**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) who had severe cognitive impairment, was safely discharged when the facility failed to: 1. Ensure an Interdisciplinary Meeting ([IDT] gathering where healthcare professionals from different disciplines collaborate to discuss a patient's care, develop shared understandings, and coordinate treatment plans) for discharge planning was conducted for Resident 1. 2. Ensure Resident 1 ' s discharge location (house) could meet the resident ' s needs. 3. Follow up with Resident 1 after his discharge from the facility to the house, to ensure Resident 1 was safe and comfortably settled. 4. Ensure Resident 1 had a designated individual to safely administered his medications including Risperdal (medication to treat mental health conditions) and gabapentin (medication to treat nerve pain). 5. To contact the Local Contact Agency (a state-designated entity that provides options counseling to individuals in long-term care facilities interested in exploring community-based services and supports) to notify of Resident 1 ' s discharge. 6. Implement its Policies and Procedures (P&P) titled, Transfer or Discharge, Facility-Initiated, which indicated facility-initiated transfers and discharges, must meet specific criteria, and require resident/representative notification, orientation, and documentation. These deficient practices resulted in Resident 1 being discharged to a house in which her needs could not be met, and the resident was placed at risk for falls, injuries, and worsening medical and psychiatric conditions. On 4/7/2025, Resident 1 became unconscious and was transferred to a General Acute Care Hospital (GACH) for evaluation and treatment. On 4/9/2025 at 3:54 p.m., an Immediate Jeopardy ([IJ] a situation in which the facility's noncompliance with one or more requirements of participation had caused, or is likely to cause serious injury, harm, impairment, or death to a resident) was called in the presence of the AssistantAdministrator (AADM) and Director of Nursing (DON) due to the facility ' s failure to ensure Resident 1 who had severe cognitive impairment, was safely discharged . On 4/11/2025 at 3:39 p.m., the facility submitted an acceptable IJ Removal Plan ([IJRP] a plan with interventions to correct the deficient practice). After validating the IJRP ' s implementation onsite, the IJ was removed on 4/11/2025 at 4:01 p.m. in the presence of Administrator (ADM), AADM, DON, Quality Assurance (QA), and Quality Assurance Consultant (QAC) The IJRP included the following immediate actions: 1. On 4/7/2025, the DON contacted staff member at the property (house) regarding Resident l's discharge location and verified the correct address and contact information. 2. The facility DON and Registered Nurse (RN) supervisor provided in-service to all licensed nurses regarding resident assessment prior to discharge to ensure residents with impaired cognition and inability to make decision to ensure that the receiving facility is safe and appropriate to provide the needed care to the resident after being discharged from the facility. 3. The DON provided in-service to licensed nurses regarding medication safety for discharges. The licensed nurse who assists with discharge will provide detailed instructions to include but not limited to: a. Medication administration, including medication name, dosage, frequency and route, quantity of each medication provided to the resident/responsible party, to ensure sufficient quantity of medications will be provided upon discharge. b. Home health (a healthcare provider that provides medical services to patients in their homes) follow-up to ensure medication compliance after being discharged . 4. The DON provided one-to-one in-service to the social service personnel and emphasized the following: a. 24 hours prior to discharge, the social service will verify the receiving facility/home to ensure accurate address, contact information and a valid license as indicated. b. Within 72 hours after discharge, the social service will contact the resident/responsible party/receiving facility/home health to ensure the resident is well settled-in at the new environment after the discharge. 5. On 4/9/2025, the ADM and the DON notified all licensed nurses and the Social Service personnel of the findings outlined in the IJ template dated 4/9/2025 and conducted in-services regarding the Transfer/Discharge policy, which included the following key components: Conduct a Discharge IDT meeting and develop a discharge care plan after admission to the facility, and then quarterly and as needed to assist the resident in discharge planning and to ensure all discharges are appropriate and safe. 6. The DON provided in-service to licensed nurses and social service personnel regarding measures to ensure residents are discharge to a location that can meet the resident's individual needs. The measures include but not limited to: a. Develop and implement discharge care plan for all residents after admission, and then quarterly and as needed. b. Conducting assessments prior to discharge. c. Verifying the receiving facility/home health to ensure accurate information. d. Following up with resident/responsible party/receiving facility after discharge to ensure the discharge location can meet the resident's needs. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses of dementia (progressive decline in cognitive abilities, such as memory, thinking, and problem-solving,) traumatic fracture (a break in a bone caused by a forceful impact or injury, like a fall or car accident), and schizophrenia (chronic mental health condition characterized by disruptions in thought processes, perceptions, emotions, and behavior.) During a review of Resident 1 ' s Care Plan titled Falls/Injury because of behavioral problems, dementia, and impaired cognition dated 5/8/2022, the care plan indicated to provide 1:1 (one-on-one patient care, where a healthcare professional provides constant attention to a single patient) every shift as ordered due to poor safety awareness. During a review of Resident 1 ' s Minimum Data Set ([MDS], a resident assessment tool), dated 1/29/2024, the MDS indicated Resident 1 was sometimes able to understand and be understood by others. The MDS indicated Resident 1 required supervision for eating, and upper body dressing. The MDS indicated Resident 1 required moderate assistance (helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with oral hygiene, toileting hygiene, showering/bathing, lower body dressing, putting on/taking off footwear and personal hygiene. The MDS indicated Resident 1 required supervision with rolling left to right, sit to lying, lying to sitting on side of bed, chair/bed-to-chair transfer, tub/shower transfer, and walking 10, 50 and 150 feet. The MDS indicated Resident 1 required moderate assistance to sit, stand and for toilet transfer. The MDS indicated Resident 1 required a mechanically altered diet (change in texture of food or liquids e.g. pureed food, thickened liquids.) The MDS indicated Resident 1 was on antipsychotic (medications used to treat mental health conditions characterized by psychosis [mental health condition characterized by a loss of touch with reality], such as schizophrenia and bipolar [mental health condition characterized by extreme mood swings between periods of high energy, elevated mood, and low mood, loss of interest, and fatigue] disorder) medications. During a review of Resident 1 ' s Order Details dated 1/22/2025, the order indicated Risperidone (drug used to treat certain mental disorders, such as schizophrenia and bipolar disease) 3 milligrams ([mg] unit of measurement), give 1 tablet by mouth at bedtime, for schizophrenia. During a review of Resident 1 ' s Order Details dated 2/21/2025, the order details indicated Gabapentin (medication for seizures or nerve pain) oral capsule 300 mg by mouth, two times a day for neuropathy (condition where nerves are damaged or malfunctioning), hold for drowsiness. During a review of Resident 1 ' s Multidisciplinary Progress Record dated 2/26/2025, the record indicated Resident 1 remained disorganized, delusional with positive agitation. During a review of Resident 1 ' s Order Details dated 3/14/2025, the order details indicated may discharge Resident 1 to an Assisted Living Facility. During a review of Resident 1 ' s Los Angeles Fire Department (LAFD) Patient Care Report dated 4/7/2025 at 6:29 p.m., the LAFD report indicated Resident 1 was unconscious, and her mental status was deteriorating (to become worse in condition). The LAFD report indicated a private ambulance was called but upon arriving to the house, 911 had been called due to Resident 1 ' s altered level of consciousness. The LAFD report indicated Resident 1 was not alert and oriented and her vital signs were normal. During a review of Resident 1 ' s GACH records titled emergency room (ER) template dated 4/8/2025 at 8:20 a.m., the report indicated, Resident 1 was brought for altered mental status. The report indicated Resident 1 was non-verbal and did not follow commands or open her eyes and move to pain. During a review of Resident 1 ' s GACH records titled Resident Family Medicine History and Physical (H&P) dated 4/8/2025 at 2:39 p.m., the record indicated Resident 1 was stuporous (confused and slow to react ) with a Glasgow Coma Scale ([GCS] tool used to assess a patient's level of consciousness after a brain injury or other neurological issue) 10 (score of 10 suggests the person is drowsy, reduced alertness or consciousness, but may still be able to open their eyes and respond to painful stimuli). The H&P indicated Resident 1 was non-verbal and not following commands. Resident 1 was able to open her eyes and move to pain. The H&P indicated Resident 1 ' s laboratory (lab) results indicated the resident had a urinary tract infection ([UTI] bacterial infection that affects any part of the urinary system,). The report indicated Resident 1 was started on empiric (used when the cause of an illness is uncertain) antibiotics (medications that kill or stop the growth of bacteria). During an interview on 4/8/2025 at 8:26 a.m., with Resident 1 ' s Family Member (FM 1), FM 1 stated the facility called him on 3/14/2024 to inform him Resident 1 was being transferred to another facility because Resident 1 no longer needed the services at facility. FM 1 stated the facility gave him the name and address of the new facility (house)but when he attempted to google the address, he could not find it. FM 1 stated he then attempted to find the name of the facility (house) provided to him and he could not find it either. FM 1stated he called the Skilled Nursing Facility ([SNF] long-term care facility that provides specialized nursing care and rehabilitation services to individuals who need medical or nursing care, or rehabilitation services due to injury, disability, or illness), but the facility told him Resident 1 was no longer under their care and they were no longer responsible for the resident. FM 1 stated Resident 1 did not have a cell phone and was unable to use one because the resident had dementia. During an interview on 4/8/2025 at 8:49 a.m., with the Ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities), the Ombudsman stated she had received a complaint from FM 1 stating he could not locate Resident 1. The Ombudsman stated FM 1 called the facility, but the facility was not responding. The Ombudsman stated she had not received a discharge notification for Resident 1. During an interview on 4/8/2025 at 10:48 a.m., with Certified Nurse Assistant (CNA 1), CNA 1 