Health inspection·August 28, 2025

Code of Federal Regulations F689 §483.25(d) Accidents. 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. Title 22 California Code of Regulations §72311(a)(1) & )(2) Nursing Services – 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 of 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. On 7/18/2025, at 12:29 pm, the California Department of Public Health (CDPH) conducted an unannounced visit to investigate an entity-reported incident regarding a resident’s elopement (Resident 1). The facility failed to provide a safe and secured environment for Resident 1, who was identified at risk for elopement (when a person with cognitive impairment leaves a safe area, such as a care facility or home, without awareness of the potential dangers), wandering out of the facility, and at risk for falls by failing to: 1.Ensure Resident 1 was supervised, visually monitored hourly, and checked on during a physician scheduled appointment outside the facility on 7/17/2025, in accordance with the care plans for Risk for Elopement, Falls, and the physician order for elopement precautions. 2. Ensure the facility has a system in place to ensure residents who are identified at risk for elopement are provided with supervision while going to a physician appointment, outside the facility to prevent elopement. Registered Nurse (RN) 1 and the facility’s Social Services Director (SSD) sent Resident 1 with a medical transport driver (Driver 1) who dropped off and left Resident 1 unsupervised in the Oncologist [a physician who has special training in diagnosing and treating cancer] office on 7/17/2025 at 1:15 PM. The facility failed to inform the Oncologist Office Staff Resident 1’s needs to be supervised and monitored due to elopement risk. As a result of these failings, Resident 1 eloped and was reported missing by Driver 1 and Oncologist Office Staff on 7/17/2025, at 2:30 PM, at the Oncologist Office and had the potential to be exposed to extreme weather, be struck by motor vehicles, and/or sustain medical complications. A review of Resident 1's Admission Record (AR), indicated Resident 1 was a 74 year old female admitted to the facility on 5/20/2025, with diagnoses including encephalopathy (a change in brain function due to injury or disease), hypertension (high blood pressure), chronic pulmonary embolism (a blockage in one of the blood vessels in the lungs), malignant neoplasm (abnormal growth of tissue [cancerous cells] that can travel to other parts of the body) of the rectum, and dementia (a progressive state of decline in mental abilities). A review of Resident 1’s Minimum Data Set (MDS – a federally mandated resident assessment tool) dated 5/26/2025, indicated Resident 1 had moderately impaired (decision poor; cues/supervision required) cognition (the process of knowing and understanding). The MDS also indicated that Resident 1 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) for oral and personal hygiene, upper body dressing, roll left and right, and sit to lying position. The MDS also indicated that Resident 1 used a walker and wheelchair for her mobility and required partial/moderate assistance (helper does less than half the effort) on walking ten feet on uneven surfaces, wheeling 50 feet with two turns, and wheeling 150 feet with a manual wheelchair. A review of Resident 1’s Elopement Risk Assessment (ERA) dated 5/20/2025, indicated Resident 1 was assessed with the following: 1.Mobility Status: Resident 1’s status was marked check for “Able to propel a wheelchair.” 2.Behaviors: Resident 1’s status was marked check for “Wanting to go home, to work, or somewhere else. And history of wanting to leave the facility within the last 30 days.” The ERA indicated a conclusion that Resident 1 was identified as “At risk for elopement.” The ERA indicated to develop a care plan for Resident 1’s risk for elopement. A review of Resident 1’s care plan for Falls dated 5/21/2025, indicated Resident 1 was at risk for falls with Fall Risk Assessment score of 18. The care plan indicated that a Fall Risk Assessment with a score of 14 and above is considered high risk for falls. The care plan goal included decreasing the resident’s risk for falls and injury with interventions. The care plan interventions included providing assistance with transfers and mobility, and “visual monitoring every hour for falling star program.” A review of Resident 1’s Care Plan dated 5/22/2025, indicated that Resident 1 was at risk for elopement and wandering out of the facility. The care plan goals indicated to decrease Resident 1’s risk for elopement and wandering out of the facility and providing a safe and supervised environment for wandering. The care plan interventions included avoiding overstimulation which can occur in noisy environments, provide activities that will divert Resident 1’s attention from wandering, create a secure environment by securing doors and alarms, check Resident 1’s whereabouts, and