Health inspection·July 25, 2025

F689 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. § 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 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 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. (3) Notifying the attending licensed healthcare practitioner acting within the scope of his or her professional licensure promptly of: (A) The admission of a patient. (B) Any sudden and/or marked adverse change in signs, symptoms or behavior exhibited by a patient. (C) An unusual occurrence, as provided in Section 72541, involving a patient. (D) A change in weight of five pounds or more within a 30-day period unless a different stipulation has been stated in writing by the patient's licensed healthcare practitioner acting within the scope of his or her professional licensure. (E) Any untoward response or reaction by a patient to a medication or treatment. (F) Any error in the administration of a medication or treatment to a patient which is life threatening and presents a risk to the patient. (G) The facility's inability to obtain or administer, on a prompt and timely basis, drugs, equipment, supplies or services as prescribed under conditions which present a risk to the health, safety or security of the patient. 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 6/10/25, the California Department of Public Health (CDPH) conducted a facility reported incident investigation regarding quality of care and patient safety. As a result of the investigation, the CDPH determined the facility failed to ensure staff provided supervision for Patient 1, who was on a Lanterman-Petris-Short conservatorship did not elope from the facility on 6/7/25 between the hours of 3:30 a.m. to 5:55 a.m. in accordance with the facility's Policy and Procedure (P&P) titled, "Elopements and Wandering Patients." As a result of this violation, Resident 1 eloped on 6/7/25 between the hours of 3:30 a.m. to 5:55 a.m. and exposed Patient 1 to medical complications such as dehydration, hypoglycemia, hyperglycemia and placing Patient 1 at risk for harm from not receiving Patient 1's psychotropic medication and insulin that could lead to serious injury, serious harm, or death. A review of Patient 1's Admission Record (AR) indicated Patient 1, a 53-year-old female was admitted to the facility on 7/12/24 and re-admitted on 12/10/24, with diagnoses that included bipolar disorder, diabetes mellitus, dysphagia, hypertension and acquired absence of left leg below the knee. The AR indicated Patient 1's Responsible Person (RP) was a conservator/guardian. A review of Patient 1's most recent "History and Physical (H&P)", dated 5/31/25 indicated Patient 1 did not have the capacity to make medical decisions. A review of Patient 1's Physician Orders (POs) active as of 6/7/25 indicated Patient 1 had the following orders: 1. Eliquis 2.5 mg milligrams two times a day for deep vein thrombosis prophylaxis for 6 months, with the start date of 12/11/24. 2. Insulin Regular Human Injection Solution 100-unit milliliter to inject as per sliding scale subcutaneously before meals and at bedtime, with the start date of 1/22/25. 3. Lantus Subcutaneous Solution 100-unit ml to inject 10 units subcutaneously at bedtime for DM, hold if blood sugar levels below 100 mg/dL with the start date of 1/22/25. 4. Amlodipine Besylate tablet, 5 mg orally, once a day for hypertension, and hold if systolic blood pressure is below 110 millimeters of mercury (mmHg) or heart rate below 60 beats per minute, with the start date of 5/14/25. 5. Hydralazine Hydrochloride tablet, 10 mg. administered orally, every 12 hours as needed for systolic blood pressure above 160 mm Hg with the start date of 5/15/25. 6. Clonidine Hydrochloride tablet, 0.1 mg, orally, every 8 hours as needed for systolic blood pressure greater than 160 mmHg, with the start date of 5/18/25. 7. Seroquel tablet, 50 mg, orally at bedtime for bipolar disorder manifested by irritable mood, with start date of 5/23/25. A review of Patient 1's Change of Condition (COC)/Interact Assessment Form (SBAR) dated 6/7/25 indicated on 6/7/25 between 3:20 a.m. to 3:30 a.m., Patient 1 was last seen in Patient 1's room. The SBAR indicated on 6/7/25, at around 5:50 a.m., Patient 1 could no longer be found by facility staff. The SBAR indicated when Patient 1 was not found in Patient 1's room nor the restroom, a Code Green was activated by a staff member. A review of Patient 1's Nurses' Progress Note (PN) dated 6/7/25 at 5:55 a.m. indicated Patient 1 was not found in Patient 1's room. The PN indicated on 6/7/25 at 6:20 a.m., the Local Police Department was notified and a report for missing patient was filed. A review of Patient 1's late entry PN dated 6/7/25 at 7:05 a.m. indicated the Medical Assistant from Patient 1's Primary Care Physician/Medical Doctor 1 (MD 1) was notified that Patient 1 left the facility (on 6/7/25) at around 5:55 a.m. unsupervised. A review of Patient 1's Interdisciplinary Care Conference dated 6/9/25 at 10:55 a.m. indicated Patient 1 left the facility without notifying staff. During an interview on 6/10/25 at 9:28 a.m. with the ADM, the ADM stated the ADM was unable to determine how Patient 1 left the facility on 6/7/25. The ADM stated the facility had cameras, but the camera footage was only for a few hours and then the camera footage would be overwritten. The ADM stated there was no camera footage that showed how Patient 1 left the facility on 6/7/25. The ADM stated, as of 6/10/25, the facility had not been able to locate or been in contact with Patient 1. During an interview on 6/10/25 at 12:15 p.m. with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated, "Patient elopement is when a patient leaves the facility, and no staff member was aware." LVN 1 stated Patient 1 was on conservatorship and Patient 1 eloped from the facility (on 6/7/25). LVN 1 stated, since Patient 1 eloped from the facility, Patient 1 was at risk for high blood sugar, high blood pressure, psychotic episodes and blood clot due to Patient 1 not receiving any prescribed medications. LVN 1 stated Patient 1 could experience symptoms such as increased thirst, frequent urination, fatigue, blurry vision and increased risk for stroke or heart attack. During an interview on 6/10/25 at 1:42 p.m. with Certified Nurse Assistant 1 (CNA 1), CNA 1 stated, Patient 1 used a walker and left prosthesis to get around in the facility. CNA 1 stated Patient 1 eloped from the facility on 6/7/25 in the morning (unable to remember exact time). A review of Patient 1’s H&Ps dated 12/13/24 and 5/31/25 and interview with the Care Coordinator (CC) for MD 1 on 6/11/25 at 12:43 p.m. indicated Patient 1 did not have capacity to make medical decisions. The CC stated Patient 1's H&P dated 12/13/24 and the most recent H&P dated 5/31/25 indicated Patient 1 lacked the capacity to make medical decisions. During a telephone interview on 6/12/25 at 9:17 a.m. with Patient 1's Public Guardian (PG), the PG stated Patient 1 was initially placed on a temporary LPS conservatorship on 5/6/22 and on permanent LPS conservatorship on 7/1/22. The PG stated, Patient 1 has been under LPS conservatorship since 7/1/22 to present day (6/12/25) and Patient 1 cannot make any legal, financial, medical or care decisions. The PG stated Patient 1's elopement from the facility on 6/7/25 was considered absence without leave (AWOL, generally refers to a patient leaving the facility without proper authorization or supervision). The PG stated Patient 1 was unable to make decisions due to being gravely disabled. A review of the letter written by Patient 1 to the facility Administrator (ADM) dated 6/16/25 indicated Patient 1 contacted and met the facility’s ADM on 6/16/25. A review of the facility's current P&P titled, "Elopements and Wandering Patients," revised 12/19/22 indicated "Elopement occurs when a patient leaves the premises or a safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so." The P&P indicated "for monitoring and managing patients at risk for elopement and unsafe wandering, staff should provide adequate supervision to help prevent accidents or elopements." These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of Patient 1.