed because Resident 1 was outside the facility, unsupervised and was not in an area visible by the facility staff. RN 1 stated Resident 1's behavioral care plan intervention indicating to check the resident's whereabouts were vague (unclear). RN 1 stated she (RN1) did not know how to implement that intervention. RN 1 stated the behavioral care plan intervention indicated to allow Resident 1 to move around the facility safely was not implemented, because without supervision at the lobby and exit door, the hallway was unsafe when she [RN 1] left the lobby. RN 1 stated Resident 1 had history of dementia, Alzheimer's disease, and generalized weakness that increased Resident 1's risk of falling. RN 1 stated on 1/9/2026 at around 8:45 a.m., Receptionist 1 asked her (RN 1) to observe the front door and lobby, and ensure residents' safety, prevent residents from leaving, and to great/assist visitors because Receptionist 1 had to go on break. RN 1 stated she did not see Resident 1 or any residents at the lobby, so she left the lobby area to access her bag in the Medication Room 1. RN 1 stated the lobby and exit area could not be vie