**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to implement the facility ' s policy and procedure (P&P) titled, Smoking Policy-Residents, dated 8/2022, to ensure eight of eight sampled residents (Residents 2, 3, 9, 14, 18, 56, 67 and 136) who were smokers (residents who smoked cigarettes) had an environment free of accident hazards (risk) by failing to: 1. Provide supervision while smoking to Residents 2, 3, 9, 14, 18, 56, 67 and 136 when Resident 2, 3, 14, 18, 56, 67 and 136, were assessed by the facility as unsafe smokers, and when Resident 9 ' s smoking assessment was not completed by the facility. 2. Ensure Resident 9 was assessed for the level of supervision while smoking. 3. Ensure Resident 3 did not store cigarettes and lighters in Resident 3 ' s drawer. 4. Ensure Resident 14, who was assessed by the facility as unable to light tobacco [a preparation of the nicotine (a toxic colorless or yellowish oily liquid that is the chief active constituent of tobacco) rich leaves of an American plant, which are cured by a process of drying and fermentation for smoking or chewing safely, did not pass/share cigarettes with Residents 9, 56 and 136, and used Resident 67 ' s lighter to light cigarettes. 5. Ensure Receptionist (REC) 1 did not provide lit cigarettes and allowed Residents 9 and 14 to smoke unsupervised during nonscheduled smoking time. 6. Identify Residents 2, 9, 14, 18 and 136 as noncompliant with the facility ' s smoking policy when Residents 2, 9, 14, 18 and 136 smoked during nonscheduled smoking time. 7. Ensure Residents 3, 56 and 67 who were identified as non-compliant with facility ' s smoking policy, were not allowed by the facility to continue to keep cigarettes and lighters in Resident 3, 56 and 67 ' s possession. 8. Ensure a designated staff was scheduled to supervise the smoking patio area during the scheduled and nonscheduled smoking time. 9. Ensure the facility has a plan of action in place on how to care for residents who did not comply with the facility ' s smoking policy. These deficient practices had the potential for Residents 2, 3, 9, 14, 18, 56, 67 and 136 to be at risk for accidental burn, fire hazards that could affect the health, safety, wellbeing of residents, staffs, visitors and result in serious injuries, hospitalization and death. On October 22, 2024, at 3:32 PM, while onsite at the facility, the California Department of Public Health (CDPH) identified an Immediate Jeopardy situation (IJ, a situation in which the provider ' s noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death of a resident) regarding the facility ' s failure to prevent smoking hazards by not monitoring and supervising smoking activities for Residents 2, 3, 9, 14, 18, 56, 67 and 136. The facility also failed to safely secure/store lighters and cigarettes. On 10/24/2024 at 1:42 PM, the IJ was removed in the presence of the Director of Nurses (DON, who was covering and acting as the facility ' s Administrator), Quality Assurance Consultant 1, and Clinical Consultant 1 after the facility submitted an acceptable IJ Removal Plan (a plan that identifies all actions the facility will take to immediately address the noncompliance that has resulted in the IJ situation) and while onsite at the facility, the surveyors verified/confirmed the facility ' s implementation of the IJ Removal Plan and the IJ situation was no longer present. The facility had a plan in place to supervise all smokers. The IJ Removal Plan dated 10/24/2024, included the following: 1. On 10/21/2024 at around 5 PM, Residents 3, 56 and 67 ' s two packs of cigarettes and lighter were taken from Residents 3, 56 and 67 ' s bedside drawers by the DON and kept in the locked drawer in the receptionist desk. 2. On 10/21/2024 at around 5 PM, Resident 67 was provided education by the Social Service Director (SSD), and the DON regarding facility staff keeping the smoking materials and Resident 67 would not smoke without any supervision by the facility staff. Resident 67 agreed to comply with the facility staff after discussion with Resident 67. The facility ' s receptionist would be the keeper of the smoking items and smoking materials. Only staff would have access to the keys of the smoking items. 3. On 10/21/2024 at around 5 PM, Resident 3 was educated by the SSD on the facility ' s smoking P&P including surrendering cigarettes and smoking materials to facility staff. 4. On 10/21/24 Residents 3 and 56 ' s Care Plans (CPs, a document that outlines the facility ' s plan to provide personalized care to a resident based on the resident ' s needs) for smoking were updated by the licensed nurses indicating the interventions for Resident 3 and 56 to safety smoke, and the DON initiated additional CPs for Resident 3 and 56 ' s non-compliance with smoking per P&P. 5. On 10/21/2022 Resident 136 was transferred to the General Acute Hospital (GACH) and would be re-educated by the SSD or designee regarding the facility ' s smoking P&P including not giving and not receiving cigarettes from other residents. 6. On 10/22/24 the smoking attendants were provided education by the DON/Designee on the facility ' s smoking P&P regarding the importance of supervision and being on the designated smoking area during smoking schedule. No smoking attendant would be assigned as a smoking attendant without being educated on the importance of being at smoking area during smoking schedule. 7. On 10/22/24, the facility implemented dedicated smoking attendants to monitor smokers 24 hours a day during scheduled and nonscheduled smoking times. The Activities Director (AD)/designee was responsible to schedule the smoking attendants weekly or as needed. The dedicated smoking attendant would log the behavior of the identified non-compliant residents and would intervene accordingly if residents found to not following the facility ' s P&P such as smoking on nonscheduled times or having in possession smoking paraphernalia (any device used, intended for use, or designed for use in smoking) when inside or outside the facility. 8. On 10/22/2024, Residents 2, 9, 14, and 18 ' s CPs were updated to reflect smoking non-compliance. 9. On 10/22/2024 at around 6 PM, Resident 9 was re-educated regarding the facility ' s P&P for smoking including lighting cigarettes in the smoking area by the delegated smoking supervisor. 10. On 10/22/2024, around 6 PM, Residents 3 and 56 were provided education by the SSD about safety on smoking and not to smoke without any supervision by staff. 11. On 10/24/2024, Resident 14 was re-educated by the SSD regarding the facility ' s smoking P&P including not giving and not receiving cigarettes from other residents. 12. On 10/24/2024, REC 1 was provided a 1:1 (a direct encounter between 2 persons) in-service by the DON regarding the facility ' s new smoking P&P including supervision of smokers. 13. On 10/24/2024, the SSD and Interdisciplinary Team (IDT, a team of people from different disciplines who work together to improve patient/resident care) members initiated a discussion with all residents who smoke (not limited to Residents 3 and 56) regarding the facility ' s P&P on smoking and importance of adhering to the policy for safety. Residents 3 and 56 agreed on complying on 10/24/2024 per IDT discussion. 14. On 10/24/2024, the quality Assessment and Assurance Committee (QAA, committee established for the purpose of improving the safety and quality of health services) members with the medical director and administrator updated the smoking policy with the policy not limited to addressing supervision of smokers and indicating potential outcomes for the non-compliant smokers. 15. On 10/24/2024, the DSD/designee initiated an in-service to licensed, non-licensed staff and smoking attendants on the importance of ensuring supervision of smokers In-service to all staff would be continued until all smoking attendants that would l be scheduled were provided education on supervision. Total of 8 residents were observed non-compliant with the facility ' s smoking policy and procedure. The facility ' s census was 84 and there were 23 smokers. Findings: a. During a review of Resident 2's admission Record (AR), the AR indicated the facility admitted Resident 2 on 6/23/2016 and readmitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD, a lung disease characterized by long-term poor airflow) and nicotine dependence, cigarettes (occurs when the resident needed nicotine and could stop using it). During a review of Resident 2 ' s History and Physical (H&P, a comprehensive physician ' s note regarding the assessment of the resident ' s health status), dated 12/29/2023, the H&P indicated, Resident 2 did not have the capacity to understand and make decisions. During a review of Resident 2 ' s Order Summary Report (OSR), the OSR indicated on 12/16/2023, Resident 2 had a physician order that Resident 2 may smoke cigarette per preference with staff supervision in designated smoking area and in accordance with facility ' s smoking policy. During a review of Resident 2 ' s Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 8/15/2024, the MDS indicated Resident 2 ' s cognition (ability to think, remember, and reason) was severely impaired, and Resident 2 needed supervision in walking 150 feet in a corridor or similar space. During a review of Resident 2 ' s Smoking and Safety (S&S), dated 8/15/2024, the form indicated Resident 2 was a tobacco user. During a review of Resident 2 ' s CP, titled Smoking, dated 8/27/2024, the CP indicated Resident 2 was at risk for hazard/injury (burns) related to smoking cigarettes. The interventions included for facility staff to provide frequent monitoring to Resident 2 during smoking times. b. During a review of Resident 3's AR, the AR indicated the facility admitted Resident 3 on 10/10/2017 and readmitted on [DATE] with diagnoses that included hemiplegia [a condition that causes half of the body to be paralyzed (or unable to move)] and hemiparesis (weakness or the inability to move on one side of the body) following cerebral infarction (or a stroke, which is a medical emergency that occurs when blood flow to the brain is cut off) affecting right dominant side, and COPD. During a review of Resident 3 ' s OSR, the OSR indicated on 5/6/2024, Resident 3 had a physician order that Resident 3 may smoke cigarette per preference with staff supervision in designated smoking area and in accordance with facility ' s smoking policy. During a review of Resident 3 ' s H&P, dated 5/8/2024, the H&P indicated Resident 3 had the capacity to understand and make decisions. During a review of Resident 3 ' s MDS, dated [DATE], the MDS indicated Resident 3 ' s cognition was intact. The MDS indicated Resident 3 was a tobacco user, and able to independently (resident completes the activity by themselves with no assistance from a helper) utilize the wheelchair to manually wheel at least 50 feet, make two turns or at least 150 feet in a corridor or similar space. During a review of Resident 3 ' s S&S, dated 9/6/2024, the S&S indicated Resident 3 had balance problems while sitting or standing, and required supervision during