Health inspection·September 12, 2025

Code of Federal Regulations, Title 42, Section 483.25 Quality of care. Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents’ choices, including but not limited to the following: Code of Federal Regulations, Title 42, Section 483.25(d) Accidents. (d)The facility must ensure that – (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. Code of Federal Regulations, Title 42, Section 483.21(b) Comprehensive Care Plans. (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. California Code of Regulations, Title 22, Section 72301. Required Services. (f) The facility shall ensure that all orders, written by a person lawfully authorized to prescribe, shall be carried out unless contraindicated. California Code of Regulations, Title 22, Section 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: (A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. (B) Development of an individual, written patient care plan which indicates the care to be given, the objectives to be accomplished and the professional discipline responsible for each element of care. Objectives shall be measurable and time limited. (C) Reviewing, evaluating and updating the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient's condition. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. California Code of Regulations, Title 22, Section 72313. Nursing Service - Administration of Medications and Treatments. (a) Medications and treatments shall be administered as follows: (2) Medications and treatments shall be administered as prescribed. (3) Tests and taking of vital signs, upon which administration of medications or treatments are conditioned, shall be performed as required and the results recorded. 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 7/29/2025, the California Department of Public Health (CDPH) conducted an unannounced visit to the facility for its annual health recertification survey and to investigate a facility-reported incident (FRI) regarding resident elopement. The facility failed to provide supervision to Resident 97, who was cognitively impaired (refers to difficulties with thinking, learning, remembering, and using judgment, among other mental abilities), unable to verbalize needs due to aphasia (a disorder that makes it difficult to speak), had history of falls and elopement, and was identified as at risk for elopement, by failing to: 1. Monitor Resident 97’s whereabouts on 7/25/2025 at 12:14 p.m. (date and time of Resident 97’s elopement). The facility staff were not aware Resident 97 had left the facility until around 5 p.m. when Certified Nursing Assistant (CNA) 2 was distributing the dinner trays and Resident 97 was not in his (Resident 97) room. Facility staff (CNA 1, CNA 2, CNA 3, Licensed Vocational Nurse [LVN] 1, Registered Nurse [RN] 1, and RN 2) did not know Resident 97 was an elopement risk and did not know what interventions are in place to prevent Resident 97 from eloping. There were multiple missed opportunities for the facility staff to prevent Resident 97’s elopement and to remain aware of Resident 97’s whereabouts: a. On 7/25/2025 at 12:07 p.m., CNA 1 documented in Resident 97’s Nutritional Amount Eaten Percentage (%) as “50%” and “set-up or clean-up assistance” was provided to Resident 97 without directly observing Resident 97 eat his (Resident 97) lunch. Resident 97 had a physician’s order to provide Resident 97 with “supervision during meals” which was not followed. b. On 7/25/2025 at 12:53 p.m., LVN 1 documented a blood pressure (BP - the pressure of circulating blood against the walls of blood vessels) reading of 110/62 millimeters of mercury (mmHg- unit of pressure, normal range is between 90/60 mmHg and 120/80 mmHg) for Resident 97, stating that he (LVN 1) used the BP reading previously obtained on 7/25/2025 at 8:00 a.m. Resident 97 had a physician’s order to monitor Resident 97’s BP every six hours (midnight - 6 a.m.-12 p.m.- 6 p.m. intervals). c. Resident 97 had physician’s orders for monitoring every shift for falls and episodes of depression (a mental health condition that makes you feel persistently sad and lose interest in things you usually enjoy) manifested by crying which were not completed during the 7 a.m. to 3 p.m. shift on 7/25/2025. d. During the 3 p.m. hand off report (change of shift) on 7/25/2025, CNA 2 stated there was no mention of Resident 97. RN 2 stated that RN 1 did not provide any information regarding Resident 97. Both RN 1 and RN 2 were unaware that Resident 97 had an elopement incident on 1/29/2025 and had been identified as an elopement risk. 2. Implement the facility’s Policy and Procedures (P&P) titled, “Wandering and Elopements,” last reviewed on 4/24/2025 indicating, “... the resident’s care plan will include strategies and interventions to maintain the resident’s safety.” Resident 97’s care plan titled, “Elopement Risk,” initiated on 1/30/2025, was not person-centered (prioritizing the resident’s needs, preferences, values and goals) and did not include interventions for monitoring and supervision to ensure Resident 97’s safety. 