Health inspection·December 9, 2025

§ 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: (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. F689 §483.25(d) Accidents. The facility must ensure that – §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2) Each resident On 11/12/2025 at 1:52 PM, the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to investigate accidents. The facility failed to provide a safe and secured environment for Resident 1, who has a diagnosis of Dementia (loss of memory, language, problem-solving and other thinking abilities) by sending Resident 1 without supervision to a Physicians (Orthopedic- a medical specialty that focuses on the musculoskeletal system, which includes bones, joints, ligaments, tendons, and muscles) appointment outside the facility that was scheduled for another resident (Resident 2) on 11/12/2025.   As a result, Resident 1 was placed into a taxicab and left the facility, unaccompanied, to the Orthopedic physician’s office, which was eleven (11) miles away from the facility, and had the potential for Resident 1 to be at risk for accidents and/or injuries. A review of Resident 1’s Admission Record (AR) indicated Resident 1, a 71-year-old female, was originally admitted to the facility on 5/13/2025. The AR indicated the resident’s diagnoses include Cerebral infarction (when the blood supply to part of the brain is blocked or reduced), Dementia (loss of memory, language, problem-solving and other thinking abilities).   A review of Resident 1’s Minimum Data Set (MDS- a resident assessment tool) dated 8/18/2025, indicated that Resident 1 had severe cognitive impairment. The MDS indicated Resident 1 requires maximal assistance (helper does more than half the effort) in toileting, shower, lower body dressing and putting on and taking off footwear. The MDS indicated Resident 1 required partial assistance (helper does less than half the effort) in oral hygiene, upper body dressing and personal hygiene, chair to bed transfers. The MDS indicated Resident 1 had an active diagnosis of Dementia.   A review of Resident 1’s Progress Notes dated 11/06/2025, written by Social Service Director (SSD), indicated Orthopedic appointment with Physician 1 on 11/12/2025 at 10 AM. The Note indicated, “Called transportation and confirmed. Pick up time in the facility at 9:05 AM. Responsible Party (RP) 1 made aware and will meet Resident 1 at the clinic.”   A review of Resident 1’s Progress Notes dated 11/12/2025, timed at 9:48 AM and written by SSD, indicated at 9:30 AM, SSD received a telephone call from Responsible Party  (RP) 1 who stated RP 1 was informed via a text message informing RP 1 that Resident 1 was picked up by transportation, and that RP 1 was unaware that Resident 1 was leaving the facility. The Note indicated that SSD called the medical office to where Resident 1 was going to, and to watch over Resident 1 when she arrived at the medical office. The Note indicated SSD called the transportation to check on the status on Resident 1, and transportation stated Resident 1 was dropped off five (5 minutes) ago. The Note indicated SSD informed transportation to turn back around and pick up Resident 1 at the dropped off location (medical office). The Note indicated SSD called the medical office to confirm that Resident 1 arrived at the medical office. The Note indicated transportation arrived back to pick up Resident 1 at the medical office at approximately 9:55 AM and returned to the facility at 10: 20 AM.   A review of Resident 2’s AR indicated Resident 2 was admitted to the facility on 7/7/2025 with a diagnosis of fracture to the right femur and orthopedic aftercare.   A review of Resident 2’s MDS, dated 10/11/2025, indicated Resident 2 had a BIMS of 15 (no cognitive impairment). The MDS indicated Resident 2 was independent with eating and oral hygiene.  The MDS indicated Resident 2 required supervision with upper body dressing. The MDS indicated Resident 2 required maximum assistance with toileting. The MDS indicated Resident 2 was dependent with showers, lower body dressing, and putting on/taking off footwear.   During a telephone interview on 11/12/2025 at 12:13 PM with RP 1, RP 1 stated this morning she received a text alert from a transportation company indicating Resident 1 was on-route. RP 1 stated she was able to see on the message the route began at the facility where Resident 1 resides to an unknown ending address for RP 1, which was a medical office. RP 1 stated she was confused and alarmed as she had not received any notification from the facility that Resident 1 was leaving the facility. RP 1 stated Resident 1 has Dementia and was very forgetful and should not go anywhere unaccompanied as, Resident 1 could get lost or hurt. RP 1 stated she immediately called the facility to ask where Resident 1 was going. RP 1 stated she spoke to the facility’s Case Manager Assistant (CMA) who stated she was unaware that Resident 1 was not in the facility, and CMA transferred the call to SSD. RP 1 stated the facility staff was unaware Resident 1 was mistakenly sent to Resident 2’s appointment, and that RP 1 stated there was no urgency from facility staff to locate Resident 1. RP 1 stated she hung up with facility and drove to the unknown medical office address to locate Resident 1 herself as she was afraid Resident 1 would be scared, anxious and confused, since Resident 1 was being taken to an unknown location by herself. RP 1 stated the facility was only alerted of their mistake when RP 1 called the facility to check on Resident 1’s wellbeing.   During an interview on 11/12/2025 at 1:52 PM with Director of Nursing (DON), DON stated Resident 1 had been sent out to a medical appointment unaccompanied by mistake. DON stated the facility had three (3) residents with the same first name and somehow SSD entered an order for a medical appointment and booked transportation for Resident 1, when the appointment and transportation was intended for Resident 2.    