smoking breaks. The form indicated the goal was for Resident 3 to adhere to the facility ' s Tobacco/Smoking Policies. During a review of Resident 3 ' s CP titled, Smoking, dated 10/2024, the CP indicated Resident 3 was at risk for discomfort, shortness of breath (SOB, the feeling of not get enough air into the lungs) and injury related to smoking. The interventions included for facility staff to provide frequent monitoring, remind Resident 3 of smoking schedule, and reorient Resident 3 to the smoking area. During a review of Resident 3 ' s CP, tilted Non-Compliance with Smoking, dated 10/2024, the CP indicated Resident 3 was not following smoking schedule and was keeping/hiding smoking paraphernalia such as lighters, matches and at risk for injury related to smoking and non-compliance behavior. The interventions included for staff to conduct an IDT conference with Resident 3 and for facility staff to supervise designated smoking area. c. During a review of Resident 9's AR, the AR indicated the facility admitted Resident 9 on 6/24/2019 with diagnoses that included COPD, and arthritis [the swelling and tenderness of one or more joints (places where two bones meet, such as the elbow or knee)]. During a review of Resident 9 ' s OSR, indicated on 7/11/2019, Resident 9 had a physician order that Resident 9 may smoke cigarette per preference with staff supervision in designated smoking area and in accordance with facility ' s smoking policy. During a review of Resident 9 ' s MDS, dated [DATE], the MDS indicated Resident 9 ' s cognition was intact, and Resident 9 was able to wheel the wheelchair at least 150 feet in a corridor or similar space. During a review of Resident 9 ' s S&S, dated 6/3/2024, the S&S indicated Resident 9 was a tobacco user and the CP ' s goal was for the resident to adhere to the facility ' s Tobacco/Smoking Policies. d. During a review of Resident 14's AR, the AR indicated the facility admitted Resident 14 on 1/13/2020 and readmitted on [DATE] with diagnoses that included COPD, and nicotine dependence, cigarettes. During a review of Resident 14 ' s OSR, dated on 5/30/2014, the OSR indicated Resident 14 had a physician order that Resident 14 may smoke cigarette per preference with staff supervision in designated smoking area and in accordance with facility ' s smoking policy. During a review of Resident 14 ' s MDS, dated [DATE], the MDS indicated Resident 14 ' s cognition was intact, and Resident 14 needed supervision in walking 150 feet in a corridor or similar space. During a review of Resident 14 ' s S&S, dated 8/22/2024, the S&S indicated Resident 14 was a tobacco user. The form indicated Resident 14 was unable to light tobacco safely, and Resident 14 required supervision during smoking breaks. e. During a review of Resident 18's AR, the AR indicated the facility admitted Resident 18 on 7/6/2017 and readmitted on [DATE] with diagnoses that included COPD, and nicotine dependence, cigarettes. During a review of Resident 18 ' s OSR, dated 4/7/2023, the OSR indicated Resident 18 had a physician order that Resident 18 may smoke cigarette per preference with staff supervision in designated smoking area and in accordance with facility ' s smoking policy. During a review of Resident 18 ' s MDS, dated [DATE], the MDS indicated Resident 18 ' s cognition was intact. The MDS indicated Resident 18 was a tobacco user and was able to utilize the wheelchair with supervision to wheel at east 150 feet in a corridor or similar space. During a review of Resident 18 ' s H&P, dated 4/4/2024, the H&P indicated Resident 18 had the capacity to understand and make decisions. During a review of Resident 18 ' s S&S, dated 8/14/2024, the S&S indicated Resident 18 was a tobacco user, and Resident 18 had balance problems while sitting or standing. During a review of Resident 18 ' s CP titled, Smoking, dated 8/16/2024, the CP indicated Resident 18 was at risk for hazards/injury (burns) related to smoking cigarettes. The interventions included for facility staff to provide frequent monitoring to Resident 18 during smoking times. f. During a review of Resident 56's AR, the AR indicated the facility admitted Resident 56 on 4/10/2024 with diagnoses that included nicotine dependence, cigarettes, and psychoactive substance (a drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior) abuse. During a review of Resident 56 ' s OSR, dated 4/10/2024, the OSR indicated Resident 56 had a physician order that Resident 56 may smoke cigarette per preference with staff supervision in designated smoking area and in accordance with facility ' s smoking policy. During a review of Resident 56 ' s H&P, dated 4/10/2024, the H&P indicated Resident 56 was a smoker, and had the capacity to understand and make decisions. During a review of Resident 56 ' s MDS, dated [DATE], indicated Resident 56 ' s cognition was intact. The MDS indicated Resident 56 needed supervision (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) when walking 150 feet in a corridor or similar space. During a review of Resident 56 ' s CP titled, Smoking, dated 4/10/2024, the CP indicated Resident 56 was at risk for discomfort, SOB and injury related to smoking. The interventions included for staff to frequent monitoring Resident 56 while smoking, remind Resident 56 of smoking schedule, and to wear smoking apron. During a review of Resident 56 ' s Activity Participation Notes, dated 9/23/2024, the notes indicated Resident 56 was noncompliant with Smoking Policy and Procedure. The notes indicated Resident 56 smoked whenever and wherever Resident 56 wanted, and Resident 56 continued to supply cigarettes to other residents. The notes indicated Resident 56 declined to surrender smoking paraphernalia like lighters and cigarettes. During a review of Resident 56 ' s S&S, dated 10/16/2024, the S&S indicated Resident 56 was a tobacco user and was noncompliant with smoking times. g. During a review of Resident 67's AR, the AR indicated the facility admitted Resident 67 on 4/18/2024 with diagnoses that included COPD due to drugs, and nicotine dependence, cigarettes. During a review of Resident 67 ' s H&P, dated 7/5/2024, the H&P indicated Resident 67 had a smoking history, and had the capacity to understand and make decisions. During a review of Resident 67 ' s S&S, dated 7/25/2024, the S&S indicated Resident 67 was a tobacco user. The S&S indicated Resident 67 had balance problems while sitting or standing, and required supervision during smoking. During a review of Resident 67 ' s CP titled, Smoking, dated 7/5/2024, the CP indicated Resident 67 was at risk for discomfort, SOB and injury related to smoking. The interventions included for facility staff to provide frequent monitoring, reorienting Resident 67 to the smoking area, and offering smoking apron. During a review of Resident 67 ' s IDT Care Conference notes, dated 7/30/2024, the notes indicated the IDT met with Resident 67 regarding the smoking P&P. The notes indicated Resident 67 was re-educated and the resident agreed to comply with the smoking scheduled time. The notes indicated Resident 67 was reminded that any smoking paraphernalia should be surrendered to the activity staff, including cigarettes and lighters for safekeeping. During a review of Resident 67 ' s CP titled, Noncompliance with Smoking, dated 8/1/2024, the CP indicated Resident 67 did not follow the facility ' s smoking schedule. The CP indicated Resident 67 shared/passed only one cigarette and smoked the same cigarette with other residents. The CP indicated Resident 67 was at high risk for transmitting infection. The interventions included for facility staff to supervise designated smoking area, offer smoking apron every schedule smoking time to Resident 67, and notify Resident 67 ' s Medical Doctor (MD) about Resident 67 ' s non-compliance. During a review of Resident 67 ' s Activity Participation Notes, dated 9/23/2024, the notes indicated Resident 67 was noncompliant with Smoking P&P. The notes indicated Resident 67 smoked whenever and wherever she wanted. The notes indicated Resident 67 continued to supply cigarettes to other residents and declined to surrender smoking paraphernalia like lighters and cigarettes. During a review of Resident 67 ' s MDS, dated [DATE], the MDS indicated Resident 67 ' s cognition was moderately impaired. The MDS indicated Resident 67, needed supervision in walking 150 feet in a corridor or similar space. h. During a review of Resident 136's AR, the AR, indicated the facility admitted Resident 136 on 10/1/2024 and readmitted on [DATE] with diagnoses that included lack of coordination, drug induced secondary parkinsonism (condition that manifested by tremors, muscle stiffness and slow movement), and hypertension (high blood pressure). During a review of Resident 136 ' s H&P, dated 10/2/2024, the H&P indicated Resident 136 had the capacity to understand and make decisions. During a review of Resident 136 ' s MDS, dated [DATE], the MDS indicated Resident 136 ' s cognition was moderately impaired. The MDS indicated Resident 136 needed partial assistance (helper does less than half the effort) in walking at least 10 feet in a room, corridor, or similar space. During a review of Resident 136 ' s OSR, dated 10/17/2024, the OSR indicated Resident 136 had a physician order that Resident 136 may smoke cigarette per preference with staff supervision in designated smoking area and in accordance with facility ' s smoking policy. During a review of Resident 136 ' s S&S, dated 10/17/2024, the S&S indicated Resident 136 was a tobacco user. The S&S indicated Resident 136 had balance problems while sitting or standing, and Resident 136 needed staff supervision during smoking hours. During a concurrent observation and interviews on 10/21/2024 at 10:34 AM with Residents 14 and 136 in the smoking area, Residents 14 and 136 were smoking during nonscheduled smoking time. The Smoking time/schedule sign were as follows: 8AM-9AM, 1PM-2PM, 6PM-7PM. Resident 136 stated, Resident 136 could smoke anytime he wanted. Resident 136 stated, Resident 14 gave Resident 136 cigarettes. Resident 136 stated, Resident 14 lit the cigarettes for Resident 136. Resident 14 stated, Resident 14 got the cigarettes and lighter from REC 1 at the front desk. During a concurrent observation and interview on 10/21/2024 at 10:46 AM with Resident 14, Resident 14 walked out of the facility ' s entrance door with a lit cigarette in Resident 14 ' s hand and smoked his cigarette approximately 10 feet away from the designated smoking area in the patio without any staff supervision. Resident 14 stated, he received the cigarette from REC 1. After smoking a cigarette, Resident 14 threw the cigarette butt on the ground and stamped on the lit cigarette with Resident 14 ' s right foot instead of disposing the lit cigarette in the designated smoking receptacle (container or device used to extinguish and dispose of cigarette waste). During an observation on 10/21/2024 at 11:10 AM in the smoking area, seven (7) residents including Resident 18 were smoking in the patio during nonscheduled smoking time without a staff supervising the