Health inspection·April 11, 2025

Code of Federal Regulations, Title 42, Section 483.25 (d) Accidents. The facility must ensure that – §483.25(d)(1) The patient environment remains as free of accident hazards as is possible; and §483.25(d)(2) Each patient receives adequate supervision and assistance devices to prevent accidents. Code of Federal Regulations, Title 42, Section 483.21(b) Comprehensive Care Plans §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following — (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40. California Code of Regulations, Title 22, Section 72311. Nursing Service-General (a) Nursing service shall include, but not be limited to, the following: (2) Implementing of 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. On 2/21/2025, the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to investigate a facility reported incident (FRI) regarding quality of care and resident safety of Resident 1. As a result of the investigation, the CDPH determined the facility failed to provide supervision to prevent elopement for Resident 1, who was assessed as “at risk for elopement” as indicated in the facility's policy and procedure (P&P) titled, "Elopements and Wandering Residents." The facility failed to: 1. Implement Resident 1’s Care Plan (CP) titled, “Care Plan Report,” revised on 2/8/2025, to minimize Resident 1’s episode of behavior by promoting safety precautions at all times, and redirecting Resident 1’s behavior. 2. Implement Resident 1’s CP titled, “Care Plan Report,” revised on 2/10/2025, to provide frequent visual checks to ensure Residents 1’ needs are met, and safety is assured. These failures resulted in Resident 1 leaving the facility without supervision on 2/19/25 at 8:45 pm. These deficient practices had the potential to compromise Resident 1’s safety and placed Resident 1 at risk for injuries. Resident 1 was found on 3/8/25 and was readmitted to the facility on 3/17/25. A review of Resident 1's Admission Record, indicated the facility originally admitted Resident 1, a 47-year-old male, on 9/13/24, and readmitted Resident 1 on 2/7/25, with diagnoses which included schizophrenia (a serious mental illness that interferes with a person's ability to think clearly, manage emotions, make decisions, and relate to others) and anxiety disorder (feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). A review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 12/21/24, indicated Resident 1 was able to verbalize Resident 1's needs. The MDS indicated Resident 1's cognition was moderately impaired with a Brief Interview for Mental Status (BIMS – a standardized assessment to evaluate cognitive function ranging from 0 to 15) score of 12 (0-15 = cognitive intact, 8-12 = moderate impairment, and 0-7 = severe impairment). The MDS indicated Resident 1 required setup or clean-up assistance with eating and oral hygiene and required supervision or touching assistance with toileting hygiene, showering/bathing, upper and lower body dressing, putting on/taking off footwear, and personal hygiene. The MDS indicated Resident 1 walked with supervision or touching assistance. A review of Resident 1's Elopement Risk Evaluation, dated 2/7/25, indicated Resident 1 was at risk for elopement due to a history of elopement or an attempted elopement while at home and due to Resident 1’s wandering behavior. A review of Resident 1's physician order, dated 2/7/25, untimed, indicated to admit Resident 1 to the secured unit (any area in the facility designed and operated to ensure that all its entrances and exits are locked to prevent residents from leaving the facility without permission and/or supervision) of the facility due to wandering behavior. A review of Resident 1's Nursing Progress Note (NPN), dated 2/7/25, timed at 2:52 pm, indicated Resident 1 was readmitted to the secured unit from General Acute Care Hospital (GACH) 1. A review of another Resident 1’s physician order, dated 2/7/25, untimed, indicated Resident 1 may transfer to Station 6 (an unsecured or open unit in the facility). A review of Resident 1’s physician orders, dated 2/7/25, untimed, indicated Resident 1 had medication orders for Buspar oral tablet 330 milligrams (mg), give one (1) tablet by mouth two times a day for anxiety disorder manifested by cursing at others for no reason, Depakote oral tablet delayed release, give 750 mg by mouth two times a day for unspecified mood affective disorder manifested by episodes of verbally abusive to others, and Zyprexa oral tablet 15 mg by mouth two times a day for paranoid schizophrenia manifested by striking out for no reason. A review of Resident 4's NPN, dated 2/7/25, timed at 6:12 pm, indicated, "Resident (Resident 1) was transferred