The resident, identified in records as Resident 1, needs extensive help with basic daily tasks following cervical spine surgery, along with treatment for COPD, chronic pain, depression and other conditions. His care plan specifically states he requires "one-person physical assist required for ambulation and locomotion."
Nobody noticed he was gone until Licensed Vocational Nurse B went looking for him around 11:30 a.m. to give him his noon medication.
"LVN B was looking for Resident 1 for his noon medication around 11:30 p.m., and found out that Resident 1 was not in the facility," Certified Nursing Assistant D told inspectors during a phone interview. Both nurses searched everywhere inside the building and couldn't find him. Staff called police.
The receptionist had seen someone in an orange shirt walk out between 11:00 a.m. and noon, still wearing the facility's identification wristband. She tried to follow the person outside but couldn't locate them. She wasn't sure which resident had left.
"She immediately attempted to follow the individual but was unable to locate the person outside the facility building," the inspection report states. The receptionist confirmed it was her job to monitor the front entrance and make sure residents checked out when leaving.
Staff conducted room-to-room searches to figure out which resident in an orange shirt was missing. Licensed Vocational Nurse A told inspectors she and other staff members went to nearby stores looking for Resident 1.
The resident never received his scheduled noon medication that day. LVN B, who was the nurse on duty, told inspectors he didn't know when Resident 1 had left the facility.
Police filed a missing person report that afternoon.
The facility's own policy requires nurses to get a doctor's order before any resident can leave for therapeutic reasons. Registered Nurse A confirmed to inspectors that there was no such order for Resident 1 to leave the facility.
During the inspection, the Director of Nursing reviewed Resident 1's care plan and confirmed "that it was not safe for him to walk out of the facility by himself." The care plan lists his extensive medical needs, including the results of C2-C5 spinal surgery to relieve compression on his spinal cord, along with lung disease, chronic pain, anxiety, muscle spasms and other conditions requiring daily assistance.
The facility's comprehensive care planning policy states that the interdisciplinary team works with residents and families to develop person-centered care plans. Resident 1's plan clearly identified his need for walking assistance and help with eating, bathing, dressing and other basic tasks.
Mountain View police classified the incident as a "Found Missing Person" case.
The facility never reported the incident to the California Department of Public Health, despite having a policy requiring reports of "unusual occurrences or other reportable events which affect the health, safety, or welfare of our residents." The Director of Nursing confirmed during the inspection that no report was filed with state authorities.
The facility's unusual occurrence reporting policy, last revised in December 2007, specifically requires reporting events that interfere with facility operations. A resident walking out undetected while requiring assistance, missing medication, and prompting a police search would appear to meet that standard.
The inspection found the facility failed to ensure the resident received proper supervision consistent with his care plan needs. Federal investigators classified this as a violation with minimal harm or potential for actual harm, affecting few residents.
The case highlights the vulnerability of residents with complex medical needs who require assistance with basic mobility. Resident 1's conditions following spinal surgery, combined with breathing difficulties, chronic pain and other health issues, made unsupervised walking potentially dangerous.
Staff spent considerable time that day searching inside the facility and at nearby businesses, not knowing their resident had simply walked out the front door hours earlier while wearing his identification wristband.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Grant Cuesta Sub-acute and Rehabilitation Center from 2025-11-17 including all violations, facility responses, and corrective action plans.
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