Health inspection·October 7, 2025

42 CFR §483.25(d) Accidents. The facility must ensure that - (1) The resident environment remains as free of accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. 42 CFR § 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. 22 CCR §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. 22 CCR §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. On 8/20/2025, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a Facility Reported Incident regarding Resident 1's elopement (the act of leaving a facility unsupervised and without prior authorization). The facility failed to ensure Resident 1 who was confused, had a diagnosis of dementia (a progressive state of decline in mental abilities), and had a history of falls, did not elope the facility on 8/20/2025 at approximately 3:45 AM. The facility failed to ensure: 1. Registered Nurse 1 (RN1) and other licensed nurses (in general) identified and assessed Resident 1 as a high risk for elopement. 2. RN2, Licensed Vocational Nurse (LVN) 3, and LVN2 supervised Resident 1 when Resident 1 tried to leave the facility on 8/20/2025 at 3:20 AM. 3. RN supervisors (in general) enabled the facility's door alarms as indicated in the facility's Audible (able to be heard) Battery-Operated Door Alarm policy and procedure (P&P). These failures resulted in Resident 1's elopement on 8/20/2025 at approximately 3:45 AM. The resident was at high risk for falls, serious harm. On 8/20/2025 at 4:28 AM, the Emergency Medical Services (EMS-professionals who provide emergency care to people who require medical attention outside of a hospital) transported Resident 1 by an ambulance from a public area (unidentified) to the General Acute Care Hospital (GACH) with complaints of unsteady (not firm) gait (how a person walks), left knee pain, and unable to ambulate (walk) witnessed by bystanders (unidentified). The GACH admitted Resident 1 for evaluation of unsteady gait and confusion. During a review of Resident 1's Admission Record, the Admission Record indicated the facility originally admitted Resident 1 a seventy-six-year-old-male on 7/4/2025 and readmitted the resident on 8/21/2025 with diagnoses that included dementia, weakness, hypertension (HTN-high blood pressure), and history of falling. During a review of Resident 1's Risk of Elopement Assessment dated 7/4/2025, the Risk of Elopement Assessment indicated RN1 completed the assessment. The Risk of Elopement Assessment indicated Resident 1 was not at risk for elopement. The Risk of Elopement Assessment indicated Resident 1 was ambulatory (able to walk). The Risk of Elopement Assessment indicated Resident 1 did not have any indications of a diagnosis of dementia. The Risk of Elopement Assessment indicated if Resident 1 was ambulatory and had a diagnosis of dementia. The Risk of Elopement Assessment indicated the facility was supposed to initiate (start) a care plan for potential elopement. During a review of Resident 1's Care Plan Report dated 7/4/2025, the Care Plan Report indicated Resident 1 was at risk for falls related to the history of falls, dementia, general weakness, and hospice (care for people who are nearing the end-of-life prioritizing comfort and quality of life by reducing pain and suffering). The Care Plan Report indicated the intervention was to implement fall precautions (unidentified). During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool) dated 7/10/2025, the MDS indicated Resident 1 usually could make himself understood and had the ability to understand others. The MDS indicated Resident 1 had severe cognitive (ability to think and process information) impairment (loss). During a review of Resident 1's History and Physical (H&P) dated 7/27/2025, the H&P indicated Resident 1 did not have the capacity (ability) to understand and make decisions. During a review of Resident 1's Emergency Department (ED) GACH note dated 8/20/2025 at 4:28 AM, the ED GACH note indicated the EMS arrived with Resident 1 from a public area (unidentified) with complaints of unsteady gait, unable to ambulate, and left knee pain, witnessed by bystanders (unidentified). During a review of Resident 1's Progress Notes dated 8/20/2025 at 5 AM, the Progress Notes (documented by LVN2) indicated Resident 1 woke up around 2:40 AM. The Progress Notes indicated at 3:20 AM a charge nurse (LVN 3) found out that Resident 1 tried to go out /leave the facility and he (LVN3) called him (LVN2) to put Resident 1 in Resident 1's room. The Progress Notes indicated RN2 and LVN 2 gave Resident 1 "emotional support." The Progress Notes indicated at 3:45 AM a Certified Nursing