Health inspection·June 13, 2025

F689 Code of Federal Regulations, Title 42, Section 483.25(d) Accidents. The facility must ensure that - (1) The resident environment remains as free of accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. California Code of Regulations, Title 22, § 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. § 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 4/28/2025, at 9:26 AM, the California Department of Public Health (CDPH) conducted a recertification survey and an abbreviated standard survey regarding resident safety and quality of care/treatment. As a result of the investigation, the CDPH determined the facility failed to ensure that Resident 3, who was cognitively impaired (refers to difficulties with thinking, learning, remembering, and using judgment, among other mental abilities) and assessed at risk for elopement (the act of leaving a facility unsupervised and without prior authorization), did not elope from the facility’s secured unit (specialized healthcare setting that restricts patient/resident movement and access to promote safety with measures such as locked doors and surveillance) on 4/24/2025, at 7: 06 PM. Th facility failed to ensure: 1. Certified Nursing Assistant (CNA) 6 closed/locked the door when CNA 6 exited the facility’s secured unit and ascertained Resident 3 did not follow CNA 6 out of the secured unit. 2. CNA 7 implemented Resident 3's Care Plan (CP) titled, “Elopement Risk,” indicating to monitor Resident 3 and to follow the facility’s visual check protocol (to check the resident where about with the naked eyes) for every 15-minute monitoring. These violations resulted in: (1) Resident 3’s elopement on 4/24/2025, at 7:06 PM, which placed Resident 3 at risk for vehicular accidents because the facility is located on a busy street with many cars driving by; (2) negative outcome from not receiving Resident 3’s medication as ordered; and, (3) exposure due to extreme temperatures (heat during the day and cold during the night) that could have led to serious injury, serious harm, or death. A review of Resident 3’s Admission Record (AR), indicated Resident 3 was a 56-year-old female and was admitted to the facility on 7/23/2019, and re-admitted to the facility on 9/9/2024, with diagnoses that included paranoid schizophrenia, anxiety disorder, unspecified convulsions, epilepsy, cognitive communication deficit, and diabetes mellitus. A review of Resident 3’s CP, titled “Elopement Risk,” initiated 8/21/2023, indicated that Resident 3 sometimes left the facility without authorization/permission. The CP’s interventions required staff to continue to provide frequent visual checks (every 15 minutes) of Resident 3’s whereabouts in the secured unit, and to follow the protocol for visual checks. A review of Resident 3’s Change of Condition (COC)/Interact Assessment Form (SBAR, a sudden clinically important deviation from a resident’s baseline in physical, cognitive, behavioral, or functional domains), dated 8/30/2024, indicated that on 8/30/2024, at 8 AM, Resident 3 showed exit-seeking behaviors and increased delusions that someone was waiting for Resident 3 outside of the facility. The COC indicated (on 8/30/2024) at 10 AM, that Resident 3 was noted to be walking up and down the hallways looking hypervigilant, looking to get out [of the facility], screaming and shouting “I need to get out of here now.” A review of Resident 3’s Physician Orders (POs) for the month of September 2024, indicated the following orders: 1. Admit Resident 3 to the secured unit, dated 9/9/2024. 2. Humalog Injection Solution (a rapid-acting insulin) 100-unit milliliter (ml) to inject as per sliding scale (a scale followed, dose of insulin varies based on blood sugar levels), dated 9/20/2024. 3. Lantus Solostar solution pen-injector inject (a device that provides a nonelectrically-powered, mechanically operated method of accurately injecting medication/insulin) 100 unit/ml, administer 15 units at bedtime for diabetes mellitus with hyperglycemia (high blood sugar), check finger stick blood sugar before administration, dated 9/9/2024. 4. Tegretol (carbamazepine, medication used to treat seizures) tablet, 200 milligrams (mg) administered by mouth, three times a day, dated 9/9/2024. 