Other·May 28, 2026

The following reflects the finding of the California Department of Public Health during Investigation for: Complaint number: 2995356; and Facility reported incident number: 2988134 A Class AA citation was issued. REGULATORY VIOLATIONS: 42 CFR §483.21(b) Comprehensive Care Plans (1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at § 483.10(c)(2) and § 483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. (2) A comprehensive care plan must be- (i) Developed within 7 days after completion of the comprehensive assessment. (ii) Prepared by an interdisciplinary team, that includes but is not limited to- (A) The attending physician. (B) A registered nurse with responsibility for the resident. (C) A nurse aide with responsibility for the resident. (D) A member of food and nutrition services staff. (E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan. (F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident. (iii) Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. 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 §483.35 Nursing Services The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at § 483.71. (a) Sufficient Staff. (4) Providing care includes but is not limited to assessing, evaluating, planning and implementing resident care plans and responding to resident's needs 42 CFR §483.90 (i) Other Environmental Conditions The facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public. 22 CCR § 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: (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. 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 4/21/2026, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a complaint and reported facility incident allegation regarding a resident elopement and death. The facility failed to provide adequate supervision and implement effective interventions to prevent elopement (when a resident leaves the facility grounds or a designated safe area without the staff knowing and/or without the supervision the resident needs) for Resident 1, an 84-year-old male, who was assessed at risk for wandering (walking around without a clear purpose) and elopement. The facility failed to: 1. Accurately assess and identify elopement risk. The facility's Wandering & Elopement Assessment dated 4/18/2026 indicated a "Low Probable Risk" even though Resident 1 demonstrated repeated exit-seeking, wandering, and attempts to elope on 4/18/2026. RN 2 stated the assessment was inaccurate and should have reflected a "Moderate Actual Risk (is where a hazard is present and has a fair or intermediate likelihood of occurring)." 2. Identify the sliding door in Resident 1's room and in Rooms 126, 128, 130, 132, 134, 136, and 138 as a potential elopement route and evaluate the need for an alarm or other safety device for these exits, despite Resident 1's repeated exit-seeking behavior. 3. Identify the two patio gates at the back of the facility that lead to Avenue 1 and Street 2 as a risk and install alarms prior to Resident 1's elopement. 4. Implement the interventions outlined in the Elopement Risk/Wanderer Care Plan (CP - is a structured, individualized document created by healthcare professionals in collaboration with the patient to outline specific health conditions, treatment goals, and necessary services) to ensure that a resident is properly evaluated for the need for increased supervision and close monitoring, including continuous visual observation. 5. Revise and strengthen elopement interventions despite Resident 1's repeated and escalating exit-seeking behaviors during both the 7 a.m.-3 p.m. and 3 p.m.-11 p.m. shifts on 4/18/2026. As a result of these deficient practices, Resident 1 eloped from the facility on 4/19/2026 between 7:54 a.m. and 8:30 a.m. and was not found by facility staff. At approximately 11 p.m., on 4/19/2026, an unidentified individual called 911 (the telephone number used to reach emergency medical, fire, and police services) after finding Resident 1 on the street. Emergency responders reported that Resident 1 had been robbed, beaten, and set on fire. Paramedics (are advanced allied health professionals in the Emergency Medical Services (EMS) system who provides critical, life-saving prehospital care to patients) found Resident 1 lying unconscious on the ground with burns to the neck, shoulders, face, scalp, and back, and with swelling of the face and tongue. The resident was transported to General Acute Care Hospital (GACH 2), arriving on 4/20/2026, at 12:23 a.m., and was subsequently transferred to GACH 3. On 4/20/2026, at 9:45 a.m., Resident 1 expired at GACH 3. A review of Resident 1's General Acute Care Hospital (GACH 1) Psychiatry (A field of medicine that focuses on