F0725

D

Licensed Nurse Left Facility, Leaving Residents Without On-Site Nursing Coverage

Alturas, California Survey Completed on 01-14-2026

Penalty

No penalty information released

Summary

The facility failed to ensure a licensed nurse was present in the building at all times when residents were in the facility. On the night of 12/5/25, the only Licensed Nurse (LN A) on duty left the facility to get food, after first sitting in their car for approximately 15 minutes, and then driving away from the facility grounds. Security camera footage reviewed by the Director of Nursing (DON) showed that LN A left the facility around 11:10 pm or 11:15 pm and was out of the building for approximately one hour, with no other licensed nurse present in the facility or on the grounds during that time. The facility’s assessment tool dated 11/10/25 indicated the facility would staff two LNs on the night shift, while an undated staffing ratio document for revamping staffing indicated that when the census was less than 30, there would be one LN working the night shift.

During this period, only two CNAs, including CNA B, were in the facility providing care to residents without an on-site licensed nurse. CNA B reported that LN A left for a smoke break, drove away, and was gone for about an hour, confirming there was no LN in the facility or on the grounds. A resident who was awake at the time stated that the nurse said she was going on break and did not return for a long time, and that they notified the Nurse Manager (NM). NM confirmed receiving a call from CNA B on the evening of 12/5/25 about LN A leaving the facility. LN A later stated they left to get food, confirmed they were the only LN working that evening, and explained they were used to another nurse arriving to provide a lunch break and did not realize that reporting off to CNAs would leave the facility without a nurse. The report states this failure had the potential to impact resident health status and could have caused a decline in psychosocial well-being.