Health inspection·July 11, 2025

F689- §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. § 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) (a)Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. 22 CCR §72527 – Patients’ Rights (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (1) To be fully informed, as evidenced by the patient's written acknowledgement prior to or at the time of admission and during stay, of these rights and of all rules and regulations governing patient conduct. (5) To receive all information that is material to an individual patient's decision concerning whether to accept or refuse any proposed treatment or procedure.  (c) If a patient lacks the ability to understand these rights and the nature and consequences of proposed treatment, the patient's representative shall have the rights specified in this section to the extent the right may devolve to another, unless the representative's authority is otherwise limited. The patient's incapacity shall be determined by a court in accordance with state law or by the patient's physician unless the physician's determination is disputed by the patient or patient's representative. 22 CCR 72528 (a) It is the responsibility of the attending licensed healthcare practitioner acting within the scope of his or her professional licensure to determine what information a reasonable person in the patient's condition and circumstances would consider material to a decision to accept or refuse a proposed treatment or procedure. Information that is commonly appreciated need not be disclosed. The disclosure of the material information and obtaining informed consent shall be the responsibility of the licensed healthcare practitioner who, acting within the scope of his or her professional licensure, performs or orders the procedure or treatment for which informed consent is required. On 5/30/2025 at 2:35 PM, an unannounced visit was conducted to investigate a facility reported incident regarding a resident elopement (a resident who is incapable of adequately protecting himself, and who departs the health care facility unsupervised and undetected). The facility failed to ensure Resident 1 who has a diagnosis of intracerebral hemorrhage (ICH, also known as hemorrhagic stroke in brain stem), assessed with severe cognitive impairment (difficulty thinking, remembering and reasoning) for daily decision making, and at risk for elopement, was supervised to prevent injury and did not elope on 5/30/2025 between 8:40 AM to 9:30 AM by failing to: 1. Immediately reassess Resident 1, who was assessed as low risk for elopement on 5/8/2025, after Resident 1 was observed by Certified Nurse Assistant (CNA) 1 packing his belongings and verbalizing wanting to leave the facility on 5/30/2025 from 8:40 AM to 9:30 AM, in accordance with the facility's Resident Elopement Policy. 2. Implement interventions such as a detailed monitoring plan to prevent elopement after Resident 1 was observed packing his belongings and verbalizing wanting to leave the facility on 5/30/2025 at around 8:40 AM, in accordance with the facility's Resident Elopement Policy. 3. Supervise Resident 1 by ensuring the facility doors were being monitored to prevent Resident 1 from leaving the facility unsupervised, as instructed by the Director of Nursing (DON) after Resident 1 was observed packing his belongings and verbalizing wanting to leave the facility on 5/30/2025 at around 8:40 AM. 4. Respect Resident 1’s right to be fully informed, as evidenced by written acknowledgement, of his rights and of all rules and regulations regarding patient discharges and leaving against medical advice, including receiving all material information relating to his risk of leaving the facility. 5. Respect Resident 1’s right to a lawful representative being informed of his rights, and the rules and regulations regarding patient discharges against medical advice, to the extent that Resident 1 lacked the ability to understand his rights and evaluate the consequences of leaving or remaining in the facility. 6. Ensure that an attending licensed healthcare practitioner acting within the scope of his or her professional licensure determined what information a reasonable person in the patient's condition and circumstances would consider material to a decision to remain in the facility or leave, and to ensure that Resident 1 or his lawful representative provided informed consent. These failures resulted in Resident 1 eloping from the facility on 5/30/2025 around 9:30 AM and had the potential to expose Resident 1 to harsh environmental conditions including excessive heat and or cold, the potential to be hit by a car as well as experiencing medical complications including malnutrition, dehydration, heat stroke , and death. Resident 1 returned to the facility on 5/30/2025 at 3:45 PM (six hours and 15 minutes after resident eloped), accompanied by an unidentified individual. A review of Resident 1's Admission Record indicated Resident 1 is a 78-year-old-male initially admitted