Health inspection·December 17, 2025

Code of Federal Regulations 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. Cal. Code Regs. Tit. 22, § 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. On 11/5/2025, an unannounced visit was made to the facility by the California Department of Public Health (CDPH) to investigate an entity self-reported incident regarding resident safety due to elopement (when a person with cognitive impairment leaves a safe area, such as a care facility or home, without awareness of potential dangers). During the investigation CDPH determined that the facility failed to provide a safe and secured environment for Resident 1, who has a diagnosis of dementia (a progressive state of decline in mental abilities) and was identified as being at high risk for elopement and wandering (when a person roams and becomes lost or confused about their location) when the facility failed to:   1. Adequately care plan Resident 1’s history of wandering when the facility identified the resident to be a “known wanderer”, as indicated in the “Elopement- Wandering Risk Scale Assessment” dated 10/21/2025. 2. Implement Resident 1’s care plan for wandering and elopement, to ensure that facility staff monitored Resident 1 who required hourly monitoring, to remain safe and secured between hours when no staff was monitoring the resident’s whereabouts.   On 10/28/2025 between the hours of 5 PM to 6 PM, Resident 1 was left unattended in the facility’s Activity/Dining Room, which was located adjacent to an exit door. Resident 1 wandered out of the facility unsupervised. 3. Ensure that Activity Staff (AS) 1 was informed of Resident 1’s needs to be monitored due to  high risk for elopement , in accordance with the facility’s policy and procedure (P&P) titled “Elopement Risk Reduction Approaches,” when Licensed Vocational Nurse (LVN) 1 observed the resident wandering out of her room on 10/28/2025 and  left the resident with AS 1 in the facility’s Activity/Dining Room.  AS 1 left the facility and Resident 1 unattended in the facility’s Activity/Dining Room at the end of her shift on 10/28/2025 at around 5 PM.    As a result of these deficient practices, Resident 1 wandered out of the facility and was later found the same day, on 10/28/2025, at approximately 6:07 PM, sitting at a bus stop on a busy street 0.4 miles from the facility. Resident 1 was located and returned to the facility by a family member (Responsible Party [RP] 1).  Resident 1 was placed at significant risk including falls, injury from motor vehicular accidents, and extreme weather conditions due to the facility’s failure to provide Resident 1 with a safe and secure environment.   A review of Resident 1’s admission record indicated Resident 1 was admitted to the facility on 10/21/2025, with diagnoses that included multiple fracture (a broken bone) of left side ribs, repeated falls, and dementia.   A review of Resident 1’s Elopement- Wandering Risk Scale Assessment dated 10/21/2025, indicated Resident 1 was identified at high risk for wandering/elopement due to forgetful/short attention span, diagnosis of dementia with psychosis (a collection of symptoms that affect the mind, where there has been some loss of contact with reality), and a known wanderer, including history of wandering. The Assessment did not indicate any recommendations from the facility’s licensed nurse who completed the Elopement- Wandering Risk Scale Assessment.       A review of Resident 1’s Care Plan titled “At risk for Wandering and Elopement” dated 10/22/2025, indicated the goal was to ensure Resident 1 would remain safe within the facility and free from injury. The care plan interventions included the following interventions:        1. Keep environment free from clutter;         2. Monitor resident whereabouts every 1 hour;      3. Redirect resident calmly when attempts to ambulate unassisted occurs.   The Care Plan did not include having all interdisciplinary care team members made aware of Resident 1’s high risk for elopement and the type of supervision required for Resident 1 to remain safe and secured between hours when no staff was monitoring the resident’s whereabouts.      