Health inspection·February 19, 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. 22 CCR § 72311 Nursing Service--Patient Care (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. 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 1/26/2025, the California Department of Public Health (CDPH) conducted an unannounced annual recertification survey at the facility. The facility failed to: 1. Follow its policy and procedure (P&P) titled, “Wandering, Unsafe Resident,” which indicated the facility will identify residents at risk for harm due to unsafe wandering (the act of roaming around and becoming lost or confused about their location) and elopement (the act of leaving a facility unsupervised and without prior authorization), and its P&P titled, “Safety and Supervision of Residents,” which indicated each resident’s risk factors were identified and interventions implemented to meet the Resident 118’s needs, by failing to ensure: a. Resident 118, who was assessed as high risk for wandering and elopement, did not elope from the facility on 10/13/2024 and 11/24/2024 (42 days after the first elopement). b. Staff were aware of all residents at risk for wandering and elopement. c. Staff were aware of Resident 118’s high risk for elopement and how to prevent Resident 118 from leaving the facility unnoticed. d. A person-centered care plan (document that helps nurses and other team care members organize aspects of resident care) with measurable interventions was created for Resident 118, after Resident 118 eloped from the facility on 10/13/2024, to prevent Resident 118 from eloping again on 11/24/2024. e. A readmission 72-Hour Monitoring was conducted for Resident 118 after he eloped and was readmitted on 10/21/2024, to ensure Resident 118 did not have exit seeking behaviors. f. Resident 118 was not placed in a room near the lobby exit door, after he eloped on 10/13/2024 and was readmitted to the facility. g. An interdisciplinary care team ([IDT], a group of different disciplines working together towards a common goal for a resident) meeting was conducted to address Resident 118’s elopement on 10/13/2024, to prevent further elopements. h. Staff were in-serviced (a professional training on a particular subject) on how to care for residents at risk for wandering and elopement. As a result, Resident 118 eloped from the facility on 11/24/2024 and as of 2/12/2025, Resident 118 has not been found. There is a likelihood for Resident 118 to suffer medical complications such as malnutrition, dehydration, stroke, exposure to harsh environmental conditions including excessive cold, fire, motor vehicle accident, and and/or possible death. Resident 118, was a 75-year-old male, initially admitted to the facility on 9/21/2024 and readmitted on 10/21/2024 with diagnoses that included Alzheimer’s disease (a disease characterized by a progressive decline in mental abilities), psychoactive substance-induced persisting dementia (a deterioration of mental function resulting from the persisting effects of alcohol use), and altered mental status (a change in mental function, such as a decline in awareness, attention, or consciousness). A review of Resident 118’s Minimum Data Set ([MDS], a resident assessment tool), dated 10/3/2024, indicated Resident 118’s cognition (process of thinking) was moderately impaired. The MDS indicated Resident 118 required moderate assistance (helper does less than half the effort) with toileting, bathing, lower body dressing, and putting on and taking off footwear. The MDS indicated Resident 118 used a walker (a mobility aide that helps people walk by providing stability and balance) for mobility. a. A review of Resident 118’s Progress Note, dated 11/24/2024 and timed at 7:24 p.m., indicated on 11/24/2024 at 3:35 p.m., Resident 118 was nowhere to be found within the facility. The Progress Note indicated Resident 118 “stepped out of the facility unsupervised and undetected for the second time.” The Progress Note indicated staff made a thorough search inside and outside the facility. The Progress Note indicated Resident 118’s physician was notified, and the physician instructed the staff to report the incident to the police. During a concurrent interview and record review on 1/27/2025 at 2:07 p.m., with Registered Nurse (RN) 1, Resident 118’s Elopement and Wandering Risk Scale, dated 10/21/2024, was reviewed. RN 1 stated the Elopement and Wandering Risk Scale indicated Resident 118 was at high risk for wandering. RN 1 stated when a resident was determined to be a high risk for wandering and elopement, additional interventions must be put into place to promote safety for the resident. RN 1 stated once Resident 118 was assessed as high risk for wandering and elopement, immediately the facility should have initiated a plan to put “extra set of eyes” on him, educate the staff of Resident 118’s wandering and elopement score, updated his care plan, and conducted a room change to prevent Resident 118’s second elopement on 