Health inspection·September 4, 2025

The following reflects the findings of the California Department of Public Health during the investigation of complaint number 2567822. A Class A Citation was written Regulatory Violations. Title 22 California Code of Regulations: § 72301. Required Services. (d) Written arrangements shall be made for obtaining all necessary diagnostic and therapeutic services prescribed by the attending physician, podiatrist, dentist, or clinical psychologist subject to the scope of licensure and the policies of the facility. If the service cannot be brought into the facility, the facility shall assist the patient in arranging for transportation to and from the service location. § 72307. Physician Services--Supervision of Care. (a) Each patient admitted to the skilled nursing facility shall be under the continuing supervision of a physician who evaluates the patient as needed and at least every 30 days unless there is an alternate schedule, and who documents the visits in the patient health record. § 72501. Licensee-General Duties. (a) The licensee shall be responsible for compliance with licensing requirements and for the organization, management, operation and control of the licensed facility. The delegation of any authority by a licensee shall not diminish the responsibilities of such licensee. § 72527. Patients' Rights. (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (12) To be treated with consideration, respect and full recognition of dignity and individuality, including privacy in treatment and in care of personal needs. § 72541 Unusual Occurrences Occurrences such as epidemic outbreaks, poisonings, fires, major accidents, death from unnatural causes or other catastrophes and unusual occurrences which threaten the welfare, safety or health of patients, personnel or visitors shall be reported by the facility within 24 hours either by telephone (and confirmed in writing) or by telegraph to the local health officer and the Department. An incident report shall be retained on file by the facility for one year. The facility shall furnish such other pertinent information related to such occurrences as the local health officer or the Department may require. Every fire or explosion which occurs in or on the premises shall be reported within 24 hours to the local fire authority or in areas not having an organized fire service, to the State Fire Marshal. § 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. On 8/1/2025, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a complaint regarding resident abuse and misappropriation of property. Resident 3 had a history of blindness, was wheelchair bound, and needed assistance with activities of daily living including personal hygiene. The facility did not meaningfully search for or report Resident 3 as missing when she failed to return to the facility from an outside appointment, even though she had a history of being found outside covered in feces. Based on record review and interviews, CDPH determined that the facility failed to: 1. Assist in arranging Resident 3's return transportation from an outside medical appointment location when the facility allowed the resident to leave with a family member but did not ensure that she returned. 2. Treat Resident 3 with consideration and respect when the facility did not report Resident 3 as missing or conduct a meaningful search when she eloped from the facility by not returning from the appointment. 3. Administer treatment as prescribed in the physician order dated 7/23/2025 authorizing Resident 3 to go out on a pass with a family member on 7/24/2025 at 7:30 AM via a transportation service for an outside medical appointment. A pass enables a resident to leave and return to the facility, but Resident 3 did not return. 4. Provide continuing physician supervision when Resident 3 was communicating by phone with the facility's physician while she was absent from the facility. 5. Fulfill its operation and control responsibilities for the facility when Resident 3 was missing for nine days while still admitted under the facility's care by failing to provide records reflecting a discharge by physician's order or against medical advice. 6. Implement the policy and procedure for "Elopements," last reviewed 11/21/2024, which indicated to initiate a search if a resident was not on authorized leave, notify law enforcement, and call 911 if there was an elopement. As a result, Resident 3 's whereabouts and well-being remained unknown for nine calendar days (7/24/2025-8/1/2025) after Resident 3 left for her appointment. A review of the admission record for Resident 3, the record indicated Resident 3 was admitted to the facility on 7/8/2025 with diagnoses including blindness of right and left eye category 3 (severe visual impairment), abnormality of gait and mobility, and dysphagia (difficulty swallowing). A review of history and physical (H&P) dated 7/11/2025 at 3:53 pm, the H&P indicated Resident 3 had a past medical history of blindness, cataracts (a clouding of the eye's natural lens, which can cause blurry, hazy, or faded vision), wheelchair bound secondary to MVA (motor vehicle accident). The same H&P indicated Resident 