residents. During an observation on 10/21/2024 at 12:05 PM in Resident 14 ' s room, Resident 14 was holding a full pack of cigarettes. During an observation on 10/21/2024 from 1PM to 2PM (scheduled smoking time) in the facility ' s designated smoking area, Residents 2, 9, 14, 18 and 136 were smoking without a staff supervising the residents. During an observation on 10/21/2024 at 3:09 PM (nonscheduled smoking time) in the patio, Resident 9 was smoking with no staff presented to supervise the resident. Resident 9 pointed to REC 1 and stated Resident 9 received his lit cigarette from REC 1 who was sitting at the front desk inside the facility. During a concurrent observation and interview on 10/21/2024 at 3:10 PM in the facility ' s designated smoking area with Resident 56, Resident 56 threw Resident 56 ' s cigarette butt behind the planter and took Resident 14 ' s cigarette after Resident 14 offered a lit cigarette to Resident 56. Resident 56 stated, Resident 56 had his own cigarette lighter since admission and Resident 56 kept the lighter in his pant pocket. During an observation on 10/21/2024 at 3:12 PM (nonscheduled smoking time) in the patio, Residents 2, 14, and 67 with five (5) other residents were smoking without any staff to supervise the residents. During a concurrent observation and interview on 10/21/2024 at 3:15 PM (nonscheduled smoking time) with Resident 67 and Resident 14 in the patio, Resident 67 was sitting on a wheelchair smoking with no staff supervision, Resident 67 ' s cigarette ashes dropped down on Resident 67 ' s clothes from the top part of Resident 67 ' s chest to the resident ' s waist. One blue cigarette lighter was observed on top of a napkin in Resident 67 ' s wheelchair ' s cup holder. Resident 67 stated, she usually smoked one to one and a half pack of cigarettes per day and Resident 67 could smoke anytime she wanted. Resident 67 stated, she kept a lighter within her possession since she was admitted to the facility. Resident 14 stated he used Resident 67 ' s lighter to light his cigarettes. During an interview on 10/21/2024 at 3:20PM with REC 1, REC 1 stated, the designated smoking area was right outside of the facility ' s entrance. REC 1 stated, he was assigned to give out lit cigarettes to the smokers and watched the residents smoke through the facility ' s glass door while sitting inside the facility. REC 1 pointed to a monitor on the right side of the front desk and stated, he could observe the smokers through the monitor but was not assigned to monitor the residents in the smoking area because he was assigned to do other tasks such as answer phone calls and watch the people coming in and out of the facility. REC 1 stated, REC 1 gave cigarettes to the residents whose names were on the smoking list. REC 1 stated, he was aware that Resident 3 and Resident 67 had their own cigarettes and lighters. REC 1 stated, he allowed Resident 3 and Resident 67 to keep their cigarettes and lighters because their families ' members had been supplying them with the smoking materials. During a concurrent observation and interview on 10/21/2024 at 3:43 PM with Certified Nursing Assistant (CNA) 4 in Resident 3 ' s room, there was one red lighter in the left corner of Resident 3 ' s bedside drawer. CNA 4 stated, the lighter was functional and should not be kept in Resident 3 ' s bedside drawer due to potential of fire hazard. During an interview on 10/21/2024 at 4 PM with CNA 3, CNA 3 stated no resident should keep the lighters or cigarettes. CNA 3 stated, Resident 14 and Resident 56 wanted to continuously smoke even during nonscheduled smoking time. During an interview on 10/21/2024 at 4:25 PM with the DON, the DON stated, it was the facility ' s policy not to allow residents to keep their cigarettes and lighters within their possession due to fire hazard and accidental burns. The DON stated, staff supervision during scheduled smoking time was essential to ensure the residents safely smoke their cigarettes without hurting themselves such as cigarette burn and burn from the cigarette ashes. The DON stated the facility resident ' s population included residents (unspecified) with behavior problems so staff supervision was required so that the residents would not fight or became aggressive during the smoking time. The DON stated the activity staff who was scheduled to observe and supervise in the smoking area was supposed to give out cigarettes and light the cigarettes for the residents. The DON stated, when a resident was noncompliant with the facility ' s smoking policy, she expected the previous AD (AD 1) to develop a CP and conduct an IDT meeting to address the resident ' s noncompliance. The DON stated AD 1 was no longer working for the facility since 10/10/2024 and the new hired AD (AD 2) should know how to take care of residents who were noncompliance with smoking policy. The DON stated, since AD 1 was no longer worked for the facility, no one oversaw the activity staffs to make sure the activity staffs were present during the scheduled smoking time or knew how to care for noncompliant residents. During a concurrent record review and interview on 10/21/2024 at 4:30 PM with the MDS Nurse (MDSN), Resident 56 ' s CPs including the CP tilted, Smoking, dated 4/10/2024, and Resident 56 ' s IDT records since admission on [DATE] were reviewed. The MDSN stated, Resident 56 was known to be noncompliant with the facility ' s smoking policy because Resident 56 kept Resident 56 ' s cigarettes and lighter at his bedside drawer. The MDSN stated, the MDSN could not find any documented evidence that a CP related to noncompliance with smoking policy in Resident 56 ' s medical record (chart). The MDSN stated there was no IDT meeting conducted for Resident 56. During a concurrent review and interview on 10/21/2024 at 4:35 PM with the MDSN, Resident 3 ' s CP tilted, Noncompliance with Smoking, dated 10/2024, indicated Resident 3 was noncompliant with the smoking schedule time, Resident 3 kept/hid his smoking cigarettes, lighter, matches and Resident 3 was at risk for injury related to smoking and non-compliance behavior. The MDSN stated, the interventions included to conduct IDT conference with Resident 3. The MDSN stated, per record, no IDT meeting was conducted with Resident 3 since 9/23/2024. During a concurrent record review and interview on 10/21/2024 at 4:40 PM with the MDSN, Resident 67 ' s CP titled, Noncompliance with Smoking, dated 8/1/2024, and Resident 67 ' s progress notes titled, Activity Participation Notes, dated 9/23/2024, were reviewed. The MDSN stated, per record, Resident 67 had been keeping the cigarettes/lighters in Resident 67 ' s possession. The MDSN stated Resident 67 did not follow the facility ' s smoking schedule and Resident 67 shared her cigarettes with other residents in the facility since 7/30/2024. The MDSN stated Resident 67 ' s CP titled, Noncompliance with Smoking, dated 8/1/2024, was not revised, and IDT meeting was not conducted when Resident 67 was found to be noncompliant with smoking during nonscheduled smoking time, and when Resident 67 refused to surrender her cigarette/lighter and supplied cigarettes to other residents on 9/23/2024. During an interview on 10/21/2024 at 4:45 PM with Payroll Staff (PS) 1 in the presence of the DON, PS 1 stated, the PS 1 was in charge of staffing scheduling. PS 1 stated, AD 1 ' s last working date was 10/9/2024. PS 1 stated, when AD 1 left, nobody was assigned to cover for the AD 1 ' s role. During an interview on 10/21/2024 at 4:51 PM with the DON, the DON stated, for residents (Resident 2, 9, 14, 18 and 136) who were noncompliant with their smoking policy, the facility supposed to develop a CP followed by an IDT meeting to go over the noncompliant issue and offer solutions, interventions, suggestions and discuss with the residents for the plan of care. The DON stated, when Resident 67 continued to be noncompliant on 9/23/2024, the AD 1 supposed to review and revise the CP to find out why Resident 67 continued to be noncompliant and to

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to prevent and respond to the elopement (an act of leaving a care facility or safe area independently without notifying anyone) of one of three residents (Resident 1), who had severely impaired cognition (a condition that significantly impacts a person's ability to learn, remember, think, and communicate, making it difficult or impossible for them to live independently), by failing to implement the facility's policy and procedures by: 1. Not assessing and identifying Resident 1 as at risk for unsafe wandering (aimlessly going to places) and elopement when the facility observed the resident wandering to other resident ' s room and front lobby as indicated in the facility ' s policy and procedure titled Wandering and Elopement. 2. Not providing adequate supervision to ensure Resident 1 who had fluctuating capacity to understand and make decisions, with diagnoses including, schizoaffective disorder (mental illness that can affect thoughts, mood, and behavior) , HIV (Human Immunodeficiency Virus), dysphagia (difficulty swallowing) and lack of coordination was properly assessed for risk of wandering and elopement as indicated in the facility ' s policy and procedure titled Nursing- Wandering and Elopement. 3. Not conducting a thorough investigation on how Resident 1 eloped and exited the facility to prevent other residents at risk of elopement from eloping in the exit areas as indicated in the facility ' s policy and procedure titled Accidents and Incidents- Investigating and Reporting. 4. Not developing a care plan to ensure Resident 1 received interventions, monitoring, and supervision to prevent elopement and wandering to other resident ' s rooms as indicated in the facility ' s policy and procedure titled Nursing- Wandering and Elopement. 