stated Resident 1 had a sitter because she was confused and would try to get out of bed without assistance. CNA 1 stated Resident 1 was at high risk for falling which was the reason the facility had to keep a close eye on her. During a concurrent interview and record review on 4/8/2025 at 11:00 a.m., with Licensed Vocational Nurse (LVN 1), Resident 1 ' s Social Services (SS) Note dated 3/14/2025 at 2:41 p.m., was reviewed. LVN 1 stated the note indicated Resident 1 was accepted at an assisted living facility. LVN 1 attempted to look up the address provided in the SS note through a google search but could not find the listed address. LVN 1 stated she did not know the location of the assisted living facility. LVN 1 stated FM 1 called to inquire about the where abouts of Resident 1, but the facility did not have the information. LVN 1 stated there were no IDT notes, or discharge care plans noted in Resident 1 ' s medical record. During a concurrent interview and record review on 4/8/2025 at 12:17 p.m., with the SS, Resident 1 ' s Social Services IDT Resident Discharge Planning dated 10/30/2024 at 9:26 a.m., was reviewed. The SS stated the record indicated Resident 1 was in the facility without a discharge potential (the likelihood to be discharged ). The SS stated the record indicated Resident 1 preferred not to return to the community. The SS stated Resident 1 required a dementia unit, and she (the SS) had not conducted an IDT meeting regarding sending Resident 1 to a house, or assisted living facility. The SS stated the facility ' s marketer initiated Resident 1 ' s transfer and the discharge location was not a dementia unit. The SS stated she received an incorrect address from the marketer, which she provided to FM 1 on 3/14/2025. The SS stated the facility ' s process was to conduct an IDT meeting on admission, quarterly, and as needed to identify the needs and goals for a resident and create a care plan with interventions that would assist the staff to achieve each resident ' s goals. The SS stated she did not conduct an IDT meeting for Resident 1 discharge on [DATE]. The SS stated she did not notify the Local Contact Agency (not known), or Ombudsman and she did not follow up to ensure Resident 1 was comfortably settled after discharge. The SS stated it was important to inform the Ombudsman because the Ombudsman was the resident ' s advocate and could follow up on Resident 1 ' s concerns if there were any. The SS stated the facility met Resident 1 ' s needs and she did not know why the resident was discharge to a house, where his needs could not be met. The SS stated Resident 1 or FM 1 and 2 were not involved in selecting the new location because the marketer found it (the house). The SS stated on 3/14/2025, she informed Resident 1, of the transfer but she was not sure Resident 1 understood. The SS stated with transfers or discharges, the facility was supposed to provide discharge documents to the new (receiving) facility, where Resident 1 was discharged , but no one answered her calls, so she did not provide any discharge documents or information about Resident 1 to the discharge location. The SS also stated that she never followed up to ensure Resident 1 was comfortably settled after discharge. During an interview on 4/8/2025 at 1:33 p.m., with FM 2, FM 2 stated when he visited the house on 4/7/2025 (time unknown), he noticed Resident 1 looked pale (when the skin appears whiter than usual, often due to illness or fear), like she had lost weight, and the resident could not even talk. FM 2 stated he asked the Landlord (owner of the house) to call 911 for Resident 1 to be transferred to a GACH for evaluation and treatment. During an interview on 4/9/2025 at 10:08 a.m., with the Landlord, the Landlord stated it was his home and he was not running an assisted living facility. The Landlord stated he advertised to rent a bedroom on craigslist (free online classified ads platform where individuals can post and browse listings for jobs, housing, items for sale, services, and more) to help him pay his mortgage. The Landlord stated he was contacted by a Marketer (MK) about a resident (Resident 1) at the facility looking for a place to live. The Landlord stated MK told him (the Landlord) that Resident 1was to be discharged and the resident had no medical issues. The Landlord stated he was not in the healthcare profession and only accepted Resident 1 into his home for rent. The Landlord stated FM 2 requested Resident 1 be sent to a GACH because Resident 1 bruises and FM wanted the GACH to document the bruises. Landlord stated even though he did not observe any bruises on Resident 1 ' s body, he agreed to send Resident 1 to GACH for safety. During an interview on 4/9/2025 at 2:18 p.m., with Physical Therapist (PT), PT stated Resident 1 was unsteady and required someone to walk with her at all times, for safety. PT 1 stated that was the reason she had a sitter otherwise she would fall. During an interview on 4/9/2025 at 1:03 p.m. with Registered Nurse (RN), RN 1 stated on 3/14/2025 around 3:10 p.m. he discharged Resident 1 to what he thought was an assisted living facility. RN 1 stated he attempted to call the receiving facility (house) to give a handoff report on the resident, but the facility (house) did not answer the phone, and he did not call back. RN 1 stated Resident 1 ' s verbal report was not provided to the facility. RN 1 stated on 3/14/2025 at 3:10 p.m., he gave the Emergency Medical Technician (EMT) Resident 1 ' s verbal medication administration information and a printout list of the resident ' s medications. RN 1 stated he did not document the medications Resident 1 was discharged with and did not remember how many pills he gave the resident. RN stated Resident 1 was given important medications like Risperdal and