3 was at General Acute Care Hospital (GACH) due to being found outside covered in feces and was discharged to the facility for rehabilitation and placement. A review of Resident 3's Minimum Data Set (MDS - a resident assessment tool) dated 7/15/2025, the MDS indicated Resident 3 was cognitively intact (able to understand and make decisions). The same MDS indicated Resident 3 was dependent on staff for his Activities of Daily Living (ADL) such as lower body dressing, putting on/taking off shoes, chair/bed-to-chair transfer, and tub/shower transfers. Resident 3 required substantial/maximal assistance for personal hygiene and had not been evaluated for toilet transfers, sit to lying, and sit to stand due to medical condition or safety concerns. The MDS further indicated Resident 3 was dependent on wheelchair use. A review of a Care Plan created 7/15/2025, the care plan indicated Resident 3 had an ADL self-care performance deficit related to activity intolerance, impaired balance, muscle weakness, impaired vision included interventions including: -The resident requires substantial assist by 1 staff for toilet - The resident requires substantial assist by 1 staff to move between surfaces frequently and as necessary. A review of a nursing noted dated 7/16/2025 at 11:35 pm, indicated, "At around 18:45 (6:45 pm) patient (Resident 3) eloped from the facility without notifying any nursing staff. Pt. is alert and oriented x3 and to make needs and wants to be known. Has hx (history) blindness secondary to cataracts and spinal injury resulting in inability to walk. Pt. is wheelchair bound. The nursing staff searched and was unable to locate patient's whereabouts inside the facility. Initiated facility protocol, called the authorities. MD was notified and made aware. At around 2110 (9:10 pm), police officers arrived at the facility and helped with the effort to locate the patient. Contacted patient's emergency contacts on file and was able to call FM that often visit the patient. FM: She's with me, we are here at another facility a few blocks away from Resident 3's facility'. Police office went the location with 3 nursing staff to assist the patient back to the facility. However, the patient refused to go back to the facility. Explained all risks multiple times, FM was able to help convince her to go back to the facility and agreed to be referred to social services for proper discharge to another facility of pt's choice." A review of a physician order dated 7/23/2025, the physician order indicated, "May go out on pass with Family Member (FM) on 7/24/2025 @ (at) 7:30 AM via transportation for Americans with disabilities) for IHSS (In-Home Supportive Services - provides in-home assistance to eligible aged, blind, and disabled individuals as an alternative to out-of-home) appointment." During an interview with Licensed Vocational Nurse (LVN) 1 on 8/1/2025 at 1:04 pm, LVN 1 stated that on the morning of 7/24/2025 during medication pass (between 8-to-10 am) noticed that Resident 3 was not in the facility and was made aware by the Social Worker (SW) that Resident 3 had left the facility earlier for an appointment. LVN 1 stated that Resident 3 had not returned to the facility by the end of her shift at 3 pm. LVN 1 stated that she had notified administration, the supervisor, as well as the oncoming LVN. During a concurrent interview and record review of Resident 3's medical record with the Director of Nursing (DON) on 8/4/2025 at 3:35 pm, the DON stated that Resident 3 had left to go for a personal appointment on 7/24/2025 in the morning and did not return to the facility to date. The DON stated that Resident 3 had left the facility in the company of a Family Member (FM) who was a resident of another facility. The DON stated that the facility had not spoken with Resident 3, nor were they aware of where she (Resident 3) was. The DON confirmed that Resident 3's care plan initiated 7/16/2025 indicated she (Resident 3) was dependent on staff for ADLs related to medical conditions (blindness to both eye). The DON did not have an answer for how Resident 3 would be able to function outside the facility with no assistance. During an interview with the Facility Administrator (FA) on 8/4/2025 at 3:45 pm, the FA confirmed that Resident 3 was expected to return to the facility after her appointment within the allotted time of at least four hours. The FA stated that the facility staff were not able to speak with Resident 3 to confirm that she was ok, nor were they able to speak with the FM. The FA stated that Resident 3 had left Against Medical Advise (AMA- leaving facility without physician recommendation/approval) and had not eloped which was decided after Resident 3 failed to return to the facility. The FA stated that the difference between AMA and elopement were: AMA- There has to be a physician order, resident must sign a form confirming they are leaving AMA, resources such as medications and where to receive assistance provided, leave with their belongings. Elopement- Unknown when resident leaves facility, where they are, why and was unexpected. The FA confirmed that Resident 3's failure to return was unexpected, her whereabouts were unknown, there