Health inspection·May 16, 2025

§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 receives adequate supervision and assistance devices to prevent accidents. §483.21(b) Comprehensive Care Plans §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following - (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and §72311(a)(2) Nursing Service -General (a) Nursing service shall include, but not be limited to, the following (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. §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 4/2/2025, the California Department of Public Health (CDPH) received a complaint alleging a resident (Resident 1), who after his medication dose was decreased and he was moved closer to the nursing station, went missing from the facility on 4/1/2025 at 8 p.m. According to the complaint, Resident 1's family came to the facility and witnessed the facility's courtyard gate was open, the front door was unlocked, there was no lockdown protocol in place and the facility refused the family's request to share security footage of Resident 1's elopement (the act of leaving a facility unsupervised and without prior authorization) from the facility. On 4/3/2025, CDPH received a Facility Reported Incident (FRI) indicating on 4/1/2025 at 7 p.m., the facility staff were unable to locate Resident 1. On 4/3/2025 at 9:50 a.m., CDPH conducted an unannounced visit to the facility to investigate the complaint allegation and FRI. CDPH determined Resident 1, whose cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and senses) was severely impaired, and who was assessed at risk for elopement, was not adequately supervised to prevent the risk of elopement from the facility. The facility failed to: 1. Ensure Resident 1, whose cognition was severely impaired, and who was assessed at risk for elopement, was supervised to prevent his elopement from the facility. 2. Ensure a Care Plan was created based on Resident 1's at risk for wandering/elopement identified on Resident 1's Wandering/Elopement Evaluation dated 3/11/2025. 3. Ensure staff followed the facility's Policy and Procedure (P/P), titled "Wandering and Elopement" dated 1/31/2023, that indicates "the resident's risk for elopement and preventative interventions will be documented in the resident's medical record and the Interdisciplinary Team ([IDT] a group of medical professionals from different disciplines who work together to help a resident achieve their goals) will develop a plan of care considering the individual risk factors of the resident." These deficient practices resulted in Resident 1 eloping from the facility on 4/1/2025 at approximately 7 p.m., and CDPH not being made aware of this unusual occurrence. Resident 1 was found by a good Samaritan on 4/2/2025 at approximately 12:30 p.m., (a little over 17 hours after Resident 1 eloped from the facility) approximately 14 miles from the facility. Resident 1 was transferred to a General Acute Care hospital (GACH) for evaluation before being readmitted to the facility on 4/2/2025. This deficient practice created a substantial risk that Resident 1 could suffer consequences from elopement including, adverse effects from missed medication, severe injury, exposure to harsh environmental conditions, and death. A review of Resident 1's Admission Record (Face Sheet) indicated Resident 1, a 69 year old male, was admitted to the facility on 12/12/2022 with a diagnosis of schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior). A review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 3/11/2025, indicated Resident 1's cognition was severely impaired, and he required supervision or touch assistance (when a helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity, assistance may be provided throughout the activity or intermittently) to walk. A review of Resident 1's Elopement Evaluation dated 3/11/2025 indicated a score of two, which indicated a high risk of elopement. A review of Resident 1's Care Plan dated 6/6/2024 indicated Resident 1 was at risk for wandering/elopement. Under this Care Plan, a goal for Resident 1 was for him not to leave the facility unattended. The Care Plan's interventions included engaging Resident 1 in purposeful activities, physical and social environments that provided activities appropriate for Resident 1's cognitive functioning and interest including opportunities for walking, exploring and social interactions, as well as identifying Resident 1's triggers for wandering/eloping. The Care Plan did not indicate what triggers to look for. Continued review of Resident 1's Care Plan indicated the previous risk for Resident 1's wandering/elopement, goals and interventions dated 6/6/2024 were cancelled on 10/7/2024. No other Care Plan was developed to address Resident 1's elopement risk identified on the Elopement Evaluation dated 3/11/2025. A review of Resident 1's Physician's Orders dated 10/8/2024 indicated Resident 1 was taking the following medications: 1. Depakote Sprinkles Oral Capsule Delayed Release (DR), sprinkle 125 milligrams ([mg] metric unit of measurement, used for medication dosage and/or amount), give two capsules two times a day for mood disorder manifested by (m/b) persistent racing thoughts. 2. Memantine HCI (used in medications for better absorption) oral tablet 10 mg, give one tablet two times a day for Alzheimer's disease (a disease characterized by a progressive decline in mental abilities). 