Health inspection·February 11, 2026

Regulatory Violations: California Code of Regulations § 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 resident s, 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. On 12/23/205 at 8 AM, an unannounced visit was made to the facility by the California Department of Public Health (CDPH) to investigate a complaint regarding supervisions and accidents. As a result of the investigation, CDPH determined that the facility failed to follow its policy and procedure titled ‘Unusual Occurrence Reporting’ for a one resident (Resident 1), who had a behavior and history of leaving the facility without permission and failing to return from out on pass, to ensure that unusual occurrences affecting the resident's health, safety, or welfare were reported to CDPH within 24 hours. On 12/16/2025, Resident 1 left the facility without permission. Resident 1 left the facility after being dropped off by a transportation driver to the Dialysis center on 12/20/2025 and did not come back to the facility until 12/30/2025. Resident 1 was transferred to a general acute care hospital (GACH) for evaluation on 12/30/2025 and readmitted back to the facility on 1/3/2026 with diagnoses of hyperkalemia (high potassium level) and liver cirrhosis. This deficient practice had the potential to result in a lack of timely oversight by appropriate agencies, placing Resident 1 at risk for unsafe conditions and unmet care needs.   A review of Resident 1’s Admission Record (AR) indicated that the facility originally admitted a 66-year-old male on 12/19/2024 with diagnoses including End-Stage Renal Disease (kidneys have permanently lost nearly all of their ability to function), Diabetes (high blood sugar), and Dependence on renal dialysis (kidneys no longer work well enough on their own to keep the resident alive, requiring toxins in the blood to be removed by a machine).   A review of Resident 1’ s History and Physical dated 3/12/2025, indicated Resident 1 has the capacity to understand and make decisions.   A review of Resident 1’s Minimum Data Set (MDS), a federally mandated resident assessment tool, dated 12/09/2025, indicated that Resident 1 was cognitively intact (alert, oriented, and able to think, remember, and communicate clearly) with functional limitations requiring a walker for assistance with ambulation. The resident needed supervision or touching assistance, meaning the helper provided verbal cues and/or steadying or contact guard assistance as the resident completed all indicated activities of daily living (ADLs), such as eating, oral hygiene, toileting hygiene, showering/bathing, upper body dressing, lower body dressing, putting on and taking off footwear, and personal hygiene. A review of Resident 1’s Order Summary Review indicated the following physician orders: * Dated 04/11/2025: The order indicated that Resident 1’s dialysis was scheduled every Tuesday and Saturday from 1:30 PM to 5:30 PM via regular transportation. * Dated 07/23/2025: The order indicated that Resident 1 may go out on pass with a family member for therapeutic purposes, not to exceed four hours. A review of Resident 1’s progress note dated 12/20/2025 at 11:20 PM, the note indicated that the staff from 3–11 PM shift reported Resident 1 did not return to the facility and staff were unable to contact the resident by phone. The note further indicated that the local police department was contacted at this time, and a missing person report was filed for Resident 1.   A review of Resident 1’s progress note dated 12/20/2025 at 3:27 PM, the note indicated that the facility received a call from staff at the dialysis center on 12/20/2025 at 2:15 PM indicating that Resident 1 did not arrive for his dialysis treatment that day. The note indicated that RN 1 called the transportation company and relayed that dialysis center staff reported Resident 1 had not arrived for his dialysis appointment. The note further indicated that the transportation company informed RN 1 that the driver had dropped off Resident 1 at the dialysis center on 12/20/2025, about an hour prior to the phone call. During a review of Resident 1’s progress notes dated 12/21/2025 at 8:12 AM, the note indicated Resident 1 was still missing and no updates from the police department. A review of Resident 1’s progress note titled “Discharge Summary,” dated 12/22/2025 at 2:55 PM, the record indicated that Resident 1 had been missing from the facility since 12/20/2025. The record indicated that the local police department and Resident 1’s emergency contact were notified. The note also indicated that staff tried to reach out to Resident 1 but Resident 1 did not answer his cell phone. The note further indicated that