Health inspection·May 30, 2025

F689 Code of Federal Regulations, Title 42, Section 483.25(d) Accidents. (d) The facility must ensure that – (2) Each resident receives adequate supervision and assistance devices to prevent accidents. California Code of Regulations, Title 22, Section 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. California Code of Regulations, Title 22, Section 72521. Administrative Policies and Procedures. (a) Written administrative, management and personnel policies shall be established and implemented to govern the administration and management of the facility. (b) All policies and procedures required by these regulations shall be in writing and shall be carried out as written. They shall be made available upon request to patients or their agents and to employees and the public. Policies and procedures shall be reviewed at least annually, revised as needed and approved in writing by the governing body or licensee. (c) Each facility shall establish at least the following: (2) Policies and procedures for patient admission, leave of absence, transfer, pass and discharge, categories of patients accepted and retained, rate of charge for services included in the basic rate, type of services offered, charges for extra services, limitations of services, cause for termination of services and refund policies applying to termination of services. California Code of Regulations, Title 22, Section 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 California Department of Public Health (CDPH) on 4/17/2025 to investigate a complaint regarding an allegation that Resident 1 left the facility and did not come back after being out on pass (OOP, temporary permission of a resident to leave the facility for a specified time) on 4/15/2025, and a Facility Reported Incident regarding Resident 1 went out of the facility on pass and did not return after more than 24 hours. The facility failed to ensure Resident 1, who was assessed at risk for elopement (a resident who is incapable of adequately protecting himself, and who departs the health care facility unsupervised and undetected), did not elope after going out- on- pass (OOP, temporary permission of a resident to leave the facility in a specified time) on 4/15/2025 at 6 PM by failing to: 1. Develop a care plan and interventions to address Resident 1’s risk for elopement. 2. Implement procedures based on the facility’s Elopement Risk policy to search for Resident 1 when Resident 1 did not return to the facility while OOP. 3. Ensure facility staff implemented the facility’s elopement policy by clearly delineating when Resident 1 was expected to return to the facility; and failing to report to local police, administrator, and resident representative within two (2) hours and to California Department of Public Health (CDPH) within 24 hours from when Resident 1 eloped on 4/15/2025. 4. Ensure the facility has a system in place to identify risks for residents who independently go OOP such as wandering, falling, and/or injuries. As a result, Resident 1 left the facility on OOP unsupervised on 4/15/2025 and did not return until 4/20/2025 at 8:45 am, nearly 5 full days after leaving the facility. Being away from the facility unsupervised at all, much less for nearly 5 days had the potential for resident to be exposed to harsh environmental conditions including excessive heat and or cold, potential of being hit by a car and medical complications including malnutrition (lack of proper nutrition, caused by not having enough to eat, not eating enough of the right things, or being unable to use the food that one does eat), dehydration (body loses too much water and other fluids that it needs to work normally), heat stroke (a life-threatening condition where the body's temperature rises dangerously high), and death. A review of Resident 1’s admission record, indicated the facility admitted Resident 1, a 72-year-old-male, on 3/11/2025. Resident 1 had diagnoses of psychoactive substance abuse (drug addiction, is a disease that affects a person's brain and behavior and leads to an inability to control the use of a legal or illegal drug or medicine), unspecified alcohol- induced disorder (a medical condition characterized by an impaired ability to stop or control alcohol use despite adverse social, occupational, or health consequences), generalized muscle weakness (a decrease in muscle strength), and unsteadiness on feet (the person is walking in an abnormal, uncoordinated, or unsteady manner). A review of Resident 1’s Minimum Data Set (MDS, standardized care and screening tool), dated 3/24/2025, indicated Resident 1 had intact cognitive (process of thinking and reasoning) skills for daily decision making. The MDS also indicated Resident 1 required partial moderate assistance (Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort) with walking 10 feet (ft., a unit to measure the length or distance) once standing and walking 50 ft. with