Assistant (CNA8) found that Resident 1 had "disappeared." The Progress Notes indicated all nurses (unidentified), and CNAs (unidentified) could not find Resident 1 inside or outside the facility. During a review of Resident 1's ED note dated 8/20/2025 at 7:28 AM, the ED note indicated Resident 1was presented to the emergency room with the EMS for evaluation of unsteady gait and confusion. The ED note indicated Resident 1 was found next to a car in a standing position and no other information was known. The ED note indicated Resident 1 was unable to give any additional information. During a review of Resident 1's Progress Notes dated 8/20/2025 at 9:32 AM, the Progress Notes indicated the facility received a report from the local police department that Resident 1 was found at the GACH. During a review of Resident 1's Progress Notes dated 8/20/2025 at 10 AM, the Progress Note indicated the facility was able to verify Resident 1 was brought to the GACH via emergency services and the GACH planned to admit Resident 1 to the GACH. During an interview on 8/20/2025 at 1:11 PM with the GACH Emergency Room (ER) Registered Nurse (ERRN), the ERRN stated Resident 1 was admitted to the GACH due to a mental status change (when a person's thinking, awareness, or behavior suddenly shifts from their normal state, often described as being confused, disoriented, agitated, or having trouble focusing). During an interview on 8/20/2025 at 3:40 PM with CNA 1, CNA 1 stated Resident 1 would attempt to leave the facility in general (unidentified date and time) and that she (CNA1) notified LVN 1. During a concurrent interview and record review on 8/20/2025 at 3:45 PM with LVN 1 and RN 5, Resident 1's Risk of Elopement dated 7/4/2025 was reviewed. LVN 1 and RN 5 stated Resident 1 had a diagnosis of dementia, and the licensed nurse (RN1) should have identified Resident 1 as a risk for elopement. During a concurrent interview and record review on 8/20/2025 at 4:25 PM with the ADM and the DON, the facility's Admission Inquiry form (medical history prior to the facility's admission), dated 7/2/2025 was reviewed. The ADM and DON stated the Admission Inquiry form indicated Resident 1 had dementia. The ADM and DON stated the nurse (RN 1) who performed the Risk of Elopement should have identified Resident 1 as an elopement risk. During an interview on 8/20/2025 at 4:42 PM with LVN 2, LVN 2 stated Resident 1 tried to get out of bed on the night of his (Resident 1) elopement (8/20/2025). LVN 2 stated the other charge nurse (unidentified) whose name he (LVN2) did not know, noticed Resident 1 tried to leave the facility. LVN 2 stated a CNA whose name LVN 2 did not know, and a charge nurse whose name LVN 2 did not know, took Resident 1 back to Resident 1's room. LVN 2 stated 30 minutes later the staff (unidentified) could not locate Resident 1. LVN 2 stated he (LVN2) did not hear any door alarms go off. During an interview on 8/20/2025 at 4:46 PM with RN 2, RN 2 stated she (RN2) redirected Resident 1 and LVN 3 brought Resident 1 back to his bed in the early morning of 8/20/2025. RN 2 stated 15 minutes later the facility staff (unidentified) could not locate Resident 1. RN 2 stated she (RN2) could not explain why the exit door alarms did not sound on the morning of 8/20/2025 when Resident 1 eloped from the facility. During an observation on 8/21/2025 at 5:50 AM, CNA3 was observed sitting in front of a room next to one of the exits to the front of the facility. The surveyor knocked and CNA 3 came to the front exit/entrance to the facility facing a street avenue and opened the door from the inside and the door alarm did not sound. There were no staff observed at the front desk. During a concurrent observation and interview on 8/21/2025 at 5:52 AM, with RN 1 and CNA 4, the facility's front door entrance/exit was observed facing a street avenue did not sound. RN 1 stated she (RN1) disarmed the front door entrance/exit at 4 am because the housekeeping staff (unidentified) came in at 4 AM. RN 1 stated the facility would disarm (turn off) the alarm in the front door entrance/exit "for a long time," (RN 1 could not give a specific timeframe). Station 1 exit door was open, and the alarm did not sound. RN 1 stated she (RN 1) left station 1 exit door unarmed to let the housekeeping staff (unidentified) inside. RN 1 stated if the front door was not armed, a resident (in general) could leave the facility without the staff (in general) knowing. RN 1 stated the facility's policy (unidentified) allowed her (RN1) to disarm the alarms (in general) at 4 am to let the housekeeping staff inside the facility. During a concurrent