Gabapentin. RN 1 stated if Resident 1 did not take her medications it could lead to worsening of symptoms. RN 1 stated there was also a potential for Resident 1 to overdose, and it was important to educate the resident about his medications, administration times, dosages, and side effects. During an interview on 4/9/2025 at 4:05 p.m., with Resident 1 ' s Physician (MD 1), MD 1 stated she did not give an order for Resident 1 to be discharged because Resident 1 was not ready for discharge to a lower level of care. MD 1 stated no staff notified her that Resident 1 was discharged from the facility. MD 1 stated Resident 1 still required care from the facility. MD 1 stated all communications with the facility were done through messages and the orders were signed by her in batches (group of multiple orders). MD 1 stated she did not review it individually and might have signed the discharge order by accident. MD 1 stated Resident 1 still required care from the facility ' s staff and should not have been discharged . During a review of the facility ' s Policies and Procedures (P&P) titled Transfer or Discharge, Facility-Initiated, dated October 2022, the P&P indicated facility-initiated discharges, must meet specific criteria, and required resident/representative notification, orientation, and documentation. The P&P indicated the facility should provide the resident and his representative thirty (30)-day advance written notice of an impending discharge from the facility. The P&P indicated the resident, and representative should be notified in writing, the specific reason for the transfer or discharge, including the effective date of the transfer or discharge, the specific location to which the resident is being discharged . The P&P indicated the facility must send a copy of the discharge notice to the Office of the State Long-Term Care Ombudsman at the same time the notice of discharge was provided to the resident and representative. The P&P indicated a post-discharge plan should be developed for each resident prior to her discharge, and must be reviewed with the resident, and/or his or her family, at least twenty-four (24) hours before the resident's discharge from the facility. The P&P indicated the nursing notes should include documentation of appropriate orientation and preparation of the resident prior to the discharge. The P&P indicated if the resident was discharged for any reason, the basis for the discharge, contact information of the practitioner responsible for the care of the resident, resident representative information including contact information, all special instructions or precautions for ongoing care should be communicated to the receiving facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to protect one of three sampled residents (Resident 1), from physical abuse (willful infliction of injury with resulting physical harm, pain, or mental anguish) by Resident 2, by failing to: 1. Ensure Resident 1 (victim) was not subjected to a repetitive physical abuse from Resident 2 (aggressor). 2. Ensure Resident 1 and Resident 2 were separated and were not left to continue residing in the same room, after Resident 1 reported to a Licensed Vocational Nurse (LVN 1) that Resident 2 hit him on 4/1/ 2024. 3. Ensure Resident 1 and Resident 2 were separated, after Resident 2 hit Resident 1 on the right eye on 4/23/2024, causing Resident 1 to sustain a red bruise (an injury appearing as an area of discolored skin on the body, caused by a blow or impact) and swelling around the right eyelid. 4. Develop a care plan for Resident 1 and 2, with interventions to prevent further abuse on 4/1/2024 and 4/23/2024, after Resident 1 alleged to have been hit by Resident 2. 5. Follow their policy and procedure (P&P) Abuse & Mistreatment of Residents, which indicated when incidents involved the health, welfare, or safety of residents were reported, the involved resident(s) should be removed from the environment that threatened resident's health, welfare, or safety. As a result, Resident 2 hit Resident 1, and Resident 1 sustained a swelling and red discoloration to the right eyelid on 4/23/2024.This deficient practice also placed Resident 1 and other residents at risk for further abuse, that could result in serious physical harm/ injuries, hospitalization, and death. On 4/24/2024 at 2:30 p.m., an Immediate Jeopardy ([IJ] a situation in which the facility's noncompliance with one or more requirements of participation has cause, or is likely to cause serious injury, harm, impairment, or death to a resident) was called in the presence of Director of Nursing (DON) and Administrator (ADM) due to the facility ' s failure to protect Resident 1 from physical abuse by Resident 2 on 4/1/2024 and 4/23/2024, that resulted to swelling and red bruise (when a part of the body is injured and small blood vessels leak out) on the right eyelid. On 4/26/2024 at 11:01 a.m., the facility submitted an acceptable IJ removal plan ([IJRP] interventions to immediately correct the deficient practices). After verification of IJRP ' s implementation through observation, interview, and record review, the IJ was removed while onsite on 4/26/24 at 12:18 p.m., in the presence of the DON, ADM, Nurse Consultants 1 and 2. The IJRP included the following immediate actions: 1. On 4/23/2024, the facility moved Resident 1 from room B to C. 2. On 4/24/2024, the psychiatrist (a physician specializes in mental illness) conducted a bedside evaluation for Resident 1 and Resident 2. 3. On 4/23/24, the DON updated the care plan for Residents 1 and 2 and addressed the allegations of abuse. 4. On 4/24/2024, LVN 1 was placed on suspension pending investigation. 