Health inspection·September 26, 2025

F689 Code of Federal Regulations, Title 42, §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. California Code of Regulations, Title 22, Section § 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 begiven, 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 of 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 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. (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 8/12/2025, the California Department of Public Health (CDPH) conducted an unannounced visit to the facility to investigate a complaint regarding a resident’s elopement. Based on observation, interview, and record review, the CDPH determined the facility failed to ensure Resident 1, who was on a Lanterman-Petris-Short (LPS, a California law enacted in 1969 that regulates the involuntary commitment of individuals with mental health disorders) conservatorship did not elope from a Special Treatment Program (STP, for residents with severe and chronic mental illnesses who require high level of supervision and structured care that is not available in less restrictive community settings) secured facility on 7/28/2025 at 9:27 PM. The facility failed to ensure: 1. Certified Nursing Assistant (CNA) 1 reported to Licensed Vocational Nurse (LVN) 1 (charge nurse), when CNA 1 found Resident 1, unsupervised, past a locked gate and in the facility’s parking lot on 7/28/2025 at 9 PM (the parking lot was an unauthorized area to residents at 9 PM) as indicated in the facility’s protocol titled, “Supervision Level Protocol and Guidelines.” 2. Adequate supervision was provided to Resident 1 to ensure Resident 1 was placed on one-to-one supervision (1-1 supervision, one staff supervises one resident) on 7/28/2025 at 9 PM, after Resident 1 was found in the parking lot as indicated in the facility’s protocol titled, “Supervision Level Protocol and Guidelines,” and the facility’s Policy and Procedures (P&P) titled, “Elopements,” and “Safety of Residents,” so that Resident 1 did not elope by using a trash can to climb over a locked gate. These violations resulted in Resident 1’s elopement on 7/28/2025 at 9:27 PM, who was not found until 7/29/2025 at 11 PM. Resident 1 was transferred to the General Acute Care Hospital (GACH) on 7/30/2025 at 10:27 AM for an evaluation. Resident 1 tested positive for amphetamines at the GACH. Resident 1 was at risk for serious harm and injury when Resident 1 tested positive for amphetamines and did not receive regularly scheduled prescribed medications to address his medical conditions, including psychotropic, anticonvulsant, and anticholinergic medications. A review of Resident 1’s Admission Record (AR) indicated the facility admitted Resident 1, a 27-year-old male, on 11/7/2024 with diagnoses including paranoid schizophrenia and diseases of the musculoskeletal system and connective tissue. The AR indicated Resident 1’s Responsible Party (RP) was a conservator (a person appointed by the court to care for an individual who was deemed unable to care for his/herself). A review of Resident 1’s History and Physical (H&P), dated 11/8/2024 indicated Resident 1 did not have the capacity to make decisions. A review of Resident 1’s Care Plan (CP), initiated 11/7/2024 indicated, “Resident [1] is at risk for elopement related to being in an open placement setting [residents are able to access dining room and patio areas within a secure unit].” The CP’s goal indicated, “[Resident 1] will maintain 0 [zero] Absence Without Leave (AWOL- gestures, actions or behaviors that indicate someone is absent without permission) by [the] next review.” A review of Resident 1’s Physician Progress Note (PN) dated 7/24/2025 indicated Resident 1 was an LPS conservatee (a person deemed incapable of managing his/her own affairs by a court and placed under the care of a conservator). A review of Resident 1’s PN, dated 7/24/2025, timed at 10:20 PM indicated, “at approximately 7:10 p.m., on 7/24.2025, [Resident 1] was seen by staff jumping [the] exterior wall near [the] gate [an unauthorized area]. The PN indicated [Resident 1] appeared to be moving towards [the] facility trailer and facility staff were able to redirect [Resident 1] and brought [Resident 1] back to [a] secure area of facility. The PN indicated [Resident 1] was placed on [every]15 [minute] monitoring.” A review of Resident 1’s PN-Interdisciplinary Team Meeting (IDT) notes, dated 7/29/2025, timed at 3:09 PM indicated, “On 7/28/2025…at [9 pm] [Resident 1] took [Resident 1’s] last medication for the day, then [CNA 1] was walking to the parking lot and noticed [Resident 1] was in an unauthorized area… At [10:15 PM LVN 1] was not able to account for [Resident 