interview and record review on 8/21/2025 at 5:52 AM, with RN 1, the facility's policy and procedure (P&P) "Audible Battery-Operated Door Alarms," dated 1/2023 were reviewed. RN1 stated the P&P indicates the front door alarm should be armed from 10 PM to 7 AM. RN 1 stated the front door was not armed because staff (in general) would go in and out of the facility. During an observation on 8/21/2025 at 5:55 AM, the front door alarm did not sound when the surveyor opened the door. During an observation on 8/21/2025 at 5:57 AM, the station 1 back exit door was wide open without an alarm sound. During an interview on 8/21/2025 at 6:50 AM with CNA 4, CNA 4 stated the RN Supervisors (in general) would disarm the alarms for station 1 back door and the front lobby door alarms around 4 am to let housekeeping staff (in general) inside the facility. CNA 4 stated RN 2 would disarm the alarms around 4 am. During an interview on 8/21/2025 at 7 AM CNA 5, CNA 6, and the Laundry Aid (LA), they all stated that the night RN Supervisors (in general) would disarm the facility's alarms (in general). During an interview on 8/21/2025 at 7:05 AM Housekeeper 1 (HK 1), HK 2, and HK 3, they all stated the night RN Supervisor (in general) would disarm the alarms (in general) in the early morning to let them (housekeeping staff) into the facility. During an interview on 8/21/2025 at 7:20 AM the Infection Preventionist (IP), stated he (IP) did not know why the doors were not armed on 8/20/2025 in reference to Resident 1's elopement. During an interview on 8/21/2025 at 9:02 AM with Resident 1's Power of Attorney 1 (POA 1 - a legal document where a trusted person makes healthcare decisions for you if you become unable to make them yourself), POA1 stated Resident 1 had a history of trying to elope from two previous GACHs (unidentified) on two previous occasions. The POA1 stated Resident 1 was "very good at escaping." Resident 1 lived alone and could no longer take care of himself (Resident 1). The facility did not ask him (POA 1) about Resident 1's history of attempting to elope. During a concurrent interview and record review on 8/21/2025 at 12:05 PM with RN 3, DON, and the ADM, Resident 1's all care plans (in general) were reviewed. RN 3 and the DON stated there was no care plan for elopement for Resident 1. During an interview on 8/21/2025 at 4:27 PM with the ADM, the ADM stated CNA 8 reported Resident 1 went missing from the facility on the morning of 8/20/2025. During a review of the facility's Audible Battery-Operated Door Alarm P&P dated 1/2023, the P&P indicated the facility provides a safe environment for all staff and residents. The P&P indicated the RN supervisor on duty was responsible for ensuring the alarms are enabled. The P&P indicated the nursing staff should be notified if the alarms are not working and to check on resident's who are at high risk for elopement frequently. During a review of the facility's Elopement P&P dated 1/2025, the P&P indicated impaired (decreased) judgment (mental abilities that help a person understand and decide on something), perception (awareness), and thought processes of cognitively impaired persons make the residents at high risk for elopement. The P&P indicated precautions, procedures (unidentified) and staff and visitor education have been put into place to maximize resident safety. The P&P did not indicate how to prevent an elopement. The facility failed to ensure: 1. Registered Nurse 1 (RN1) and other licensed nurses (in general) identified and assessed Resident 1 as a high risk for elopement. 2. RN2, Licensed Vocational Nurse (LVN) 3, and LVN2 supervised Resident 1 when Resident 1 tried to leave the facility on 8/20/2025 at 3:20 AM. 3. RN supervisors (in general) enabled the facility's door alarms as indicated in the facility's Audible (able to be heard) Battery-Operated Door Alarm policy and procedure (P&P). These failures resulted in Resident 1's elopement on 8/20/2025 at approximately 3:45 AM. The resident was at high risk of falls, serious harm. On 8/20/2025 at 4:28 AM, the Emergency Medical Services (EMS-professionals who provide emergency care to people who require medical attention outside of a hospital) transported Resident 1 by an ambulance from a public area (unidentified) to the General Acute Care Hospital (GACH) with complaints of unsteady (not firm) gait (how a person walks), left knee pain, and unable to ambulate (walk) witnessed by bystanders (unidentified). The GACH admitted Resident 1 for evaluation of unsteady gait and confusion. These violations presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result to Resident 1.