11/24/2024. b. During an interview on 1/27/2025 at 2:10 p.m., RN 1 stated the facility did not have a way to easily identify residents who were at high risk for wandering and elopement. RN 1 stated the licensed nurses conducted the change-of-shift huddle (a brief meeting where nurses would discuss patient care, safety, and workload) to discuss the residents’ needs within their assigned areas. RN 1 stated the facility was divided into four stations and the individual change-of-shift huddles did not incorporate any resident information outside of the station. RN 1 stated when a resident was assessed as high risk for elopement, the CNAs were instructed verbally to “keep an eye” on them. During an interview on 1/28/2025 at 12:26 p.m., RN 2 stated during change-of-shift huddle, the licensed nurses did not communicate any high risk for elopement residents in other stations and only focus on the residents within their station. During an interview on 1/28/2025 at 2:52 p.m., the Director of Nursing (DON) stated once a resident was assessed as high risk for wandering and elopement, that resident’s information was included in the change-of-shift huddle for the station. The DON stated if a resident who was high risk for wandering and elopement ambulated (walking) to a different station, the nurses would not be aware of the resident’s status. c. During an interview on 1/27/2025 at 2:10 p.m., RN 1 stated Resident 118’s risk for wandering and elopement was only communicated to the nurses and CNAs within the East Nurses Station and not to the other three stations. RN 1 stated Resident 118 was ambulatory and if Resident 118 walked to a different station, the staff would not know Resident 118 required close supervision to prevent wandering and elopement. During an interview on 1/27/2025 at 3:40 p.m., Certified Nursing Assistant (CNA) 2 stated on 11/24/2024, she was assigned to Resident 118. CNA 2 stated on 11/24/2024 she last saw Resident 118 at 3:30 p.m., in the dining room. CNA 2 stated during change-of-shift huddle, she was instructed to just “keep an eye on the resident”, however, there was no direction on how often to monitor Resident 118’s whereabouts and nowhere to document her observations. CNA 2 stated she and other staff were unable to constantly monitor Resident 118 to prevent the resident from eloping. During an interview on 1/28/2025 at 10:32 a.m., Licensed Vocational Nurse (LVN) 2 stated Resident 118 was “very sneaky” and eloped from the facility two times. LVN 2 stated Resident 118 was ambulatory with a walker and would walk around the facility. LVN 2 stated during his rounds on 11/24/2024 at 3:35 p.m., he realized Resident 118 was nowhere to be found. LVN 2 stated he was unsure how Resident 118 eloped from the facility. LVN 2 stated Resident 118 required close supervision and when an extra CNA was available, the CNA was assigned to Resident 118 to closely monitor and supervise him throughout the shift. LVN 2 stated this type of close monitoring was not always possible and the RN on duty would take it upon herself to have Resident 118 sit with her at the nurse’s station during the shift to ensure Resident 118’s whereabouts. LVN 2 stated the facility did not have a documented plan of care to address Resident 118’s behaviors. LVN 2 stated the nurses and CNAs were verbally instructed to monitor Resident 118 closely. During an interview on 1/29/2025 at 9:10 a.m., LVN 1 stated during change-of-shift huddle the CNAs were verbally instructed to do frequent visual checks on the residents who required close monitoring. LVN 1 stated she did not document any visual checks, Resident 118’s whereabouts, nor any redirection interventions for Resident 118. LVN 1 stated she was only aware of the residents in her station and did not know about any residents at high risk for wandering and elopement in the other stations. During an interview on 1/29/2025 at 2:49 p.m., CNA 2 stated the facility did not have a universal way to monitor and supervise residents at risk for wandering and elopement. CNA 2 stated when a resident required monitoring for a new behavior or change of condition, the nurses would initiate a “Stop and Watch” form for nurses and CNAs would document on. CNA 2 stated Resident 118 did not have a Stop and Watch form, nor any other required documentation specific for monitoring and supervising the resident. CNA 2 stated without direction to monitor behaviors of wandering and elopement, the facility would be unable to care for the resident and prevent the resident from eloping. d. During a concurrent interview and record review on 1/27/2025 at 2:13 p.m., with RN 1, Resident 118’s Care Plans, dated 9/21/2024 through 11/24/2024, were reviewed. RN 1 stated the Care Plans did not indicate Resident 118’s high risk for wandering and elopement score and nor was Resident 118’s first elopement on 10/13/2024, addressed and care planned. RN 1 stated no care plan was developed to address Resident 118’s high risk for wandering and elopement