5. On 4/24/2024, the DON informed Resident 2 ' s physician of the alleged abuse, the physician ordered Resident 2 to be transferred to the general acute care hospital (GACH) for further evaluation, but Resident 2 refused. The physician was made aware and instructed the facility to continue to monitor Resident 2. 6. On 4/24/2024, the DON informed Resident 1 ' s physician of alleged abuse. The physician ordered Resident 1 to be transferred to GACH for further evaluation. 7. On 4/24/24, The DON notified the California Department of Public Health (CDPH), local police department, and Ombudsman (patient advocate) regarding two alleged physical abuse incidents that occurred on 4/1/24 and 4/23/24. 8. On 4/24/24, the ADM and the DON initiated investigations for the two allegations that occurred on 4/1/24 and 4/23/24. 9. On 4/24/2024, the ADM/DON/QA Consultant conducted in-services for all staff regarding the facility ' s abuse prevention policy. The staff were trained on securing the resident (victim) by removing and/or separating the resident from the alleged perpetrator, conduct assessments on resident(s) who were involved in the allegation, investigate the incident and report to mandated agencies. Findings: a). A review of Resident 1 ' s admission record, dated 4/23/2024, indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis of essential primary hypertension (high blood pressure) type 2 diabetes mellitus (abnormal blood sugar) and muscle weakness. A review of Resident 1 ' s Minimum Data Set ([MDS], a standardized assessment and care screening tool), dated 1/5/2024, indicated Resident 1 had an intact cognition (mental capacity), required supervision (oversight help) with toileting and showers and was independent with personal hygiene and mobility (resident completes the activity with no assistance). A review of Resident 1 ' s History and Physical (H&P), dated 1/30/2024 indicated Resident 1 had the capacity to understand and make decisions. A review of Resident 1 ' s care plan, titled Abuse, dated 4/1/2023, indicated Resident 1 will be free from abuse. One of the interventions indicated, I am aware of the facility policy for reporting abuse and completing the concern form. b). A review of Resident 2 ' s admission record, dated 4/23/2024, indicated Resident 2 was admitted to the facility on [DATE], with diagnoses of schizophrenia (a chronic and severe mental disorder that affects how a person thinks, feels, and behaves) with striking out behavior, hypertensive heart disease (high blood pressure that affects the heart). A review of Resident 2 ' s MDS, dated [DATE], indicated Resident 2 had intact cognition and was independent with mobility. The MDS indicated Resident 2 had schizophrenia and was on antipsychotic medication (medication to manage schizophrenia). A review of Resident 2 ' s H&P, dated 7/21/2023 indicated Resident 1 had the capacity to understand and make decisions. A review of Resident 2 ' s care plan, titled Episodes of striking out, dated 1/12/2024, indicated staff will monitor and record episodes of striking out behavior. A review of Resident 2 ' s physician ' s order dated 9/13/2023, indicated quetiapine fumarate (medication for mental disorders) 50 milligrams ([mg] unit of measurement) at bedtime for schizophrenia manifested by episodes of striking out. A review of LVN 1 ' s progress notes dated 4/1/2024 at 0152 (1:52 a.m.), indicated the LVN 1 responded to a loud, slammed door at Resident 2 ' s room. The progress notes indicated when LVN 1 asked Resident 2 what happened, Resident 2 stated he slammed the door because the M F kept opening the door (referring to Resident 1). The notes indicated Resident 2 shouted at LVN 1 to close the door. During a concurrent observation and interview on 4/23/2023 at 8:17 a.m. with Certified Nurse Assistant (CNA) 1, Resident 1 and Resident 2 were observed in the same room. CNA 1 confirmed Resident 1 and Resident 2 were still in the same room (Room B). During a concurrent observation and interview on 4/23/2024 at 8:17 a.m., Resident 1 and Resident 2 were in the same room (Room B). Resident 1 stated Resident 2 hit him on the face on 4/1/2024, and on 4/23/2024 early morning. Resident 1 was observed with a red bruise and a swollen right eye lid. Resident 1 stated Resident 2 hit him on the face (pointing to both eyes and bridge of the nose). Resident 1 stated he told the licensed nurses, and CNA that Resident 2 kept hitting him. Resident 1 stated Resident 2 used to close the door so no one would see him hitting Resident 1. Resident 1 stated the facility did not offer him a room change and he did not feel safe with sharing a room with Resident 2. During an interview with Resident 2 on 4/23/2024 at 8:46 a.m., Resident 2 stated he did not like Resident 1 leaving the door open. Resident 2 stated he preferred the door closed so he could sleep better, and for privacy. During an interview with CNA 1 on 4/23/2024 at 8:46 a.m., CNA 1 stated Resident 1 complained Resident 2 hit him on the right eye on 4/23/2024 at approximately 1:30 a.m. CNA 1 stated he immediately informed LVN 1 and LVN 1 assessed Resident 1. CNA 1 stated the concerns about Resident 2 hitting Resident 1 had been reported to the DON and ADM. CNA 1 stated he did not know if anything had been done for Resident 1. During a phone interview with former Housekeeping Supervisor (HKS) on 4/23/2024 at 9:12 a.m., the HKS stated, on 4/1/2024, he observed Resident 2 and Resident 1 in their room, and Resident 2 hit Resident 1. The HKS did not remember the part of Resident 1 ' s body Resident 2 hit. The HKS stated a CNA and LVN (unable to recall names) went into the room to check the residents but left both residents in the same room. The HKS stated he did not know the facility ' s protocol regarding resident-to-resident abuse incidents. During a phone interview with the facility ' s Secretary on 4/23/2024 at 10:58 a.m., the Secretary stated he translated (Spanish to English) for