5. The facility did not implement CODE [NAME] (a code called out in the facility ' s paging system [microphone announce a message] to alert staffs and visitors that a resident is missing or eloped) immediately when the resident was found missing as indicated in the facility ' s policy and procedure titled Use of Wander Guard(Wander Guard-a set of equipment, consisting of a watch-like device worn by a person and a door alarm that is set off once the watch-like device gets in close proximity to the door alarm; used for the purpose of preventing a person from exiting an area) and Nursing Wandering and Elopement. As a result of these failures, on 9/16/2024 at around 1:15 PM, Resident 1 was discovered to be missing, exposing Resident 1 to extreme weather, medical complications, malnutrition (lack of sufficient nutrients in the body), and death. Resident 1 missed her daily medications, including psychoactive medication (medication to manage mental disorders) and antiviral medication (medication to manage viral diseases such as HIV). Resident 1 remained missing on 9/19/2024. On 9/17/2024 at 9:20 AM, the California Department of Public Health conducted an unannounced visit to the facility to investigate Resident 1 ' s elopement. On 9/17/2024 at 7:15 PM, while onsite at the facility, the California Department of Public Health (CDPH) identified an Immediate Jeopardy situation (IJ, a situation in which the provider ' s noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death of a resident) regarding the failure to prevent and investigate how Resident 1 eloped and other residents at risk for elopement from the facility. The facility ' s Administrator (ADM) and Director of Nursing (DON) were notified of the IJ situation on 9/17/2024 at 7:15 PM. On 9/18/2024 at 12:13 PM, the Administrator (ADM) provided an acceptable IJ Removal Plan (a detailed plan to address the IJ findings). On 9/19/2024 at 5:33 PM, the IJ was removed in the presence of ADM and DON after the facility submitted an acceptable IJ Removal Plan (a plan that identifies all actions the facility will take to immediately address the noncompliance that has resulted in the IJ situation) and the surveyor verified/confirmed during onsite the facility ' s implementation of the IJ Removal Plan and the IJ situation was removed. The IJ Removal Plan Dated 9/19/2024, included the following: Immediate action(s) taken for the resident found to have been affected included: On 9/16/2024 the facility initiated an investigation, notified law enforcement, residents responsible party, primary physician and CDPH. The facility contacted hospitals in the area to inquire if they have admitted the resident. Multiple staff members searched in the nearby areas including, parks, stores, shopping centers as well as neighboring areas. The facility will continue its efforts to search for the resident on a daily basis for 3 months which would include contacting law enforcement as well as local hospitals and additionally search the local area weekly for 3 months. Identification of other residents having the potential to be affected was accomplished by: On 9/16/2024, the DON immediately initiated a review making sure that all residents are accurately reassessed, monitored, and supervised residents at risk of wandering behavior and elopement. Residents at risk for elopement are monitored and their whereabouts always accounted for and only three residents were identified in this category of which two of them have a wander guard and one of them was on a one-on-one monitoring (one staff monitoring one resident) until a wander guard can be placed on her. On 9/18/2024 sliding doors in Rooms B and C were reported to be opening to a width that a person could pass through. On 9/18/2024 The maintenance supervisor immediately made appropriate adjustments by putting a stopper making sure the door does not open to a width that a person can pass through. On 9/18/2024 the maintenance supervisor assessed the rest of the facility and made sure that there were no possible exit doors or windows that residents with risk of elopement could exit from by making sure that the alarms that are on them are working and that if they were to be opened the staff would be alerted. Based on the facilities investigation it seems that the resident exited from the main lobby doors. Actions taken/systems put into place to reduce the risk of future occurrence include: A scheduled 24 hour receptionist is in place to monitor the front doors. Additional monitoring of residents every 2 hours by the assigned nurse and reviewed by the shift charge nurse. Additional staff monitor implemented at the outside entrance of the facility from 7 am to 7pm and an alarm that cannot be easily removed without special tools will be activated at the facility's front door from 7pm to 7am. The Maintenance supervisor/ Designee will conduct daily audits making sure that they are working. On 9/16/2024 the DON/ Designee initiated in-services on: How to accurately assess residents for risk of wandering behavior and elopement How to care for residents at risk for elopement, based on the elopement assessment the plan of care will be individualized How to monitor and supervise residents for wandering behavior and elopement to identify risk factors for each resident such as cognitive impairment, history of wandering and/or elopement and conducting elopement risk assessment upon admission quarterly and as needed. Ensuring residents at risk for elopement were monitored and their whereabouts were always accounted for, and a wander guard was placed on them or other measures such as a one on one monitoring. Staff respond promptly by the following: Charge nurse should be contacted right away and immediately do the following: Page Code Green. Assign staff members to search throughout the inside of the facility premises and search in the immediate outside vicinity. Verify whether or not the resident has gone out on pass or at an appointment. And immediately contact: Law enforcement, resident ' s family members, physician and CDPH (California Department of Public Health) within 2 hours. The maintenance supervisor was in serviced by the administrator on 9/18/2024 in regard to the importance of making sure all sliding doors are only opening enough that a person can't pass through it. The maintenance supervisor/Designee will conduct daily checks for 3 months on the sliding doors, ensuring they are only opening enough that a person can't pass through it. Inservice was conducted on 9/19/2024 to all supervisors in regard to properly investigating any incidents including interviewing staff, roommates, residents' family members or any other person that might be able to provide useful information. Monitoring of the Removal Plan include: Starting the week of 9/16/2024 the DON/ Designee will conduct weekly audit logs making sure that residents are being accurately assessed for the risk of wandering behavior and elopement, residents at risk for elopement are monitored and their whereabouts always accounted for every 2 hours. The Director of Staffing Development (DSD) will conduct weekly Audits by asking random staff on how to care for residents that have been found to be at risk for elopement and that staff are responding promptly by calling out Code green per the facilities policy and procedures. The administrator will review on a daily basis from Monday through Friday for 3 months the previous days log for the additional monitoring staff. The administrator will conduct weekly checks on resident room sliding doors for 3 months making sure that they are functioning properly. The Administrator will conduct weekly checks on the door alarms for 3 months making sure that they are working properly. A Quality Assurance Program Improvement- (QAPI measures set by the facility to improve delivery of care at the facility) has been initiated in regard to ensuring that there is a system in place for residents who are at risk or maybe at risk for elopement, Elopement risk assessments, and elopement management. The administrator will conduct a weekly review of all investigations for three months making sure that incidents are being thoroughly investigated and include Interviews of staff, roommates, residents' family members or any other person that might be able to provide useful information. The results will be reviewed by the QA for further evaluation and recommendation if necessary. Findings: 1. A review of Resident 1 ' s admission Record indicated the resident was originally admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses that included lack of coordination, schizophrenia (a chronic and severe mental disorder that affects how a person thinks, feels, and behaves), anemia (a condition that develops when your blood produces a lower-than-normal amount of healthy red blood cells), and dysphagia (difficulty swallowing). A review of Resident 1 ' s History and Physical (H&P), dated 5/3/2024, indicated the resident has fluctuating capacity to understand and make decisions. The H&P also indicated Resident 1 has a diagnosis of HIV (Human immunodeficiency virus is a virus that attacks the body's immune system, specifically white blood). A review of Resident 1 ' s Minimum Data Set (MDS, a comprehensive standardized assessment and screening tool), dated 6/17/2024, indicated the resident has severe cognitive impairment. The MDS indicated Resident 1 can walk 150 with supervision (helper provides verbal cues and/or touching assistance). The MDS also indicated Resident 1 does not use any mobility devices such as a cane, walker, or wheelchair and did not exhibit wandering behavior. A review of Resident 1 ' s Change in Condition Evaluation form, dated 9/16/2024, timed at 4:07 PM, conducted with the Director of Nursing (DON), indicated on 9/16/2024 at 1PM, Certified Nursing Assistant (CNA) was doing rounds and she noticed that [Resident 1] is not in her room. She looked if the resident is in the front which she always frequented but nowhere to be found. A review of Resident 1 ' s Order Summary Report dated 9/17/2024, included the following orders: -Olanzapine (medication that affects mood and behavior) tablet 15 MG (milligrams - a unit of measurement) to give 2 tablets orally (by mouth) at bedtime for Schizophrenia [manifested by] delusions [as evidenced by] believing her food has been poisoned -Tivacay (Dolutegravir Sodium-medication used to treat HIV virus) oral tablet 50 MG to be given one tablet by mouth one time a day for HIV. A review of Resident 1 ' s Progress Notes from 6/3/2024 to 9/17/2024, indicated no documented evidence that staff implemented interventions to monitor, supervise Resident 1 with wandering behavior of going into other resident ' s room. A review of Resident 1 ' s plan of care indicated no documented evidence that the facility developed a plan of care and implemented interventions to monitor, supervise and prevent Resident 1 from wandering or eloping from the facility after the facility observed Resident 1 wander to other resident ' s room and wanders to the front lobby near the exit door that leads to a busy street. During an interview on 9/17/2024 at 11:15 AM with Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 1 usually sits in the front lobby, by the front exit. CNA 1 stated Resident 1 can walk by herself independently. CNA 1 stated the last time she saw Resident 1 was on 9/16/2024 at around 12 PM when Resident 1 was eating lunch inside of the resident ' s room. During an interview on 9/17/2024 at 11:32 AM with Receptionist (RP) 1, RP 1 stated Resident 1 was sitting by the front entrance in the lobby at around 11 AM to 11:30 AM on 9/16/2024 but did not notice Resident 1 leave the facility. During an interview on 9/17/2024 at 11:49 AM with RP 2, RP 2 stated he last saw Resident 1 sitting in the front lobby near the facility ' s entrance door at around 11 to 11:30 AM on 9/17/2024. RP 2 stated he did not see where Resident 1 went after 11:30 AM because it became busy, and visitors started coming in. During an interview on 9/17/2024 at 12:08 PM with CNA 1, CNA 1 stated she noticed Resident 1 was missing at 1:15 PM because she could not find Resident 1 in her room and the front entrance. CNA 1 stated she reported to Licensed Vocational Nurse (LVN) 1 that Resident 1 was missing at around 1:20 PM. During an interview on 9/17/2024 at 12:10 PM, with LVN 1, LVN 1 stated she