3. Implement their P&P titled, “Safety and Supervision of Residents,” last reviewed on 4/24/2025 indicating, “Resident safety and supervision and assistance to prevent accidents are facility-wide priorities.... The care team shall target interventions to reduce individual risks related to hazards in the environment including adequate supervision.... Monitoring the effectiveness of interventions shall include… Modifying or replacing interventions… Evaluating the effectiveness of new or revised interventions…. Resident supervision is a core component of the system’s approach to safety. The type and frequency of resident supervision is determined by the individual resident’s assessed needs....” As a result, Resident 97 eloped from the facility on 7/25/2025 at 12:14 p.m., placing Resident 97 at serious risk of harm, injury, or death from traffic, missed medications, extreme heat, and potential assault. On 7/25/2025, in the afternoon (exact time not indicated), Resident 97 was found on the ground in the street (not known) with a small contusion (known as bruise, an injury to the soft tissue often produced by a blunt force such as a kick, fall, or blow) to the right frontal scalp (area at the very front of your head where your hairline begins and the hair that frames your face, including the area around your temples). Resident 97 was admitted to General Acute Care Hospital (GACH) 1 on 7/25/2025 at 2:23 p.m. for trauma (a physical injury or wound caused by an external force, or a psychological or emotional upset resulting from severe mental or emotional stress or physical injury). On 7/29/2025, Resident 97’s family visited Resident 97 at GACH 1 and upon seeing the family member, Resident 97 cried for 10 minutes. A review of Resident 97’s Admission Record (AR), indicated the facility originally admitted Resident 97 on 4/3/2024 and readmitted the resident on 5/10/2024 with diagnoses including aphasia, dysphagia (difficulty swallowing), history of falling, anxiety (a feeling of unease, worry, or fear), and depression. A review of Resident 97’s Minimum Data Set (MDS – a resident assessment tool), dated 5/17/2025, indicated that Resident 97 was sometimes able to understand others and was sometimes understood by others. A review of Resident 97’s History and Physical (H&P – comprehensive assessment conducted by a healthcare provider that includes gathering a thorough medical history from the resident and performing a physical examination to assess their overall health and identify any potential medical concern), dated 5/22/2025, indicated Resident 97 did not have the capacity to understand and make decisions. A review of Resident 97’s Care Plan for aspiration (when something swallowed enters the airways or lungs), initiated on 5/16/2024 and revised on 3/12/2025, indicated Resident 97 was at risk for aspiration of food and liquids secondary to dysphagia. The care plan interventions included monitoring signs and symptoms of aspiration (such as choking [refers to the inability to breathe due to a blockage in the airway, typically caused by a foreign object lodged in the throat], shortness of breath [SOB], respiration changes), and resident’s tolerance of prescribed diet and fluid intake. A review of Resident 97’s Care Plan for self-care deficits, initiated on 7/29/2024, indicated Resident 97 required total assistance from staff with eating. The care plan intervention indicated to provide Resident 97 with a safe environment. A review of Resident 97’s Change of Condition (COC – when there is a sudden change in a resident’s condition) Interaction Assessment form, dated 1/29/2025, timed at 9 p.m., indicated Resident 97 eloped and fell in front of the facility. The nursing notes indicated that on 1/29/2025 at 9 p.m., Resident 97 was walking on the sidewalk in front of the facility and attempted to cross the street. The CNA and LVN were able to bring Resident 97 back to the facility and as Resident 97 was walking up the stairs, Resident 97 lost his footing and fell. A review of Resident 97’s Care Plan for elopement, initiated on 1/29/2025, indicated Resident 97 leaves the facility at times without authorization and permission. The care plan interventions included administering medications as ordered, notifying the physician and responsible party of the COC, and assisting Resident 97 to resident’s activities of choice. A review of Resident 97’s Elopement Evaluation, dated 5/18/2025, indicated Resident 