F0656

D

Failure to Develop Elopement Care Plan for At-Risk Resident

Stockton, California Survey Completed on 02-17-2026

Penalty

No penalty information released

Summary

Surveyors identified that the facility failed to develop a comprehensive, person-centered care plan addressing elopement risk for one resident. The resident’s admission record showed multiple diagnoses, including End Stage Renal Disease, dependence on renal dialysis, and sequelae of cerebral infarction. An Elopement Evaluation dated 12/24/25 documented that the resident was at risk for elopement. Despite this documented risk, review of the resident’s care plans revealed that no elopement care plan had been created.

During a concurrent interview and record review on 2/12/26 at 3:20 PM, the DON confirmed that the resident did not have an elopement care plan and stated there should have been one. The DON acknowledged that not having such a care plan put the resident at risk of elopement and emphasized that a comprehensive care plan is important to guide staff with interventions and to help them be more vigilant if a resident attempts to leave the facility. Review of the facility’s “Wandering and Elopements” policy, revised 3/19, showed that when a resident is identified as at risk for wandering or elopement, the resident’s care plan is required to include strategies and interventions to maintain safety, which was not done in this case.