Resident 1 was alert and oriented to person, place, time, and situation and was “deemed to have left the facility against medical advice (AMA) as of 12/22/2025. During a review of Resident 1’s GACH 1 records titled “History of Present Illness” dated 12/31/25 timed at 10:47 PM, the GACH record indicated Resident 1 was admitted to the GACH for missed hemodialysis treatments and received “catch up hemodialysis” at the GACH. The GACH record further indicated Resident 1 received 5 units of insulin intravenously (IV) and corrected hyperkalemia of 5.7 (normal levels at 3.6 to 5.2 millimoles per liter) upon arrival to the GACH. During a review of Resident 1’s Progress notes dated 1/3/26, the notes indicated Resident 1 was readmitted back from a general acute care hospital (GACH) on 1/3/26 with diagnoses including ESRD, hyperkalemia, and cirrhosis of the liver. The notes indicated the local police department and the resident’s second emergency contact was made aware. During a review of Resident 1’s Progress notes, dated 1/4/26, the notes indicated the local police officer arrived at the facility to check on Resident 1. The note indicated Resident 1 informed the police officer that he went to a hotel through a bus during the times that he was missing from 12/20/2025 to 12/30/2025. During an interview on 12/23/2025 at 11:42 AM with Registered Nurse (RN) 1, RN1 stated that Resident 1 had been missing since Saturday, 12/20/2025. RN1 stated the resident was picked up from the facility by transportation, and approximately one hour later, the dialysis center called to inquire about the resident’s whereabouts. RN1 stated she informed the dialysis center that Resident 1 had been transported to their location. RN1 stated the transportation company returned at the scheduled time to pick up the resident, but the resident was not found. RN1 stated the police were not notified until the end of the shift, as staff hoped the resident would return for pickup. RN1 further stated that Resident 1 tends to be sneaky and has a history of leaving without notice. During an interview on 12/23/2025 at 12 PM with the Director of Nursing (DON), the DON stated that on 12/20/2025, Resident 1 was dropped off at the hemodialysis center and had requested the driver to return at 4:45 PM. Approximately one hour later, the hemodialysis center called and notified the facility that Resident 1 had never checked into the center for treatment. The DON stated that Resident 1 had been missing since 12/20/2025 and remained missing as of 12/23/2025 (three days). The DON stated that she notified the police and filed a missing person report but did not notify the Department of Public Health (CDPH). The DON explained that the reason for not notifying CDPH was because she was hoping the resident would call. The DON also stated that no unusual occurrence report was completed. Furthermore, the DON stated that she believed the facility had 48 hours to complete such a report and that reporting to CDPH was only required for incidents involving extreme danger, such as bomb threats. The DON stated she was now reporting the incident due to the resident’s health conditions.   A review of the facility’s policy and procedure titled ‘Unusual Occurrence Reporting,’ dated December 2007, indicated that the facility is required to report unusual occurrences or other reportable events that affect the health, safety, or welfare of residents to the appropriate agencies within the required time frames. This includes reporting by telephone within 24 hours and submitting a written report within 48 hours, as required by federal and state regulations. As a result of the investigation, CDPH determined the facility failed to follow its policy and procedure titled ‘Unusual Occurrence Reporting’ for a one resident (Resident 1), who had a behavior and history of leaving the facility without permission and failing to return from out on pass, to ensure that unusual occurrences affecting the resident's health, safety, or welfare were reported to CDPH within 24 hours. On 12/16/2025, Resident 1 left the facility without permission. Resident 1 left the facility after being dropped off by a transportation driver to the Dialysis center on 12/20/2025 and did not come back to the facility until 12/30/2025. Resident 1 was transferred to a GACH for evaluation on 12/30/2025 and readmitted back to the facility on 1/3/2026 with diagnoses of hyperkalemia and liver cirrhosis. This deficient practice had the potential to result in a lack of timely oversight by appropriate agencies, placing Resident 1 at risk for unsafe conditions and unmet care needs.   This violation had a direct or immediate relationship to the health, safety, or security of resident s.