LVN 1, when LVN 1 was interviewing Resident 1 on 4/1/2024, regarding the alleged abuse incident. The Secretary stated Resident 1 reported that Resident 2 wanted the door to their room (Resident 1 and 2) closed but Resident 1 wanted the door open (date and time unknown). The Secretary stated, on 4/23/2024 at approximately 1:30 a.m., she also translated for LVN 1, regarding a second abuse incident involving Residents 1 and 2. The Secretary stated Resident 1 reported that Resident 2 hit him on his face and rib cage. The Secretary stated LVN 1 notified the ADM and DON of both incidents but did not move the residents to separate rooms. During a concurrent interview and record review with the DON on 4/23/2024 at 11:12 a.m., Resident 2 ' s Medication Administration Records (MAR) for March and April 2024, were reviewed. The DON stated the MAR indicated a total of six (6) episodes of striking out behavior from 3/31/2024 to 4/2/2024. The DON stated staff ' s interventions for Resident 2 ' s striking out behavior included monitoring the resident for 72 hours after each incident, deescalating the situation, distracting the resident, and having one staff monitor the resident closely. The DON stated staff did not intervene on 4/1/2024, when or after Resident 2 hit Resident 1. During a concurrent observation and interview with the DON on 4/23/2024 at 11:20 a.m., in the residents ' room, Resident 1 was observed sitting at the edge of his bed. The DON stated Resident 1 ' s right eyelid was swollen `with a red bruise. The DON stated Resident 1 pointed at the bridge of his nose and partially to both eyes when asked where Resident 2 had hit him. The DON stated he did not think Resident 1 was hit on the right eyelid. The DON stated both residents should have been separated after the first alleged abuse incident dated 4/1/2024, to prevent further abuse. The DON stated he did not investigate the abuse incident on 4/1/2024, because he did not know about it. The DON also stated on 4/23/2024, LVN 1 texted the DON to report that Resident 2 hit Resident 1. The DON stated the residents were left in the same room because Resident 1 was asleep. During a phone interview with LVN 1 on 4/23/2024 at 12:07 p.m., LVN 1 stated CNA 1 reported to her (LVN 1) that Resident 1 alleged Resident 2 hit him on the face, on 4/23/2024 around 1:30 a.m. LVN 1 stated she left both residents in the same room, did not document the incident in the residents ' progress notes, or change of condition (COC) form. LVN 1 stated she did not create a care plan with interventions to prevent further abuse and did not start a 72-hour monitoring for both residents. LVN 1 stated she should have moved Resident 1 to another room, for safety and prevent further abuse. LVN 1 stated if the residents were moved to separate rooms after the first incident on 4/12024, Resident 2 could not have hit Resident 1 for the second time on 4/23/2024. A review of the facility ' s undated P&P titled, Abuse & Mistreatment of Residents, indicated when incidents involved the health, welfare, or safety of residents were reported, the involved resident(s) should be removed from the environment that threatened the resident ' s health, welfare, or safety. The P&P indicated the charge nurse and/or nursing supervisor should conduct an immediate resident assessment to identify any injuries or extent of injuries, if any, notify the attending physician of incident for necessary interventions. The P&P indicated the charge nurse and/or nursing supervisor shall initiate resident care plan to reflect current conditions and measures taken to prevent recurrence of event, document findings and if the suspected perpetrator was another resident, the resident shall be separated to avoid further contact.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide supervision to prevent the resident, who was at risk for elopement and had a physician order for one-to-one [(1:1) one staff to resident supervision] monitoring, from eloping (leaving unnoticed/unsupervised without permission/authorization) from the facility, for one of five sampled residents with elopement risks (Resident 1). The facility failed to: 1. Ensure the Licensed Vocational Nurse (LVN 3) assigned staff to conduct 1:1 monitoring of Resident 1 on the night shift of 12/29/2022 as ordered by the physician. 2. Ensure the nursing staff monitor Resident 1 at frequent intervals as documented in the resident's care plan titled 'Elopement/Wandering Risk.' 3. Ensure the nursing staff provided 1:1 monitoring of Resident 1 to prevent complications as documented in the resident's care plan titled 'Resident on multiple medications.' Resident 1, had a history of elopement, had impaired cognitive (ability to think and reason) skills for daily decision making, with wandering behavior (walking around aimlessly without a fixed plan), became agitated and combative (eager to fight), striking out at staff and pacing anxiously while continuing to escalate (increase in extent) a hostile behavior. On 12/29/2022 Resident 1 was placed on 1:1 monitoring by the resident's psychiatrist (medical doctor who diagnose and treats mental, emotional, and behavioral disorders) as verbal order, until Resident 1's transferred out to the hospital. On 12/13/2022, Resident 1 went missing and was last seen on 12/30/2022 at approximately 4 a.m. On 12/30/2022, at approximately 8:15 a.m. (over four hours after the resident was last seen), the facility's staff noticed Resident 1 was missing and called a Code [NAME] (to alert staff of a missing resident). The facility conducted an official head count of all the residents at the facility and confirmed Resident 1 had eloped from the facility. This deficient practice resulted in Resident 1 eloping from the facility on 12/30/2022 at an unknown time and was last seen