Health inspection·December 19, 2025

F689 §483.25(d) Accidents. The facility must ensure that - §483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents. § 72523. Patient Care Policies and Procedures (a) (a)Written patient care policies and procedures shall be established and implemented to ensure that patient-related goals and facility objectives are achieved. § 72309. Nursing Service. Nursing service means a service staffed, organized and equipped to provide skilled nursing care to patients on a continuous basis. An unannounced visit was conducted by California Department of Public Health (CDPH) on 11/4/2025 to investigate a Facility Reported Incident (FRI) regarding an allegation that Resident 1 was missing from the facility. The facility failed to supervise and ensure the safety of Resident 1 to prevent accidents and failed to follow the facility's Wandering and Elopement (leaving the facility without the staff’s knowledge and/or supervision) Policy and Procedure (P&P). As a result, Resident 1 eloped from the facility on 11/1/2025 around 4:15 PM which placed the resident at risk for exposure to extreme weather, medical complications, injury, serious harm, and/or death. Resident 1 was not found until approximately eight (8) hours later, on 11/2/2025, at 12:11 AM at the general acute care hospital (GACH) with no visible injuries. A record review of Resident 1’s Admission Record indicated Resident 1, a 74 year-old male, was initially admitted to the facility on 9/28/2022 and readmitted on 9/22/2025 with diagnoses of chronic obstructive pulmonary disease (CODP, a group of lung diseases that block airflow and make it difficult to breathe) and chronic pulmonary edema (a condition where fluid builds up in the lungs causing persistent shortness of breath). A record review of Resident 1’s Minimum Data Set (MDS – a resident assessment tool), dated 9/24/2025, indicated the resident was moderately impaired with cognitive (ability to think, remember, and reason) skills for daily decision making. Resident 1 was dependent (helper does all of the effort; resident does none of the effort to complete the activity or the assistance of two or more helpers is required for the resident to complete the activity) with toilet transfer and lower body dressing. Resident 1 needed substantial/maximal assistance (helper does more than half the effort) with chair/bed-to-chair transfers, going from lying to sitting on the side of the bed, and needed supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with eating. A record review of Resident 1’s Situation, Background, Assessment and Recommendation (SBAR) documentation, dated 11/1/2025 at 9 PM, indicated during shift change, Resident 1 was not in his room and the morning shift nurse reported that Resident 1 went to the patio after lunch. The SBAR further indicated Resident 1 did not return to his room at the usual time later in the evening. Registered Nurse 1 (RN 1) was notified and facility staff looked for Resident 1 in every unit and around 12 AM on 11/2/2025, Resident 1 was confirmed by local authorities to be admitted at GACH. A record review of Resident 1’s RN (Registered Nurse) Note, dated 11/2/2025 at 12:20 AM, indicated the following: a. Resident 1 was last seen on 11/1/2025 around 4:09 PM leaving the patio area of the facility and was seen by the Activities Director (AD) going towards the facility’s 200 and 300 units. b. At approximately 10 PM on 11/1/2025 when the footage from the facility security camera was reviewed, it showed that on 11/1/2025 around 4:15 PM, Resident 1 was sitting by the facility’s parking lot gate wearing a black hat, grey torso shirt with black short sleeves and an unknown pedestrian wearing a hat and light-colored clothing was seen approaching the resident. The pedestrian pressed on the button to open the parking lot gate and Resident 1 wheeled himself out of the facility. The pedestrian was then seen walking away but then turned around to help Resident 1 push his wheelchair towards the sidewalk. c. Local authorities arrived at the facility approximately at 11:32 PM on 11/1/2025. d. On 11/2/2025 at 12:11 AM, it was confirmed by the local authorities that Resident 1 was found at GACH. A record review of Resident 1’s GACH Note, dated 11/1/2025, indicated Resident 1 was “found by a neighbor who called the ambulance after finding the resident roaming on a wheelchair for a substantial period of time.” During an interview on 11/4/2025 at 11:18 AM with Quality Assurance Nurse (QAN), the QAN stated that on 11/1/2025 Resident 1 was in the activity room in the afternoon and then went back to unit 200 (where Resident 1’s room was located) and was not sure what happened. QAN stated Resident 1 was able to wheel himself out to the parking gate on the side of the facility where an unknown pedestrian passed by, pressed the button to request to open the parking lot gate which the receptionist did. QAN stated this side parking gate to the left of the facility only opens if staff have a key card, with a clicker (remote control) or if anyone pressed the parking gate button