Health inspection·June 6, 2025

42 CFR § 483.25 Quality of care (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. 22 CCR § 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. 22 CCR §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: (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. (2) Implementing each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. (3) Notifying the attending licensed healthcare practitioner acting within the scope of his or her professional licensure promptly of: (C) An unusual occurrence, as provided in Section 72541, involving a patient. On 4/18/2025, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate the facility reported incident (FRI) involving a resident (Resident 1) who, on 4/6/2025, was found at the driveway of the facility, falling out of his wheelchair, with multiple injuries. The facility failed to: 1. Follow its policy and procedures (P&P) titled "Accidents and Supervision," which indicated the facility will implement interventions to prevent injury to residents, including Resident 1 who fell from his wheelchair after eloping from the facility. 2. Follow its P&P titled "Elopements and Wandering Residents," which indicated residents with a risk for elopement would receive supervision to prevent accidents. 3. Ensure door locks/alarms were in place and exit doors were monitored to prevent Resident 1 from eloping. 4. Develop a care plan to ensure interventions were in place for Resident 1 to prevent elopement after Resident 1 was assessed as elopement risk on 8/292/204. As a result, on 4/5/2025, Resident 1 eloped from the facility and was found at the end of the facility’s driveway near the sidewalk. Resident 1 had fallen out of a wheelchair onto the ground and sustained scrapes to the face, lip and knees. Resident 1 was transferred to the general acute care hospital (GACH), where it was discovered that Resident 1 had sustained fractures (broken bones) to the nose, mandible (jawbone), 6th to 8th right ribs, a lip laceration (cut), a bump on the right side of the head, an injured right knee, and broken upper dentures and lower teeth implants. Resident 1 was a 95-year-old female, admitted to the facility on 9/15/2018 and readmitted on 6/13/2024 with diagnoses including Alzheimer’s Disease (a disease characterized by a progressive decline in mental abilities) and dementia (a progressive state of decline in mental abilities). A review of Resident 1’s History and Physical (H&P) dated 11/19/2024, indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1’s Minimum Data Set (MDS- a resident assessment tool), dated 2/11/2025, indicated Resident 1’s cognitive skills (ability to think, remember and reason) for daily decision making were impaired. The MDS indicated Resident 1 required moderate assistance (helper does less than half) for toileting hygiene, dressing, and personal hygiene. The MDS indicated Resident 1 required supervision for oral hygiene and putting on/taking off footwear. The MDS indicated Resident 1 required set up or clean up assistance for eating. The MDS indicated Resident 1 required moderate assistance to walk 50 feet with two turns. The MDS indicated Resident 1 used a manual wheelchair for mobility. The MDS indicated Resident 1 had the ability to wheel herself at least 150 feet. A review of Resident 1’s Elopement Risk assessment, dated 8/29/2024, indicated Resident 1 was at risk for elopement and had wandering behaviors, a history of attempting to leave the facility without informing staff, and verbally expressed the desire to go home, packaged belongings to go home or stayed near an exit door. A review of Resident 1’s Situation, Background, Assessment, and Recommendation form ([SBAR], used for information transfer, especially when discussing critical situations or changes in a patient's condition), dated 4/5/2025, indicated on 4/5/2025, Resident 1 had a fall in the street. The SBAR indicated Resident 1 stated she fell from the wheelchair and landed on her face. The SBAR indicated Resident 1 had right forehead swelling, a cut to the right lower lip, and blood noted. A review of Resident 1’s GACH H&P Report dated 4/5/2025 at 5:29 p.m., indicated Resident 1 had a ground level fall and sustained a right jawbone and nasal (nose) bone fractures and was admitted to the GACH for syncope (a brief loss of consciousness caused by a temporary decrease in blood flow to the brain) and fall. A review of Resident 1’s GACH Computed Tomography ([CT], non-invasive imaging technique that uses X-rays to create cross-sectional images of the body) face results dated 4/5/2025, indicated Resident 1 had nondisplaced (a break in a bone where the bone fragments remain aligned) lateral (side) and inferior (a break or crack in the bones surrounding the left maxillary sinus on the lateral and inferior sides) wall fractures of the left maxillary sinus (a hollow space in the bones around the nose, located in the maxillary bone, part of the upper jaw, on the left side of the face), a nondisplaced left nasal bone fracture, and right facial and scalp soft tissue injury (damage to the non-bony structures of the body, such as