approximately 4 a.m. that morning, which placed Resident 1 at high risk for exposure to harsh environmental conditions including excessive cold and rain, at risk for injuries and medical complications including malnutrition (lack of proper nutrients [molecules in food that are needed for growth and energy]), dehydration (not enough water in the body), respiratory problems due to the resident's diagnosis of chronic obstructive pulmonary disease ([COPD] a group of diseases that cause airflow blockage and breathing-related problems) and possible death. As of 1/11/2023 (12 days later), Resident 1's whereabouts remains unknown. On 1/9/2023 at 3:57 p.m., an Immediate Jeopardy [(IJ) a situation in which the facility's noncompliance with one or more requirements of participation has cause, or is likely to cause, serious injury, harm, impairment, or death to a resident] was identified due to facility's staff failing to implement Resident 1's one-to-one monitoring as ordered and a care plan for Resident 1's elopement including the resident's supervision and monitoring. Resident 1 eloped from the facility on 12/30/2022 without staff knowledge, placing Resident 1 at risk for serious injury or death. The IJ was called in the presence of a minimum data set (MDS) coordinator registered nurse, Director of Medical Records, and the Administrator (ADM). On 1/11/2023 at 3:50 p.m., the ADM submitted an acceptable IJ Removal Plan ([IJRP] interventions to immediately correct the deficient practice). The IJ was removed on 1/11/2023 at 4 p.m., while onsite, after observations, interviews, and record reviews were completed to confirm implementation of the IJRP. The acceptable IJRP included the following for the other residents at risk for elopement, as Resident 1's whereabouts remain unknown, as follow: 1. The facility shall ensure all residents with physician's order for 1:1 monitoring shall be followed and will only be discontinued when the physician gives the discontinuance order. All orders given by the physician shall be in writing. If or when an order is given verbally or by telephone order by the physician, the licensed nurse receiving the order shall transcribe/input the order(s) and communicate the new order(s) to other licensed nurses. Licensed nurse(s) shall initiate care plan to reflect 1:1 monitoring order and update 1:1 monitoring care plan quarterly or as needed. An in-service will be conducted by the DON/designee to all licensed nurses regarding 1:1 monitoring and care planning on 1/11/2023 until all licensed staff have been in-serviced. All newly hired licensed staff shall undergo an in-service by the DON/designee on 1:1 monitoring and care planning. In-service on 1:1 monitoring shall be conducted by DON/designee every six (6) months. 2. Implementing staffing contingency plan, utilizing registry and offer overtime, in case of staffing shortage. The administrator and the DSD will review the projected and actual staffing daily, to ensure adequate staffing. The MDS nurse reviewed all risk assessments and identified one resident requiring hourly monitoring. The MDS nurse shall initiate a review of current residents on 1:1 order today, 1/10/2023, and shall present findings to the Administrator and DON/designee daily during stand-up meeting for three (3) months. Currently, no other resident is on 1:1 monitoring for elopement. 3. Close monitoring shall be done every hour for 24 hours daily by nursing staff for residents with a high risk for elopement based on their elopement risk assessments and history of elopement. The hourly monitoring shall be done for one week starting 1/11/2023 to 1/18/2023. At the end of one week, the results of monitoring recapitulations shall be presented to the QAPI team for evaluation. The QAPI team shall determine if further monitoring shall be necessary. a. The identified 4 other residents with a high risk for elopement are included in the hourly monitoring. b. All nursing staff shall do a 2-hour monitoring/rounds for all other residents to ensure no elopements occurs. Monitoring will be done using a midnight census log/head count and facility rounds every shift by licensed nurses. c. For any missing resident(s), licensed nurses shall inform the DON/designee and ADM and follow the facility P/P titled Missing Residents. d. The ADM has ordered additional video cameras and replacements for the defective video cameras to ensure more video coverage in and out of the facility. Order was done on 12/13/2022. The video cameras shall be installed upon receipt of the video cameras. The camera is scheduled to be installed on 1/16/2023. e. The facility has hired additional personnel as gate watchers on 1/9/2023. The entrance gate has 24 hours gate watcher coverage. The alarms in the building shall be checked by maintenance/designee and recorded daily in a logbook every shift by staff to ensure that all alarms are in working condition. f. The ADM and the DON shall review the daily monitoring logs during daily stand-up meeting to ensure compliance for three (3) months. The DON/designee shall attend the resident IDT meetings every quarter to ensure that the staff have implemented the elopement care plan. 4. The facility shall ensure all staff are notified of residents with a high risk of elopement through shift reports and group huddles conducted by the charge nurse at the start of each shift for three (3) months. 5. The MDS nurse/ DSD/designee will make rounds daily to ensure licensed nurses are aware of residents' care plans and adhere/implement the care plan. Immediate Action 1.All residents assessed as a high risk for elopement shall be monitored and logged every 1 hour by staff to prevent elopement. Effective 1/11/2023. 