A review of Resident 1’s Care Plan titled “At risk for falls” dated 10/22/2025, indicated that Resident 1 had cognitive impairment and history of recent falls resulting in rib fracture. The care plan interventions indicated that Resident 1 needs a safe environment including even floor, free from spills and clutters, adequate lighting, an accessible call light, and handrails on walls.      A review of the facility Minimum Data Set (MDS – a resident assessment tool) dated 10/25/2025, indicated Resident 1 had severely impaired (significantly limits one person’s physical or mental ability to do basic work activities) cognition (thought process). The MDS also indicated Resident 1 required supervision or touching assistance (helper provides verbal cues and/or contact guard assistance as resident completes activity) during sit-to-stand, and partial/moderate assistance (helper does less than half the effort) on walking 50 feet.     A review of Resident 1’s Monitoring Log dated 10/28/2025 timed at 4 PM marked “R” indicated that Resident 1 was in the resident’s room, and another one timed at 5 PM marked “D” indicated that Resident 1 was in the “Dining Room” (Activity Room).     During a telephone interview conducted on?11/05/2025 at 11:30 AM, Certified Nurse Assistant (CNA) 1 stated that she was assigned to care for Resident 1?on?10/28/2025. CNA 1 stated that Resident 1 was identified as being at risk for elopement and required hourly monitoring. CNA 1 recalled that at approximately 5:00 PM on 10/28/2025,?Licensed Vocational Nurse (LVN 1)?escorted Resident 1 to the Activity Room. CNA 1 stated she was attending to another resident at that time and was not asked by LVN 1?to supervise or monitor Resident 1 while the resident was in the Activity Room. CNA 1 further stated that she became aware that Resident 1 was missing from the facility at approximately?5:30 PM on 10/28/2025?and?immediately reported the incident to the charge nurse.    During a telephone interview conducted on?11/05/2025 at 11:44 AM,LVN 1 stated that on 10/28/2025, between the hours of 4:00 PM and 5:00 PM, LVN 1 observed Resident 1walking out of his room. Resident 1 was dressed and appeared to be wandering. LVN 1 stated that she redirected and accompanied Resident 1 to the Activity Room, where she handed off the resident to AS 1. LVN 1 stated that she was not certain whether AS 1 was aware of Resident 1’s high risk for elopement and the need for close monitoring. She (LVN 1) assumed AS 1 would supervise Resident 1, as it is the facility’s expectation that no resident should be left unsupervised.  During an interview on 11/05/2025 at 12:20 PM,AS 1 stated  she was not informed by LVN 1 that Resident 1?was at risk for elopement and was not familiar with the resident’s medical history. AS 1 stated that she does not typically know most residents’ diagnoses but acknowledged that no resident should be left unsupervised.  On?10/28/2025 at around 5:00 PM, as she was preparing to leave for the day, she went to the Nursing Station to inform Registered Nurse (RN) 1 that someone needed to get Resident 1 from the Activity Room. AS 1 stated that there were two dietary staff members present in the Activity/Dining Room when she stepped out to look for the RN 1. AS 1 stated that it was not appropriate to expect dietary staff to supervise Resident 1 and stated that she should not have left Resident 1 unsupervised in the Activity Room on 10/28/2025.    During an interview on 11/05/2025 at 2:45 PM, RN 1 stated that she completed an elopement risk assessment for Resident 1 upon admission. RN 1 stated that all staff, including nurses and activity staff, were informed about Resident 1’s high risk for elopement. RN 1 stated that on 10/28/2025, at around 5:00 PM, while making resident rounds prior to her 30-minute meal break, she observed Resident 1 with AS 1 in the Activity Room. RN 1 stated that she was on her meal break and was not aware of the time AS 1 ended her shift. RN 1 stated AS 1 did not inform her that Resident 1 needed someone to supervise Resident 1 in the Activity Room prior to leaving the facility at end of her (AS 1) shift, on 10/28/2025.  Upon returning from her break at approximately 5:35 PM, RN 1 stated she was notified by LVN 1 that Resident 1 was missing.    