to the facility on 5/7/2025 with diagnoses of nontraumatic intracerebral hemorrhage in brain stem and type two diabetes mellitus (DM2, a disorder characterized by difficulty in blood sugar control and poor wound healing) with diabetic chronic kidney disease (damage to the kidneys caused by long-standing high sugar levels leading to impaired kidney function and potentially kidney failure). A review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 5/14/2025, indicated Resident 1 had severe impairment with cognitive skills for daily decision making. Resident 1 needed substantial/maximal assistance (helper does more than half the effort) with walking 10 feet. Resident 1 needed partial/moderate assistance (helper does less than half the effort) with transfers (how resident moves to and from bed, chair, wheelchair, standing position), personal hygiene, putting on/taking off footwear, upper and lower body dressing (the ability to dress and undress above and below the waist), and needed setup or clean-up assistance (helper sets up or cleans up, resident completes activity) with eating. A review of Resident 1's Elopement Risk Evaluation, dated 5/8/2025, indicated Resident 1 was evaluated as low risk for elopement. A review of Resident 1's Health Status Note, dated 5/30/2025, timed at 11:42 AM indicated on 5/30/2025 at 8:45 AM (22 days from Resident 1's initial Elopement Risk Evaluation), "The Activities Director (AD) stated resident (Resident 1) voiced he would like to leave the facility." A review of Resident 1's SBAR documentation, dated 5/30/2025 at 2:19 PM, indicated Resident 1 left the building by walking without notifying anyone. The SBAR did not indicate the time Resident 1 left on 5/30/2025. During an interview on 5/30/2025 at 2:48 PM with the DON, the DON stated on the morning of 5/30/2025, she was informed by the AD that Resident 1 was packing his clothes and wanted to leave. The DON stated she called the Social Services Assistant (SSA) to speak with Resident 1 regarding Resident 1 wanting to leave. The DON then stated the SSA verified that Resident 1 wanted to leave and was going to call Resident 1's family so that Resident 1 could speak with them. The DON told the SSA to monitor Resident 1 and ensure Resident 1 does not walk out of the facility's doors unsupervised. During the same interview on 5/30/2025 at 2:48 PM with the DON, the DON stated after the 9:30 AM meeting with all the facility department heads, CNA1 came up to all the department heads to ask if they have seen Resident 1. The DON stated she called a code silver (a signal used to alert staff of an older resident who has gone missing) and all staff started looking for Resident 1 around the facility premises and two blocks away from the building both on foot and by car. The DON stated that they had gone to the store across the street from the facility, and the owner of the store had informed them that they had seen Resident 1 walk out through the doors of the facility and towards the bus stop. The DON then stated around 11:45 AM, they received a call from a staff at Resident 1's previous residence (apartment) that Resident 1 was outside the apartment building. During the same interview on 5/30/2025 at 2:48 PM with the DON, the DON stated she had called 9-1-1 emergency response to go to Resident 1's previous residence to check on the resident. The DON stated after a while, paramedics told her that they could not force Resident 1 to go back to the hospital or facility, since Resident 1 refused to leave his apartment. The DON then stated she called the Psychiatric Emergency Team (PET, a mobile team that provides crisis intervention and stabilization for individuals experiencing a mental health crisis) to go check on Resident 1 at his apartment. During the same interview on 5/30/2025 at 2:48 PM with the DON, the DON stated the doors of the facility are always to be monitored by the receptionist or another staff member. The DON added that if the facility staff monitoring the doors needs to step away or leave, she/he needs to be properly relieved by other staff, so the doors are continuously monitored to ensure residents do not walk out of the facility unsupervised. During an interview on 5/30/2025 at 3:54 PM with the DON, the DON stated Resident 1 returned to the facility at 3:45 PM on 5/30/2025 with an unknown individual. During an interview on 5/30/2025 at 4:01 PM with the DSD, the DSD stated a staff member should always be monitoring the door to help prevent resident elopement. DSD stated the receptionist normally comes around 9:30 AM to 10 AM and works until 6 PM. DSD stated if the receptionist is not there to monitor the facility doors, another staff member should be assigned to monitor the door. During an interview on 5/30/2025 at 4:08 PM with AD, AD stated on 5/30/2025 around 8:50 AM to 9:05 AM while he was doing his rounds in the hallway, he passed CNA 1, who told him that Resident 1 wanted to leave the facility and was observed packing his belongings into a bag. AD stated he went straight