Health inspection·December 19, 2025

22 CCR §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. § 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 11/5/2025, the California Department of Public Health (CDPH) made an unannounced visit to investigate a complaint regarding quality of care. The facility failed to report an incident of elopement (the act of leaving a facility unsupervised and without prior authorization) involving Resident 1, in accordance with the facility’s policy and procedure (P&P) titled "Unusual Occurrence Reporting,” when on 9/16/2025 at approximately 8 p.m. Resident 1 eloped. As a result, there was a delay in an onsite inspection by the California Department of Public Health to ensure the safety and well-being of Resident 1, which placed the resident at risk for harm, including potential injury, emotional distress and trauma. A review of Resident 1's Admission Records (AR) indicated the facility admitted Resident 1 on 9/3/2025 with diagnoses including a fracture (break) of right femur (thigh bone), unspecified dementia (a condition that affects the brain which makes it hard to remember things, think clearly, or make decisions), and malnutrition (a condition in which the body does not receive adequate nutrients). A review of Resident 1’s History and Physical (H&P), dated 9/05/2025, indicated Resident 1 had fluctuating capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 9/06/2025, indicated Resident 1’s cognition (the mental process of thinking, knowing, learning and remembering) was moderately impaired. The MDS further indicated Resident 1 required partial/moderate assistance from facility staff with toileting, showering, upper body dressing, lower body dressing, putting on/taking off footwear and personal hygiene. A review of Resident 1's Psychiatry Note, dated 9/10/2025, indicated that Resident 1 had the capacity to make decisions. A review of Resident 1’s Change of Condition (COC) form dated 9/16/2025 at 8:20 p.m., indicated that on 9/16/2025 at 7:45 p.m., Certified Nursing Assistant (CNA) 1 assisted Resident 1 with activities of daily living (ADLs – fundamental self-care tasks a person needs to perform in order to properly care for themselves). The COC form indicated that on 9/16/2025, at 8:00 p.m., during routine rounds, CNA 1 observed that Resident 1 was not in bed and could not be located within the facility. The COC form further indicated that Resident 1 had left the facility without notifying staff. On 9/16/2025 at 8:45 p.m., a police officer arrived at the facility, spoke with the Administrator (ADM), and then proceeded to Resident 1’s address that was on file. A review of facility provided document titled, “Investigation Summary,” dated 9/18/2025, indicated CNA 1 last saw Resident 1 on 9/16/20205 at approximately 7:45 p.m., when CNA 1 provided care to Resident 1. On 9/16/2025, at 8 p.m., after CNA 1 returned from his break, CNA 1observed that Resident 1 was no longer in the room. CNA 1 notified Licensed Vocational Nurse 1 (LVN 1) after he (CNA 1) searched the facility and was unable to locate Resident 1. The Investigation Summary further indicated that LVN 1 attempted to contact Resident 1’s caregiver, who was the last individual known to have visited Resident 1 that evening (9/16/2025) at approximately 8 p.m., however, Resident 1’s caregiver did not answer, and a voicemail message was left requesting a return call. The Investigation Summary indicated that on 9/17/2025 at 12:03 p.m., police officers located Resident 1 at her (Resident 1) residence and spoke with Resident 1, who stated that she (Resident 1) wanted to remain at home and was with her caregiver. The Investigation Summary indicated the police officers encouraged Resident 1 to return to the facility, however, Resident 1 refused and stated that she wanted to stay home. Resident 1's physician was notified of Resident 1's decision and subsequently gave an order for discharge Against Medical Advice (AMA). During an interview on 11/06/2025 at 11:29 a.m., with the ADM, the ADM stated that on 9/16/2025, he (ADM) was informed by the DON at approximately 8:20 p.m. that Resident 1 was not in the facility. The ADM stated that CNA 1 last saw Resident 1 at 7:45 p.m., and at 8:00 p.m., CNA 1 discovered that Resident 1 was no longer in her room. The ADM stated that LVN 1 confirmed that no discharge or authorized outing had been communicated. The ADM further stated that on 9/16/2025 at approximately 8:35 p.m., local law enforcement was contacted. The ADM stated that when police officers arrived at the facility, staff provided them with Resident 1’s home address and relevant identifying information. The ADM stated that at 12:03 PM, police officers were able to make contact with Resident 1, and they (police officers) confirmed that Resident 1 was found and had chosen to remain at home with her (Resident 1) caregiver. During a concurrent interview and record review on 11/05/2025 at 12:01 p.m. with the ADM, the facility’s policy titled " Unusual Occurrence Reporting” dated 2021 was reviewed. The ADM stated not being able to locate Resident 1 was an unusual occurrence and should have been reported to CDPH. The ADM stated it was his (ADM) responsibility to report the incident within 24 hours; however, he (ADM) failed to do so in accordance with state regulations. During a review of facility P&P titled " Unusual Occurrence Reporting” dated 2021, indicated the purpose of the policy is to ensure timely reports are made to designated agencies as required by state and federal law. The facility will follow all applicable federal and state always and regulations regarding reporting unusual occurrences. The facility will report the following events by phone (and confirmed in writing) to the appropriate State or Federal Agencies for occurrences that continue interferences with facility operations that affect the welfare, safety or health of residents. Unusual occurrences are reported to appropriate agency within 24 hours by telephone and then confirmed in writing) Facility will retain copy of confirmation of letter. The facility failed to report an incident of elopement involving Resident 1, in accordance with the facility’s P&P titled "Unusual Occurrence Reporting,” when on 9/16/2025 at approximately 8 p.m. Resident 1 eloped. As a result, there was a delay in an onsite inspection by the California Department of Public Health to ensure the safety and well-being of Resident 1, which placed the resident at risk for harm, including potential injury, emotional distress and trauma. The above violation had a direct or immediate relationship to the health, safety, or security of Resident 1.