knows it was the usual routine of Resident 1 to sit on the chair by the front entrance of the facility. LVN 1 stated she was notified by CNA 1 at around 1:15 PM to 1:30 P.M on 9/16/2024 that Resident 1 was missing. LVN 1 stated she informed CNA 1, CNA 2, and CNA 3 to look for Resident 1. LVN 1 stated she immediately checked the rooms, starting from rooms in her station LVN 1 stated after checking the rooms in her station ' s rooms, she checked the rooms in 2 other stations and the front lobby. LVN 1 stated when she could not find the resident, she informed the Director of Nursing (DON) at around 2PM on 9/16/2024. During an interview on 9/17/2024 at 12:12 PM, LVN 1 and CNA 1 both stated they panicked and forgot to announce the Code Green into the facility ' s paging system. LVN 1 stated announcing code green a code used to alert all facility staff that a resident is missing or has eloped. During an interview on 9/17/2024 at 1:13 PM with CNA 2, CNA 2 stated he was verbally informed by LVN 1 that Resident 1 was missing at around 1:15 PM on 9/16/2024. CNA 2 stated Resident 1 usually wanders to other resident ' s room and bathrooms, on 9/16/2024 at 1:15 PM when she looked for the resident, she did not find the resident in the facility. During an interview on 9/17/2024 at 1:27 PM with CNA 3, CNA 3 stated she was informed by LVN 1 that Resident 1 was missing at around 1:30 PM. CNA 3 stated Resident 1 walks around the facility without any help from the staff. CNA 3 stated Resident 1 goes to other residents ' rooms but when she looked for the resident on 9/1/6/2024, she did not find the resident in the facility. During an interview on 9/17/2024 at 12:28 PM with the DON, the DON stated LVN 1 reported to her that Resident 1 was missing at around 2PM. DON stated her initial response was to go out of the facility to look for the resident. The DON stated she and LVN 1 drove around the facility ' s area and came back at around 3PM but did not find Resident 1. DON stated when she came back into the facility, and she informed the Administrator (ADM) that Resident 1 was missing, and reported the resident was missing to the police department. DON stated, Code Green was never announced on the facility ' s paging system because she and the other staffs panicked. The DON stated announcing Code Green was used by the facility to help spread information to all staff that a resident has gone missing and to potentially help in preventing the resident from going out and far from the facility ' s premises. During an interview on 9/17/2024 at 1:58 PM with CNA 1, CNA 1 stated Resident 1 can walk without any need for assistance or devices. CNA 1 stated Resident 1 was not under any supervision or monitoring because she is quiet and just walks slowly. During an interview on 9/17/2024 at 1:59 PM with LVN 1, LVN 1 stated Resident 1 was not under any supervision and monitoring for wandering and elopement. LVN 1 stated Resident 1 was not one of the three residents listed in the elopement binder to be at risk for elopement in the facility. LVN 1 stated residents that are at risk for elopement are listed in the elopement binder. During an interview on 9/17/2024 at 2:52 PM with Registered Nurse (RN) 1, RN 1 stated the facility has an elopement binder labeled, Elopement Risk Residents which has a list of resident's names that are at risk for elopement. RN 1 stated residents are added into the list based on the assessment of the resident by the nurse using the Elopement Evaluation form. RN 1 stated if the resident was assessed to have any risk factor, then the resident must be added into the list. RN 1 stated a resident who was at risk for elopement must have interventions put in place to prevent an elopement such as monitoring the resident ' s whereabouts and supervision. During a concurrent interview and record review on 9/17/2024 at 3PM with RN 1, Resident 1 ' s Elopement Evaluation form, dated 6/17/2024 and 9/16/2024 were reviewed. RN 1 stated the following questions were incorrectly answered No instead of answering Yes. -Has the resident verbally expressed the desire to go home, packed belongings to go home or stayed near an exit door. -Does the resident wander. -Is the wandering behavior a pattern, goal-directed (an action taken with the specific intention of achieving a desired outcome). -Is the wandering behavior likely to affect the privacy of others. Score value or 1 or higher indicate Risk of Elopement. During a follow up interview on 9/17/2024 at 3:05 PM with RN 1, RN 1 stated the questions should have been answered yes and the score should be greater than one because Resident 1 frequently stays in the front lobby, walks around the facility, and even wanders to other residents ' rooms. RN 1 stated if the form was answered correctly, Resident 1 could have been assessed as a high risk for elopement and put on the list for residents at risk for elopement. RN 1 stated Resident 1 should have been monitored to prevent elopement. During another concurrent interview and record review on 9/17/2024 at 3:06 PM with RN 1, Resident 1 ' s Elopement Evaluation form, dated 9/16/2024, was reviewed. RN 1 stated she did identify Resident 1 as at risk for wandering and elopement because she followed the answers in the previous Elopement Evaluation form dated 6/17/2024 that indicated Resident 1 as not at risk for wandering and elopement. RN 1 stated because she evaluated the resident as not at risk for elopement, the staffs would not know that the resident was at risk for elopement. During an interview on 9/18/2024 at 10:01 AM with Director of Staff Development (DSD), DSD stated residents who wander around the facility aimlessly and have psychiatric (mental, behavioral, and emotional disorders) medical diagnosis like Resident 1 are at risk for elopement. DSD added residents with psychiatric illness like Resident 1 have tendency to go out if the doors are left open which can jeopardize the safety of the resident and other residents who have behavior of wandering if they are not monitored or supervised. During a concurrent interview and observation on 9/18/2024 at 2:14 PM with CNA 5, Room B and Room C were checked. CNA 5 stated Room B and Room C both have sliding doors that opens wide enough for a person to walk out to and leave the facility. CNA 5 stated any resident could go out of the sliding doors that leads to the back side of the building and elope. During a concurrent interview and observation on 9/18/2024 at 2:30 PM with DON, Room B and Room C were checked. DON stated Room B was next to Resident 1 ' s room and Resident 1 could have eloped through the sliding doors. DON stated there were no alarms after a resident has passed through the sliding doors that could have alerted staff that a resident was eloping. DON stated there are no locks to the gate outside the sliding doors that could prevent any resident from leaving the facility. DON stated the sliding doors of Room B and Room C were not supposed to open wide enough for a person to be able to walk out. During an interview on 9/18/2024 at 2:40 PM with Maintenance Supervisor (MS), MS stated the area outside the sliding doors of Room C and Room D do not have any alarms, sensors, or cameras that could notify staff if a resident was outside. MS stated the facility does not lock the gate outside of the sliding doors. A review of Resident 2 ' s admission Record indicated the resident was originally admitted on [DATE], readmitted on [DATE], with diagnoses that included spondylosis (abnormal wear on the cartilage [flexible tissue that lines joints] and bones of the back) and dysphagia. A review of Resident 2 ' s H&P, dated 10/25/2023, indicated Resident 2 has the capacity to understand and make decisions. A review of Resident 2 ' s MDS, dated [DATE], indicated Resident 2 had no cognitive impairment. During an interview on 9/18/2024 at 3:20 PM, Resident 2 stated Resident 1 mentioned to her that Resident 1 was anxious to go home. Resident 2 stated no one has asked her regarding Resident 1 who was missing. A review of Resident 3 ' s admission Record indicated the resident was originally admitted on [DATE], readmitted on [DATE], with diagnoses that included fibromyalgia (a chronic condition that causes widespread pain and tenderness in the muscles and soft tissues of the body) and epilepsy (a chronic brain disorder that causes recurrent seizures, which are episodes of involuntary brain activity). A review of Resident 3 ' s H&P, dated 5/6/2024, indicated Resident 3 has the capacity to understand and make decisions. A review of Resident 3 ' s MDS, dated [DATE], indicated Resident 2 has no cognitive impairment. During an interview on 9/18/2024 at 3:23 PM, Resident 3 was interviewed. Resident 3 stated no one has interviewed her regarding Resident 1. Resident 3 stated she sees the resident wander around the facility. During a concurrent interview and record review on 9/19/2024 at 9:52 AM with ADM, ADM ' s written statement and the facility ' s investigation report were reviewed. ADM stated he and the DON did not interview residents to verify if Resident 1 had wandering behavior or if the resident verbalized wanting to leave the facility during the facility ' s investigation about Resident 1 ' s elopement. ADM stated residents should have been interviewed because they can be witnesses that could provide valuable information and it is basic to interview residents. ADM stated he and DON leads the investigation to Resident 1 ' s elopement. ADM added the investigation was not thorough because no resident interviews were conducted and he does not know the possible area where Resident 1 exited from the facility on the day the resident eloped because the doors that were possible exit doors were not checked until the surveyor informed him about the sliding doors that could be opened and used as exit. During an interview on 9/19/2024 at 10:01 AM with Social Services Director (SSD), SSD stated she was not instructed to interview any residents about Resident 1 ' s elopement. SSD stated she did not interview Resident 2 and other residents regarding Resident 1 ' s elopement. During a phone interview on 9/19/2024 at 11:05 AM with Medical Doctor (MD), MD stated the facility never contacted him to provide a physician orders to prevent Resident 1 from eloping. MD stated the facility did not consider Resident 1 as at risk for elopement. During an interview on 9/19/2024 at 12:54 PM with SSD, Resident 2 was interviewed concurrently with SSD. During the interview, Resident 2 stated Resident 1 has been verbalizing of wanting to go home. During an interview on 9/19/2024 at 2:39 PM with DON, DON stated Resident 1 ' s cognitive ability was not reliable because of her medical diagnoses of schizophrenia. DON stated it was risky that Resident 1 was walking around the facility without any supervision or monitoring. DON also stated the facility should have contacted the police right away for assistance when they could not find the resident in the facility, instead of driving outside before calling the police. DON added it was her booboo or mistake on instructing staff to copy the Resident 1 ' s