The 65-year-old resident disappeared on June 27, 2025, sometime before 5 p.m. Staff didn't discover she was gone until the next morning. But the certified nursing assistant continued filling out her fall monitoring log through 11 p.m. that night, documenting checks that never happened.
When inspectors confronted him about the false entries on September 18, the assistant admitted his mistake. "Resident 1 was missing and he made a mistake in documentation in the fall monitoring log," according to the federal inspection report.
The resident spent the night outdoors. A citizen found her the following afternoon around 3:44 p.m., nearly 19 hours after she vanished. Police noted she "was not in a clear state of mind" and was "talking and pointing about a dog but there was no dog in sight."
Emergency room doctors at the local hospital documented extensive injuries from her night outside. She had "multiple bodily scratches/abrasions including a gaping scalp wound requiring repair." Medical staff started a warming device to treat "significant hypothermia" and diagnosed her with rhabdomyolysis — a dangerous condition where muscle tissue breaks down and releases damaging proteins into the bloodstream.
The hospital record noted she had "likely" been outside all night.
Forest Hill Manor had no technological safeguards to prevent such escapes. The facility lacked both a wander guard system — which uses bracelets and door sensors to alert staff when residents approach exits — and any alarm system, the director of nursing confirmed during interviews with inspectors.
The resident's family had hired a private sitter just three weeks earlier, paying for 12-hour shifts from 7 a.m. to 7 p.m. starting June 6. But the facility's social services director convinced a family member to discontinue the service after just four days.
During a June 10 discussion, the social services director told the family "the resident did not need a sitter," according to inspection records.
Seventeen days later, the resident was gone.
The California Highway Patrol activated a Silver Alert within a three-mile radius when police realized an at-risk senior had disappeared. The Pacific Grove Police Department posted missing person flyers on social media and organized volunteer search teams to comb the area systematically.
The monitoring failures extended beyond the night she disappeared. Inspection records show gaps in documentation for multiple shifts: no entries for June 18 from 8 a.m. to 2 p.m. or 4 p.m. to 11 p.m., June 19-20 from 4 p.m. to 11 p.m., June 21 from 7 a.m. to 11 p.m., June 23 from midnight to 7 a.m., and June 24-26 from various afternoon and evening hours.
The director of nursing acknowledged during a September 3 interview that "the monitoring entries were not complete."
Forest Hill Manor's own policies appeared inadequate for preventing such incidents. The facility's wandering and elopement policy, last revised in March 2019, "did not address preventative measures to prevent elopement," inspectors found.
When questioned about this gap, the director of nursing insisted the policy did address preventative measures, contradicting what inspectors had documented.
The resident's medical complications from her overnight exposure were severe. Beyond hypothermia and the head laceration requiring surgical repair, doctors diagnosed altered mental status and a urinary tract infection. The rhabdomyolysis condition can cause kidney failure and other life-threatening complications.
Federal inspectors classified the violation as causing "actual harm" to residents, finding that Forest Hill Manor failed to provide adequate supervision and assistance devices to prevent accidents for residents who required such interventions.
The case highlights how documentation fraud can mask serious safety failures in nursing homes. While the missing resident faced life-threatening exposure to Pacific Grove's overnight elements, staff continued creating false records suggesting normal care was being provided.
The resident was found talking incoherently about a nonexistent dog, nearly 20 hours after she had walked out of a facility that was supposed to be monitoring her every few hours.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Forest Hill Manor Health Center from 2025-10-01 including all violations, facility responses, and corrective action plans.
Additional Resources
- View all inspection reports for Forest Hill Manor Health Center
- Browse all CA nursing home inspections