During a telephone interview on 11/06/2025 at 2:10 PM, RP 1 stated that she received a call from the facility on 10/28/2025 at around 5:30 PM, informing her that Resident 1 was missing from the facility. RP 1 stated that she and other family members immediately searched from their cars and searched for Resident 1. RP 1 stated that they found Resident 1 while driving toward the facility. Resident 1 was sitting at a bus stop near a busy street intersection, 0.4 miles away from the facility. RP 1 stated Resident 1 appeared to be sweating heavily from walking. RP 1 stated that Resident 1 looked lost and was surprised to see her and the other family members. Resident 1 did not respond when asked why he was there.      During an interview on 11/05/2025 at 3:50 PM with the Administrator (ADM) and Director of Nursing (DON), the DON stated that the supervision and safety of residents is very important, and that staff communication should be thorough at all times. The ADM stated that AS 1 should not have assumed that any dietary or non-clinical staff present would be responsible for monitoring or supervising a resident. The ADM further stated that AS 1 should have remained with Resident 1 until relieved by a clinical staff member.  A review of the facility’s Policy and Procedures (P&P) titled “Wandering and Elopement” revised 8/1/2014, the P&P indicated that resident’s risk for elopement and preventative interventions will be documented in the resident’s medical record, and will be reviewed and re-evaluated by the IDT upon admission, readmission, quarterly, and upon change of condition according to the RAI (Resident Assessment Instrument- a standardized process that nursing homes use to evaluate a resident's needs and develop an individualized care plan) guidelines. The P&P further indicated that the IDT may consider interventions listed in the “Elopement Risk Reduction Approaches for residents identified to be at risk for elopement.”    A review of the facility’s P&P titled “Elopement Risk Reduction Approaches,” the P&P indicated “As necessary, provide new residents (to the facility, wing, unit, etc.) with additional staff assistance until they are comfortable in their new environment.” The P&P further indicated that for residents identified at risk for wandering, facility staff needs to know the following information:   1. How to identify and understand the resident’s needs.   2. The resident’s propensity to wander and the triggering conditions.   3. Recognition of the consequences of limited mobility.   4. The consequences of unsafe wandering, the protocols to follow to minimize successful exiting    As a result of the above violations, CDPH determined that the facility failed to provide a safe and secured environment for Resident 1, who has a diagnosis of dementia and was identified as being at high risk for elopement and wandering when the facility failed to:   1. Adequately care plan Resident 1’s history of wandering when the facility identified the resident to be a “known wanderer”, as indicated in the “Elopement- Wandering Risk Scale Assessment” dated 10/21/2025. 2. Implement Resident 1’s care plan for wandering and elopement, to ensure that facility staff monitored Resident 1 who required hourly monitoring, to remain safe and secured between hours when no staff was monitoring the resident’s whereabouts.   On 10/28/2025 between the hours of 5 PM to 6 PM, Resident 1 was left unattended in the facility’s Activity/Dining Room, which was located adjacent to an exit door. Resident 1 wandered out of the facility unsupervised. 3. Ensure that Activity Staff (AS) 1 was informed of Resident 1’s needs to be monitored due to  high risk for elopement , in accordance with the facility’s policy and procedure (P&P) titled “Elopement Risk Reduction Approaches,” when Licensed Vocational Nurse (LVN) 1 observed the resident wandering out of her room on 10/28/2025 and  left the resident with AS 1 in the facility’s Activity/Dining Room.  AS 1 left the facility and Resident 1 unattended in the facility’s Activity/Dining Room at the end of her shift on 10/28/2025 at around 5 PM.    Resident 1 wandered out of the facility and was later found the same day, on 10/28/2025, at approximately 6:07 PM, sitting at a bus stop on a busy street 0.4 miles from the facility. Resident 1 was located and returned to the facility by a RP 1.   Resident 1 was placed at significant risk and exposure from falls, injury from motor vehicular accidents, and extreme weather conditions due to the facility’s failure to provide Resident 1 with a safe and secure environment. This violation 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.