Health inspection·October 24, 2025

California Code of Regulations, Title 22, § 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 the 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 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 each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. California Code of Regulations, Title 22, Section 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. (b) All policies and procedures required of these regulations shall be in writing, made available upon request to physicians and other involved health professionals, patients or their representatives, employees and the public shall be carried out as written. Policies and procedures shall be reviewed at least annually, revised as needed and approved in writing by the patient care policy committee. On 10/8/2025 at 8:30 AM, an unannounced visit was conducted to the facility by the California Department of Public Health (CDPH) to investigate a complaint regarding resident elopement. During the investigation, the department determined that the facility failed to provide safe, secure environment, and implement the facility’s policy and procedures titled, “ “Wandering and Elopement,” “Care Plans, Comprehensive Person-Centered,” and “Safety and Supervision of Residents” to prevent Resident 1 who has cognitive impairment, and was at risk of elopement and wandering by failing to ensure: 1. Facility staff provided supervision or touching assistant to Resident 1 when Resident 1 walked for more than 150 feet at indicated in Resident 1’s Minimum Data Set (MDS – a resident assessment tool) dated 3/7/2025. 2. Facility staff developed a care plan to address Resident 1’s risk of elopement to include interventions related to monitoring and supervision of Resident 1 to prevent elopement. 3. Facility staff contact the attending Physician and report the findings and conditions of Resident 1, when Resident 1 returned to the facility on 7/16/2025 after the elopement. 4. The Safety Committee evaluated and analyzed the cause of how Resident 1 eloped and developed strategies to mitigate or remove the risk of Resident 1’s elopement. As a result, Resident 1 was found unexpectedly wandering alone on the street approximately 0.3 miles away from the facility on 7/16/2025 around 8 PM. Resident 1 was brought back to the facility-by-facility staffs (Admission Coordinator [AC] and Social Service Designee [SS 1]). These deficient practices put Resident 1 at risk of harm and injuries due to potential falls, accidents and/or being struck by motor vehicles. A review of Resident 1’s clinical record indicated Resident 1 was admitted to the facility on 3/1/2025 with diagnoses that included Alzheimer and dementia. A review of Resident 1’s Elopement- Wandering Risk Scale Assessment, dated 3/1/2025 indicated Resident 1 was at moderate risk for wandering/elopement with score 7 ( 7 out of 18 considered moderate risk on the scale) due to impaired cognition and impaired decision-making skills. The assessment indicated for Resident 1 to attend daily activities and for staff to provide frequent visual checks. A review of Resident 1’s Minimum Data Set (MDS – a resident assessment tool) dated 3/7/2025 indicated Resident 1 had severely impaired cognition. The MDS indicated Resident 1 required supervision or touching assistance on sit-to-stand and walking 150 feet. A review of Resident 1’s Nursing Progress Notes (NPN), with a “Late entry” dated 7/16/2025 timed 9:54 PM indicated Resident 1 was asleep in bed with no visible injury or discoloration. The NPN indicated “per CNA (unidentified) Resident 1 was found wandering outside of the community, unable to state where she was going and was redirected to the facility. Vitals stable.” A review of the Administrative Investigation Notes, signed by the Administrator (ADM), dated 7/18/25 indicated the ADM received a call on 7/16/2025 from the AC who reported that she and SSD 1 were driving home, and they saw Resident 1 walking outside of the facility. The notes indicated Resident 1 was driven back to the facility in the staff’s private vehicle. The note indicated Licensed Vocational Nurse (LVN) 1 was interviewed by LVN 2 who reported that she just saw Resident 1 “a few moments before and the resident was in bed, and she was unaware that the resident was missing.” The note did not include Resident 1’s condition nor Resident 1’s physician was notified regarding Resident 1’s elopement. During an interview on 10/8/2025 at 12:30 PM, the AC stated at around 8 PM on 7/16/2025, she and SS 1 were driving home after dinner and saw Resident 1 walking on the street near a fast-food restaurant. The AC stated she immediately pulled over to the fast-food restaurant parking lot and Resident 1 told her Resident 1 was looking for Resident 1’s sister. The AC explained that Resident 1 was referring to Resident 1’s deceased sister. The AC stated Resident 1 was pleased to see her and SS1 and agreed to go back to the facility. The AC stated she notified the Administrator and Resident 1’s Responsible Party (RP 1) regarding Resident 1’s elopement when she arrived at the facility with Resident 1. During an interview and concurrent review of Resident 1’s care plans on 10/8/2025 at 2 PM, there was no care plan addressing Resident 1’s wandering and elopement behaviors. The Director of Nursing (DON) stated she could not find a care plan in Resident 1’s record addressing Resident 1’s wandering and elopement behaviors with interventions to prevent elopement prior to Resident s1’s elopement on 7/16/2025. During an interview on 10/9/2025 at 9:10 AM with LVN 2, LVN 2 stated she was notified about Resident 1’s elopement the next morning on 7/17/2025. LVN 2 stated she completed the SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents) and notified Resident 1’s physician on 7/17/2025. LVN 2 stated she was not asked to investigate the incident by the ADM while the DON was on vacation. LVN 2 stated she did not keep a record of the report indicating the conversation with the assigned nursing staff on 7/16/2025 regarding Resident 1’s elopement and she “did not know the details of the incident (Resident 1’s elopement).” During an interview on 10/9/2025 at 10:05 AM, the ADM stated that he was notified on 7/16/2025 evening, through a telephone call from the AC about Resident 1’s elopement. The ADM stated he did not