Health inspection·April 11, 2025

42 CFR § 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, the comprehensive person-centered care plan, and the residents' choices §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. §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 2/24/2025, the California Department of Public Health (CDPH) received a Facility Reported Incident (FRI) indicating that a resident (Resident 1) was not found in her room during morning rounds. On 2/25/2025, CDPH conducted an unannounced visit to the facility to investigate the FRI. Upon investigation, CDPH determined the facility's front door's alarm was not activated on 2/24/2025, and Resident 1, who was under conservatorship (a legal status in which a judge appoints a person [conservator] to manage the financial and personal affairs of a minor incapacitated person), was known to wander (random or repetitive locomotion maybe goal directed, or non-goal directed) around the hallways in the facility, and was assessed incorrectly during her elopement (act of leaving a facility unsupervised and without prior authorization) evaluation, eloped from the facility on 2/24/2025. Resident 1 was located approximately four hours and 30 minutes after leaving the facility, approximately four miles away from the facility The facility failed to: 1. Ensure the facility's front door's alarm was activated when the facility's Receptionist (RCP) left the facility at 9 p.m., on 2/24/2025. 2. Ensure Resident 1, who had wandering behavior, was accurately assessed during her Elopement Evaluation on 12/24/2024. 3. Ensure staff followed the facility's Policy and Procedure (P/P), titled "Wandering and Elopement" revised 1/31/2023 that indicated the facility would identify residents at risk for elopement upon admission and when there was a change in condition (COC) to minimize the risk of elopement. As a result of these deficient practices, Resident 1 eloped from the facility on 2/24/2025 between 6 a.m., when she was last seen during a blood pressure check (BP), and 7 a.m., when she was not found in her room during morning rounds. Resident 1 was found approximately four miles from the facility, on the same day (2/24/2025), at 10:27 a.m. (approximately four hours and 30 minutes after she was last seen in the facility). A review of Resident 1's Admission Record (Face Sheet), indicated Resident 1 was initially admitted to the facility on 6/14/2024 and re-admitted on 8/29/2024 with diagnosis including schizophrenia (a mental illness that is characterized by disturbances in thought), a brief psychotic disorder (a mental health condition characterized by a sudden onset of psychotic symptoms that last for at least one day but less than one month), generalized anxiety disorder (a mental health condition characterized by excessive, persistent, and uncontrollable worry about a variety of everyday events), dementia (a progressive state of decline in mental abilities), and aphasia (a disorder that makes it difficult to speak). A review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool), dated 12/19/2024, indicated, Resident 1's cognition (thinking) was moderately impaired. The MDS indicated Resident 1 required supervision or touch assistance for walking. A review of Resident 1's Elopement Evaluation form dated 8/29/2024, indicated Resident 1 had a history of elopement or attempted leaving the facility without informing staff, and wandering. Continued review of the Elopement Evaluation form indicated there were no goals, interventions or clinical suggestions checked. A review of Resident 1's Elopement Evaluation form dated 12/24/2024, indicated Resident 1 did not have a history of elopement or attempting to leave the facility without informing staff, and Resident 1 did not wander. The Elopement Evaluation form indicated a contradiction from the previous Elopement Evaluation form dated 8/29/2024. A review of Resident 1's Situation, Background, Assessment, Recommendation ([SBAR] a communication tool used by healthcare workers when there is a change of condition among the residents) dated 2/24/2025, indicated at 7:34 a.m., Certified Nursing Assistant (CNA) 3 reported to Licensed Vocational Nurse (LVN) 2 that Resident 1 was not in her room. The SBAR indicated LVN 2 performed a sweep of the facility and Resident 1 was not found. A review of the local area Police Department's Missing Person's Report dated 2/24/2025, indicated Resident 1 was located and identified at 10:27 a.m., approximately four miles from the facility, wearing a yellow sweater, brown skirt, and gray socks. The Police Department's Missing Person's Report indicated Resident 1 was evaluated and transported to a General Acute Care Hospital (GACH) where she was placed on a medical hold (a temporary involuntary detention of a patient in a hospital allowing for medical examination and treatment when the patient lacks the capacity to make informed decisions). A review of a Paramedic Run Sheet (a document that records information about a patient's encounter with ambulance services) dated 2/24/2025, indicated Resident 1 was