Health inspection·July 11, 2025

483.25(d) Accidents. The facility must ensure that - (d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents. 22 CCR § 72311 (a) Nursing service shall include, but not be limited to, the following: (2) Implementing each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. 22 CCR § 72523 (a) Written patient care policies and procedures shall be implemented to ensure that patient related goals and facility objectives are achieved. On 6/9/2025 at 4:32 p.m., the California Department of Public Health (CDPH) received a facility reported incident (FRI) indicating Resident 1 eloped (left the facility unsupervised) from the facility on 6/9/2025 at 12:20 p.m. through a window with screen removed. On 6/10/2025, CDPH conducted an unannounced visit at the facility to investigate the FRI. The facility failed to: 1). Ensure Resident 1's window was secured with a screw (an equipment used to secure the window) to prevent the resident from eloping on 6/8/2025. 2). Thoroughly and accurately assess Resident 1's elopement risk by not interviewing Resident 1's responsible party (RP). Resident 1 had a history of elopement while at home. 3). Monitor Resident 1's triggers (causes) for elopement including confusion and agitation. As a result, Resident 1 left the facility unsupervised and was exposed to medical complications such as dehydration (when the body loses more fluid than it takes in), hypoglycemia (low blood sugar), hypertension, exposure to harsh environmental conditions such as cold weather and heat, motor vehicle accidents, and death. There is a potential for Resident 1 to be without medications from 6/8/2025-6/12/2025, a total of five (5) days. Resident 1 has not been found on 6/12/2025. Resident 1 was 61-year-old female admitted to the facility on 6/4/2025 with diagnoses including paranoid schizophrenia (a mental illness that is characterized by disturbances in thought), chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing), anxiety (a feeling of fear, dread, and uneasiness), hypertension (high blood pressure), and type 2 diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing). A review of Resident 1's order summary report, dated 6/4/2025, indicated amlodipine besylate (medication used to treat high blood pressure) 5 milligram (mg, a unit of measurement) one tablet one time a day for hypertension, aripiprazole (medication used to treat schizophrenia) 15 mg, one tablet two times a day for schizophrenia, divalproex sodium (medication used to treat seizures, a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness) 250 mg, three tablets two times a day for schizophrenia, glimepiride (medication used to treat high blood sugar) 2 mg, one tablet one time a day for diabetes mellitus type 2, lorazepam (medication used to relieve anxiety) 1 mg, one tablet every six hours as needed for anxiety, Novolin R Injection (medication used to treat high blood sugar) sliding scale (a varied dose of insulin based on blood glucose level) before meals and at bedtime for diabetes mellitus type 2, and quetiapine fumarate (medication used to treat schizophrenia) one tablet at bedtime for schizophrenia. A review of Resident 1's elopement evaluation, dated 6/4/2025, indicated Resident 1 was not at risk for elopement and did not have a history of elopement or an attempted elopement while at home. A review of Resident 1's care plan, titled, "The resident is an elopement risk/wanderer (moving from place to place without a specific destination or purpose) related to impaired safety awareness, schizophrenia, episode of eloping the facility," dated 6/5/2025, the care plan interventions indicated to identify patterns of wandering and intervene as appropriate. The interventions indicated the resident's triggers (cause) for wandering/eloping were confusion and agitation and the resident's behaviors de-escalated by redirection (divert). A review of Resident 1's history and physical (H&P) dated 6/5/2025, 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 6/8/2025, indicated Resident 1 was able to understand and be understood by others. The MDS indicated Resident 1 had severe cognitive impairment. The MDS indicated Resident 1 required supervision from staff for activities of daily living such as eating, and partial assistance (Helper does less than half the effort) from staff for oral hygiene, toileting hygiene, showering, dressing, and putting on and taking off footwear. The MDS indicated, Resident 1 required supervision from staff for rolling left and right, sitting to lying, lying to sitting on side of bed, chair to bed transfer, toilet transfer, and walking. A review of Resident 1's change in condition (COC), dated 6/8/2025 at 11:40 p.m., indicated Resident 1, who resided in Room A, was observed entering the bathroom while the Licensed Vocational Nurse (LVN) 1 was making rounds. The COC indicated on 6/9/2025 at 12:20 a.m., Resident 1's roommate (Resident 2), left Room A and alerted staff members that Resident 1 was missing. The COC indicated the LVN 1 went to Room A and found the window opened and the window screen torn. The COC indicated LVN 1 searched for Resident 1 inside and outside the facility but was unable to locate the resident. During an observation on 6/10/2025 at 11:34 a.m., in Room A, the window with the screen bent outwards and partially removed, where Resident 1 eloped from, was on a ground level with a view to the parking lot leading to a street and stores. During an interview on 6/10/2025 at 12:34 p.m., with the Maintenance Supervisor (MS), the MS stated the windows in the rooms facing the street were secured with locks to prevent the windows from sliding open. The MS stated the top window