Health inspection·July 8, 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. § 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 5/19/2025, the California Health Department of Public Health (CDPH) received a Facility Reported Incident (FRI) regarding an elopement (the act of leaving a facility unsupervised and without prior authorization) incident involving two residents (Resident 1 and Resident 2). On 5/20/2025, the CDPH received two complaints alleging two residents (Resident 1 and Resident 2) who were diagnosed with dementia (a progressive state of decline in mental abilities) went missing from the facility. On 5/20/2025, the CDPH conducted an unannounced visit to the facility to investigate the FRI and complaint allegations. During the investigation, the CDPH determined Resident 1 and Resident 2, who were assessed as high risk for wandering/elopement, eloped from the locked facility (a skilled nursing facility or unit where residents are prevented from leaving independently due to safety concerns, particularly those residents with cognitive impairments like dementia, and wo are at risk for wandering or elopement) on 5/18/2025 through the facility's front door. The facility failed to: 1. Ensure Resident 1 and Resident 2 were supervised to prevent elopement from the facility. 2. Follow their Policy and Procedures (P/P) titled "Wandering Residents and Elopements" that indicated the facility maintains a process to assess residents for elopement risk, or who were at risk of unsafe wandering and implement risk reduction strategies with interventions to identify residents who are high risk for elopement included but may not be limited to the physical plant secured to minimize the risk of elopement through safety locks or keypad entry that restricts access to dangerous areas. These deficient practices resulted in Resident 1 and Resident 2 eloping from the facility on 5/18/2025 at approximately 12 p.m., without staff awareness. Resident 1 and Resident 2 were located by Resident 1's Family Member (FM) 1, approximately 20 miles from the facility on 5/19/2025 at approximately 3 p.m. (approximately 27 hours after they were believed to have eloped from the facility). Both residents were transported to a General Acute Care Hospital (GACH) for evaluation and treatment, where they remained for four days. Resident 1 was admitted to the GACH with altered mental status (AMS), and Resident 2 was assessed and treated for a urinary tract infection (UTI). These deficient practices placed Resident 1 and Resident 2 at risk of exposure to inclement weather, vehicular accident and injury, harm by other individuals and death, and placed 144 residents, who resided in the facility, and who were assessed as high risk for wandering/elopement, at risk for leaving the facility without staff knowledge. A review of Resident 1's Admission Record (Face Sheet) indicated Resident 1, a 74 year old female, was admitted to the facility on 3/25/2025 with diagnoses including paranoid schizophrenia (a mental illness that affects a person's thoughts, feelings and behaviors) and dementia. A review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 4/1/2025 indicated Resident 1 had moderately impaired cognitive skills (problems with a person's ability to think, learn, remember, use judgement, and make decisions) for daily decision making and required supervision to complete activities of daily living (ADLs). A review of Resident 1's Wandering Risk Observation/Assessment dated 3/25/2025 indicated a score of nine, indicating Resident 1 was at risk for wandering. A review of Resident 1's untitled Care Plan dated 4/23/2025 indicated Resident 1 was an elopement risk/wanderer related to her attempts to leave the facility unattended. The goal of the care plan indicated Resident 1 would not leave the facility unattended. The Care Plan's interventions included distracting Resident 1 from wandering by offering pleasant diversions, structured activities, food, conversation, television, and books, monitoring Resident 1's location every two hours and documenting wandering behavior and attempted diversional interventions in the behavior log. A review of Resident 1's Change of Condition (COC) form dated 5/18/2025 indicated at approximately 5:41 p.m., Resident 1 could not be located anywhere in the facility and "Code Black" (an alert to facility staff to initiate a search of the building and premises for a resident who left the facility without authorization) was initiated. The COC form indicated at 5:41 p.m., the facility's Director of Nursing (DON) and Administrator (ADM), local police and Resident 1's Responsible Party (RP) were notified of Resident 1's disappearance. A review of Resident 1's Nursing Progress Note dated 5/19/2025 and timed at 2:56 p.m., indicated FM 1 reported he located Resident 1 near his (FM 1) residence. The Nursing Progress Note indicated Resident 1 was transported to a GACH by the facility's