to (an) open unit Station 6." A review of Resident 1's CP titled, “Care Plan Report,” revised on 2/8/2025, the CP indicated Resident 1 was at risk for injuries. The CP goal was for staff to minimize Resident 1’s episode of behavior. The CP interventions were for staff to promote safety precautions at all times, and redirect Resident’ 1’s behavior. A review of Resident 1's History and Physical, dated 2/10/25, indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1's CP titled, “Care Plan Report,” revised on 2/10/2025, the CP indicated Resident 1 was at risk for impaired thought process secondary to anxiety disorder manifested by pacing back and forth. The CP goal was for staff to help minimize Resident 1’s anxiety symptoms. The CP interventions were for staff to provide frequent (often, occurring on many occasions in quick succession) visual checks to ensure resident’s needs are met, and safety is assured. A review of Resident 1's SBAR (Situation, Background, Assessment, Recommendation), dated 2/19/25, untimed, indicated Resident 1 "left the facility without notifying staff." The SBAR indicated the certified nursing assistant (CNA) assigned to care for Resident 1 (CNA 14) did not find the resident in Resident 1's room and bathroom on 2/19/25 at 8:45 pm. The SBAR indicated all the staff looked for Resident 1 in all the rooms and bathrooms, the facility grounds, neighboring parks, stores, gas stations, and smoke shops, and called hospitals, but were unable to find Resident 1. A review of Resident 1's NPN, dated 2/19/25, timed at 8:45 pm, indicated the licensed vocational nurse (LVN) assigned to care for Resident 1 (LVN 4) saw Resident 1 walk past the nurses' station at 7:45 pm. The NPN indicated CNA 14 saw Resident 1 walking around the unit at 8:04 pm. At 8:45 pm, CNA 14 did not find Resident 1 in Resident 1's room and bathroom. The NPN indicated staff in the unit searched in all the rooms and bathrooms in the unit and did not find Resident 1. The facility emergency code for missing resident was called and all the staff in the facility searched all the rooms, all the bathrooms, the facility grounds, drove around the neighboring areas, and called hospitals around the area but were unable to find Resident 1. The NPN indicated the local police department was called at 10:05 pm and the police visited the facility for investigation and report at 10:55 pm. During a concurrent observation and interview on 2/21/25 at 2:28 pm, LVN 1 stated there were 4 exit doors in Station 6: the main door (in front of the nurses' station), the exit door at the end of East Hall, the exit door at the end of West Hall, and the exit door by the kitchen. LVN 1 stated the East, West, and kitchen exit doors were alarmed but not locked, and the main door was not alarmed and never locked. The East and West doors were visible when standing in the middle of the main hallway of Station 6, which was divided into the East Hall and the West Hall. The kitchen exit door was not visible from the main hallway of Station 6. During a tour of Station 6, LVN 1 opened the East, West, and kitchen exit doors and a loud alarm went off. LVN 1 used a key to silence the red alarm located on top of the East, West, and kitchen exit doors. LVN 1 stated LVN 1 was not very familiar with Resident 1 because Resident 1 had only been in Station 6 for two weeks. LVN 1 stated Resident 1 moved to Station 6 from the secured unit. LVN 1 stated Resident 1 paced back and forth in the hallways of Station 6 and liked using the vending machine in Station 6 to get snacks. The vending machine in Station 6 was located by the kitchen exit door, which was not visible from the East and West halls and was not visible from the nurses' station. During an interview on 2/21/25 at 2:57 pm, LVN 2 stated LVN 2 worked in Station 6 on 2/19/25, when Resident 1 "went missing." LVN 2 stated LVN 2 worked in the West side and Resident 1 resided in the East side. LVN 2 stated on 2/19/25 at approximately 8 pm, CNA 14 told LVN 2 that Resident 1 was not in Resident 1's room. LVN 2 told LVN 4 Resident 1 was missing, and LVN 2 and LVN 4 took turns searching for Resident 1. LVN 2 searched in Resident 1's room and searched outside facility, then LVN 2 continued with medication administration. LVN 2 stated LVN 4 and CNA 14 continued to search for Resident 1 along with other facility staff and the Registered Nurse (RN) Supervisor. LVN 2 stated all exit doors in Station 6 were kept locked except for the main door. LVN 2 stated the maintenance staff put up an alarm on the kitchen exit door after Resident 1 went missing. LVN 2 stated, "Now (we are) required to lock and turn on the alarm there (kitchen exit door)." LVN 2 stated Resident 1 "paced a lot." During an