3. Mirtazapine tablet 15 mg, give one tablet at bedtime for depression m/b persistent verbalization of hopelessness. A review of Resident 1's Change in Condition (COC) dated 4/1/2025 indicated Resident 1 was missing at 7 p.m. The COC indicated Resident 1's physician was notified, and the facility staff conducted a search for Resident 1, but he was not located. A review of the GACH's Emergency Department (ED) documentation, dated 4/2/2025 and timed at 1: 48 p.m., indicated Resident 1 was brought to the ED by ambulance on 4/2/2025 at 1:04 p.m. The ED documentation indicated a call came in from a bystander and Resident 1 was found on the streets, lying supine (on the back or with the face upward) in front of a business. During an observation on 4/3/2025 at 9:50 a.m., the facility's reception desk was observed in a hall to the right of the facility's front exit door, which was approximately 20 feet from the front door. When standing directly in front of the reception desk, there was no direct view of the front exit door or the hallway leading to the front exit door. During an interview on 4/3/2025 at 10:55 a.m., the Administrator (ADM) stated they have a camera system, but it is so old and does not work and he was unable to provide video footage of Resident 1 leaving the facility. During an interview on 4/3/2025 at 11:23 a.m., Resident 1's Responsible Party (RP) stated he received a call from the facility on 4/2/2025 (time unknown) that Resident 1 was found by a good Samaritan, passed out on the ground 14 miles away from the facility. The RP stated Resident 1 attempted to elope from the facility about a year ago but facility staff were able to stop him from going far. During an interview on 4/3/2025 at 12:31 p.m., Receptionist (RC) 1, stated she did not have a clear visual line that allowed her to monitor the front exit door to monitor residents who got near the front exit door. RC 1 sated she had to lean to the left to see residents near the front exit door while sitting at the receptionist's desk. During an interview on 4/3/2025 at 2:53 p.m., RC 2 stated one of his job responsibilities was to ensure residents did not go out of the facility's front exit door and the reception desk should not be left unattended. RC 2 stated, on 4/1/2025, he was outside on the main patio from 6 p.m. until 6:15 p.m., with another resident, and did not see Resident 1 outside on the main patio. RC 2 stated, at approximately 7 p.m., Registered Nurse 1 (RN 1) notified him that Resident 1 was missing. During an interview on 4/3/2025 at 3:58 p.m., RN 1 stated, the last time she saw Resident 1 on 4/1/2025, he was in the dining room at 6:15 p.m., watching television. RN 1 stated she left Resident 1 alone in the dining room because he had finished eating dinner and he was watching television. RN 1 stated, RC 2 was at the reception desk, and she (RN 1) went to the nurses' station, which was down the hall from the dining room. RN 1 stated she could not see the dining room from the nursing station. RN 1 stated, at approximately 7 p.m., during her rounds, she checked Resident 1's room and bathroom, and he was not there. RN 1 stated when the dining room was checked, Resident 1's wheelchair was there but he was not. During an interview on 4/4/2025 at 12:32 p.m., the Administrator (ADM) stated Resident 1 most likely eloped through the facility's front exit door. During an interview on 4/4/2025 at 1:10 p.m., the Director of Nursing (DON) stated the RC, when sitting at the front desk, does not have direct view of the front exit door, and the RC would have to lean to the left to view the hallway that leads to the front exit door. The DON stated the RC could potentially miss a resident who attempted or walked out of the front exit door. The DON stated, "residents should not be left alone in the dining room because anything could happen to them, such as a fall." The DON stated before 8 p.m., the front exit door alarm is not turned on, so it was possible for a resident to leave through the front exit door undetected before 8 p.m. A review of the facility's P/P, titled, "Wandering and Elopement," dated 1/31/2023, indicated the resident's risk for elopement and preventative interventions will be documented in the resident's medical record and the IDT will develop a plan of care considering the individual risk factors of the resident. The facility failed to: 1. Ensure Resident 1, whose cognition was severely impaired, and who was assessed at risk for elopement, was supervised to prevent his elopement from the facility. 2. Ensure a Care Plan was created based on Resident 1's at risk for wandering/elopement identified on Resident 1's Wandering/Elopement Evaluation dated 3/11/2025. 3. Ensure staff followed the facility's P/P, titled "Wandering and Elopement" dated 1/31/2023, that indicates "the resident's risk for elopement and preventative interventions will be documented in the resident's medical record and the IDT will develop a plan of care considering the individual risk factors of the resident." These deficient practices resulted in Resident 1 eloping from the facility on 4/1/2025 at approximately 7 p.m., and CDPH not being made aware of this unusual occurrence. Resident 1 was found by a good Samaritan on 4/2/2025 at 4:20 p.m., (a little over 21 hours after Resident 1 eloped from the facility) approximately 14 miles from the facility. Resident 1 was transferred to a GACH for evaluation before being readmitted to the facility on 4/2/2025. This deficient practice created a substantial risk that Resident 1 could suffer consequences from elopement including, adverse effects from missed medication, severe injury, exposure to harsh environmental conditions, and death. This violation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result to Resident 1.