During an interview on 11/12/2025 at 1:08 PM with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated he was not familiar with Resident 1 and was unaware she had a diagnosis of Dementia. LVN 1 stated at the beginning of his shift he saw an appointment folder that had been prepared by the previous shift for Resident 1. LVN 1 stated he checked the facility appointment calendar and saw Resident 1 had a scheduled doctor’s appointment at 10 AM and proceeded to notify CNA 1 to get Resident 1 ready for her appointment. LVN 1 stated he saw Resident 1 already seated in her wheelchair around 8:50 AM - 9:00 AM and gave Resident 1 the envelope to give to the doctor. LVN 1 stated he did not see when Resident 1 left. LVN 1 stated while he was doing medication pass around 9:50 AM he noticed Resident 1 sitting in her wheelchair in front of the nurse’s station and proceeded to ask social service assistant (SSA) who he saw walking by and asked if Resident 1 had gone to her appointment to which SSA notified him the appointment was scheduled by mistake. LVN 1 stated he did not know that Resident 1 had a diagnosis of Dementia, and if he knew, verification to Resident 1’s RP would have been made to confirm Resident 1 could leave the facility to a scheduled appointment, unaccompanied, per RP 1’s wishes.   During an interview on 11/12/2025 at 3:13 PM with Resident 1, Resident 1 stated a taxi man (a professional who drives a public passenger vehicle) came and took her somewhere this morning and “could not remember whereas my mind is not all here.” Resident 1 stated she asked the driver where he was taking her. Resident 1 stated all she remembered was the driver saying, “don’t worry it’s not going to bother you.”  Resident 1 stated when the taxi man stated that, Resident 1 felt anxious and afraid because she had never gone anywhere without her sisters or daughter.   During an interview on 11/12/2025 at 3:20 PM with SSD, SSD stated she received a call from CMA stating Resident 1’s RP 1 was on the telephone asking if Resident 1 had gone out to an appointment. SSD stated RP 1 informed SSD that RP 1 received a notification from a transportation company notifying RP 1 that Resident 1 was on her way to a clinic. SSD stated she would investigate and call RP 1 back. SSD stated realizing that Resident 1 was mistakenly sent to an appointment, which was intended for Resident 2. SSD stated she then received a call from the physician’s office stating there was a resident (Resident 1) in their office who had been dropped off by transportation but did not know why she was there and that Resident 1 did not have an appointment. SSD stated she asked the physician’s office receptionist to please keep the resident and watch her as Resident 1 was sent by mistake and has Dementia. SSD stated she did not know how Resident 2’s physician appointment was inputted by mistake into Resident 1’s medical record, in which SSD inputted the appointment herself. SSD stated there must have been a “glitch” (malfunction or irregularity) in the system, since SSD could not explain how Resident 1 was scheduled for an appointment instead of Resident 2.   During an interview on 11/13/2025 at 1:44 PM with Registered Nurse (RN 1), RN 1 stated Resident 1 should not go to appointments by herself unless it was requested by RP 1. RN 1 stated if RP requested for Resident 1 to travel alone, the nurse assigned to Resident 1 should have called RP 1 to verify their request and, should have called RP 1 before Resident 1 left the facility to confirm they were at the agreed upon location and let them know Resident 1 would be leaving the facility. RN 1 stated Resident 1’s nurse should have notified the transportation driver about Resident 1’s diagnosis to ensure Resident1 would not be left alone or unattended.   During an interview on 11/13/2025 at 3:53 PM with Director of Nursing (DON), DON stated the nurse for Resident 1 should have called Resident 1’s RP before Resident 1 left the facility to let RP 1 know Resident 1 was about to leave the facility, and to confirm that RP 1 would be waiting for Resident 1 at the doctor’s office.   A review of the Policy and Procedure (P&P) for Dementia Care, revised 1/2021, indicated the facility would provide residents who display or was diagnosed with dementia with the appropriate treatment and services, and procedure which included to modify the environment to accommodate resident care needs. A review of the facility’s P&P for “Out on Pass or Leave of Absence,” with a revision date of 1/2022, indicated the following information “It is the policy of this facility that continuity of care during resident leave of absence or while out on a pass will be maintained. Furthermore, the facility further stated “Purpose: to provide a mechanism for continuity of care while a resident is away from the Facility for short periods.” A review of the facility’s P&P for “Social Services, Provision of Medically Related,” revised on 12/2023, indicated the facility would provide medically related social services (services provided by the facility’s staff to assist residents in attaining or maintaining their mental and psychosocial health) to attain the highest practicable physical, mental, or psychosocial wellbeing of each resident. The policy indicated that social services acts as an advocate for residents related to residents’ rights. The facility failed to provide a safe and secured environment for Resident 1, who has a diagnosis of Dementia by mistakenly sending Resident 1 without supervision to a Physicians appointment outside the facility that was scheduled for another resident (Resident 2) on 11/12/2025.   As a result, Resident 1 was placed into a taxicab and left the facility, unaccompanied, to the Orthopedic physician’s office, which was eleven (11) miles away from the facility, and had the potential for Resident 1 to be at risk for accidents and/or injuries. These violations, jointly, separately or in any combination, had a direct or immediate relationship to the health, safety, or security of Resident 1.