Health inspection·December 4, 2025

The following reflects the findings of the California Department of Public Health during the investigation of complaint number 2653116. A Class B citation was written. Regulatory Violations: California Code of Regulations, Title 22, Section 72521. Administrative Policies and Procedures. (a) Written administrative, management and personnel policies shall be established and implemented to govern the administration and management of the facility. (c) Each facility shall establish at least the following: (2) Policies and procedures for patient admission, leave of absence, transfer, pass and discharge, categories of patients accepted and retained, rate of charge for services included in the basic rate, type of services offered, charges for extra services, limitations of services, cause for termination of services and refund policies applying to termination of services. California Code of Regulations, Title 22, Section 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 11/7/2025, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a complaint regarding resident elopement (when a patient leaves a healthcare facility without authorization or supervision). The facility failed to implement its policy and procedures (P&P) titled 1. "Out On Pass" by allowing Resident 8 to leave the facility on 10/24/2025, without a physician's order. This failure resulted in Resident 8 departing the premises without proper medical authorization or documentation. 2. "Discharging Against Medical Advice" by not providing Resident 8 with an explanation of the benefits of remaining in the facility and the potential consequences, risks, or complications of leaving against medical advice. Additionally, the required AMA form was not completed or signed by the resident prior to departure, and no documentation was placed in the clinical record as required. As a result, Resident 1 exited the facility without proper medical authorization or documentation, thereby compromising the continuity and safety of care of Resident 1 which increased the potential for the development of blood clots, elevated blood pressure, and elevated or decreased blood sugar Resident 8 did not return to the facility. A review of the admission record for Resident 8, indicated Resident 8 was admitted to the facility on 10/16/2025 with diagnoses diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), depression (a common mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest or pleasure in activities once enjoyed), and heart failure when the heart muscle doesn't pump blood as well as it should). A review of the physician orders dated 10/16/2025 indicated the following: - Apixaban Oral Tablet 5 MG (Apixaban) Give 1 tablet by mouth two times a day for A-fib [Atrial fibrillation - is a common heart arrhythmia characterized by an irregular and often rapid heartbeat]. - Glucophage Tablet 1000 MG (MetFORMIN HCI) Give 1 tablet by mouth two times a day for Dm [diabetes mellitus - a disorder characterized by difficulty in blood sugar control] give with meals - Metoprolol Tartrate Tablet Give 12.5 mg by mouth two I times a day for HTN [high blood pressure]. A review of Resident 8's Minimum Data Set (MDS - a resident assessment tool) dated 10/20/2025, indicated Resident 8 was cognitively intact (able to understand and make decisions). The same MDS indicated Resident 8 required between supervision or touching assistance to independence for his Activities of Daily Living (ADL- as lower body dressing, putting on/taking off shoes, chair/bed-to-chair transfer, and tub/shower transfers, personal hygiene). A review of the document titled, "Resident Out On Pass Log," dated 10/24/2025, indicated, Resident 8 signed out at 7:30 am. A review of a physician order dated 10/24/2025 entered at 3:51 pm, indicated, "May discharge AMA [Against Medical Advise]). A review of the Social Services Director (SSD) progress note for Resident 8 dated 10/24/2025 at 5:55 pm, [late entry] indicated, "Resident (Resident 8) left the facility (10/24/2025) on an approved out-on-pass at 7:30 AM. Prior to departure, resident was reminded of the 4-hour out-on-pass limit and verbalized understanding. Resident [Resident 8] has not yet returned to the facility. Multiple phone calls were made to the resident, but no return calls have been received". The same note indicated, "Resident has a valid out-on-pass order and signed the out-on-pass binder prior to leaving the facility. The attending physician was notified of the situation, and an AMA order was obtained." During a concurrent interview and record review of Resident 8's chart with Licensed Vocational Nurse (LVN) 2 dated 10/29/2025 at 1:44 pm, LVN stated that she (LVN 2) was assigned to Resident 8 on 10/24/2025. LVN 2 further stated that she had not checked Resident 8's room. LVN 2 stated that an AMA is when a resident decides to leave on their own terms, without physician orders. LVN 2 stated that there must be a physician order and facility forms signed for AMA and that education must be provided to the resident indicating the adverse effects of living without physician clearance. LVN 2 stated and confirmed that the AMA order was written on 10/24/2025 at 3:51 pm which was after Resident 8 had left the facility at on 10/24/2025 at 7:30am. LVN 2 stated that there must be an order for all residents going OOP of which LVN 2 confirmed that there was no order for OOP for Resident 8 at 7:30am. During a concurrent interview and record review of Resident 8's chart with the Director of Nursing (DON), on 10/29/2025 at 2:45 pm, the DON stated that when a resident wanted to leave AMA, the physician must be notified and an order obtained prior to the resident leaving the facility. The DON stated that the resident will also be educated on the risks of leaving against medical advice, asked to sign a form confirming that they have understood and still choose to leave and provided them with their medication as well as community resources. The DON confirmed that there was no order for Resident 8 out on pass, no form that was signed by Resident 8 acknowledging that he was leaving AMA. The DON confirmed that the order for AMA was written at 3:51 pm and that Resident 8 had left the facility at 7:30 am. The DON was unable to respond if Resident 8's diabetes, BP, or a-fib would worsen if he did not take his metformin as well as his metformin. A review of the facility's P&P dated 4/11/2025, titled, "Out On Pass," indicated "If the resident's attending physician or psychiatrist (if applicable) determine that the resident may participate in activities outside the facility, the attending physician will write/give an order for a resident to go out pass." A review of a P&P titled, "Discharging Against Medical Advice," dated 12/16/2024, indicated, "permit residents to exercise their rights under the law." The same P&P indicated, in the event a resident who has medical-decision making capacity, requests discharge AMA. The nurse will: I. To discern the reason for the resident wanting to leave and attempt to address any relevant issues. II. Provide the resident an explanation of the benefits of remaining in the facility and the potential consequences, risks, or complications of leaving the facility against the advice of the physician. The resident and or resident representative will sign the AMA form, and it will be placed in the clinical record. If the resident and or resident representative refuses to sign, the nurse writes open quotation refuse to sign close quotation on the AMA form, signed the form and a second staff member signs as a witness and it will be placed in the clinical record. Documentation will be made in the medical record with details of the discharge to include: I. Persons and agencies notified. II. Statement of reason for discharge (if known) III. Explanation of benefits of remaining in the Facility. The facility failed to implement its P&Ps titled 1. "Out On Pass" by allowing Resident 8 to leave the facility on 10/24/2025, without a physician's order. This failure resulted in Resident 8 departing the premises without proper medical authorization or documentation. 2. "Discharging Against Medical Advice" by not providing Resident 8 with an explanation of the benefits of remaining in the facility and the potential consequences, risks, or complications of leaving against medical advice. Additionally, the required AMA form was not completed or signed by the resident prior to departure, and no documentation was placed in the clinical record as required. As a result, Resident 1 exited the facility without proper medical authorization or documentation, thereby compromising the continuity and safety of care of Resident 1. The above violation had a direct relationship to the health, safety, and security of Resident 1.