That happened at Santa Anita Convalescent Hospital at noon on August 15, 2025.
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What they found, on the afternoon of August 15, 2025, was a system running badly out of control in both directions at once.
The incident happened on August 10, 2025, during what should have been a routine shower.
The elopement happened on August 1, 2025, the resident's first day at the facility.
Activity Aide #70 told inspectors she had been approached by SS #210 and asked to have residents sign receipts that had no amount written on them.
Federal inspectors documented the finding during a complaint investigation completed August 20, 2025, at the facility on North Hamilton Road.
The incident happened on July 19, 2025, at Resorts at Beaufort.
Her diagnoses included cerebrovascular disease, paraplegia, and atherosclerotic heart disease.
The violation centered on how staff recognized, monitored, and reported life-threatening changes in resident condition.
The citation, known as immediate jeopardy, means inspectors concluded that residents faced a risk of serious harm or death.
The deficiency centered on elopement: a resident had left the facility, and the systems meant to prevent that, and to respond when it happens, had failed.
The inspection was triggered by a complaint.