report the incident to the appropriate state agency and police department because at the time he was notified that Resident 1 eloped, Resident 1 already returned to the facility. The ADM stated he or designee did not thoroughly investigate the root cause on how Resident 1 exited the facility without any staff’s awareness, and there were no in-services provided to the staffs and no new written action plan to prevent Resident 1 and other residents at risk of wandering/elopement from leaving the facility unsupervised after Resident 1’s elopement on 7/16/2025. During a telephone interview on 10/9/2025 at 1:05 PM, CNA 1 stated she was assigned to Resident 1 on 7/16/2025 and she was aware that Resident 1 was at risk of elopement, seeking an exit and making excuses to leave since Resident 1 was admitted to the facility. CNA 1 stated the last time she saw Resident 1 was on 7/16/2025, between 7 PM and 7:30 PM before she went on break at 7:30 PM. On 10/9/2025 at 1:38 PM, a phone interview was conducted with LVN 1, LVN 1 stated she was assigned to care for Resident 1 on 7/16/2025. LVN 1 stated she was aware that Resident 1 was at risk of elopement and always seeking an exit to leave. LVN 1 started on 7/16/2025 between 7 PM to7:30 PM as she was passing by the exit door next to the Rehabilitation room and saw Resident 1 opened the side exit door so she and CNA 1 re-directed Resident 1 back to the resident’s room. LVN 1 stated after Resident 1 attempted to exit through the exit door, LNV 1 attended to other residents and did not inform other CNAs to provide continuous supervision to Resident 1 to prevent elopement. During a telephone interview on 10/10/2025 at 3:11 PM with the ADM and DON, the ADM stated during his investigation he could not determine how Resident 1exited the facility unsupervised. The ADM stated there was no alarm to the door next to the laundry area where he thinks Resident 1 possibly eloped from on 7/16/2025. The ADM stated the instruction to all staff to monitor the residents was given verbally but not written. The DON and ADM stated there was no one specifically assigned to the exit door without an alarm in the laundry area to monitor the residents leaving the facility from that exit. During a phone interview on 10/10/2025 at 4:50 PM with CNA 2, CNA 2 stated she covered CNA 1 for meal break between 7:30 PM and 8 PM on 7/16/2025. CNA 2 stated she knew Resident 1 was at risk for elopement and many of the CNAs were also aware of Resident 1’s wandering behavior. CNA 2 stated she saw Resident 1 on 7/16/2025 at around 7:45 PM, before Resident 1 eloped. CNA 2 stated she saw another CNA (unidentified) speaking to Resident 1 in the resident’s room before she answered another resident’s call light. CNA 2 stated she could not recall what time when she heard the AC brought bring Resident 1 from the “street" back to the facility. A review of the facility’s P&P titled, “Safety and Supervision of Residents,” revised in 7/2017, the P&P indicated the following: a. The facility strives to make the environment as free from accidents and hazards as possible. b. The facility will provide residents’ safety and supervision and assistance to prevent accidents are facility wide priorities. c. When accident hazards are identified, the QAPI/ Safety Committee shall evaluate and analyze the cause of the hazards and develop strategies to mitigate or remove the hazards to the extent possible. d. The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision. e. Implementing interventions to reduce accident risks and hazards shall include the following: i. Assigning responsibility for carrying out interventions. ii. Ensuring that interventions are implemented. iii. Documenting interventions. f. Monitoring the effectiveness of interventions should include the following: i. Ensuring that interventions are implemented correctly and consistently. ii. Evaluating the effectiveness of interventions. iii. Modifying or replacing interventions as needed. A review of the facility’s P&P titled, “Wandering and Elopements,” revised in 3/2019, the P&P indicated that when the resident returns to the facility, the Director of Nursing Services or charge nurse shall: 1. Identify residents at risk for unsafe wandering and strive to prevent harm. 2. Develop a care plan will include strategies and interventions to maintain residents’ safety. 3. Complete and file an incident report 4. Document relevant information in the resident’s medical record. A review of the facility P&P titled, “Care Plan, Comprehensive Person-centered” dated 12/2016 indicated the following: a. The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. b. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment with measurable objectives and timeframes. The facility failed to provide safe, secure environment, and implement the facility’s policy and procedures titled, “related to “Wandering and Elopement,” and “Care Plan, Comprehensive Person-Centered,” and “Safety and Supervision of Residents,” to prevent Resident 1 who has cognitive impairment with impaired cognition, was at risk of elopement and wandering by failing to ensure: 1. Facility staff provided supervision or touching assistant to Resident 1 when Resident 1 walked for more than 150 feet at indicated in Resident 1’s Minimum Data Set (MDS – a resident assessment tool) dated 3/7/2025. 2. Facility staff A care plan was developed to address Resident 1’s risk for elopement and to include interventions related to monitoring and supervision of Resident 1 to prevent elopement. 3. Facility staff contact the attending Physician and report the findings and conditions of Resident 1, when Resident 1 returned to the facility on 7/16/2025 after the elopement. 4. The Safety Committee evaluated and analyzed the cause of how Resident 1 eloped and developed strategies to mitigate or remove the risk for the residents to elope again. As a result of these deficiencies, Resident 1 was found unexpectedly wandering alone on the street approximately 0.3 miles away on 7/16/2025 around 8 PM. Resident 1 was brought back to the facility-by-facility staff. These deficient practices put Resident 1 at risk of harm and injuries due to had the potential falls, accidents and/or being struck by motor vehicles. The above violation had a direct or immediate relationship to the health, safety, or security of Resident 1.