1] while [LVN 1] was doing rounds. At [10:26 PM] via video footage, [Resident 1] was seen leaving [the] facility.” A review of Resident 1’s PN-Change of Condition (COC), dated 7/30/2025, timed at 1:52 AM indicated, “[Resident 1] was returned to the facility post AWOL… [Resident 1] had redness on bilateral eyes and states to [LVN 2] that [Resident 1] smoked something earlier, but [Resident 1] was fine now…” A review of Resident 1’s Physician Order (PO), dated 7/30/2025, timed at 9:11 AM indicated “May send [Resident 1] to [GACH] for further evaluation and treatment [related to] safety one time only for 1 day [manifested by] AWOL.” A review of Resident 1’s GACH records, titled “Emergency Trauma Documentation,” dated 7/30/2025, indicated, “…The patient does confess to methamphetamine and alcohol use. The caregivers (facility staff who accompanied Resident 1 to the GACH) stated that the patient [Resident 1] jumped a large wall to elope from the facility… highly suspicious of schizophrenia and methamphetamine abuse given history of taking and clinical exam findings. The record indicated Resident 1’s toxicology notable for amphetamines…” A review of Resident 1’s GACH Toxicology report, dated 7/30/2025, indicated amphetamines were detected in Resident 1’s urine. A review of Resident 1’s Order Summary Report (OSR), dated active as of 8/13/2025, indicated Resident 1 had the following physician orders: 1. Valproic acid (medication used to treat certain types of seizures or used as a mood stabilizer) 750 milligrams administered by mouth at bedtime for irritable affect related to paranoid schizophrenia, start date of 11/11/2024. 2. Zyprexa (medication used to treat certain mental disorders including paranoid schizophrenia) 15 mg administered by mouth two times a day for withdrawn behavior related to paranoid schizophrenia, start date of 11/11/2024. 3. Haloperidol (medication used to treat certain mental disorders including paranoid schizophrenia) 15 mg administered by mouth in the morning and at bedtime manifested by responding to internal stimuli (RTIS) related to paranoid schizophrenia, start date of 12/12/2024. 4. Lexapro (medication used to treat anxiety) 5 mg administered by mouth one time a day for feelings of sadness and withdrawn behavior related to paranoid schizophrenia, start date of 4/12/2025. 5. Benztropine Mesylate (medication used to manage extrapyramidal symptoms [involuntary movements, tremors, and muscle stiffness] caused by antipsychotic medications) one mg administered by mouth at bedtime for tremors and stiffness of muscles, start date of 7/25/2025. A review of Resident 1’s Medication Administration Record (MAR), dated July 2025, indicated: 1. Resident 1 did not receive the 9 PM dose of Benztropine Mesylate 1 mg on 7/29/2025. 2. Resident 1 did not receive the 11 AM and 9 PM dose of Haloperidol 15 mg on 7/29/2025. 3. Resident 1 did not receive the 7 AM dose of Lexapro 5 mg on 7/29/2025. 4. Resident 1 did not receive the 9 PM dose of Valproic Acid 750 mg on 7/29/2025. 5. Resident 1 did not receive the 12 PM and 9 PM dose of Zyprexa 15 mg on 7/29/2025. A review of Resident 1’s rounding report (a visual confirmation of Resident 1’s location) titled “General Resident Supervision Rounds and Area Safety/Security Inspection Rounds,” dated 7/28/2025, indicated Resident 1 was observed hourly on 7/28/2025 from 12 AM to 10 PM. During a concurrent observation of the facility’s surveillance video and interview on 8/12/2025 at 11:10 AM, with the Administrator (ADM), the facility’s surveillance video indicated that on 7/28/2025 at 9:27 PM, Resident 1 moved a wheeled trash can to the facility’s locked gate. The video indicated Resident 1 climbed onto the wheeled trash can, climbed over the locked gate, and eloped from the facility. The ADM stated Resident 1 climbed over the locked gate and eloped from the facility. Resident 1 was found at a homeless encampment on 7/29/2025 by LVN 2. Resident 1 was returned to the facility around 11 PM on 7/29/2025. During a telephone interview on 8/12/2025 at 12:30 PM with CNA 1, CNA 1 stated CNA 1 saw Resident 1 in the parking lot around 9 PM on 7/28/2025. CNA 1 stated residents (in general) were not allowed in the parking lot area without staff supervision. Resident 1 went through a locked gate to get into the parking lot. Resident 1 tried to hide from CNA 1 under a tree and CNA 1 asked Resident 1 how Resident 1 had made it to the parking lot past the locked gate. Resident 1 refused to answer. CNA 1 stated CNA 1 returned Resident 1 to Resident 1’s room but did not report that Resident 1 was found in an unauthorized area [parking lot] to other staff members including the assigned charge nurse (LVN 1). During an interview