previous elopement evaluation onto a new elopement evaluation form. During a concurrent interview and record review on 9/19/2024 at 2:39 PM with DON, Resident 1 ' s entire medical records were reviewed. DON stated there was no care plan developed for Resident 1 to prevent the resident from elopement. DON stated there was no documented evidence that staff monitored or intervened to prevent Resident 1 from eloping. DON stated Resident 1 ' s Elopement Evaluation, dated 6/17/2024, was not answered correctly. DON stated Resident 1 should have been one of the residents in the facility ' s elopement list. DON stated she admits the facility was at fault of Resident 1 ' s elopement because of not accurately assessing and identifying Resident 1 as at risk of elopement and not implementing any interventions to prevent Resident 1 from eloping. DON stated the facility could have used a Wander guard to prevent Resident 1 from eloping. DON stated Resident 1 ' s medical condition could worsen because Resident 1 has not received the scheduled medications while out in the facility since 9/16/2024 and the resident had not been found. A review of the facility ' s Elopement Risk Residents binder conducted with the DON on 9/19/2024 at 2:39 PM did not include Resident 1 on the list. During a concurrent interview and record review on 9/19/2024 at 5:12 PM with ADM, the facility ' s policy and procedure (P&P) titled, Accidents and Incidents- Investigating and Reporting, revised 7/2017, was reviewed. ADM stated the investigation should include witnesses and their accounts of the accident or incident. ADM stated residents are witnesses that could provide valuable information to the investigation. A review of the facility ' s job description for Director of Nursing Services undated, indicated it is the DON ' s responsibility to promote a safe environment within the facility, which includes fire and accident prevention. The job description also indicated the DON assumes responsibility for investigations of alleged abuse or unusual occurrence. A review of the facility ' s P&P titled, Use of Wander guard, dated 7/23/2021, indicated when a resident is wearing a Wander guard or wristband that transmitter attempts to exit a monitored doorway, an audible alarm sounds. The P&P indicated Wander guard may be used for residents who has impaired cognition & decision-making skills yet verbalizes of wanting to leave the facility without supervision. The P&P also indicated if a resident is noted missing, the nurse will call Code [NAME] and organize a search immediately. A review or the facility ' s P&P titled, Nursing- Wandering and Elopement, released 6/2018, indicated residents who are deemed to be high risk for elopement or wandering will have a photograph maintained in their medical record. The P&P indicated the facility will develop a plan of care considering the individual risk factors of the resident. A review of the facility ' s P&P titled, Safety and Supervision of Residents, revised 7/2017, indicated the facility shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents. The P&P indicated resident supervision is a core component to safety. The P&P indicated risk factors include wandering. A review of the facility ' s P&P titled, Elopements, revised 12/2007, indicated if an employee discovers a resident is missing, he/she shall initiate an extensive search of the surrounding area. The P&P also indicated if the resident is not located in the facility ' s building(s) and premises, he/she shall notify law enforcement. A review of the facility ' s P&P titled, Wandering and Elopements, revised 3/2019, indicated the facility will identify residents who are at risk for unsafe wandering and elopement, the resident ' s care plan will include strategies and interventions to maintain resident ' s safety. The P&P also indicated if a resident is missing, initiate a search of the building(s) and premises; and if the resident is not located, notify the administrator and director of nursing services, the resident ' s legal representative, the attending physician, law enforcement officials.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure behavioral health care and services were provided for one of two sampled residents (Resident 7) who have suicidal ideations (means thinking about wanting to take own life), in accordance with the facility policy, by failing to: 1. Identify and address Resident 7's behavioral issue of verbalizing wanting to hurt himself (suicidal ideations) and prevent the resident from harming oneself. 2. Develop and implement Resident 1's care needs on 5/28/2021 when Resident 7 was identified to have suicidal ideations by Registered Nurse (RNS) 2 and prevent the resident from attempting to hang himself with a call light on 7/1/21 while residing in the facility. 3. Develop individualized interventions related to Resident 7's identified underlying issues by providing a comprehensive behavioral assessment of Resident 7's Social Service needs (an activity aiming to promote the welfare of others) that may have contributed to the resident's suicidal ideations. The Social Services Designee (SSD) did not conduct a comprehensive assessment and behavioral follow up assessments of Resident 7's behaviors that included verbalization of wanting to hurt himself due to a failed relationship, a failed attempt to hang himself using a call light cord, and suicidal ideations from 5/4/2021 to 7/29/2021. 4. To evaluate and alter the resident's environment (Resident 7's room) upon readmission back to the facility, on 7/12/2021 after the resident attempted to hang himself with a call light cord while residing in the facility on 7/1/2021. The same call light cord was observed on 7/28/2021 inside Resident 7's room at the resident's bedside. These deficient practices and failures had the potential to result in Resident 7's continued attempts of suicide and possible death, including other four residents identified with history of suicidal ideations in the facility. The Department called an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirement of participation has caused or is likely to cause serious injury, impairment, or death to a resident) situation on 7/28/2021 at 6:33 PM, in the presence of the Administrator (ADM) and Director of Nursing (DON). The ADM and DON were informed of the facility's failure to have systems in place to address Resident 7's suicidal ideations. On 7/29/2021 at 3:34 PM the survey team verified the implementation of the acceptable Plan of Action (POA, a detailed plan) through observation, interviews, and record review. The ADM and DON provided an acceptable plan of action on 7/29/2021 and the POA was accepted on 7/29/2021. On 7/29/2021 at 3:52 PM the survey team confirmed the removal of the IJ and IJ was lifted in the presence of the ADM and DON. The facility's plan of action included: 1. Resident 7 was placed on one-on-one person monitoring (continuous observation) with a certified nurse assistant, on 7/28/2021 to monitor the resident's whereabouts and to ensure his safety and well-being. Resident 7's attending psychiatrist ordered to transfer the resident to the acute hospital for further evaluation. 2. The Interdisciplinary Team (IDT; a group of health care professionals from diverse fields who work in a coordinated fashion toward a common goal for the patient) would continue to meet on a weekly basis to reassess Resident 7's concerns and psychosocial well-being and provide additional interventions as needed such as identifying possible causes of depression or suicidal thoughts, diversional activities, use knowledge of past interests and hobbies to engage, involve, and distract; reach out to friends and family members and involve in plan of care if possible; referral to pharmacist for medication regimen review as needed for psychotropic medications; referral to registered dietitian, assess environmental safety such as use for plastic utensils versus silverware for meals, replace call bell as an alternative for call light system, full-room sweep to make sure it is free from objects that may be used for self-harm. 3. When Resident 7 is readmitted back to the facility (discharged to acute hospital on 7/29/2021), the facility's Behavioral Management Committee, which included the Quality Assurance Nurse, the Social Services Director, Activity Director, and Psychiatrist would review acute hospital's history and physical and progress notes, would assess Resident 7 utilizing the trauma informed assessment, and conduct interview to evaluate for psychosocial needs. Hourly Behavioral Monitoring Form will be initiated for 72 hours and licensed nurses would also monitor resident for any changes every shift for 14 days. Any changes in behavior in relation to suicidal ideation such as verbalization of depression, tearfulness and/or crying would be promptly reported to resident's attending psychiatrist and/or physician and/or psychologist for further orders and/or interventions for evaluation. 4. On 7/29/2021, the Clinical Resource Consultant conducted an in-service to the members of the Behavioral Management Committee regarding their role in reviewing the resident's acute hospital's history and physical and progress notes, assessing the resident utilizing the trauma informed assessments, and conduct interview to evaluate for psychosocial needs. 5. Person-Centered Care Plan (formal process that includes correctly identifying existing needs, as well as recognizing potential needs) was initiated on 7/28/21 for Resident 7 to reflect plan of care such as provision of 1:1 CNA, plastic utensils versus silverware for meals, call lights in the room where Resident 7 was located were removed on 7/28/2021 and replaced with a call bell as an alternative for call light system. Registered Nurse made a full room sweep to make sure it was free from objects that may be used for self-harm. Licensed nurses would observe resident's behavior upon admission, utilize facility's non-pharmacologic interventions if note, & focus on verbalization of suicidal ideation, suicide threats, and suicide attempts. 6. Social Services on 7/28/2021 initiated a re-visit for Resident 7 to address psychosocial support. The Social Service Director and Social Service Designee will provide psychosocial support daily. In-service was provided on 7/29/2021 by the Administrator and DON to the Social Services Director (SSD) and Designee regarding assessing resident's needs for psychosocial support and providing visits daily to reassess the resident. 7. On 7/28/21, licensed nurses were provided in-service education by the Director of Staff Development consultant on identification of residents with potential suicidal ideation and provision of interventions for resident safety. In-services will be completed by facility's Director of Staff Development by 8/4/2021. 