and his first elopement on 10/13/2024. RN 1 stated care plans were developed as a template on who the resident was, their problems or risk factors, goals to be accomplished, and interventions the staff were to implement to provide care. RN 1 stated without the care plans addressing Resident 118’s risk for elopement and actual elopement, the staff was unaware how to properly care for Resident 118. RN 1 stated without a plan to properly care for Resident 118’s new behavior and actual elopement, Resident 118 was able to elope again on 11/24/2024 and had not returned to the facility. During an interview on 1/28/2025 at 11:11 a.m., the MDS Coordinator (MDSC) stated Resident 118 did not have a care plan that addressed his elopements on 10/13/2024 and 11/24/2024, nor his high risk for wandering and elopement. The MDSC stated those care plans were essential in promoting Resident 118’s safety by directing the staff to implement interventions such as observing Resident 118’s whereabouts frequently, utilizing a wander guard (a monitoring device), if necessary, redirecting Resident 118 if he were to be close to an exit, and utilize the social services department to frequently assess Resident 118’s needs and concerns for leaving the facility. During an interview on 1/28/2025 at 2:52 p.m., the DON stated the type, the frequency, and the person responsible of the monitoring for a high risk for wandering and elopement resident would be indicated on the Care Plan and physician’s order. The DON stated without a care plan with specific interventions, Resident 118 would not receive the necessary care and monitoring to prevent Resident 118 from eloping from the facility. e. During a concurrent interview and record review on 1/27/2025 at 2:16 p.m., with RN 1, Resident 118’s Progress Notes, dated 9/21/2024 through 11/25/2024 were reviewed. RN 1 stated the Progress Notes did not indicate Resident 118 was monitored when readmitted to the facility on 10/21/2024. RN 1 stated the licensed nurses did not perform and did not document a 72-Hour Monitoring for Resident 118, after the resident eloped on 10/13/2024. RN 1 stated it was important to conduct a 72 Hour monitoring to assess the resident’s adjustment to the facility and other behaviors such as exit-seeking. During an interview on 1/28/2025 at 2:52 p.m., the DON stated the 72-Hour Monitoring was important to indicate how a resident was adjusting to the facility and if there were any concerns to be addressed. f. During an interview on 1/27/2025 at 1:44 p.m., RN 1 stated Resident 118 was readmitted to the facility on 10/21/2024, and was placed in a room near the lobby’s exit. RN 1 stated Resident 118’s room placement was inappropriate because Resident 118 might have eloped the second time on 11/24/2024, through the lobby exit door. RN 1 stated Resident 118 should have been placed in a room closer to the nurse’s station, so Resident 118 could be closely monitored. RN 1 stated she did not know how Resident 118 eloped on 10/13/2024. During an interview on 1/28/2025 at 12:26 p.m., RN 2 stated she readmitted Resident 118 to the facility on 10/21/2024. RN 2 stated Resident 118’s room assignment was predetermined prior to his arrival to the facility. RN 2 stated Resident 118 was placed in a room close to the lobby door and the idea of a room change crossed her mind due to Resident 118’s prior elopement but she did not initiate a room change. RN 2 stated the conversation of a room change should have been brought up to initiate a room change away from an entrance/exit door and closer to the nurse’s station to prevent Resident 118, from possibly eloping. g. During a concurrent interview and record review on 1/28/2025 at 11:07 a.m., with the MDSC, Resident 118’s IDT Meeting Notes, dated 9/21/2024 through 11/24/2024, were reviewed. The MDSC stated the IDT Meeting Notes did not indicate Resident 118’s had a high risk for wandering and elopement. The MDSC stated the notes did not address Resident 118’s elopement on 10/13/2024. The MDSC stated the facility did not conduct an IDT meeting after Resident 118 was readmitted to the facility on 10/21/2024 following his elopement on 10/13/2024 nor after Resident 118 was assessed as a high risk for wandering and elopement. The MDSC stated conducting an IDT meeting when Resident 118 was readmitted to the facility was important to find out the reason Resident 118 eloped from the facility on 10/13/2024. The MDSC stated during the IDT meeting, the facility could have assisted Resident 118 with a safe discharge if that was desired or addressed other concerns that prompted Resident 118 to elope from the facility. The MDSC stated during the IDT meeting, Resident 118 would have been educated on the importance of safety and encouraged not to elope from the facility due to the risk of getting hit by a car or ultimately death. The MDSC stated because the IDT did not address Resident 118’s reason for eloping nor his high risk for wandering and elopement, the IDT was unabl