Health inspection·May 2, 2025

F689 42CFR §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. 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: (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. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. (3) Notifying the attending licensed healthcare practitioner acting within the scope of his or her professional licensure promptly of: (C) An unusual occurrence, as provided in Section 72541, involving a patient. 22 CCR §72471. Special Treatment Program Service Unit – Patient Health Records and Plans for Care. (a) The facility shall maintain an individual health record for each patient which shall include but not be limited to the following: (1) A list of the patient's care needs, based upon an initial and continuing individual assessment with input as appropriate from the health professionals involved in the care of the patient. Initial assessments by a licensed nurse shall commence at the time of admission of the patient and shall be completed within seven days after admission. (2) The plan for meeting behavioral objectives. The plan shall include but not be limited to the following: (3) Development and implementation of an individual, written care plan based on identified patient care needs. The plan shall indicate the care to be given, the objectives to be accomplished, and the professional discipline responsible for each element of care. The objectives shall be measurable, with time frames, and shall be reviewed and updated at least every 90 days. § 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 the California Department of Public Health on 3/20/2025 at 6 a.m. to investigate a complaint indicating Resident 1 left the facility without facility staff’s knowledge. The facility failed to implement the facility’s Wandering and Elopement Policy and Procedures (P&P) by failing to: 1. Develop a care plan to ensure interventions were in place for Resident 1 to prevent elopement after Resident 1 was assessed as elopement risk on 11/4/2024. 2. Notify Resident 1’s family and physician after Resident 1 eloped on 11/16/2025 at 7:30 AM and was found walking around Recreation Park 1 on 11/16/2025 between 10:15 AM to 10:24 AM (approximately two [2] hours). 3. Examine and assess Resident 1 for injuries upon return to the facility on 11/16/2025. 4. Follow its policies and procedures after an elopement by failing to document all relevant information regarding resident elopement, the facility’s efforts to look for the resident and determine how Resident 1 returned to the facility in the Resident 1’s medical record. These failures resulted in Resident 1 eloping from the facility on 11/16/2024 at 7:30 AM which placed the resident at risk for exposure to extreme weather, medical complications, injury, serious harm, and/or death. A review of Resident 1’s Admission Record, indicated Resident 1 is a 79- year- old- female admitted at the facility on 11/4/2024 with diagnoses that included dementia with psychotic disturbance (also known as dementia-related psychosis, occurs when individuals with dementia experience delusions or hallucinations), hypertension, generalized muscle weakness, and unsteadiness on feet. A review of Resident 1’s Minimum Data Set (MDS-a resident assessment tool), dated 11/11/2024, indicated Resident 1 had intact cognitive skills for daily decision making. The MDS indicated Resident 1 required set up or clean up assistance with eating and oral hygiene. The MDS indicated Resident 1 required supervision or touching assistance and walking 50 ft with two turns and required partial/moderate assistance with walking 10 feet on uneven surfaces. During a concurrent interview and record review on 3/20/2025 at 9:03 AM with the Director of Nursing (DON), the Admission Assessment for elopement risk dated 11/4/2024 and care plan dated from 11/4/2024 to 11/16/2024 were reviewed. The Admission Assessment for elopement risk indicated Resident 1 was at risk for elopement. The DON stated there was no care plan for elopement in Resident 1’s medical record initiated from 11/4/2024 when the resident was assessed as at risk for elopement through 11/16/2024, the date Resident 1 eloped. The DON stated it was important to initiate the elopement care plan immediately after conducting the elopement risk assessment so staff would know what interventions to implement to prevent Resident 1 from eloping. The interventions should include how frequent the resident should be monitored, documenting resident’s behavior of wandering and looking for exits, and notifying the MD and family representative if elopement occurs. The DON stated if the care plan was initiated as soon as the elopement risk was identified, the incident of Resident 1 eloping on 11/16/2024 could have been prevented. The DON also stated that she was not made aware of any elopement incident for Resident 1 on 11/16/2024 because she was off duty that day. During a concurrent interview and record review on 3/20/2025 at 9:25 AM with the DON, Resident 1’s Progress notes dated 11/16/2024 to 3/20/2025 were reviewed. There was no documentation of Resident 1’s elopement incident on 11/16/2024 in Resident 1’s medical records. The DON stated any elopement incidents should be documented in the resident’s medical record. During an interview on 3/20/2025 at 10:30 AM with MDS Nurse (MDSN), the MDSN stated a care plan for Resident 1 at risk for wandering/elopement should have been initiated on 11/4/2024 when Resident 1was identified as at risk for wandering/elopement. The MDSN stated she does not know why a care plan for Resident 1’s risk for wandering/ elopement was only initiated on 11/18/2024. The MDSN stated that care plans are initiated so all staff are aware and should implement interventions to prevent elopement. During a phone interview on 3/20/2025 at 11:04 AM with Licensed Vocational Nurse 1 (LVN) 1, stated she was on duty on 11/16/2024 from 7AM to 3PM and she recalled Resident 1 went missing on 11/16/2024 during LVN 1’s shift (unable to recall time). LVN 1 stated she called the police department on 11/16/2024 at around 8:46 AM when the facility staff discovered Resident 1 was missing. A police