place a wander-guard bracelet for elopement precautions. A review of Resident 1’s Physician’s Orders dated 5/22/2025, indicated to place wander guard bracelet (a type of wearable device used in healthcare facilities, to prevent residents from wandering or eloping) on for elopement precautions and monitor for proper placement and battery function (of the Wander guard) every shift. A review of Resident 1’s Social Service Assessment- Initial (SSAI) dated 5/23/2025, indicated Family Member (FM) 1 informed the facility that Resident 1 cannot return home with FM 1. A review of Resident 1’s Physician’s Orders dated 7/14/2025, indicated a follow-up appointment with Oncology on 7/17/2025 at 1:20 PM. A review of Resident 1’s Progress Note (PN) dated 7/17/2025, timed at 12:30 PM, indicated that Resident 1 went to the [Oncologist] appointment and was picked up by medical transportation (to the appointment) in stable condition. A review of Resident 1’s PN dated 7/17/2025, timed at 2:30 PM, indicated that a phone call was received from the Oncologist Office Staff looking for Resident 1 because Resident 1 took the restroom keys with her. At 2:30 PM, Driver 1 called the facility and notified the facility that Driver 1 could not find Resident 1 at the Oncologist Office. At 4 PM, the facility’s supervisor notified the Police Department that Resident 1 was missing. A review of a facility record titled “Risk Meeting Notes (RMN)” dated 7/18/2025, indicated that Resident 1 did not return from the Oncologist appointment to the facility. The RMN also indicated the following: 1. On admission, Resident 1 expressed the desire to go home with FM 1. 2. The plan is to continue to work and communicate with the Police Department in locating the resident (Resident 1) to ensure safety. The record indicated “Will continue to attempt to reach out to FM 1.” During an interview on 7/18/2025, at 1:10 PM, with the Director of Nursing (DON), the DON stated on 7/17/2025, immediately after the medical transportation Driver 1 notified the facility of Resident 1’s elopement, the DON went to the Oncologist office and looked for Resident 1. The DON stated that he also searched for Resident 1’s home address indicated on the Admission Record. The DON stated Resident 1 was alert and oriented and had never attempted to elope or wander during appointments outside the facility. The DON acknowledged that Resident 1 was identified by the facility as being at risk for elopement, and the facility staff did not send a facility staff to provide one-on-one supervision because Resident 1 was alert and oriented and able to verbalize her needs. An interview on 7/18/2025, at 2:10 PM, was conducted with the SSD, who stated upon Resident 1’s admission to the facility, the facility was made aware that Resident 1 was “homeless” and FM 1 informed the facility that Resident 1 would need a placement upon discharge. SSD 1 stated that on 7/3/2025, Resident 1 was asking to go to FM 1’s house and the SSD tried to contact FM 1. The SSD stated Resident 1 did not appear to plan for elopement and had never tried to elope during or after previous physician appointments. During an interview on 7/18/2025, at 2:55 PM, with Registered Nurse (RN) 1, RN 1 stated Resident 1 did not appear to be a wanderer. RN 1 stated on 7/17/2025, she escorted Resident 1 on the way out of the facility prior to the Oncologist appointment and endorsed Resident 1 to Driver 1. RN 1 stated she removed Resident 1's wander guard battery in front of Driver 1. RN 1 stated she did not want to mention “elopement risk” in front of Resident 1 but Driver 1 should have been aware of Resident 1’s risk for elopement. RN 1 stated that it was more appropriate that the SSD communicate Resident 1’s risk for elopement to Driver 1 and the Oncologist office staff, when the SSD made these physician appointments for Resident 1. On 7/18/2025, at 3:40 PM, an interview was conducted with Driver 1, and Driver 1 stated he has previously been informed by the facility (could not recall which facility staff) about Resident 1’s elopement risk. Driver 1 stated he “dropped off” Resident 1 at the Oncologist’s Office on 7/17/2025, at around 1:15 PM and informed the Oncologist Office staff by saying, “Call me when Resident 1 is ready for pick up. Don’t let Resident 1 go anywhere else.” However, Driver 1 stated he did not receive instructions from RN 1 or any facility staff that he needed to stay and supervise Resident 1 one-on-one, while in the Oncologist office. Driver 1 stated he did not receive a call back from the Oncologist office staff that Resident 1 was ready to be “picked up,” so Driver 1 went back to the Oncologist Office on 7/17/2025, at around 2:15 PM (approximately one hour after dropping the resident off), but Driver 1 stated he did not see Resident 1 at the waiting area of the Oncologist Office. Driver 1 stated the Oncologist Office staff told him (Driver 1) that Resident 1 went to the restroom. Driver 1 stated he then