was no physician order for AMA, belongings were still in the facility, medications were not provided, nor was the AMA form signed. The FA confirmed that Resident 3 had eloped from the facility before. The FA stated that the facility did not have Resident 3's cellphone number to follow up on Resident 3's whereabouts, but that the staff had attempted to call the facility where FM resided. The calls remained unanswered. During an interview with the facility's Receptionist (RCPT) on 8/4/2025 at 3:58 pm, the RCPT stated that on Friday 8/1/2025 around 3 pm she received a call from Resident 3 requesting to go to the facility on Saturday to pick up her belongings. The RCPT stated that Resident 3 informed her that she was staying at a hotel (Hotel X) in the neighborhood. During an interview with Resident 3's physician (MD) on 8/5/2025 at 4:03 pm, MD confirmed that Resident 3 had some visual impairments due to Resident 3's history of cataracts. MD stated that Resident 3 had signed out on pass and was accompanied by a FM. MD stated that the facility had reached out to the FM to let him know that Resident 3 had not returned to the facility. MD stated that Resident 3 had called MD several times since leaving the facility asking for a new prescription for different medication which she was never on at the facility. MD stated that he was assured that she (Resident 3) was safe. During a telephone interview with RCPT 2 from Hotel X on 8/6/2025 at 10:15am, RCPT 2 stated that Resident 3 had left the hotel earlier that morning but did not know where or when she was coming back. During a review of the facility's P&P titled "Elopements," last reviewed 11/21/2024, the P&P indicated to call 911 if there was an elopement. The same P&P indicated: If an employee discovers that a resident is missing from the facility, he/she shall: a. Determine if the resident is out on an authorized leave or pass. b. If the resident was not authorized to leave, initiate a search of the building(s) and premises. c. If the resident is not located, notify the Administrator and the Director of Nursing Services, the resident's legal representative (sponsor), the Attending Physician, law enforcement officials, and (as necessary) volunteer agencies (i.e., Emergency Management, Rescue Squads, etc.); d. Provide search teams with resident identification information; and e. Initiate an extensive search of the surrounding area. During a review of a P&P titled, "Unusual Occurrence Reporting," last reviewed 11/21/2024, indicated, "As required by federal or state regulations, our facility reports unusual occurrences or other reportable events which affect the health, safety, or welfare of our residents, employees or visitors. The same P&P indicated, "Unusual occurrences shall be reported via telephone to appropriate agencies as required by current law and/or regulations within twenty-four (24) hours of such incident or as otherwise required by federal and state regulations." During a review of a P&P titled, "Signing Residents Out," revised 11/21/2024, indicated, residents leaving the premises must be signed out. The same P&P indicated each resident leaving the premises on pass must sign out at a sign out register located at each nurses' station. The same P&P indicated residents must indicate the expected time of return. The facility failed to follow their P&P by failing to report that Resident 3 who is visually impaired, had gone for an appointment on 7/24/2025 but did not return to the facility. As of 8/1/2025, the facility was still not aware of Resident 3's whereabouts. Based on record review and interviews, CDPH determined that the facility failed to: 1. Assist in arranging Resident 3's return transportation from an outside medical appointment location when the facility allowed the resident to leave with a family member but did not ensure that she returned. 2. Treat Resident 3 with consideration and respect when the facility did not report Resident 3 as missing or conduct a meaningful search when she eloped from the facility by not returning from the appointment. 3. Administer treatment as prescribed in the physician order dated 7/23/2025 authorizing Resident 3 to go out on a pass with a family member on 7/24/2025 at 7:30 AM via a transportation service for an outside medical appointment. A pass enables a resident to leave and return to the facility, but Resident 3 did not return. 4. Provide continuing physician supervision when Resident 3 was communicating by phone with the facility's physician while she was absent from the facility. 5. Fulfill its operation and control responsibilities for the facility when Resident 3 was missing for nine days while still admitted under the facility's care by failing to provide records reflecting a discharge by physician's order or against medical advice. 6. Implement the policy and procedure for "Elopements," last reviewed 11/21/2024, which indicated to initiate a search if a resident was not on authorized leave, notify law enforcement, and call 911 if there was an elopement. As a result, Resident 3 's whereabouts and well-being remained unknown for nine calendar days (7/24/2025-8/1/2025) after Resident 3 left for her appointment. These above