muscles, ligaments, tendons, and nerves). A review of Resident 1’s GACH Discharge Summary dated 4/6/2025 at 11:34 a.m., indicated Resident 1 was diagnosed with facial and rib fractures. The discharge summary indicated Resident 1 had blood to the nose and lower lip, and a right parietal (flat bone of the skull) hematoma (a localized collection of blood outside of blood vessels, typically caused by injury or trauma). The discharge summary indicated Resident 1 had an acute buckle fracture (when one side of a bone bulges out, or buckles, without breaking through the entire bone) at the anterolateral (both anterior and lateral) right 6 - 8th ribs During an interview on 4/18/2025 at 10:00 a.m., Resident 1 stated on 4/5/2025, (time unknown) she fell and hurt herself. Resident 1 stated she did not remember where she fell. Resident 1 stated she injured her right knee, and it was very painful. Resident 1 stated after her fall she had bruises on her face and a cut on her right knee. Resident 1 stated her fall caused her dentures and implants to break. During an interview on 4/18/2025 at 10:28 a.m., Certified Nursing Assistant (CNA) 1 stated on 4/5/2025 at 9:45 a.m., she was notified by Licensed Vocational Nurse (LVN) 1 that Resident 1 wanted to use the restroom. CNA 1 stated she assisted Resident 1 to the commode (a portable toilet), and back on her wheelchair and then she wheeled the resident to the hallway, in front of her room. CNA 1 stated she left Resident 1 sitting in her wheelchair in front of her room and went to assist other residents. CNA 1 stated that was the last time she saw Resident 1. CNA 1 stated at 10:05 a.m., Resident 1 was missing and could not be located. During an interview on 4/18/2025 at 11:10 a.m., Licensed Vocational Nurse (LVN) 1 stated on 4/5/2025 at 9:30 a.m., she saw CNA 1 wheel Resident 1 outside her room. LVN 1 stated at 9:40 a.m., she saw Resident 1 propel herself down the hallway. LVN 1 stated between 10:00 a.m., and 10:45 a.m., a staff (unnamed) questioned if she had seen Resident 1. LVN 1 stated Resident 1 was found outside by a church parking lot, located adjacent to the facility. LVN 1 stated the CNAs should know to take Resident 1 to the activities or sunshine room (a room where residents watch tv, read, or do activities) to keep Resident 1 busy from wandering behaviors. During an interview on 4/18/2025 at 1:10 p.m., Resident 1’s Responsible Party (RP 1) stated on 4/5/2025 at 10:55 a.m., staff informed her Resident 1 left the facility unsupervised. RP 1 stated she was told Resident 1 propelled herself to the adjacent property (church), went down the church’s driveway and fell off her wheelchair and landed on the street. RP 1 stated the facility informed her a good Samaritan (someone who gives help to people who need it) who was driving by, stopped and called 911 emergency assistance to assist Resident 1. RP 1 stated Resident 1 sustained fractures to her nose, mandible, three right rib fractures, laceration on the upper lip, and bruising on her face, under the right breast and on her right knee. RP 1 stated she was notified by the emergency medical technician (EMT, a medically trained individual who provides emergency medical care to patients before they are transported to a hospital) that Resident 1 was found in the lane closest to the curb bleeding from her face. RP 1 stated the EMT informed her the good Samaritan blocked incoming traffic with her vehicle and called 911. During an interview 4/18/2025 at 2:15 p.m., the Director of Staff Development (DSD) stated on 4/5/2025, CNA 3 asked her (DSD) if she had seen Resident 1 because the resident was missing. The DSD stated she went outside to look for Resident 1 and found the resident on the street near the sidewalk. The DSD stated Resident 1 had fallen out of her wheelchair and had a cut on her lower lip. The DSD stated a civilian stopped her vehicle to help Resident 1 and called 911. The DSD stated she interviewed the facility’s Receptionist to determine how and when Resident 1 left the facility unsupervised. The DSD stated the Receptionist told her she did not see Resident 1 leave the facility because she left the front desk unattended to use the restroom. The DSD stated Resident 1 was at risk for falls and elopement and should have been always monitored. During an interview on 4/18/2025 at 2:45 p.m., CNA 2 stated on 4/5/2025 at 10:00 a.m., he was notified by Resident 2 that 20 minutes prior, he saw Resident 1 leave through the facility’s front doors. CNA 2 stated he began to look for Resident 1 and went outside to the parking lot and then to the street where he observed a lady waving him down. CNA 2 stated the lady was standing in the middle of the street and stopped traffic with her vehicle. CNA 2 stated the lady told him not to touch Resident 1 and that she called 911. CNA 2 stated he observed Resident 1 on the ground, in the middle of the street lying on her right side. CNA 2 stated he observed a lot of blood on the ground and on Resident 1’s face. CNA 2 stated Resident 1 was not talking. During an interview on 4/18/2025 at 3:30 p.m., Registered Nurse (RN) 1 stated on 4/5/2025 at 10:05 a.m. she heard