8. Current residents of the facility identified by the licensed nurses who have history of suicidal ideation were reassessed by the licensed nurses on 7/28/2021. Per licensed nurses' assessment, four (4) of the identified residents have not had any of the following episodes as outlined in the residents' Suicide Risk Care Plan. 9. In-service was provided to Social Services Director and Social Services Designee today 7/29/2021 by the Administrator and Director of nursing regarding assessing resident's needs upon admission and identification of suicidal thoughts/ideation or depressive symptoms for psychosocial support and providing visits daily for 72 hours and as needed thereafter per Interdisciplinary Team and Licensed Nurses re-evaluation of the residents. Findings: A review of Resident 7's Face Sheet indicated the facility admitted the resident on 10/01/2020 with diagnoses that included schizophrenia (a mental disorder that affects person's ability to think, feel, and behave clearly), dementia (loss of cognitive functioning - thinking, remembering, and reasoning that interferes with a person's daily life and activities), metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood) and recurrent depressive disorder (a mental disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). A review of Resident 7's Minimum Data Set (MDS, a standardized assessment and screening tool) dated 4/27/2021, indicated the resident had moderately impaired cognition (mental abilities such as memory and thinking skills). The MDS indicated resident needed supervision (provide resident oversight help) with bed mobility, transfer, walking, dressing, eating, personal hygiene, and toilet use. A review of Resident 20's History and Physical dated 5/13/2021, indicated Resident 20 had the capacity to understand and make decisions. A review of Resident 7's Social Services (SS) note dated 5/4/2021 indicated Resident 7 expressed his love for Housekeeping Staff (HK) 1, and stated HK 1 told the resident she misses him, and that resident wants to further the relationship and resident proposed to marry HK 1. The progress note indicated that SSD informed Resident 7 that facility does not allow anybody from facility staff to have inappropriate relationship with any of the residents. The SS note did not include a comprehensive assessment or psychosocial support offered to Resident 7 regarding the alleged (claimed) relationship between the resident and HK 1. A review of Resident 7's Social Services (SS) note dated 5/7/2021, indicated the facility's IDT discussed the alleged relationship with HK 1. The SS note indicated the allegation was denied by HK 1. A review of Resident 7's IDT Care Conference dated 5/26/2021 was conducted and attended by Registered Nurse (RNS) 1, RNS 2, SSD, and Activity Staff (AS) 3 about the alleged relationship between HK 1 and Resident 7. A review of Resident 7's care plan titled Alteration in Behavior dated 5/26/2021, indicated behaviors manifested by the resident included: Behavior #1 - thinking that Resident 7 had a romantic relationship with housekeeping staff (HK 1). Behavior #2 - Resident 7 thought that they break up [sic] and wanting to hurt himself. Behavior #3 - Negative statements. The care plan indicated interventions that included to observe and document the behavior every shift and report any changes to the physician. A review of Resident 7's Medication Administration Records (MAR) for July 2021, indicated the following behaviors were monitored: a. On 10/1/2020, for depression manifested by persistent verbalization of sadness every shift and tally. b. On 10/1/2020, for episode of depression manifested by persistent feeling of hopelessness every shift and tally. c. On 7/12/2021, for episode of schizophrenia (mental illness affects person's thinking, feelings, and behavior) manifested by delusion every shift. A review of Resident 7's IDT Care Conference dated 5/28/2021, attended by the Social Services Assistant (SSA), SSD, and the Director of Nurses (DON) indicated the IDT discussed the allegation between HK 1 and Resident 7. The IDT did not indicate a discussion about Resident 7's suicidal ideations and verbalization. A review of Resident 7's Progress notes dated 5/28/2021 and authored by RNS 2, indicated Resident 7 was upset of the recent IDT meeting (5/28/2021) with the DON and SSD. The progress note indicated Resident 7 verbalized to the IDT staff that it is, Better to hang myself and. I wish I will [sic] just drop dead, but you know that wish does not always come true. The progress note indicated Resident 7 was notified of Psychiatrist 1's order to transfer Resident 7 to the acute hospital due to verbalization of suicidal thoughts. The progress note indicated Resident 7 refused to be transferred to the acute hospital. A review of Resident 7's SS Notes dated 7/1/2021 indicated the IDT members went to Resident 7's room to meet with the resident, but the resident responded, I am not feeling talking today [sic] to their visit. A review of Resident 7's SS Notes dated 7/1/2021, indicated Social Services Director (SSD) spoke with Psychologist 1. The SS note indicated that Psychologist 1 reported to the SSD that Resident 7 was a danger to himself due to Resident 7's roommate (Resident 20) stated that Resident 7 showed him the call light cord wrapped around his neck and planned to hang himself through the curtain rod or the water sprinkler if Resident 7 had the opportunity. A review of Resident 7's Situation, Background, Assessment, and Recommendation (SBAR) form dated 7/1/2021, indicated Resident 20 reported to a psychologist (Psychologist 1) that his roommate, Resident 7, wrapped the call light cord around his neck looking for a sprinkler and curtain rod to hang himself. The SBAR note indicated Resident 7 denied the allegation, stating Resident 7 was, Just teasing Resident 20. The report indicated the facility's IDT placed Resident 7 on one-on-one monitoring for suicidal ideation (on 7/1/2021). The SBAR note indicated Psychiatrist 1 was notified and ordered a 5150 hold (allows a qualified officer or clinician to involuntarily [against their will] confine a person who is deemed to have a mental disorder that makes him or her a danger to themselves or others) for Resident 7. A review of Resident 7's MD 1 Individual Psychotherapy Progress Notes dated 7/1/2021, indicated Resident 20 reported to Psychologist 1 that he had seen the Resident 7 wrap his call light cord around his neck. The progress note indicated Resident 7's risk factors as suicidal ideation and Psychologist 1 informed the facility staff of Resident 7's suicide attempt, on 7/1/2021. The progress note indicated that Resident 7 claimed the incident never happened, and Resident 20 was lying. A review of Resident 7's Nurses Notes dated 7/1/2021 to 7/2/2021, indicated the following information: a. At 7:21 PM, on 7/1/2021, Resident 7 continued to be on one-on-one monitoring for suicidal ideations. The note indicated, no episodes noted of resident trying to wrap the call light cord around the neck. b. At 7:23 PM, on 7/1/2021, indicated that Psychiatrist 1 ordered a 5150 hold to Resident 7, due to danger to self for suicidal ideation. c. At 5:30 AM, on 7/2/2021, the nurses' note indicated Resident 7 continued to be on one-on-one monitoring for suicidal ideation and frequent visual checks were conducted for safety. d. At 11:37 PM, on 7/2/2021, the nurses' note indicated Resident 7 was transported via ambulance to the general acute care hospital (GACH) 1 for further psychiatric evaluation and treatment. A review of Resident 7's GACH 1 Mental Health Unit Crisis Team Evaluation form dated 7/2/2021, indicated Resident 7 met the criteria for 5150 due to suicidal ideation and active suicidal plan. The form indicated, Patient is experiencing depressive symptoms which are triggering suicidal ideation. A review of Resident 7's GACH 1 ED (Emergency Department) Physician Note dated 7/2/2021 timed at 9:04 PM, indicated Resident 7 was sent to GACH 1 for medical evaluation. The ED note indicated that Resident 7 was brought by the paramedics from the facility where resident tried to hang himself. The ED note further indicated Resident 7 now says that he did not try to hang himself and he is not suicidal, he apparently was making an attempt to hang himself in his bed in the emergency department [sic]. The ED note indicated Resident 7's diagnostic primary impression was Suicide attempt. The ED note indicated the plan for Resident 7 was to be admitted to the Psychiatric Unit. A review of Resident 7's Face Sheet indicated the facility readmitted back Resident 7 to the facility from GACH 1, on 7/12/2021 with diagnoses of schizophrenia, dementia, and recurrent depressive disorder. Resident 7's Psychosocial Evaluation was conducted by SSD on 7/14/2021 at 12:32 PM. The psychosocial evaluation did not indicate an assessment or information about Resident 7's psychosocial/behavioral needs due to depression manifested by wanting to hurt himself or suicidal ideations. During an interview on 7/28/2021 at 9:29 AM, Resident 7 was asked if he had any suicidal thoughts. Resident 7 stated, Not today, but they never completely go away. Resident 7 was asked if he had any current plan to commit suicide. Resident 7 stated, It happened recently three weeks ago .I am not thinking of killing my self today . It is woman problem. I am okay now. I don't know if that thoughts really go away. Resident 7 stated, The psychiatric hospital did not help me with my suicidal thoughts and the facility does not know that I tried. Resident 7 stated he was in his room during that time and was getting up into the nightstand. Resident 7 stated, I was standing, and I was pretty close. It happened a month ago and my roommate knew. During an interview and record review of Resident 7's progress notes and care plans from 5/1/2021 to 7/28/2021, on 7/28/2021 with RNS 2 at 10:45 AM, RNS 2 stated that on 5/28/2021, Resident 7 verbalized to the IDT staff that it was better to hang himself. RNS 2 stated that Resident 7 had an IDT meeting with the Administrator, DON, and SSD on 5/28/2021, but could not find documented evidence that the IDT care conferences (5/26/2021 and 5/28/2021), discussed Resident 7's suicidal ideations. RNS 2 stated she took Resident 7's verbalization of suicidal thoughts seriously and notified Psychiatrist 1 of Resident 7's verbalization of suicidal ideations, on 5/28/2021. RNS 2 further stated upon record review, she could not find documented evidence that Resident 7's behavior monitoring of wanting to hurt/harm himself were implemented as indicated in the 5/26/2021 care plan. RNS 2 stated there was no one-on-one staff monitoring implemented, after Resident 7 made RNS 2 aware of his suicidal thoughts on 5/28/2021. RNS 2 stated she should have developed an individualized care plan for Resident 7, on 5/28/2021 that was specific to Resident 7's suicidal thoughts and ideations so the facility staff could monitor the behaviors. RNS 2 stated she should have recommended and asked Psychiatrist 1 for facility staff to conduct a one-on-one monitoring on Resident 7 on 5/28/2021. During an interview on 7/28/2021 at 10:45 AM, RNS 2 stated Resident 7 was sent to GACH 1 for psychiatric evaluation on 7/2/2021. RNS 2 stated that Resident 7's roommate (Resident 20) saw Resident 7 with the call light cord wrapped around his neck (on 