understanding, diagnosing, and treating mental, emotional, and behavioral disorders) Consult Note dated 4/15/2026, indicated that Resident 1 was admitted to GACH 1 on 4/14/2026 for decreased oral intake and unintentional weight loss. The psychiatric consultation was requested due to Resident 1's increased confusion. The consultation notes further indicated that Resident 1 lacked capacity to make medical decisions. The psychiatry consultant noted that Resident 1 had a one-to-one sitter (1:1 - a staff member or trained companion assigned to provide continuous bedside supervision to ensure the patient's immediate safety). The consultant documented that Resident 1 appeared confused and was alert and oriented only to name/self (oriented ×1). Resident 1 required constant redirection due to frequent attempts to get out of bed. A review of Resident 1's admission record indicated that Resident 1 was admitted to the facility on 4/17/2026, with diagnoses including acute kidney failure (the sudden loss of kidney function that impairs the ability to filter waste, balance fluids, and regulate electrolytes), cirrhosis of the liver (late stage, often irreversible scarring of liver tissue), dementia (a decline in cognitive functioning -memory, language, problem solving, and thinking that interferes with daily life), anxiety (excessive and persistent worry or fear that disrupts functioning), protein calorie malnutrition (a deficiency of essential macronutrients needed to meet the body's requirements), restlessness (excessive, non-purposeful movement or pacing), and agitation (including verbal aggression). A review of Resident 1's Change in Condition (COC - is a sudden or significant deviation from a patient's baseline physical, cognitive, or functional status. It signifies an acute deterioration or improvement requiring intervention) form dated 4/18/2026, at 10:02 a.m., indicated Resident 1 was identified as an elopement risk starting that morning (time not indicated). Resident 1 was alert and oriented to one area, newly admitted on 4/17/2026, verbally responsive, and able to walk without assistance. Resident 1 was observed to be anxious and frequently wanting to leave the facility. A review of Resident 1's Wandering & Elopement Risk Assessment, dated 4/18/2026, at 10:10 AM, indicated that Resident 1 had not eloped but was assessed as a moderate elopement risk under section D due to recent observable wandering that was not easily ended or redirected. However, under section G the Risk Score indicated Resident 1 was a "Low Probable Risk" for elopement. A review of Resident 1's Physician Progress Note dated 4/18/2026, at 1:23 p.m., Indicated Resident 1 had increasing confusion, agitation, and significant dementia. The note stated that Resident 1's primary language is Korean speaking, appeared confused, could not participate in a goal directed conversation, and appeared disorganized. The physician documented that Resident 1 could not make needs known and did not have the mental capacity to make medical decisions. A review of Resident 1's Elopement Risk/Wanderer Care Plan (CP), initiated on 4/18/2026, indicated that Resident 1 was at risk for wandering due to exit-seeking behavior, new admission status, and verbalizations of wanting to leave the facility. The care plan goals included ensuring that Resident 1 did not leave the facility unattended and that the facility maintained the resident's safety. Interventions included addressing Resident 1's wandering behavior by walking with Resident 1 or attempting to redirect Resident 1 from inappropriate behaviors, as well as evaluating Resident 1 for the need for additional supervision and providing close monitoring ((refers to vigilant, frequent, or continuous observation of a patient by healthcare professionals to ensure patient safety) A review of Resident 1's facility Order Summary Report for April 2026 indicated the following physician orders: On 4/18/2026, monitoring of the Wanderguard (an electronic safety device worn as a bracelet or anklet to help prevent residents with cognitive impairment from wandering or eloping) on the right ankle every shift. On 4/18/2026, monitoring of the Wander guard functionality every shift using a tester. A review of Resident 1's Nurses Notes dated 4/18/2026, at 9:44 p.m., indicated that Resident 1 was ambulatory (able to walk) and required limited assistance with activities of daily living (ADLs, such as bathing, dressing, and toileting) during this shift. The progress notes documented multiple episodes (number not specified) of wandering, and a Wanderguard was placed on Resident 1's right ankle. The notes further indicated that Resident 1 had several episodes of agitation (number not specified) during the 3 p.m. to 11 