interview on 2/24/25 at 11:47 am, the Director of Nursing (DON) stated Resident 1's representative (RP) stated Resident 1 eloped from another facility where Resident 1 lived before. During a telephone interview on 2/24/25 at 12:40 pm, LVN 4 stated on 2/19/25 at 7:45 pm, LVN 4 saw Resident 1 walking in the hallway by the nurses' station. LVN 4 stated while LVN 4 was passing out medications, LVN 4 saw Resident 1 listening to the radio in Resident 1's room. LVN 4 stated CNA 14 saw Resident 1 at 8:04 pm walking in the hallway. LVN 4 stated at 8:45 pm, while LVN 4 was in another resident's room with the RN Supervisor, CNA 14 notified LVN 2 that CNA 14 could not find Resident 1 in Resident 1's room. LVN 4 stated LVN 2 informed all staff in Station 6 to look for Resident 1 in Station 6. LVN 4 stated when Station 6 staff did not find Resident 1 in Station 6, the RN Supervisor called the facility emergency code for elopement and all the staff in all the other units of the facility started looking for Resident 1. LVN 4 stated some staff from the other units searched the outside grounds outside Station 6, outside all units of the facility, and drove around the neighboring parks, stores, gas stations, smoke shops and areas. LVN 4 stated the RN Supervisor called hospitals, but the facility did not find Resident 1. LVN 4 stated the local police department was called, and a police officer came to the facility for the investigation report. LVN 4 stated LVN 4 did not hear any door alarm go off that night. LVN 4 stated on 2/19/25, the East and West exit doors had an alarm, and the kitchen exit door and the main door did not have an alarm. LVN 4 stated the kitchen exit door was now alarmed and always kept closed. During an interview on 2/24/25 at 3:01 pm, the Maintenance Supervisor (MNS) stated the MNS installed an alarm on the kitchen door in Station 6 on 2/20/25, as instructed by the Administrator (ADM) and the DON. During an interview on 2/24/25 at 4:45 pm, the DON stated, "Back door by the kitchen where vending machines were could be where Resident 1 went out." The DON stated Station 6 staff (general) had seen Resident 1 use the vending machine before, and that was why the DON, and the ADM had an alarm placed on the kitchen exit door in Station 6. The DON stated Resident 1 was originally admitted to Station 3 which was an open/unsecured unit in the facility. The DON stated while Resident 1 was in Station 3, Resident 1 was found in the parking lot and Resident 1's physician had Resident 1 moved to the secured unit. The DON stated the discharge plan for Resident 1 was to move to a Board and Care (a residential care home that provides room, meals, personal care, and basic support services to individuals who do not require care from licensed healthcare professional). The DON stated during the Interdisciplinary Team (IDT, a team of professionals from various disciplines who work in collaboration to address the resident's care) care conference in December 2024, Resident 1's RP wanted Resident 1 to be moved to an open unit so Resident 1's RP could move Resident 1 to an Assisted Living or a Board and Care facility. The DON stated that was why Resident 1 was moved to Station 6, which was an open unit, when Resident 1 came back from GACH 1 on 2/7/25. A review of the facility's P&P titled, "Elopements and Wandering Residents," dated 2/2020, indicated, "the facility ensured residents who exhibited wandering behavior and/or were at risk for elopement received adequate (sufficient/enough) 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." The P&P indicated, "the facility established and utilized a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary." The P&P indicated, "adequate supervision would be provided to help prevent accidents or elopement." The facility failed to provide supervision to prevent elopement for Resident 1, who was assessed as at risk for elopement, as indicated in the facility's P&P titled, "Elopements and Wandering Residents." The facility failed to: 1. Implement Resident 1’s CP titled, “Care Plan Report,” revised on 2/8/2025, to minimize Resident 1’s episode of behavior by promoting safety precautions at all times, and redirecting Resident 1’s behavior. 2. Implement Resident 1’s CP titled, “Care Plan Report,” revised on 2/10/2025, to provide frequent visual checks to ensure Residents 1’ needs are met, and safety is assured. These failures resulted in Resident 1 leaving the facility without supervision on 2/19/25 at 8:45 pm. These deficient practices had the potential to compromise Resident 1’s safety and placed Resident 1 at risk for injuries. The above violations presented either an imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result to Resident 1.