ADM and Social Services Worker (SSW) for assessment and clearance. A review of the GACH's Face Sheet, indicated Resident 1 was admitted to the GACH on 5/19/2025. A review of the GACH's Emergency Department (ED) Progress Note dated 5/19/2025 indicated Resident 1 was admitted with a diagnosis of AMS. A review of the GACH's Critical Care Medicine Progress Note, dated 5/20/2025, indicated Resident 1 was assessed with acute bronchitis (inflammation of the lining of the bronchial tubes), acute sinusitis (inflammation of the sinuses), and acute exacerbation (a sudden worsening or flare-up of an underlying chronic disease or condition) of chronic obstructive pulmonary disease ([COPD] a chronic lung disease causing difficulty in breathing). The Critical Care Medicine Progress Note indicated Resident 1 was treated with Intravenous ([IV] in the vein) Rocephin (a powerful antibiotic used to treat bacterial infections), Albuterol (an inhalant used to prevent and treat wheezing, difficulty breathing, chest tightness, and coughing) and Atrovent nebulizer (used in combination with Albuterol to help control the symptoms of lung diseases, such as bronchitis and to prevent worsening of COPD). A review of Resident 2's Face Sheet indicated Resident 2, a 67 year old female, was admitted to the facility on 9/5/2024 with a diagnosis of dementia, paranoid schizophrenia, lack of coordination, dysphagia (difficulty swallowing foods or liquids), and hypertension ([HTN] high blood pressure). A review of Resident 2's MDS dated 3/12/2025 indicated Resident 2 had impaired cognitive skills for daily decision making and required partial/moderate assistance to complete her ADLs. A review of Resident 2's Wandering Risk Observation/Assessment dated 9/5/2024 indicated a score of eleven, indicating Resident 2 was a high risk for wandering. A review of Resident 2's untitled Care Plan dated 9/5/2024 indicated Resident 2 was an elopement risk/wanderer related to disorientation to place and impaired safety awareness. The care plan indicated Resident 2 wandered aimlessly and significantly intruded on the privacy or activities of others. Under this Care Plan, the goal was that Resident 2 would not leave the facility unattended. The Care Plan's interventions included monitoring Resident 2's location, documenting wandering behavior and attempted diversional interventions in the behavior log. A review of Resident 2's COC form dated 5/18/2025 indicated on 5/18/2025 at approximately 5:41 p.m., Resident 1 could not be located anywhere in the facility and "Code Black" was initiated. The COC form indicated at 5:41 p.m., the DON, ADM, local police and Resident 2's RP were notified of Resident 2's disappearance. A review of Resident 2's Nursing Progress Note dated 5/19/2025 and timed at 2:56 p.m., indicated FM 1 (Resident 1's family member) reported he located Resident 2 near his (FM 1) residence. The Nursing Progress Note indicated Resident 2 was transported to a GACH by the facility's ADM and SSW for assessment and clearance. A review of the GACH's Face Sheet indicated Resident 2 was admitted to the GACH on 5/19/2025. A review of the GACH's ED Progress Note dated 5/19/2025 indicated Resident 2 was admitted to the GACH (5/19/2025) with a diagnosis of UTI, and diabetes mellitus ([DM] a disorder characterized by difficulty in blood sugar [b/s] control and poor wound healing). During an interview on 5/20/2025 at 10:56 a.m., and a subsequent interview at 12:42 p.m., the facility's Receptionist (RCP) 1 stated on 5/18/2025 between 12:10 p.m. to 12:15 p.m., Certified Nursing Assistant (CNA) 1 rang the doorbell from inside the facility's locked area alerting her (RCP 1) to unlock the door, which led to the facility's lobby area, so that Resident 1 and Resident 2, who were mistaken as visitors, could be allowed out of the locked area into the facility's lobby. RCP 1 stated she unlocked the door, Resident 1 and Resident 2 entered the lobby and continued out the facility's front entrance. RCP 1 stated she was not familiar with the residents in the facility, and she found out later that evening, those visitors were actually residents. RCP 1 stated there was no process to check out visitors when they left the facility. RCP 1 stated, after unlocking the facility's front door, she told Resident 1 and Resident 2 "goodbye and have a nice day." During an interview on 5/20/2025 at 11:48 a.m., CNA 1 stated on 5/18/2025 at approximately lunchtime (exact time unknown) she was passing by the locked doors that led to the facility's lobby area and saw two ladies that did not look like residents near the doors. CNA 1 stated she pressed the button (doorbell) to signal for RCP 1 to unlock the doors, which she (RCP 1) did, and the two ladies proceeded into the lobby area. During an interview on 5/20/2028 at 2:43 p.m., FM 1 stated he was at a grocery store near an area where Resident 1 had previously resided (20 miles from the facility) when he