Health inspection·October 15, 2025

§ 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. § 72513. Administrator. (e)The administrator shall be responsible for informing the Department, via telephone within 24 hours of any unusual occurrences as specified in Section 72541. If the unusual occurrence involves the discontinuance or disruption of services occurring during other than regular business hours of the Department or its designee, a telephone report shall be made immediately upon the resumption of business hours of the Department. § 72541. Unusual Occurrences. Occurrences such as epidemic outbreaks, poisonings, fires, major accidents, death from unnatural causes or other catastrophes and unusual occurrences which threaten the welfare, safety or health of patients, personnel or visitors shall be reported by the facility within 24 hours either by telephone (and confirmed in writing) or by telegraph to the local health officer and the Department. An incident report shall be retained on file by the facility for one year. The facility shall furnish such other pertinent information related to such occurrences as the local health officer or the Department may require. Every fire or explosion which occurs in or on the premises shall be reported within 24 hours to the local fire authority or in areas not having an organized fire service, to the State Fire Marshal. Note: Authority cited: Sections 208(a) and 1275, Health and Safety Code. Reference: Section 1276, Health and Safety Code. § 72543. Patients' Health Records. (f)Patients' health records shall be current and kept in detail consistent with good medical and professional practice based on the service provided to each patient. Such records shall be filed and maintained in accordance with these requirements and shall be available for review by the Department. All entries in the health record shall be authenticated with the date, name, and title of the persons making the entry. § 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. An unannounced visit was conducted by California Department of Public Health on 9/24/2025 at 10:30 AM to investigate a complaint regarding an allegation of Resident 1 fell, and sustained scratches on the face.  The facility failed to prevent elopement for Resident 1 who was assessed as high risk for elopement in accordance with the facility’s Policy and Procedure (P&P) titled, “Elopement and Wandering Prevention and Response,” by failing to: 1. Develop and implement a Care Plan to address Resident 1’s risk of wandering and elopement to reflect that the resident needs enhanced monitoring and use of wander alert system from 2/26/2025 to 9/14/2025. 2. Provide documented evidence Resident 1 has a wander guard as ordered by the physician and wander guard was checked for functionality from 6/20/2025 to 9/24/2025. 3. Conduct a thorough investigation and document regarding an unusual occurrence of Resident 1’s elopement incident on 9/15/2025. These deficient practices resulted in Resident 1 leaving the facility without the facility staff’s knowledge on 9/15/2025 from when the resident was last seen in the facility at 6 PM by the Certified Nurse Assistant (CNA). The facility received a call from General Acute Care Hospital on 9/15/2025 at 7 PM that Resident 1 was found outside (not indicated where) and presented in GACH’s Emergency Department (ED) with discoloration, abrasion and laceration to the left side of Resident 1’s face. 1. A review of Resident 1’s Admission Record indicated the resident was originally admitted at the facility on 2/26/2025 and was readmitted on 9/13/2025 with the following but not limited to diagnoses of dementia, difficulty in walking and muscle weakness. A review of Resident 1’s Wander/Elopement Risk Evaluation, dated 2/26/2025, indicated the resident was at increased risk for wandering behaviors with potential attempts to exit the facility. The evaluation also indicated the resident was an elopement risk/wanderer. A review of Resident 1’s Fall Risk Evaluation, dated 8/7/2025, indicated the resident was at increased risk for falls. A review of Resident 1’s Minimum Data Set (MDS – a resident assessment tool), dated 9/14/2025 indicated the resident was severely impaired in cognitive skills for daily decision making. The MDS also indicated the resident required partial/moderate assistance with toileting hygiene, shower/bathe self, lower body dressing and putting on/taking off footwear but required supervision/touching assistance with oral hygiene and upper body dressing. A review of Resident 1’s Progress Notes, dated 9/15/2025 at 10:30 PM, indicated at 3 PM Resident 1 was noted walking around the facility. At 5:15 PM, the resident was noted in her room and was offered her medications and blood sugar check. At 7 PM, the facility received a call from GACH 1 stating the resident is admitted due to a fall that was found outside the facility. The progress notes indicated at 10 PM, Resident 1 was admitted back to the facility with a skin assessment of skin discoloration of the left side of the face and left knee discoloration. Resident was also noted with discomfort. A review of Resident 1’s Care Plan with focus at risk for wandering, dated 9/15/2025, indicated to ensure doors and exits are secured per facility policy. There was no Care Plan developed to address Reisdent 1’s at risk for wandering from 2/26/2025 to 9/14/2025. A review of Resident 1’s General Acute Care Hospital (GACH) Emergency Department Note, dated 9/15/2025, indicated Resident 1 hit the left side of Resident 1’s face and is at the GACH with laceration to her face. The note also indicated Resident 1 wandered from the facility and was found on the floor outside. The note indicated a chief complaint of a fall. During an interview on 9/25/2025 at 11:20 PM, Licensed Vocational Nurse 1 (LVN 1) stated she was surprised when GACH 1 nurse called her on 9/15/2025 at 7 PM stating Resident 1 was found outside by the Emergency Medical Services (EMS) because LVN 1 did not know Resident 1 had left the facility. LVN 1 also stated the last time she saw