sliding track (a component within a sliding window system that allows the window sash [the part holding the glass] to glide horizontally (sideways) of the window frame had a screw to prevent the window from opening when lifted. The MS stated prior to Resident 1's elopement on 6/8/2025, the window did not have a screw on the top to prevent Resident 1 and other residents from opening the window. The MS stated Resident 1 might have lifted the window open to elope. During an interview on 6/10/2025 at 1:30 p.m., with Resident 2, Resident 2 stated on 6/8/2025, she went into Room A to use the restroom, and when she noticed the window was wide open with the screen removed from the window, she told LVN 1 that Resident 1 was no longer in the room. Resident 2 stated she asked Resident 3 (other roommate), what happened to the window and Resident 3 stated she saw Resident 1 leave through the window about 10 to 15 minutes (time not identified) before Resident 2 came inside the room. Resident 2 stated Resident 1 never said she wanted to leave but Resident 1 was always wandered (going from place to place without a plan or definite purpose) in and out of the room and appeared very anxious. During an interview on 6/11/2025 at 8:52 a.m., with Certified Nurse Assistant 1 (CNA 1), CNA 1 stated on 6/8/2025, after Resident 2 informed staff members Resident 1 eloped, CNA 1 went into the room and saw the glass was moved and the screen was no longer in the window. CNA 1 stated Resident 1 did not say she wanted to leave but she would come out of her room and walk around before going back to bed. CNA 1 stated she never checked the windows but knew the windows were supposed to be secured. During an interview on 6/11/2025 at 10:29 a.m., LVN 1, LVN 1 stated after Resident 2 had let the staff know that Resident 1 eloped, LVN 1 went into the room and saw the window's glass was tilted off the window frame sliding track and the screen was pushed and bent outwards. LVN 1 stated she saw a small screw on the bottom of the window glass that prevented the window from being pushed to the side. LVN 1 stated it appeared Resident 1 lifted the glass open, was able to open the window. LVN 1 stated she does not check the window because she was not aware the windows could be opened. During a concurrent observation and interview on 6/11/2025 at 12:08 p.m., with the MS in Resident 1's room, the window was observed. The MS stated the screw on the top of the window prevented the window from being lifted and slid out. The MS stated Room A's window was last checked on 6/6/2025. The MS stated the window was difficult to slide up, so he did not look for the screws on the top of the window. The MS stated it was not until he was investigating the window in Room A on 6/9/2025 that he noticed there were no screws on the top of the window. The MS stated all the windows should be secured. The MS stated if the residents' room windows were not secured, residents could open the window and elope. During an interview on 6/11/2025 at 12:50 p.m., with Resident 1's responsible party (RP), the RP stated a facility staff called her on 6/9/2025 (time unspecified) to inform her that Resident 1 eloped from the facility. The RP stated Resident 1 had eloped from a couple of other facilities before. The RP stated when Resident 1 first arrived at the facility, staff members told the RP that the facility was secured, however, the staff did not ask her if Resident 1 had previously eloped. The RP stated when she spoke to Resident 1 on Saturday 6/7/2025, Resident 1 sounded confused. During an interview on 6/11/2025 at 4:19 p.m., with the Registered Nurse Supervisor (RN 1), RN 1 stated he did not talk to the RP at the time of admission on 6/4/2025 and was unaware of Resident 1's history of elopement. RN 1 stated Resident 1's elopement assessment, dated 6/4/2025, was not accurate. RN 1 stated he asked Resident 1 who had severe cognitive impairment about any history of elopement that Resident 1 denied. RN 1 stated any history of elopement would place Resident 1 at risk of elopement. During an interview on 6/11/2025 at 4:38 p.m., with the Director of Nursing (DON), the DON stated the Resident 1's care plan intervention, dated 6/5/2025, on the elopement triggers were just for information purposes and the behaviors were not monitored. During an onsite verification of IJRP implementation on 6/12/2025, Resident 1 had not been found. A review of the facility's policy and procedures (P&P) titled, "Maintenance Service," dated 1/1/2012, indicated the maintenance department should maintain the building in good repair and free from hazards. A review of the facility's P&P titled, "Wandering and Elopement," dated 1/31/2023, indicated the facility will identify residents at risk for elopement upon admission to minimize the risk of elopement. The facility failed to: 1). Ensure Resident 1's window was secured with a screw to prevent the resident from eloping on 6/8/2025. 2). Thoroughly and accurately assess Resident 1's elopement risk by not interviewing Resident 1's RP. Resident 1 had a history of elopement while at home. 3). Monitor Resident 1's triggers for elopement including confusion and agitation. As a result, Resident 1 left the facility unsupervised and was exposed to medical complications such as dehydration, hypoglycemia, hypertension, exposure to harsh environmental conditions such as cold weather and heat, motor vehicle accidents, and death. There is a potential for Resident 1 to be without medications from 6/8/2025-6/12/2025, a total of five (5) days. Resident 1 has not been found on 6/12/2025. These violations had a direct or immediate relationship to the health, safety, or security of Resident 1.