to the DON to notify her of what Resident 1 was doing, and the DON went to check on the situation right away. During an interview on 5/30/2025 at 4:13 PM with CNA 1, CNA 1 stated on 5/30/2025 around 8:40 AM, she observed Resident 1 gathering his belongings and asked him what he was doing. CNA 1 stated Resident 1 told her it was none of her business, and she proceeded to inform AD of what she saw and continued with her assignment. CNA 1 then stated she noticed Resident 1 was gone (could not recall the exact time) after she went to follow-up after working with another resident. During an interview on 5/30/2025 at 4:22 PM with Resident 1, Resident 1 stated he left the facility on the morning of 5/30/2025, because he needed to do some things at home, and when he asked if he could leave, he was told that he could not. Resident 1 stated when the staff walked away from the doors, he walked out of the building. Resident 1 then stated when he left the facility, he went to the bus stop and his apartment. Resident 1 stated that a friend of his picked him up from his apartment and brought him back to the facility. During an interview on 5/30/2025 at 4:31 PM with the DON, the DON stated residents who are high risk for elopement are the residents verbalizing wanting to leave or showing signs, such as packing their clothes. The DON stated interventions included applying a wander guard (bracelets that residents wear, which is a tracking device to alert staff when a resident exits the facility), having a bed alarm (monitors resident's movement and alerts the staff when movement is detected) and a binder at the nurse's station to indicate which residents are at high risk for elopement. During the same interview with the DON on 5/30/2025 at 4:31 PM, a concurrent record review of Resident 1's elopement risk evaluation, dated 5/8/2025, was conducted. The DON stated the elopement risk evaluation indicated Resident 1 was assessed at low risk. The DON stated Resident 1's elopement risk should have been reassessed as soon as Resident 1 was observed packing his belongings and wanting to leave the facility, which could have increased Resident 1's risk of leaving the facility unsupervised. During an interview on 5/30/2025 at 4:37 PM with SSA, SSA stated around 8:45 AM to 8:50 AM, CNA 1 told him that Resident 1 was packing up his belongings and stated for CNA 1 to mind her own business. SSA stated the DON called him around 8:55 AM to also notify him of Resident 1 wanting to leave. DON instructed SSA to speak with Resident 1. SSA stated around 8:56 AM, he went to speak with Resident 1 to ask the resident why he was packing his belongings and Resident 1 told him it was none of his business. SSA stated around 9:05 AM, he gave the facility's cordless phone to Resident 1 so that he could speak with his family member. SSA then stated he left to go to the DON's office and was instructed by the DON to ensure the facility doors were monitored. SSA stated he went to the doors, but the receptionist was not there yet since she was running late. SSA stated there were staff (not specified) within the vicinity of the doors, but no one was specifically watching the doors. During an interview on 5/30/2025 at 5:09 PM with SSA, SSA stated on 5/30/2025 around 9:12 AM, he went to the facility front entrance, and no one was there, so he went to his office to grab his papers to get ready for the department head meeting, which he attended at 9:34 AM. SSA stated once the meeting was over around 10 AM, CNA 1 approached all the department heads and asked if anyone had seen Resident 1, since he was not in his room. During a concurrent interview and record review on 5/30/2025 at 5:31 PM of the facility's undated Policy and Procedure (P&P) titled, "Resident Elopement" and Resident 1's Care Plan, dated 5/30/2025, the DON stated the P&P did not indicate that the facility's doors should be monitored. The DON stated the facility's doors being monitored for 24 hours and seven (7) days a week (24/7) should be included in the elopement policy to prevent residents from eloping. During the same interview on 5/30/2025 at 5:31 PM with the DON, the DON stated the facility doors should have been monitored as instructed which could have prevented Resident 1 from eloping. A review of the facility's undated P&P titled, "Resident Elopement,” indicated "The facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk for elopement." Under policy interpretation and implementation, the P&P also indicated: A. "The staff will identify residents who are at risk for harm because of unsafe wandering (including elopement). B. The staff will assess at-risk individuals for potentially correctable risk factors related to unsafe wandering. C. The resident's care plan will indicate the resident is at risk for elopement or other safety issues. Intervention to try to maintain safety, such as a detailed monitoring plan will be included." The facility failed to ensure Resident 1, who has a diagnosis of nontraumatic ICH, assessed with severe cognitive