officer arrived at the facility and called Resident 1’s family representative (Family 1) to inquire if Family 1 had any contact with Resident 1. LVN 1 stated Resident 1 was found later that day on 11/16/2024 (unable to recall time) and was brought back to the facility by police. Family 1 informed the police of Resident 1’s location. LVN 1 stated that the Administrator was informed by Registered Nurse Supervisor (RN 1) of Resident 1’s elopement incident on 11/16/2024. LVN 1 stated the Administrator came to the facility and reviewed the video surveillance with LVN 1, the police, and RN 1. LVN 1 stated through the video surveillance, it was determined Resident 1 used the staff elevator and exited through the facility entrance door on 11/16/2024 at approximately 7:30 AM. LVN 1 stated LVN 1 thought RN 1 documented the elopement of Resident 1 incident in Resident 1’s medical records but LVN 1 learned the elopement was not documented. During an interview on 3/20/2025 at 12:53 PM with Medical Records Director (MRD), the MRD stated she could not find any documentation of the elopement in Resident 1’s medical records from 11/16/2024 to 3/20/2025. MRD also stated that there was no Situation, Background, Assessment, and Recommendation (SBAR- a communication tool used by healthcare workers when there is a change of condition among the residents) regarding the elopement incident for Resident 1 on 11/16/2024. MRD further stated Resident 1’s medical records did not contain an assessment after Resident 1 returned to the facility. MRD further indicated there was no documented evidence that Resident 1’s family or physician were notified of the elopement. During a concurrent interview and record review on 3/20/2025 at 1:13 PM with the Infection Prevention Nurse (IPN), Resident 1’s Progress notes dated from 11/162024 to 3/20/2025 were reviewed. IPN stated, the progress notes did not indicate documentation of elopement incident on 11/16/2024. During a phone interview on 3/20/2025 at 3:25 PM, Family 1 stated Police Officer 1 called her and left a voice message on 11/16/2024 around 9 AM to 9:20 AM notifying Family 1 that the Police Officer was called by the nursing facility to help search for Resident 1 and to call the Police dispatch if the resident contacted Family 1. Family 1 stated she was driving to the facility when she received a call from Resident 1 using a Bystander’s phone saying Resident 1 was lost. Family 1 spoke with Bystander and requested the Bystander to stay with the resident until a police officer arrived to pick up Resident 1. Family 1 stated the Bystander indicated they were walking around Recreation Park 1 when Resident 1 approached the Bystander on 11/16/2024 around 10:15 AM. Resident 1 told the Bystander she was lost and asked to use the Bystander’s phone to call Family 1. Family 1 stated she then called the Police Dispatch to notify the Police Office where to find Resident 1. Family 1 stated nursing facility staff did not notify her that Resident 1 went missing, and it was the Police officer who informed Family 1 that Resident 1 had eloped from the facility. A review of the Computer-Aided Dispatch (CAD) Call Hardcopy from the Police Department, dated 11/16/2024, the CAD indicated call was received at 8:46 AM and was made by LVN 1. The CAD indicated the call type was for a missing person. The CAD indicated Resident 1 was last seen leaving the facility at 7:30 AM. Six (6) Police units were dispatched to search the bus lines, bus stops, and train stations. The CAD indicated Resident 1’s family called and stated Resident 1 had been found at 10:24 AM. A review of the facility’s P&P titled, “Accidents and Incidents – Investigating and Reporting, “revised July 2017, the P&P indicated: 1. The nurse supervisor/charge nurse and/or the department director or supervisor shall promptly initiate and document investigation of the incident. 2. The following data, as applicable, shall be included on the Report or Incident/Accident Form: date and time the incident took place; the circumstances surrounding the incident; the names of witnesses and their accounts of the incident; the date and time the attending physician and family were notified; disposition of the resident; any corrective action taken; follow up information; and the signature and title of the person completing the report. A review of the facility’s P&P titled, “Wandering and Elopements,” revised March 2019, the P&P indicated the facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. The P&P also indicated: 1. If identified as at risk for wandering, elopement, or other safety issues, the resident’s care plan will include strategies and interventions to maintain the resident’s safety. 2. If a resident is missing, initiate the elopement/missing resident emergency procedure: if the resident was not authorized to leave, initiate a search of the building(s) and premises; and if the resident is not located, notify the Administrator and the DON, resident’s legal representative, the attending physician, law enforcement officials. 3. When the resident returns to the facility, the DON or charge nurse shall: examine the resident for injuries; contact attending physician and report findings and condition of the resident; notify resident’s legal representative; complete and file an incident report and document relevant information in the resident’s medical record. The facility failed to implement the facility’s Wandering and Elopement P&P by failing to: 1. Develop a care plan to ensure Resident 1 received interventions to prevent elopement when assessed as elopement risk on 11/4/2024. 2. Have documented evidence of Resident 1’s family and physician notification when resident eloped and was found on 11/16/2025. 3. Have documented evidence that Resident 1 was examined for injuries upon return on 11/16/2025 and have the relevant information documented in the resident’s medical record. These failures resulted in Resident 1 eloping from the facility on 11/16/2024 which placed the resident at risk for exposure to extreme weather, medical complications, injury, serious harm, and/or death. The above 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.