97 had an elopement score of one (score value of one or higher indicates risk for elopement). A review of Resident 97’s Fall Risk Evaluation, dated 5/18/2025, indicated Resident 97’s fall risk score was seven (total score of 10 or greater indicates the resident should be considered as high risk for potential falls). The Fall Risk Evaluation indicated Resident 97 had balance problems while walking. A review of Resident 97’s Physician Orders, dated 5/19/2025, indicated implementation of the falling star program, frequent visual monitoring due to the resident’s increased risk for falls and injury. The Physician’s Orders indicated to document per shift, every shift. A review of Resident 97’s Care Plan for falling star program, initiated on 5/19/2025, indicated Resident 97 was at risk for falls related to antihypertensive medication (medications used to treat high blood pressure), auditory (hearing) deficits, balance deficits, cognitive impairment, decreased strength and endurance, history of falls, noncompliant with request for assistance on use of call lights, poor safety awareness and judgment, unsteady gait (manner of walking), difficulty in walking, and muscle weakness. The care plan interventions indicated to remind staff during huddles of the resident’s high fall risk status, implementing frequent visual monitoring, and placing the resident near the nursing station for closer observation. A review of Resident 97’s Physician’s Orders, dated 5/30/2025, indicated monitoring resident’s blood pressure every six hours. A review of Resident 97’s Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) for 7/2025, indicated the following: - the monitoring for episodes of depression manifested by crying spells and tally by hashmark, was left blank for the day shift (7 a.m. to 3 p.m.) - the Falling Star Program frequent visual monitoring (due to higher risk for falls and injuries) document per shift was left blank for the day shift. - the blood pressure monitoring every six hours indicated a blood pressure of 110/62 mmHg. A review of Resident 97’s Physician Orders, dated 7/9/2025, indicated Controlled Carbohydrates (CCHO- meal plan where individuals aim to eat roughly the same amount of carbohydrates at each meal, helping to stabilize blood sugar levels) no added salt (NAS) diet, dysphagia mechanical soft (a diet that involves eating foods that have been modified to be easy to chew and swallow) texture, nectar mildly thick consistency (means the liquid is thicker than regular water but still pourable), three meals, aspiration precautions, and supervision during meals. A review of Resident 97’s ADL eating task, dated 7/25/2025, at 12:07 p.m., indicated Resident 97 was provided with setup or clean up assistance (helper sets up or cleans up resident completes activity helper assists only prior or following the activity). A review of Resident 97’s nutritional task amount eaten %, dated 7/25/2025, at 12:07 p.m., indicated Resident 97 ate 50 % of his (Resident 97) meal. A review of Resident 97’s COC form, dated 7/25/2025, timed at 5:20 p.m., indicated Resident 97 eloped. The nursing notes indicated that on 7/25/2025 at 5 p.m., while passing dinner trays, CNA 2 observed that Resident 97 was not in his (Resident 97’s) assigned room. CNA 2 informed RN 2, who immediately initiated a thorough search of the facility. A code green (missing resident) was activated to alert all facility staff and initiate a coordinated facility wide search. The COC indicated that at approximately 6:30 p.m., RN 2 contacted the Director of Nursing (DON) to report the incident, provide a timeline, and updates of the search effort. The COC form indicated that RN 2 then notified the local police department and reported Resident 97 as missing and requested assistance with the search. RN 2 contacted Resident 97’s family members to inform them of the situation and to verify whether they had seen or heard from Resident 97, neither family members reported recent contact with Resident 97. A review of Resident 97’s GACH 1 record, dated 7/25/2025, at 2:23 p.m., indicated Resident 97’s admission type was for trauma. GACH 1’s Medicine H&P notes indicated that Resident 97 was brought in by Emergency Medical Services (EMS - persons trained to give emergency medical care to people who are injured or ill, typically in a setting outside of a hospital) from the community for possible ground level fall (refers to a fall where a person falls from a standing position onto a flat surface, such as the floor or ground). GACH 1’s records indicated Resident 97 had a cervical collar (a medical device that supports the neck and limits its movement) and was tearful, crying, and pointing at the ceiling. GACH 1’s records indicated Resident 97 had a small right frontal scalp c