the resident in the facility was on 9/15/2025 at 5:30 PM and she did not notice Resident 1 wandered and left the facility without facility staff’s knowledge. LVN 1 stated Resident 1 got admitted back to the facility on 9/15/2025 with discomfort, facial grimacing with discoloration on the resident’s left side of her face and left knee. During an interview on 9/25/2025 at 1:58 PM, Certified Nursing Assistant 1 (CNA 1) stated the last time he saw Resident 1 in the facility was on 9/15/2025 at 6 PM. CNA 1 stated, CNA 1 did not know Resident 1 left the facility During a concurrent interview and record review on 9/25/2025 at 2:22 PM, with the Director of Nursing (DON), the facility’s P&P titled, “Elopement and Wandering Prevention and Response,” dated 4/10/2024 was reviewed. The P&P indicated for residents with elopement risk needs enhanced monitoring during high-risk times. The P&P also indicated residents identified as at risk will have individualized interventions in their care plan such as use of wander alert systems. The DON stated enhanced monitoring on the policy means the resident who was assessed as high risk for wandering and elopement should be monitored every 30 minutes and documented in the resident medication administration records (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident). The DON also stated high-risk times means when the resident/s have increased wandering and exiting behavior/ trying to elope. During a concurrent interview and record review on 9/26/2025 at 10:07AM, Resident 1’s care plans, dated 02/26/2024 to 9/16/2025, were reviewed. The DON stated Resident 1 did not have a care plan for wandering/elopement prior to the resident eloping on 9/15/2025. The DON also stated Resident 1 plan of care was not resident centered. A review of the facility’s undated P&P titled, “Safety and Supervision of Residents,” the P&P indicated the facility’s individualized, resident centered approach to safety addresses safety for individual residents. 2. A review of Resident 1’s Physician Orders, dated 6/20/2025, the order indicated to apply wander guard to alert staff when resident attempts to go/wander out of the facility. During an interview on 9/25/2025 at 11:20 PM, LVN 1 stated she did not check Resident 1’s wander guard for functionality on 9/15/2025. During an interview on 9/26/2025 at 12 PM, Registered Nurse 1 (RN 1) stated to check the wander guard, the staff would need to take the residents toward the exit and observe the alarm to ensure it is working properly. RN 1 also stated monitoring of the wander guard’s functionality should be documented in the resident’s MAR. During a concurrent interview on 9/26/2025 at 1:48 PM and record review with the DON, Resident 1’s MAR, dated 6/2025 to 9/202 were reviewed. The MAR did not indicate documented evidence Resident 1’s wander guard was placed on Resident 1 and did not indicate it was monitored for functionality from 6/20/2025 to 9/26/2025. The DON stated Resident 1’s MAR did not and should indicate the wander guard was placed on Resident 1 and monitoring for Resident 1’s wander guard functionality. The DON also stated when the placement of wander guard and monitoring of wander guard functionality is not in the MAR, meaning it was not done. During a concurrent interview and record review on 9/25/2025 at 2:22 PM, the facility’s undated P&P titled “Tab Alarms, Bed Alarms, Wanderguard System,” was reviewed. The P&P indicated the wanderguard bracelets are checked daily on the night shifts by the supervisor and are documented in the treatment book The DON stated the policy should indicate to check the resident’s wander guard every shift and not just daily. 3. During a concurrent interview and record review on 9/25/2025 at 2:22 PM, the facility’s undated P&P titled “Unusual Occurrence Reporting Policy,” was reviewed. The P&P indicated a telephone notification to appropriate agencies within 24 hours from the unusual occurrence. The P&P also indicated a written report will be sent to the state agency within 48 hours and the administrator is responsible for completing and submitting reports. The DON stated the facility should have reported but did not report to the state agency per facility policy the unusual occurrence of Resident 1’s elopement on 9/15/2025. The DON stated she cannot provide evidence indicated there was a written report submitted to the state agency within 48 hours from when Resident 1’s eloped on 9/15/2025. During a concurrent interview on 9/26/2025 at 10:07AM, the DON stated she did not interview other staff regarding Resident 1’s elopement, or if other staff seen the resident or heard the alarm; therefore, it was not a thorough investigation. The DON stated that she cannot provide documented evidence that a thorough investigation was completed regarding Resident 1’s elopement incident on 9/15/2025. The facility failed to prevent elopement for Resident 1 who was assessed as high risk for elopement in accordance with the facility’s P&P titled, “Elopement and Wandering Prevention and Response,” by failing to: 1. Develop and implement a Care Plan to address Resident 1’s risk of wandering and elopement to reflect that Resident 1 needs enhanced monitoring and use of wander alert system from 2/26/2025 to 9/14/2025. 2. Provide documented evidence Resident 1 has a wander guard as ordered by the physician and wander guard was checked for functionality from 6/20/2025 to 9/24/2025. 3. Conduct a thorough investigation and document regarding an unusual occurrence of Resident 1’s elopement incident on 9/15/2025. These deficient practices resulted in Resident 1 leaving the facility without the facility staff’s knowledge on 9/15/2025 from when the resident was last seen in the facility at 6 PM by the CNA. The facility received a call from General Acute Care Hospital on 9/15/2025 at 7 PM that Resident 1 was found outside and presented in GACH’s ED with discoloration, abrasion and laceration to the left side of Resident 1’s face. The above violation had a direct or immediate relationship to the health, safety, or security of Resident 1.