saw two women, one who looked like Resident 1, he called her name, and she responded. FM 1 stated he asked Resident 1 where she had been, and Resident 1 responded that she went to get some air. FM 1 stated both Resident 1 and Resident 2 were filthy, and he could tell Resident 1 had been sleeping on the concrete. FM 1 stated Resident 2 required the use of a cane to walk, they both (Resident 1 and 2) were moving slowly. FM 1 stated he brought the residents to a friend's house and called the facility's ADM. FM 1 stated this was very upsetting to him. During an interview on 5/20/2025 at 2:42 p.m., CNA 4 stated on 5/18/2025 at approximately lunchtime (exact time unknown), she did not see Resident 1 or Resident 2 when she delivered lunch trays to their shared room. CNA 4 stated she usually does rounds on her assigned residents every two hours and during her rounds on 5/18/2025 she did not see Resident 1 and Resident 2 after delivering their lunch trays and did not look for them because she assumed they were on the facility's patio. CNA 4 stated she noticed their lunch trays were still in the residents' room and were untouched. CNA 4 stated she found out later that night, Resident 1 and Resident 2 were missing from the facility. During an interview on 5/20/2025 at 2:15 p.m., CNA 5 stated when she started her shift at 3 p.m., on 5/18/2025 she noticed Resident 1 and Resident 2's lunch trays were still in their room untouched. CNA 5 stated she asked staff members if they had seen the residents, but nobody had seen them. CNA 5 stated prior to dinner time (unsure of the exact time), she asked other staff to help her look for Resident 1 and Resident 2 and they (CNA 5 and other staff - unknown) continued looking for them throughout dinner time. CNA 5 stated she found out the residents had eloped when she heard "Code Black" being activated. During an interview on 5/20/2025 at 3:04 p.m., the DON stated Resident 1 and Resident 2's whereabouts in the facility should have been monitored every two hours because they were at high risk for wandering/elopement. The DON stated staff should have confirmed if Resident 1 and Resident 2 were actual visitors prior to allowing them into the facility's lobby area and then allowing them to exit through the facility's front door. The DON stated the facility had no check out process for visitors and no check out process was utilized by RCP 1 prior to Resident 1 and Resident 2 eloping from the facility. The DON stated the residents' elopement placed them at risk for harm by car accident and/or injury by other individuals, missed medications, no access to food or water, and exposure to different weather conditions. A review of the facility's undated P/P titled "Wandering Residents and Elopements" indicated the facility maintained a process to assess residents for elopement risk, or who were at risk of unsafe wandering and implement risk reduction strategies. The P/P indicated interventions that may be used for residents identified as high risk for elopement included but may not be limited to the physical plant secured to minimize the risk of elopement through safety locks or keypad entry that restricted access to dangerous areas. The facility failed to: 1. Ensure Resident 1 and Resident 2 were supervised to prevent elopement from the facility. 2. Follow their Policy and P/P titled "Wandering Residents and Elopements" that indicated the facility maintains a process to assess residents for elopement risk, or who were at risk of unsafe wandering and implement risk reduction strategies with interventions to identify residents who are high risk for elopement included but may not be limited to the physical plant secured to minimize the risk of elopement through safety locks or keypad entry that restricts access to dangerous areas. These deficient practices resulted in Resident 1 and Resident 2 eloping from the facility on 5/18/2025 at approximately 12 p.m., without staff awareness. Resident 1 and Resident 2 were located by FM 1, approximately 20 miles from the facility on 5/19/2025 at approximately 3 p.m. (approximately 27 hours after they were believed to have eloped from the facility). Both residents were transported to a GACH for evaluation and treatment, where they remained for four days. Resident 1 was admitted to the GACH with AMS and Resident 2 was assessed and treated for a UTI. These deficient practices placed Resident 1 and Resident 2 at risk of exposure to inclement weather, vehicular accident and injury, harm by other individuals and death, and placed 144 residents, who resided in the facility, and who were assessed as high risk for wandering/elopement, at risk for leaving the facility without staff knowledge. These violations, jointly, separately or in any combination, presented either imminent danger that death or serious harm would result, or a substantial probability that death or serious physical harm would result to Resident1 and Resident 2.