waited for about five to ten minutes more for Resident 1 in the waiting area but Resident 1 did not come back. Driver 1 stated the Oncologist Office staff tried to find Resident 1 around 2:30 PM but could not find Resident 1. Driver 1 stated he called the facility immediately, when Oncologist office staff informed him, they could not find Resident 1. During an interview on 7/18/2025, at 4:55 PM, with the Oncologist Office Staff (OS) 1, OS 1 stated she recalled when checking in Resident 1 for the Oncology appointment on 7/17/2025, at around 1:10 PM, OS 1 stated Resident 1 was accompanied by only one person (Driver 1) who did not stay with Resident 1. OS 1 stated the person (Driver 1) who took Resident 1 to the Oncology appointment asked about what time to pick up Resident 1, but nothing else was mentioned. OS 1 stated the Oncologist office staff were never informed to always supervise Resident 1 due to risk of elopement. During a follow-up phone interview on 7/22/2025, at 10:00 AM, with the Administrator (ADM), the ADM stated Resident 1 remained missing and had not returned to the facility. A review of an email communication sent to the California Department of Public Health (CDPH), from General Acute Care Hospital (GACH) 1, who oversees the Oncologist Office, dated 7/22/2025, timed at 10:30 PM, titled “Notification of Potential Reportable Event” was reviewed. The email communication indicated that GACH 1 was notified by the Oncologist Office of “A potential reportable neglect event.” The email further indicated “On 7/18/2025, a social worker (unknown) was made aware of an incident that occurred on 7/17/2025.” The email indicated that a resident (Resident 1) with history of forgetfulness and dementia who was a patient at the Oncologist Office was dropped off at the Oncologist Office without a caregiver or a chaperone to attend to the resident’s needs and “Therefore [Resident 1] attended the appointment alone…” The email further indicated, “At the conclusion of the appointment, [Resident 1] checked out the [Oncologist Office] and asked for the key to the restroom which was provided. The patient [Resident 1] did not return to the lobby to return the key. [Oncologist Office staff] went to check on [Resident 1] in the restroom and did not find [Resident 1]. The key was found later in the lobby.” Further review of GACH 1’s email communication dated 7/22/2025, indicated that [Driver 1] was in the parking lot of the [Oncologist Office] waiting for [Resident 1] and did not see Resident 1. The email indicated the Police Department was notified of the concern for missing person. The email further indicated that the facility reported to GACH 1 that this had been a trend for Resident 1 and had eloped from the same facility in the past, as well as other facilities. The email indicated that on 7/22/2025, Resident 1 called the Oncologist Office staff and informed the Oncologist Office that she was “safe and staying” at FM 1’s house at the moment and that Resident 1 did not return to the facility. A review of the facility’s policy and procedure (P&P) titled “Safety Supervision of Residents” undated, the P&P indicated that resident supervision is a core component of the systems approach to safety. The P&P indicated the type and frequency of resident supervision is determined by the individual resident’s assessed needs and identified hazards in the environment. A review of the facility’s P&P titled “Resident Elopement” undated, the P&P indicated “The facility will provide a safe environment and preventive measures for elopement with the aim to monitor and document patients at risk for elopement.” The facility failed to provide a safe and secured environment for Resident 1who was identified at risk for elopement (when a person with cognitive [thought process] impairment leaves a safe area, such as a care facility or home, without awareness of the potential dangers), wandering (a person that roams around and becomes lost or confused about their location) out of the facility, and at risk for falls by failing to: 1. Ensure Resident 1 was supervised, visually monitored hourly, and checked for whereaboutsduring a physician scheduled appointment outside the facility on 7/17/2025, in accordance with the care plans for Risk for Elopement, Falls, and the physician order for elopement precautions. 2. Ensure the facility has a system in place to ensure residents who are identified at risk for elopement are provided with supervision while going to a physician appointment, outside the facility to prevent elopement. Registered Nurse (RN) 1 and the facility’s Social Services Director (SSD) sent Resident 1 with a medical transport driver (Driver 1) who dropped off and left Resident 1 unsupervised in the Oncologist [a physician who has special training in diagnosing and treating cancer] office on 7/17/2025, at 1:15 PM. The facility failed to inform the Oncologist Office Staff Resident 1’s needs to be supervised and monitored due to elop