which alerts the receptionist who can then open the gate from the front desk. During an interview on 11/4/2025 at 12:27 PM with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated, on 11/1/2025 between 3:20 PM to 3:30 PM, she noticed Resident 1 was not in his room. CNA 1 stated, at around 4:45 PM to 5 PM, during dinner tray distribution, she again noticed Resident 1 was not in his room, so she reported to Licensed Vocational Nurse 1 (LVN 1). CNA 1 stated a code green was called but the facility staff could not find Resident 1. CNA 1 stated it was important to check on the residents every 30 minutes to an hour to ensure the residents were safe. During an interview on 11/4/2025 at 11:35 AM, AD stated that on 11/1/2025 at 3:45 PM he last saw Resident 1 in the smoking patio by himself and was not sure if a facility staff was supposed to be supervising the resident. During an interview on 11/4/2025 at 1:21 PM with LVN 1 stated on 11/1/2025 at 3PM, Resident 1 was in the patio with other residents and staff members. LVN 1 stated, around 4:45 PM to 5 PM, while passing dinner trays, CNA 1 informed her that Resident 1 had not yet come back to his room. LVN 1 stated she then went to the patio to look for Resident 1 and when she did not find him. LVN 1 stated he notified RN 1 around 5 PM. LVN 1 stated a code green was called but the facility staff did not find Resident 1. LVN 1 stated Resident 1 was then found later that night at GACH. LVN 1 further stated residents are checked every one to two hours to ensure their safety. During an interview on 11/4/2025 at 11:56 AM, RN 1 stated, on 11/1/2025 around 9 PM, he was notified that Resident 1 was last seen by AD at 4 PM. RN 1 stated AD called a code green (missing resident alert) on the facility’s overhead system. RN 1 stated all rooms at the facility were checked including the back parking lot and around the neighborhood, but the facility did not find Resident 1. RN 1 stated, at approximately 12:11 AM on 11/2/2025, the facility was informed by the local authorities that Resident 1 was found at GACH. During an interview on 11/4/2025 at 1:28 PM with Receptionist 1, Receptionist 1 stated when someone presses the button located on the side of the facility’s side parking gate, it rings the phone in at the reception desk. Receptionist 1 stated, she is then able to enter a code that opens the gate. Receptionist 1 also stated she typically does not speak to the person who pressed the button to ask for their identity. During an interview on 11/4/2025 at 2:38 PM with Receptionist 2, Receptionist 2 stated she was the Receptionist on 11/1/2025 and stated on 11/1/2025, when the phone notified her that someone was at the parking gate, she did not ask who was requesting to open the gate and input the code to open it. Receptionist 2 stated she was not aware and was never trained that she needed to speak to the person at the gate to ask or screen who they were. During an interview on 11/5/2025 at 1:33 PM with Assistant Administrator (AADM), AADM stated the normal process for when someone presses the side parking gate button is for the receptionist to ask the person’s name and what they are there for since it is only authorized personnel who are allowed to use the back parking lot. AADM stated on 11/1/2025 when the person pressed the side parking button, the receptionist should have asked who they were, for their name and if they were an employee and because that process was not followed, Resident 1 was able to leave the facility. During an interview on 11/5/2025 at 2:05 PM with QAN, QAN stated that staff became complacent with Resident 1’s behavior of always staying out in the patio or his room and did not expect that he would ever wheel himself out to the back parking lot side gate and leave. QAN stated the receptionist probably assumed the person who pressed the side parking lot gate button was either staff or a delivery coming in. A record review of the facility’s policy and procedure (P&P) titled, “Wandering and Elopement,” revised 6/1/2017, indicated its purpose was, “To enhance the safety of residents of the facility,” and further indicated: a. “If Facility Staff observes a resident leaving the premises without having followed proper procedures, he/she may: b. Try to prevent departure in a courteous manner. c. Get help from other Facility Staff in the immediate vicinity, if necessary; and d. Direct another Facility Staff member to inform the Charge Nurse or Director of Nursing Services that a resident is trying to leave the premises. The facility failed to supervise and ensure the safety of Resident 1 to prevent accidents and failed to follow the facility's Wandering and Elopement P&P. As a result, Resident 1 eloped from the facility on 11/1/2025 around 4:15 PM which placed the resident at risk for exposure to extreme weather, medical complications, injury, serious harm, and/or death. Resident 1 was not found until approximately 8 hours later, on 11/2/2025, at 12:11 AM at the GACH with no visible injuries. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of patients or residents.