7/1/2021). RNS 2 stated that Resident 7 expressed to Resident 20 that if he had the opportunity to hang himself, he would hang himself. RNS 2 stated that no one in the facility knew that Resident 7 had suicidal thoughts but a history of depression. RNS 2 stated the incident (suicide attempt) occurred on 7/1/2021. During an interview on 7/28/2021 at 10:45 AM, RNS 2 stated depression care plans were developed and Resident 7's behavior was monitored for depression but there was no suicidal monitoring implemented or documented upon readmission back to the facility, on 7/12/2021. During the same interview and record review with RNS 2, on 7/28/2021 at 10:45 AM, RNS 2 further stated Resident 7's progress notes, IDT notes, and care plans from 7/12/2021, when Resident 7 was readmitted back to the facility, did not have documented evidence that the facility's IDT conducted care conferences to discuss Resident 7's behavioral healthcare needs due to suicidal ideations and develop appropriate person-centered care plans to ensure Resident 7's safety after being readmitted back from the acute hospital. RNS 2 stated that after Resident 7 came back from the acute hospital on 7/12/2021, Resident 7 seemed happy. RNS 2 stated the facility staff monitored Resident 7, but not particular for suicidal [sic]. During same interview, and record review with RNS 2, on 7/28/2021 at 10:45 AM, RNS 2 stated there were no documented evidence from Resident 7's progress notes, IDT notes, and care plans, how the facility staff monitored Resident 7's whereabouts and safety while in the facility. RNS 2 stated she could not find documented evidence that Resident 7 suicidal thoughts/ideations were monitored by facility staff upon readmission on [DATE] until the present day. RNS 2 stated Resident 7 should have an individualized care needs developed and implemented for the history of attempted suicide on 7/1/2021 and resident's suicidal thoughts/ideations that includes goals and interventions to protect and prevent the resident from harm. During another interview on 7/28/2021 at 3:55 PM, RNS 2 stated that in every readmission the facility staff must develop new individualized care plans (formal process that includes correctly identifying existing needs, as well as recognizing potential needs) for the residents. RNS 2 stated the facility provided monitoring for Resident 7 upon readmission on [DATE] for 72 hours. RNS 2 stated the facility staff provides 72-hour monitoring for all residents' readmissions, regardless if the resident had suicidal ideations. RNS 2 stated the facility staff should have monitored for Resident 7's whereabouts and behavior of suicidal thoughts and check on the resident every two hours upon readmission on [DATE]. RNS 2 stated upon readmission of Resident 7 the licensed nurse should have asked questions for suicidal ideations such as if the resident was having thoughts of hurting himself, how resident was feeling, and if resident was feeling safe. RNS 2 stated that if Resident 7 verbalized suicidal ideations, the facility staff would conduct a one-on-one monitoring, call the attending physician, and develop a care plan. During a concurrent interview and record review of Resident 7's Social Services Notes and Evaluations from 5/1/2021 to 7/28/2021, on 7/28/2021 at 3:55 PM, SSD was asked about his role and the social services department's responsibilities when a resident had suicidal ideations. The SSD stated he would refer the resident immediately for a psychological and psychiatric evaluation. The SSD stated that the SSD role is to prevent the resident from harming himself by talking to the resident, encouraging the resident to express feelings, and ask the specific underlying concerns about his suicidal ideations. The SSD stated that he should document after each discussion/meeting with the resident. The SSD stated he could not find documented evidences from the SS notes and evaluations that the social services department (SSD or SSA) had fulfilled its roles and responsibilities in meeting the behavioral healthcare needs of Resident 7 due to history of suicidal attempt and ideations of Resident 7 from 5/4/2021 to 7/28/2021. The SSD stated he did not include, and touch based on Resident 7's suicidal thoughts when he conducted his psychosocial evaluation on the resident on 7/14/2021, two days after readmission to the facility (7/12/21). The SSD stated he did not develop a comprehensive care plan for Resident 7's behavioral healthcare needs to address any underlying issues related to a recent history of suicidal thoughts/ideations or Resident 7 wanting to hurt himself to ensure the resident's safety. During an interview on 7/28/2021 at 5:33 PM, Resident 20 stated Resident 7 called him over his bed and saw that Resident 7 had the call light cord wrapped around his neck. Resident 20 was unable to recall the exact date and stated it happened a few weeks ago. Resident 20 stated Resident 7 told him that he planned on hanging it around the curtain's rod and Resident 20 stated he told Resident 7 that the curtain rod would not hold his weight. Resident 20 stated that Resident 7 had been verbalizing hurting himself since they became roommates for two and half months. Resident 20 further stated I saw Resident 7 in his bed that day and the call light cord was wrapped around his neck. Resident 20 stated that Resident 7 wanted to kill himself because he was in love with a woman and the woman did not share the same feelings. During a concurrent observation and interview on 7/28/2021 at 5:40 PM, inside Resident 7's room, in the presence of Maintenance Staff (MS) 1, a long call light cord and overhead light cord still hanged by Resident 7's wall. MS 1 stated this was the same room Resident 7 had prior to the readmission, on 7/12/2021. MS 1 measured the length of Resident 7's call light cord and stated the call light cord was seven feet long. MS 1 stated the overhead light cord above the Resident 7's bed measured four feet and seven inches long. During another interview with Resident 7 on 7/28/2021 at 5:47 PM, Resident 7 stated his attempted suicide (7/1/2021) happened a few weeks ago (unable to state exact date) and Occupational Therapist Assistant (OTA) 1 caught him inside his room when he was in the middle of wrapping the call light cord around his neck. Resident 7 stated that he was getting ready to hang himself with the call light cord while standing on top of the dresser, when OTA 1 walked into his room. Resident 7 stated he dropped the cord to the other side of the curtain when OTA 1 walked into his room. Resident 7 stated OTA 1 saw him standing on top of the dresser, but OTA 1 did not see Resident 7 holding the call light cord. During the same interview, on 7/28/2021 at 5:47 PM, Resident 7 was asked if the facility staff had asked him about his suicidal thoughts, and Resident 7 stated Nobody ever believed me to begin with, they (facility staff) told me that I act like I am too smart to do that. Resident 7 stated that he had told facility staff for several weeks before that day (7/1/2021) when he was caught with the call light cord wrapped around his neck. Resident 7 refused to disclose who were the other facility staff he had verbalized his suicidal ideations. Resident 7 added I learned by going psych world you don't tell anyone anything anymore. A review of a Physician's Telephone Order dated 7/28/2021 timed at 10:30 PM, indicated an order to transfer Resident 7 via 5150 hold to GACH 2 due to danger to self. A review of GACH 2's Mental Health Unit Crisis Team Evaluation Form dated 7/28/2021 timed at 10:31 PM, indicated Resident 7 was placed on 5150 hold and met criteria for suicidal ideation and being a danger to self. A review of GACH 2's Psychiatric 1's Consultation note dated 7/29/2021, indicated Resident 7 reported to Psychiatrist 1 that he was depressed, and suicidality would always be there. Psychiatrist 1's note indicated Resident 7 had a depressed mood with depressed affect, positive suicidal ideation, and positive for delusion of persecution (falsely believing that someone or others are going to harm or are already harming the person). The note indicated Resident 7 verbalized that he would always be suicidal but no specific plan how Resident 7 was going to harm himself. During a telephone interview on 7/29/2021 at 2:08 PM, OTA 1 stated that she worked with Resident 7 a few months ago in March and April 2021. OTA 1 stated on 5/28/2021 she found Resident 7 standing on the bed putting up a poster on the window. OTA 1 stated she told Resident 7 to get down. OTA 1 stated she did not see Resident 7 on top of the dresser and messing with call light cord. OTA 1 stated on the same time, that day (5/28/2021) Resident 20 informed OTA 1 that Resident 7 tried to hurt himself. OTA 1 stated she notified RNS 2. A review of the facility's undated job description for the Director of Social Services indicated the SSD would develop preliminary and comprehensive assessments of the social service needs of each resident and develop plans of care that identifies the problems/needs of the resident and the goals to be accomplished for each problem/need identified. A review of the facility's policy and procedure titled Behavioral Assessment, Intervention, and Monitoring Policy and Procedure revised on March 2019 indicated the following information: a. The facility would provide, and residents would receive behavioral health services as needed to attain or maintain the highest practical physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care. b. New onset or changes in behavior will be documented regardless of the degree of risk to the resident or others. c. The IDT would thoroughly evaluate new or changing behavioral symptoms in order to identify underlying causes and address any modifiable factors that may have contributed to the resident's change in condition. d. The interdisciplinary team will evaluate behavioral symptoms in residents to determine the degree of severity, distress, and potential safety risk to the resident, and develop a plan of care accordingly. Safety strategies would be implemented immediately if necessary, to protect the resident and others from harm. e. The care plan will be consistent incorporate findings from the comprehensive assessment and be consistent with current standards of practice. A review of the facility's policy and procedure titled Suicide Threats revised on December 2007 indicated the following information: a. Resident's suicide threats shall be taken seriously and addressed appropriately. b. Staff shall report any resident threats of suicide immediately to the Nurse Supervisor/Charge Nurse. c. The Nurse Supervisor/Charge Nurse shall immediately assess the situation and notify the Charge Nurse/Supervisor and/or Director of Nursing Services of such threats. d. If the resident remains in the facility, staff will monitor the resident's mood and behavior and update care plan accordingly, until a physician had determined that a risk of suicide does not appear to be present. e. Staff shall document details of the situation objectively in the resident's medical record.