on 8/12/2025 at 4:44 PM with LVN 1, LVN 1 stated Resident 1 was on hourly supervision on 7/28/2025. LVN 1 was doing rounds (structured regular visits by staff to resident rooms to check on the resident’s well-being, comfort, needs, and safety) on 7/28/2025 at 10:15 PM and LVN 1 couldn’t find Resident 1. LVN 1 was unaware Resident 1 was found unsupervised in the parking lot earlier that evening [on 7/28/2015 at 9 PM]. During an interview on 8/13/2025 at 5:45 PM with the ADM, the ADM stated the facility’s parking lot area was an unauthorized area to all residents [due to the facility being a secured facility]. The facility did not know how Resident 1 got to the unauthorized area. The ADM stated when Resident 1 was found in the parking lot on 7/28/2025 at 9 PM and Resident 1’s behavior of being in an unauthorized area, CNA 1 needed to report the incident to the charge nurse because Resident 1’s behavior indicated Resident 1 had a desire to elope from the facility. Resident 1 should have been placed on 1-1 supervision, on 7/28/2025, per the facility’s increased level of supervision protocol. A review of the facility’s P&P titled, “Safety of Residents,” effective 6/27/2022, indicated, “To provide a safe environment for residents…Upon admission, residents will be monitored for behavioral triggers including, but not limited to:…Increased pacing or wandering…Response to unsafe behavior: If a resident’s behavior becomes…unmanageable in a way that compromises his or her safety… the Charge Nurse and the [Director of Nursing Services] DNS are notified immediately. The Charge Nurse will: …Maintain 1-1 supervision of the resident until the behavior has subsided…” A review of the facility’s P&P titled, “Elopements,” revised 2/21/2025, indicated, “The residents who exhibit wandering behavior and/or are at risk for elopement receive adequate 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. Definitions: “Wandering” is random or repetitive locomotion that may be goal-directed (e.g., the person appears to be searching for something such as an exit), or non-goal directed or aimless. “Elopement” occurs when a resident leaves the premises or a safe area without authorization … and/or any necessary supervision to do so…The facility shall establish and utilize 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 effectiveness of interventions will be evaluated, and changes will be made as needed.” A review of the facility’s undated Protocol titled, “Supervision Level Protocol and Guidelines,” indicated, “When residents are under general supervision, they are expected to stay in the building except when following standard policies for leaving (e.g. therapeutic pass (authorized outing), outings, appointments, and hospital stays). A staff member entering/exiting a secure resident area is responsible for detecting any resident who attempts to leave without permission... staff member should verbally redirect the resident away from the area and alert other staff members for assistance so they can intervene to keep the residents safe. The protocol indicated, “Increased supervision is provided to…residents whose …behavior …indicated an increased level of risk…” The protocol indicated residents required 1-1 supervision when residents were actively seeking to elope or required constant observation.  The protocol indicated 1-1 supervision is an emergency intervention that may be implemented by charge nurses or RNs with a doctor’s order. The protocol indicated that a resident on 1-1 supervision will have dedicated staff assigned to have visual contact with the resident at all times, the assigned staff will have no other duties besides the 1 to 1 observation of the resident. The protocol’s guidelines indicated a resident will be placed 1 to 1 supervision per doctor’s orders for a maximum of 72 hours. The protocol indicated that the IDT would reevaluate the necessity of continuing this level of supervision. The facility failed to ensure Resident 1, who was on a Lanterman-Petris-Short conservatorship, did not elope from a secure facility on 7/28/2025 at 9:27 PM. The facility failed to ensure: 1. CNA 1 reported to LVN 1, when CNA 1 found Resident 1, unsupervised, past a locked gate and in the facility’s parking lot on 7/28/2025 at 9 PM as indicated in the facility’s protocol titled, “Supervision Level Protocol and Guidelines.” 2. Adequate supervision was provided to Resident 1 and failed to ensure Resident 1 was placed on one-to-one supervision on 7/28/2025 at 9 PM, after Resident 1 was found in the parking lot as indicated in the facility’s protocol titled, “Supervision Level Protocol and Guidelines,” and the facility’s P&P titled, “Elopements,” and “Safety of Residents.” These viol