found by a local area police department walking on the sidewalk confused, mumbling incoherently (unclear, confusing speech), and wearing approximately 10 layers of clothing. During a concurrent interview and record review on 2/25/2025, at 7:37 a.m., with Registered Nurse Supervisor (RNS) 1, Resident 1's Elopement Evaluation form dated 12/24/2024 was reviewed. The Elopement Evaluation form indicated Resident 1 was not a wanderer. RNS 1 stated Resident 1 was not a wanderer but stated she (Resident 1) walked the hallways most of the time, but she (Resident 1) did not wander into other resident's rooms, nor had she attempted to leave the facility. During an interview on 2/25/2025, at 9 a.m., CNA 3, stated, on 2/24/2025 when he was making his morning rounds at 7 a.m., he did not see Resident 1 in her bed. CNA 3 stated he asked Resident 1's roommates (Resident 2 and Resident 3) who were alert, if they knew where Resident 1 was, and both of them said they had not seen Resident 1. CNA 3 stated, Resident 1 constantly walked around the hallways all the time, and would always stop and stare at the front door but would never walk towards the front door or exit the facility, which was why he (CNA 3) did not notify anyone of her behavior of wandering. During an interview on 2/25/2025, at 9:40 a.m., the Administrator (ADM) stated, none of the cameras inside or outside of the facility had been working since 11/18/2024, and when Resident 1 eloped (2/24/2025), the alarm on the front door was not turned on, and the alarm should have been turned on. The ADM stated the licensed nurses were responsible for turning on and activating the alarm at the front entrance and it was important that the front door's alarm was on to alert staff if a resident attempted to exit the facility. The ADM stated Resident 1 probably eloped from the facility through the front door. During an interview on 2/25/2025, at 12:55 p.m., LVN 1 stated, the last time she saw Resident 1 was on 2/24/2025 after 6 a.m., when she took Resident 1's 1 BP. LVN 1 stated the alarm at the front door was not turned on during the night/morning that Resident 1 eloped, because there were CNAs and licensed nurses sitting at the front nurses station, which was close to the front entrance of the facility. LVN 1 stated she did not know if the nurses were at the front nurse's station the entire time. During a concurrent interview and record review on 2/26/2025, at 1:47 p.m., with the Maintenance Supervisor (MS), the Wander Guard/Red Alarm Monitoring Logs were reviewed. The Monitoring Log indicated the alarms for the three doors in the facility were checked daily Monday through Friday but not on the weekends or after regular business hours (after 5:30 p.m.). The MS stated he checked the alarms during the week, Monday through Friday, but he gets off work at 5:30 p.m., and he was not there to check if the alarms were on after that time. During an interview on 2/26/2025, at 4:20 p.m., the Receptionist (RCP) stated he worked Monday through Friday, and his shift ended at 9 p.m. The RCP stated when he leaves the facility, he locks the front door from the outside, but he does not turn the alarm on because he was never instructed to do so. During an interview on 2/27/2025, at 5:14 p.m., after reviewing Resident 1's Elopement Evaluation form dated 8/29/2024 the Director of Nursing (DON) stated, Resident 1 was an elopement risk since she had a history of elopement or attempting to leave the facility without informing staff. The DON stated, "a history of" means Resident 1 attempted to leave a facility in the past and a care plan should have been developed with goals and interventions. The DON stated staff should have been notified of Resident 1's wandering/elopement risk so she (Resident 1) could have been monitored closely to prevent her from eloping from the facility. A review of the facility's P/P titled, "Wandering and elopement" revised 1/31/2023, indicated the purpose of the policy was to enhance the safety of residents of the facility. The P/P indicated the facility would identify residents at risk for elopement upon admission and when there was a COC to minimize the risk of elopement. The facility failed to: 1. Ensure the facility's front door's alarm was activated when the facility's RCP left the facility at 9 p.m. on 2/24/2025. 2. Ensure Resident 1 who had wandering behaviors was assessed accurately during her elopement evaluation on 12/24/2024. 3. Ensure they followed their Policy and Procedure (P/P), titled "Wandering and Elopement" revised 1/31/2023 that indicated the facility would identify residents at risk for elopement upon admission and when there was a change in condition (COC) to minimize the risk of elopement. As a result of these deficient practices, Resident 1 eloped from the facility on 2/24/2025 between 6 a.m., when she was last seen during a BP check, and 7 a.m., when she was not found in her room during morning rounds. Resident 1 was found approximately four miles from the facility, on the same day (2/24/2025), at 10:27 a.m. 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.