Health inspection·August 12, 2025

§ 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice. 42 CFR §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. 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: (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. 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. On 6/24/2025, the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to investigate a facility reported incident regarding Resident 1's elopement (the act of leaving a facility unsupervised and without prior authorization). The facility failed to ensure Resident 1, who had diagnoses of agitation (a state of unease, restlessness, or disturbance), and paranoid schizophrenia (a mental illness that was characterized by disturbances in thought), received care and services necessary to prevent accidents. The facility failed to: 1.Develop an individual care plan with measurable interventions to address Resident 1's identified care needs and elopement risk behavior, such as exit seeking, wandering to the gate, and waiting by the door. The "Baseline Care Plan," dated 6/5/2025, and the Care Plan titled "At Risk for Elopement," dated 6/6/2025, only include general goals and interventions, such as keeping Resident 1 in a safe and secure environment and free from injury. 2. Implement the care plan's interventions to ensure a safe and secure environment and failed to ensure Resident 1's environment remained as free from accident hazards as possible when the facility's exit doors were left disarmed the evening of 6/21/2025. 3. Review and evaluate Resident 1's care plan as necessary with input from other professional personnel when the Interdisciplinary Team (IDT, a group of healthcare professionals from different specialties who collaborated to provide comprehensive and coordinated care to individuals) Conference record dated 6/5/2025 did not indicate that Resident 1's history of elopement or exit seeking behavior was discussed. 4. Ensure Resident 1 received adequate supervision on 6/21/2025 at 9:59 p.m. when Resident 1 exited his room, walked down the facility's hallway adjacent to the exit door, and walked out the unlocked, disarmed exit door. 5. Implement the facility's policy and procedure (P&P) titled, "Safety and Supervision of Residents," dated 1/2025, to ensure residents' safety to prevent accidents when the facility did not supervise Resident 1's whereabouts despite his behaviors of wandering to the exit door and waiting by the front door. 6. Implement the facility's P&P titled, "Elopements and Wandering Residents," undated, to ensure residents who were at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their "person-centered plan of care addressing the unique factors contributing to wandering or elopement risk." As a result of these failures, Resident 1 eloped from the facility located in Bell Gardens, California 90201 on 6/21/2025 at 10:13 p.m. and police found him slumped over and deceased on the roof of a building in Los Angeles, California 90063 (7.4 miles from the facility) on 6/22/2025. A review of the admission record indicated Resident 1, a 65-year-old male, was admitted to the facility in Building A on 6/5/2025 with diagnoses including restlessness, agitation, epilepsy (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness), depression (a feeling of sadness and hopelessness), paranoid schizophrenia, anxiety (an overwhelming feeling of uneasiness), chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing), and hypertension (HTN- high blood pressure). A review of Resident 1's Care Plan titled, "Baseline Care Plan," dated 6/5/2025, indicated Resident 1 was an elopement risk and a plan of care would be implemented to meet Resident 1's needs while in the facility. The care plan did not indicate any specific interventions for elopement risk. A review of Resident 1's Elopement Risk Evaluation, dated 6/5/2025, indicated Resident 1 was "recently admitted and not accepting the situation." The elopement risk evaluation indicated Resident 1 was at risk for elopement. A review of Resident 1's Social Service History and Initial Assessment, dated 6/5/2025 indicated Resident 1 exhibited behaviors such as exit-seeking, agitation, aggressiveness, impulsiveness, and lack of safety awareness. A review of the Care Plan titled "At Risk for Elopement," dated 6/6/2025, indicated Resident 1 continued to wander to the gate and sometimes waited by the front door. The Care Plan goals indicated to ensure Resident 1 would be kept in a safe environment and free from injury daily. The Care Plan interventions indicated the facility was to assure Resident 1's environment was kept safe and secure and ensure shift huddles (quick meetings amongst nursing staff to discuss important