p.m. shift, characterized by attempts to hit staff during efforts to redirect the resident back to the room when Resident 1 was attempting to exit the facility. The RN was notified. A review of Resident 1's facility Situation Background Assessment Recommendation (SBAR- a tool used in healthcare to improve patient safety by enabling fast, accurate, and concise information transfer between clinicians) dated 4/18/2026, at 9:44 p.m., indicated that Resident 1 was "restless, pacing, grimacing," which was documented as a new change in behavior. The SBAR noted that the physician was informed, no new orders were received, and no additional interventions were documented. A review of Resident 1's Nurses Notes dated 4/18/2026, at 11:09 p.m., indicated that Resident 1 displayed multiple episodes of wandering (number not specified) during the 3 p.m. to 11 p.m. shift and attempted to elope from the facility. The note further indicated that the registered nurse supervisor was made aware of the situation, and no new interventions were received at that time. A review of Resident 1's Medication Administration Record (MAR) for April 2026 indicated that on 4/18/2026, during the day shift (7 a.m. to 3 p.m.), the resident manifested five episodes of anxiety-related behaviors manifested by (m/b) agitation. Resident 1 exhibited an additional five episodes of anxiety-related behaviors during the evening shift (3 p.m. to 11 p.m.). The MAR further indicated, by check mark, that Resident 1 exhibited wandering behavior during the 3 p.m. to 11 p.m. shift. A review of Resident 1's COC dated 4/19/2026, at 8:44 a.m., indicated that the resident was identified as an elopement case. The Medication Nurse reported that Resident 1 could not be found in his room. All staff searched for the entire facility but were unable to locate the resident. The facility called 911, and a missing person report was filed with the Los Angeles Police Department (LAPD). A review of Resident 1's Nurses Notes dated 4/19/2026, at 10:57 a.m., indicated that the resident had been very agitated during the previous overnight shift (11 p.m. to 7 a.m.) and repeatedly expressed a desire to go home. On 4/19/2026, at approximately 7:40 a.m., a certified nursing assistant (CNA) assisted Resident 1 by setting up breakfast in the resident's room. At around 7:50 a.m., a Restorative Nursing Assistant (RNA, an advanced certified nursing assistant who provides specialized rehabilitative care), reported seeing Resident 1 sitting on the bed. At approximately 8:20 a.m., a charge nurse entered Resident 1's room to administer medications and observed that Resident 1 was not present. The sliding door in Resident 1's room was found open. Facility staff immediately initiated a search of the building and surrounding areas, including all resident rooms, restrooms, the backyard, and the garage. The notes indicated that Closed-Circuit Television (CCTV, a video surveillance system) footage was reviewed; however, Resident 1 was not seen existing through the main entrance or any other door. The same Resident 1's Nurses Notes indicated Resident 1's family member (FM) 1 was notified. FM 1 reported that Resident 1 had expressed a desire to go home on the previous day (4/18/2026) and confirmed that Resident 1 had significant memory impairment and was very confused. Emergency services and law enforcement were notified to file a missing person report. Resident 1's attending physician was also informed of the situation. The Nurses Notes concluded with: "At the time of this report, all staff members continued to search for the resident." A review of the Los Angeles Fire Department (LAFD) Patient Care Report dated 4/20/2026, at 12:02 a.m., showed that Emergency Medical Services (EMS- It is a comprehensive system providing out-of-hospital, acute medical care and transportation for victims of sudden illness or injury) arrived on scene at 12:09 a.m., and found Resident 1 three miles away from the facility, lying on the street with police present. EMS could not identify Resident 1 or locate any identification. Resident 1 had second-degree (partial-thickness burn) damages to the outer layer (epidermis) and part of the underlying layer (dermis) of the skin, causing severe pain, redness, swelling, and blistering, along with third-degree (is a severe medical emergency that destroys all layers of the skin-the epidermis and dermis-and can damage underlying fat, muscle, and bone) burns on the neck, face, shoulders, and back. Police suspected that a substance had been thrown on Resident 1 and then the resident was set on fire. EMS noted that the Resident 1's airway (the pathway that allows air to travel in and out of the lungs for respiration) was compromised, with swelling and burn injuries