two turns (once standing, the ability to walk at least 50 ft. and make 2 turns). A review of Resident 1’s Elopement Risk Assessment, dated 3/11/2025, indicated Resident 1 was at risk for elopement. A review of Resident 1’s Order Summary Report, dated 3/18/2025, indicated Resident 1 may go out on pass two times a week. The report did not specify how long it was medically safe for Resident 1 to be out on pass each time or how it was safe for Resident 1 to be out on pass despite needing assistance with walking as indicated in the MDS. During a concurrent review of Resident 1’s “Out on Pass (OOP)/ Leave of Absence” log and interview with Registered Nurse (RN) 1 on 4/17/2025 at 2:04 PM, RN 1 stated Resident 1 left the facility by himself to go to the store and did not return at the expected time on 4/15/2025 at 9PM. A review of Resident 1’s nurses progress notes, dated 4/15/2025 at 11:08 PM, indicated Resident 1 had not returned from OOP. The progress notes also indicated Licensed Vocational Nurse (LVN) 1 called Resident 1 on his cellular phone, but the resident did not answer. A review of Resident 1’s nurses progress notes, dated 4/16/2025 at 5:58 AM, indicated Resident 1 had not returned to the facility. A review of Resident 1’s nurses progress notes on 4/16/2025 from 10:33 AM to 1:27 PM, indicated Resident 1 was OOP. A review of Resident 1’s nurses progress notes from 4/16/2025 at 1:28 PM to 4/17/2025 at 7:59 AM, indicated there was no further documentation on the resident’s whereabouts. A review of Resident 1’s nurses progress notes, dated 4/17/2025 at 8AM, indicated a late entry for 4/16/2025 at 8:30 AM that Resident 1 had not returned to the facility. RN 1 attempted to call Resident 1 but there was no response. RN 1 informed the medical doctor (MD 1, primary physician), the Director of Nursing (DON), Administrator (ADM) and Social Service Director (SSD) that Resident 1 was not back from OOP. There were no new orders received from MD 1. During a concurrent interview and record review on 4/17/2025 at 2:10 PM, Resident 1’s Order Summary Report was reviewed with RN 1. RN 1 stated the order summary report dated 3/18/2025 indicated Resident 1 may go out on pass two times a week. RN 1 stated Resident 1’s OOP order was not specific because it did not indicate who will accompany the resident and how long the resident may go OOP. During an interview on 4/17/2025 at 4:35 PM, LVN 1 stated Resident 1 left the facility on 4/15/2025 at 6PM for OOP and was expected to return at 9PM the same night (4/15/2025). LVN 1 stated Resident 1 was not back at 9PM (4 hours after Resident 1 left) so LVN 1 called Resident 1 on his cellular phone to verify the resident’s whereabouts but did not get a reply. LVN 1 stated he did not inform the DON, ADM or the police department. LVN 1 also stated he did not search for Resident 1 when he did not return as expected at 9PM or throughout his shift (3PM to 11PM on 4/15/2025). During an interview on 4/17/2025 at 4:40 PM, RN 1 stated she notified MD 1, DON, ADM and SSD on 4/16/2025 at 8:30 AM (11 hours and 30 minutes after) that Resident 1 has not been back at the facility since Resident 1 had gone OOP on 4/15/2025 at 6PM and was expected to return on 4/15/2025 at 9PM. RN 1 also stated the facility did not search for the resident and neither did RN 1 report to the police nor to the department of public health about the Resident 1 not being back to the facility after OOP on 4/15/2025. During an interview on 4/17/2025 at 4:48 PM, the DON stated Resident 1 was at risk for elopement according to the elopement risk. The DON stated Resident 1 should have a care plan for elopement to ensure resident safety. During an interview on 4/17/2025 at 4:55 PM, the DON stated the facility did not search the facility and surrounding streets for Resident 1 on 4/15/2025 to 4/16/2025 because her understanding was that Resident 1 was not returning to the facility and did not consider it as an elopement. The DON confirmed that Resident 1 was in fact missing. The DON stated RN 2 reported to the police on 4/17/2025 at 3:15 PM (45 hours and 15 minutes from when resident left the facility) that Resident 1 has not been back to the facility since 4/15/2025 when resident went OOP. The DON stated she along with the IPN and SSD started calling hospitals and searched the facility surroundings on 4/17/2025 at 1:40 PM. A review of Resident 1’s Social Service Notes, dated 4/17/2025 at 5:42 PM, indicated Resident 1 went OOP on 4/15/2025 at 4PM according to the signed OOP log. Resident 1 has not been back to the facility since 4/15/2025. During an interview on 4/17/2025 at 6:48 PM, the DON stated any resident can go OOP even at nighttime if the resident is alert and oriented times four (4) and based on the resident’s “assessment” such as if the resident is able to walk and can go by themselves. A review of the facility’s OOP policy, revised 7/2024, indicated the resident may go out by him /herself