safety information about certain residents or reminders) at the beginning of each shift to make staff aware of residents with exit-seeking behaviors. The care plan did not indicate any specific interventions for Resident 1's identified specific elopement risk behaviors, such as exit-seeking, wandering to the gate, and waiting by the door. A review of Resident 1's History and Physical (H&P), dated 6/6/2025, 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 6/11/2025, indicated Resident 1 had serious mental illness and severely impaired cognition (process of thinking). The MDS indicated Resident 1 required supervision for Activities of Daily Living (ADLs- routine tasks/activities) such as performing oral hygiene, toileting, upper and lower body dressing, and performing personal hygiene. The MDS indicated Resident 1 required supervision (helper provided verbal cues and, or touching, steadying or contact guard assistance as resident completes activity) when he walked beyond 10 feet (ft) transitioned from a sitting to a standing position, was transferred from the bed to a chair, and transferred from the toilet. A review of Resident 1's medical record dated from 6/12 - 6/20/2025 indicated there were no nursing progress notes documented for Resident 1. A review of Resident 1's Nursing Progress Note, dated 6/21/2025, indicated at 11:10 p.m., a facility-wide search was conducted for Resident 1 and the search was unsuccessful. The progress note indicated on 6/22/2025 at 12:23 a.m., the local authorities were notified Resident 1 was missing. A review of the Medical Examiner's Death Investigation Summary dated 6/23/2025 indicated Resident 1 was discovered unresponsive on the roof of a residence. The investigation summary indicated Resident 1 sustained a fall while climbing or jumping over a wall of a residence roof. Resident 1's left leg was caught between the wall and a large pipe as the resident sustained red abrasions on the right side of his head, left flank and bruising to his left arm. The investigation summary indicated the fire department determined Resident 1's death at 7:34 p.m. on 6/22/2025 and the cause of death was due to arteriosclerotic cardiovascular disease (a condition characterized by the narrowing and hardening of arteries, leading to restricted blood flow and increased risk of heart attacks. A review of the facility faxed document sent to the Department dated 6/27/2025 indicated police found Resident 1 slumped over and deceased on the roof of a building (not the facility's building) on 6/22/2025. During a concurrent observation and interview on 6/25/2025 at 1:49 p.m. with the Administrator (ADM), CDPH's investigator observed the facility's security surveillance video footage, dated 6/21/2025 from 9:59 p.m. to 10:13 p.m. The surveillance footage revealed on 6/21/2025 at 9:59 p.m. Resident 1 exited his room located at the end of Hallway A (in Building A), adjacent to the exit door, and walked out the unlocked, disarmed exit door. The ADM stated there was no staff present in Hallway A when Resident 1 exited the building. The surveillance footage revealed Resident 1 walking in the back parking lot at 10:11 p.m., proceeded to walk down a road adjacent to the facility grounds (off the facility's property). Resident 1 was last observed leaving the facility from the parking lot at 10:13 p.m. During a concurrent observation and interview on 6/26/2025 at 1:04 p.m. with the ADM, Hallway A video footage dated 6/21/2025 and timed from 9:59 p.m. to 10:04 p.m., was reviewed again. The ADM stated the exit door alarm was not activated at 7 p.m. on 6/21/2025, when Resident 1 eloped from the facility. The ADM stated it was important to ensure exit door alarms were armed to alert staff when a resident attempted to leave the facility. During an interview on 6/23/2025 at 7:58 a.m., RN 2 stated that on 6/21/2025, RN 2 was the assigned RN supervisor for the 7 p.m. to 7 a.m. shift. RN 2 arrived on duty and performed a head count at 7:15 p.m. RN 2 stated that at approximately 11:10 p.m., LVN 4 (the charge nurse) was concerned about Resident 1's whereabouts, and made her (RN 2) aware Resident 1 was not in his room. RN 2 stated a "code yellow" was called and the facility staff searched every resident room, bathroom, and the surrounding areas. RN 2 stated she recalled seeing Resident 1 dressed in black pants at approximately 9:40 p.m. to 10 p.m. near the nurses' station. During an interview on 6/23/2025 at 3:04 p.m., LVN 1 stated that on 6/21/2025 at 10 p.m., LVN 1 recalled seeing Resident 1 in Resident 1's room, "in bed," dressed in "pants and a polo t-shirt." During a concurrent interview and record review on 6/24/2025 at 1:30 p.m. with the Social Services Director (SSD), Resident 1's Social Service