5. Zyprexa (Olanzapine, medication used to treat schizophrenia) tablet, 10 mg, give 1 tablet by mouth, one time a day, for paranoid schizophrenia manifested by delusion that a judge ordered Resident 3 to take the medication. A review of Resident 3’s History and Physical (H&P), dated 9/10/2024, indicated Resident 3 did not have the capacity to understand and make decisions. A review of Resident 3's Elopement Risk Assessments (ERAs), dated 9/26/2024, 12/24/2024, and 3/18/2025, indicated Resident 3 was assessed at risk for elopement because Resident 3 had wandered aimlessly, verbally expressed the desire to go home, packed belongings to go home, and stayed near an exit door. A review of Resident 3’s Minimum Data Set (MDS- a resident assessment and care screening tool), dated 3/18/2025, indicated Resident 3 had moderate impaired cognition. The MDS indicated Resident 3 needed assistance with oral hygiene, toileting, and personal hygiene. A review of Resident 3’s Police Report (PR), dated 4/24/2025, indicated on 4/24/2025, that at “approximately” 9:48 PM, Resident 3 was reported missing. The PR indicated (on 4/24/2025) at “around” 8 PM, facility staff looked through the entire facility and were unable to locate Resident 3. The PR indicated the facility’s surveillance video footage captured Resident 3 walking in the [facility’s] hallway (on 4/24/2025) at “approximately” 6 PM. At 7 PM, Resident 3 was seen standing by the secured unit’s double doors. The PR indicated, “A medical staff [CNA 6] opened the locked door and walked through the door. The PR indicated Resident 3 held the door open, walked behind CNA 6, then opened the front entrance door, and walked toward the north bound on [T Avenue, street located in front of the facility].” The PR indicated Resident 3 was diagnosed with several medical conditions, required constant medical attention, took prescribed medication, and was unable to care for herself. The PR indicated Resident 3 was a “Critical missing person.” The PR indicated Resident 3 left the health care facility without anyone [staff] noticing. During an observation on 4/28/2025, at 10:37 AM, of the facility’s premises, there were double glass doors located at the front of the facility’s lobby. The double doors were pushed open to exit the facility. Past the double doors, there was a busy street with multiple cars moving along the road. During a concurrent observation of the facility’s surveillance video, dated 4/24/2025, time at 7:06 PM, and interview with the Director of Nursing (DON), on 4/28/2025, at 12:13 PM, the facility’s surveillance video indicated Resident 3 exited the facility on 4/24/2025, at 7:06 PM, and walked toward the left side of the facility. The video indicated there were multiple cars driving by on the major street located in front of the facility. The DON stated, the facility’s surveillance video dated 4/24/2025, timed at 7:06 PM, indicated Resident 3 was in the secured unit’s hallway, standing next to the exit door. The DON stated, CNA 6 opened the facility’s locked door and walked out of the secured unit. The DON stated, Resident 3 placed Resident 3’s hand between the double doors to prevent the doors from closing. The DON stated Resident 3 pushed the double doors open, walked into the facility’s lobby, and walked out of the facility. The DON stated there were no staff visible past the secured unit door or in the facility’s lobby. The DON stated Resident 3 walked out of the facility’s main door, “Like a visitor,” and that the facility is located on a busy street with cars constantly driving by. The DON stated the facility’s main lobby door was unlocked and no alarm or blinking lights were heard or observed visible in the surveillance video. The DON stated there should have been a staff member (receptionist) at the front desk monitoring who entered or left the facility. The DON stated the front doors should always be locked and the alarm should have turned on [sounded] to alert facility staff when people (staff, residents and or visitors) attempted to enter or exit the facility, as a safety measure to prevent residents (in general) from eloping. During a concurrent observation of the facility’s surveillance video, dated 4/24/2025, at 7:06 PM, and an interview with the Administrator (ADM) on 4/28/2025, at 3:06 PM, the surveillance video indicated Resident 3 exited the facility on 4/24/2025, at 7:06 PM. The ADM stated, per the surveillance video, CNA 6 walked out of the facility’s secured unit into the facility’s lobby. The ADM stated Resident 3 walked behind CNA 6, pushed the lobby front doors open, walked out of the facility, and walked toward the busy street in front of the facility. The ADM stated, according to the surveillance video, no staff were seen at the front desk on 4/24/2025, since 6:30 PM, and the facility’s staff members were unaware of Resident 3’s elopement (on 4/24/2025, at 7:06 PM). A review of Resident 3's “PM Resident Check (PMRC)” log, dated 4/24/2025, and an interview with CNA 7, on 4/28/2025, at 3:33 PM, indicated Resident 3's slots on 4/24/2025, from 6:45 PM to 11 PM were left blank. CNA 7 