if he/she is self-responsible depending upon physician’s order. During a concurrent interview and record review on 4/17/2025 at 6:50 PM, Resident 1’s Order Summary Report, dated 3/15/2025 was reviewed with the ADM. The ADM stated Resident 1’s order to go out on pass two times a week was a “blanket order” because it is not specific. The ADM stated the order did not indicate how long Resident 1 was allowed to be OOP and did not indicate if Resident 1 can go OOP independently or be accompanied by a responsible person while OOP. During a concurrent interview and record review on 4/17/2025 at 6:55 PM, the Policy and Procedure titled, “Out on Pass/ Against Medical Advice (AMA)/ Doctors Appointment,” revised 7/20/2024 was reviewed with the ADM. The ADM stated the policy did not have a timeframe indicating a duration of time for when the resident can be OOP. The ADM further stated facility staff should know procedures to follow when the resident does not return from OOP that include searching for residents if residents have not returned within a 4-hour timeframe, report to the responsible party, MD, ADM, DON, local police, and CDPH. During a concurrent interview and record review on 4/17/2025 at 7 PM, the Policy and Procedure titled, “Elopement Risk Precautions and Procedures” revised 7/2024 was reviewed with the ADM. The ADM stated according to the policy, if the resident is not found within 2 hours, notify the local police, administrator, and resident representative and notify CDPH within 24 hours from when Resident 1 eloped. The ADM confirmed that IPN reported Resident 1 missing to the local law enforcement on 4/17/2025 at 3:15 PM. During a concurrent interview and record review on 4/18/2025 at 12:45 PM, Resident 1’s care plan was reviewed with RN 1. RN 1 stated Resident 1 did not have a care plan for OOP and risk for elopement. RN 1 stated Resident 1 should have had a care plan when going OOP and for risk for elopement. A review of the facility’s Policy and Procedure (P&P) titled, “Out on Pass/ Against Medical Advice/ Doctors Appointment,” revised 7/2024, indicated to provide opportunity for the resident to participate in family and community life to maintain optimal functioning, the facility will respect resident’s rights to be OOP unless otherwise contraindicated to the resident’s medical needs. The P&P indicated the resident may go out by him /herself if he/she is self-responsible depending upon physician’s order. A review of the facility’s P&P titled, “Care Plan,” revised 4/2024, indicated a care plan is a summation of the residents’ concerns, goals, approaches and interventions in order to meet the goals and help minimize if not totally eradicate residents’ problem. The P&P also indicated the resident care plan is developed within 7 days upon resident’s admission, reviewed quarterly, annually or as often as needed as there is a change in condition. The evidence of a care plan that has been reviewed should include but not limited to the new interventions that have been added in addition to the current ones. These interventions should be in chronological order as implemented and carried out. A review of the facility’s P&P titled, “Elopement Risk Precautions and Procedures,” revised 7/2024, indicated the facility to identify residents who are wanderers or who are a threat to leaving the facility unattended without the knowledge of the facility staff. The P&P indicated to ensure the resident’s safety utilizing the least restrictive means available.” It also indicated that when a resident is believed to be missing, the following steps will be implemented: 1. The charge nurse shall be alerted that the resident is missing 2. The charge nurse of designee shall alert staff about the resident elopement or missing. All employees are to report to the nurse station. The charge nurse/ supervisor will explain the situation and designate where each staff person is to search. 3. Search the building: closet, shower, bathrooms and ground thoroughly. 4. If the facility search is unsuccessful, the surrounding streets and yards will be searched. 5. If the resident was not found within 2 hours, notify local police, administrator and responsible party. 6. Give the police a description and current photo of the missing resident. 8. If resident is not found within 24 hours, even with the assistance of the police department of if found and resident sustains injury, department of public services will be notified in 24 hours. The facility failed to ensure Resident 1, who was assessed at risk for elopement did not elope after going OOP on 4/15/2025 at 6 PM by failing to: 1. Develop a care plan and interventions to address Resident 1’s risk for elopement. 2. Implement procedures based on the facility’s Elopement Risk policy to search for Resident 1 when Resident 1 did not return to the facility while OOP. 3. Ensure facility staff implemented the facility’s elopement policy by clearly delineating wh