History and Initial Assessment, dated 6/5/2025, was reviewed. The SSD stated he included Resident 1's behaviors of "exit-seeking" and "lack of safety awareness" in the assessment because Resident 1's Responsible Party (RP) 1 informed him of Resident 1's previous attempts to leave a previous facility and of the resident's exit-seeking behaviors. The SSD stated that he did not share this information during the IDT care meeting on 6/5/2025 because Resident 1's exit-seeking behavior was not observed by the facility staff. The SSD stated he should have shared the information with the IDT and nursing staff to ensure person-centered safety interventions were included in Resident 1's plan of care. During a concurrent interview and record review on 6/24/2025 at 3:04 p.m., with Minimum Data Set Nurse (MDSN) 1, Resident 1's Care Plan titled "At Risk for Elopement," dated 6/6/2025, was reviewed. MDSN 1 stated he initiated the Care Plan on 6/6/2025 based on an interview with an unidentified licensed nurse who informed him (MDSN 1) that Resident 1 was observed walking around the unit, wandering around the nurses' station, and going out to the gate in the yard and patio during the evening shift. MDSN 1 stated the nurses performed room rounds every two hours to monitor Resident 1's whereabouts. During a telephone interview on 6/24/2025 at 3:12 p.m., Responsible Party (RP) 1 stated Resident 1 had a history of unsuccessful elopement attempts in a previous Skilled Nursing Facility (SNF) and was at high risk of absence without leave (AWOL, away without permission). RP 1 stated Resident 1 was not happy about being placed in this facility and wished to live in the woods. RP 1 stated she (RP 1) could see that Resident 1 was building up anger for being locked in a facility. RP 1 stated she notified LVN 3 prior to Resident 1's admission to the facility that Resident 1 had a history of elopement attempts. During a concurrent interview and record review on 6/25/2025 at 2:47 p.m. with the Director of Nursing (DON), Resident 1's IDT Conference record dated 6/5/2025 was reviewed. The IDT conference record did not indicate Resident 1's history of elopement or exit seeking behavior was discussed. The DON stated that the IDT should have discussed Resident 1's history of elopement and wandering behavior and developed a care plan to prevent elopement. During an interview on 6/26/2025 at 1:07 p.m., LVN 2 stated she worked the 3 p.m. to 11 p.m. shift on 6/21/2025 and did not check if the exit doors were armed and did not hear the sound of an exit door alarm during that shift. During an interview on 6/26/2025 at 2:06 p.m., RN 2 stated she was the assigned RN Supervisor on 6/21/2025 from 7 p.m. to 7 a.m. and that all licensed nursing staff were expected to arm the exit door alarms at 7 p.m. or after the resident's "smoke break" at 8:30 p.m. RN 2 stated the exit door alarms alerted staff whenever a resident entered or exited Building A during the 3 p.m. to 11 p.m. and the 11 p.m. to 7 a.m. shifts. RN 2 stated she did not check if the exit door alarms were armed and did not recall hearing the distinct sound of the door alarm activate on 6/21/2025 from 7 p.m. to 7 a.m. RN 2 stated Resident 1 was at an increased risk for elopement due to the unarmed exit door and she should have ensured the door alarms were on. During an interview on 6/26/2025 at 3:15 p.m., the DON stated adequate supervision was important to prevent elopement, especially for residents with a known history of elopement attempts. The DON stated she was not aware Resident 1 had a prior history of elopement and exhibited exit-seeking behaviors. The DON stated the SSD should have made nursing aware of Resident 1's prior history of elopement and behaviors so proper interventions and adequate supervision could have been implemented. The DON stated there were no systems in place to ensure all licensed nurses manually armed the exit door alarms and ensured the alarms were armed after 7 p.m. The DON stated staff would not be aware if a resident was no longer in the building without the use of the alarms. The DON stated if exit door alarms were armed on 6/21/2025 at 7 p.m., staff could have been alerted when Resident 1 left the building. During a telephone interview on 6/27/2025 at 10:04 a.m., LVN 1 stated he worked the evening shift on 6/21/2025 and was Resident 1's assigned nurse. LVN 1 stated he (LVN 1) was not aware of Resident 1's history of elopement attempts, or exit-seeking behaviors and nursing staff did not perform a huddle before the start of the shift. LVN 1 stated he was unsure if any staff were outside in the yard to supervise Resident 1 when the resident exited Building A. LVN 1 stated supervision was required for all residents to prevent elopement,