stated all residents resided in the secured unit (including Resident 3) were to be monitored/checked every 15 minutes. CNA 7 stated CNA 7 was supposed to monitor and document the time and location of each resident assigned to CNA 7. CNA 7 stated, on 4/24/2025, (from 3 pm to 11 pm shift) CNA 7 was the primary CNA assigned to care for Resident 3. CNA 7 stated CNA 7 documented Resident 3's where abouts as being in the hallway on 4/24/2025, at 6 PM, 6:15 PM, and at 6:30 PM. CNA 7 stated CNA 7 last saw Resident 3 (on 4/24/2025), at 6:30 PM just before the scheduled smoke break for the smokers (residents who smoke) which lasted until 7 PM. CNA 7 stated "it was unrealistic to monitor (check and document the residents [all assigned residents including Resident 3'] location every 15 minutes" because CNA 7 was busy assisting and providing care to other residents. During an interview on 4/28/2025, at 3:43 PM, the Director of Staff Development (DSD) stated CNA 6 was in-serviced (educated) on the necessary safety steps to take when staff entered and exited the facility’s secured units (prior to Resident 3’s elopement). The DSD stated, after exiting the secured unit, CNA 6 needed to ensure the secured door was closed shut and that residents did not follow CNA 6 or attempted to exit the secured unit. The DSD stated, when “these steps [closed the door and make sure residents do not leave the secured unit without supervision]” are not taken, residents can elope from the facility and walk into the busy street and get hurt. During a telephone interview on 4/28/2025, at 3:54 PM, CNA 6 stated, on 4/24/2025, at “around” 7 PM, CNA 6 unlocked the secured unit doors and exited the secured unit. CNA 6 stated CNA 6 did not check if the door closed shut behind CNA 6 upon exiting the secured unit or ensure there were no residents standing close to the doors. CNA 6 stated “it was important to ensure the doors were closed shut and locked, upon exiting the secured unit, so the resident (Resident 3) did not elope.” A review of Resident 3’s PMRC log, dated 4/24/2025, and an interview with the DON on 4/29/2025, at 3:30 PM, indicated Resident 3’s slots on 4/24/2025, from 6:45 PM to 11 PM were left blank. The DON stated Resident 3 was discovered missing on 4/24/2025, between 8:40 PM to 9 PM. During an interview on 4/29/2025, at 3:40 PM, LVN 4 stated, on 4/24/2025, LVN 4 was the person in charge of the secured unit. LVN 4 stated Resident 3 was observant, smart, and aware of Resident 3’s surroundings. LVN 4 stated (on 4/24/2025, at “around” 9 PM, CNA 6 informed LVN 4 that Resident 3 was missing. A review of the facility’s undated policy and procedures (P&P) titled, “Missing Resident,” indicated, “The facility’s objective is to prevent possible injury or death to a resident and for wanderers (exit seeking residents) to be checked on a regular basis.” A review of the facility’s P&P titled, “Safety and Supervision of Residents,” revised 7/2017, indicated, “Resident safety, supervision and assistance to prevent accidents are facility wide priorities. The P&P indicated systems approach to safety included, facility-oriented and resident-oriented approaches to safety are used together to implement a system’s approach to safety, which considers the hazards identified in the environment and individual resident risk factors. The P&P indicated to adjust interventions accordingly.” A review of the facility’s P&P titled, “Wandering and Elopements,” revised 3/2019, indicated, “The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents.” As a result of the investigation, CDPH determined the facility failed to ensure that Resident 3, who was cognitively impaired and was assessed at risk for elopement, did not elope from the facility’s secured unit on 4/24/2025, at 7:06 PM. The facility failed to ensure: 1. CNA 6 closed/locked the door when CNA 6 exited the facility’s secured unit and ascertained Resident 3 did not follow CNA 6 out of the secured unit. 2. CNA 7 implemented Resident 3's CP titled, “Elopement Risk,” indicating to monitor Resident 3 and to follow the facility’s visual check protocol Q 15-minute monitoring. These violations resulted in: (1) Resident 3’s elopement on 4/24/2025, at 7:06 PM, which placed Resident 3 at risk for vehicular accidents because the facility is located on a busy street with many cars driving by; (2) negative outcome from not receiving Resident 3’s medication as ordered; and, (3) exposure due to extreme temperatures (heat during the day and cold during the night) that could have led to serious injury, serious harm, or death. The above violations jointly, separately, or in any combination, 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 3. 2