Resident 1 was missing. RN 1 stated she went outside and saw Resident 1 sitting on the street near the sidewalk. RN 1 stated Resident 1 had blood on her face. RN 1 stated she stayed with Resident 1 until the EMTs transported Resident 1 to the GACH. During an interview on 4/18/2025 at 3:54 p.m., the Administrator (Admin) stated on 4/5/2025 at 10:30 a.m., the DSD notified her, Resident 1 left the facility unsupervised and had a fall. The Admin stated Resident 1 should have been supervised every 30 minutes by staff to prevent Resident 1 from elopement, falls, and injuries. The Admin stated the Receptionist had walked away from the front desk at time Resident 1 eloped from the facility. The Admin stated there was supposed to be a person sitting at the front desk at all times to prevent residents from leaving the facility unattended. The Admin stated the Receptionist should have notified someone to relieve her before leaving the front desk. During an interview on 4/18/2025 at 4:24 p.m., the DSD stated all staff are responsible for monitoring Resident 1. The DSD stated Resident 1 needed to be monitored every hour on her whereabouts. The DSD stated the Receptionist should not leave the front desk unattended. The DSD stated the Receptionist should have notified someone to stay at the front desk to prevent residents from elopement and injuries. During a concurrent observation and interview on 4/21/2025 at 9:35 a.m., with CNA 2, in the facility’s adjacent property’s parking lot, CNA 2 pointed to the middle of the street as the location where he found Resident 1 on 4/5/2025 laying on her right side. CNA 2 stated he walked out of the facility down the driveway, and to his left he saw a lady flagging him down, waving her arms up and down. During an interview on 4/21/2025 at 12:50 p.m., the Director of Nursing (DON) stated Resident 1 was an elopement risk. The DON stated an elopement risk meant it was a risk to have Resident 1 alone in an unsupervised area and Resident 1 was not to leave the facility without supervision. The DON stated it was not safe for Resident 1 to be unsupervised in the parking lot because she was confused and could potentially fall and sustain injuries. The DON stated all staff were responsible for supervising Resident 1. The DON stated the reason Resident 1 eloped from the facility and sustained injuries was due to lack of supervision. The DON stated it was important to continuously monitor a resident with an elopement risk for the residents’ safety. During an interview on 4/21/2025 at 2:46 p.m., Resident 2 stated on 4/5/2025 at 9:30 a.m. Resident 1 was sitting in the front lobby and he was sitting out on the patio. Resident 2 stated he saw Resident 1 leave through the facility’s front exit door, which was wide open. Resident 2 stated Resident 1 propelled herself out the door and no one noticed her leave. Resident 2 stated he thought Resident 1 was going to come back but she did not. Resident 2 stated he notified the Receptionist that Resident 1 left the facility. Resident 2 stated the Receptionist went outside to look for Resident 1 but did not find her and she came back into the facility to inform staff Resident 1 was missing. Resident 2 stated 20 minutes after Resident 1 left the facility he also notified CNA 2 that Resident 1 exited through the facility’s front door and staff started to look for Resident 1. During an interview on 4/24/2025 at 12:21 p.m., the DON stated Resident 1 was supposed to be monitored every 5 minutes to prevent the resident from leaving the facility unsupervised. The DON stated there was a lapse in supervision which was the reason why Resident 1 was able to wheel herself out of the facility unnoticed. The DON stated staff were not vigilant in responding to the door alarms in a timely manner. The DON stated there was a delay in staff responding to the front exit door alarm because Resident 1 could have been found right outside the facility. The DON stated the facility’s front exit door was not monitored when Resident 1 left the facility. The DON stated all staff should have redirected Resident 1 to another area or involve Resident 1 in activities. The DON stated it was important to follow the facility’s monitoring approach in preventing elopement, accidents, and injuries for residents’ safety. The DON stated it was important to make sure door alarms were working, monitored, and staff responded to the alarms promptly to prevent elopements and accidents. A review of the facility’s P&P titled “Elopements and Wandering Residents,” undated, indicated the facility would ensure residents who exhibit wandering behavior and/or are at risk for elopement received adequate supervision to prevent accidents. The P&P indicated the facility was equipped with door locks/alarms to help avoid elopements. The P&P indicated staff would be vigilant in responding to alarms in a timely manner. The P&P indicated adequate supervision would be provided to help prevent accidents or elopements. A review of the facility’s P&P titled “Accidents and Supervision,” dated 12/19/2022, indicated residents would receive adequate supervision to prevent accidents. The P&P indic