2. The facility has a Policy & Procedure titled, Missing Residents which include elopement prevention/interventions for the staff to adhere to. An in-service was conducted by the Nurse Consultant to all staff on 1/5/2023 on missing residents and notifications. All newly hired nursing staff shall undergo an in-service by the DON/designee on Missing Residents. In-service on Missing Residents shall be conducted by DON/designee every 6 months. 3. The facility shall ensure nursing staff are notified of residents with high risk of elopement through shift reports and group huddles at the start of each shift. Findings: During an interview with the Director of Nursing (DON) on 12/31/2022 at 4:10 p.m., while in Resident 1's room, a concurrent observation indicated Resident 1's room located on the second floor of the facility, two rooms away from an exit door. This exit door led to an outside balcony with a cement wall approximately 2-3 feet in height. During this interview, the DON was asked how the staff ensures a resident does not get out from that exit door and climb over the wall, the DON stated, One CNA (a certified nursing assistant) monitors the exit because it is on the second floor and resident would not have a chance to get out from the exit. The DON stated Resident 1 was placed on 1:1 monitoring by CNA 1 (male CNA) on 12/29/2022 from 7 a.m. to 11 p.m. (worked two shifts) for his behavior of striking at CNA during a group activity. The DON stated Resident 1 was provided with 1:1 monitoring on 12/29/2022 until 11 p.m., that night as a nursing intervention. The DON stated Resident 1 was did not have 1:1 monitoring on the nightshift of 12/29/2022 due to shortage of staff. During an interview with CNA 1 on 12/31/2022 at 4:50 p.m., CNA 1 stated he worked on 12/29/2022 from 7 a.m. to 11 p.m. and was assigned to provide 1:1 monitoring to Resident 1. CNA 1 stated Resident 1 struck a staff that morning (12/29/2022) and was placed on 1:1 observation until 11 p.m. on 12/29/2022. CNA 1 stated he came back to work on 12/30/2022 at 7 a.m. and during rounds with other staff noticed Resident 1 was not in his room. During an interview with Resident 2 (Resident 1's roommate) on 12/31/2022 at 5:05 p.m., Resident 2 stated he last saw Resident 1 at approximately 4 a.m. on 12/30/2022 when Resident 1 went to the bathroom. During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was originally admitted to the facility on [DATE] and last readmitted on [DATE] with diagnoses including paranoid schizophrenia (serious mental disorder in which reality is interpret abnormal and it impairs daily functioning), major depressive disorder (serious mood disorder; affects how a person feels, think, and handle daily activities, such as sleeping, eating, or working), Bipolar disorder (a brain disorder; shifts in mood, energy, activity levels, and the ability to carry out day-to-day tasks), psychosis (effects the mind, where there has been some loss of contact with reality), muscle weakness with difficulty walking, hypertension (high blood pressure), chronic obstructive pulmonary disease ([COPD] a long term lung disease that make it difficult to breathe), and blindness in left eye. During a review of Resident 1's Minimum Data Set (MDS), a standardized e assessment and care-screening tool, dated 12/27/2022, the MDS indicated Resident 1's cognitive skills for daily decision making were moderately impaired. The MDS indicated Resident 1 required supervision for eating, bed mobility, transferring, walking, dressing, eating, toilet use, and personal hygiene. During a review of Resident 1's Elopement Risk Assessment (ERA), dated 12/20/2022, the ERA indicated Resident 1 was at risk for elopement. The ERA tool indicated the resident was always disoriented and had prior history of elopement on 7/9/2019. During a review of Resident 1's Nurse Progress Note (NPN), completed by an unknown registered nurse (RN) during admission, dated 12/20/2022 and timed at 8:58 p.m., the NPN indicated Resident 1 was awake, disoriented, and unable to state name or where he was. During a review of Resident 1's care plan, initiated on 12/21/2022 and titled, Elopement/Wandering Risk, the care plan indicated Resident 1 was at risk for leaving a safe area without supervision and the goal indicated Resident 1 will have no elopement. The staff's intervention included to monitor the resident at frequent intervals. During a review of Resident 1's care plan initiated on 12/21/2022 and titled, Altered behavior patterns related to bipolar disorder, depression and psychosis manifested by (M/B) inability to process internal stimuli causing anger interfering with the resident's daily living activities, the care plan indicated Resident 1 would have reduced episodes of manifested behavior daily. The staff's intervention included to provide reality awareness. During a review of Resident 1's care plan titled, Resident on multiple medications initiated on 12/21/2022, the care plan indicated the resident would be free of being an endanger to self and others for three months. The staff's interventions included to provide 1:1 monitoring to prevent complications. During a review of Resident 1's Interact Assessment Form indicated a Change of Condition Evaluation (COCE), dated 12/29/2022 and timed at 5:20 p.m., the COCE indicated Resident 1 had aggressive behavior, struck-out at staff and the police and the resident's psychiatrist (Physician 1) was immediately notified. The COCE indicated Physician 1 was notified and a new order to transfer the resident to the hospital for a psychiatric evaluation ([P/E] an evaluation used to diagnose problems with memory, thought processes, and behaviors). During a review of Resident 1's physician order, dated 12/29/2022, the order indicated to transfer the resident to hospital for aggressive behavior and danger to self. During a review of Resident 1's NPNs, from 12/20/2022 to 12/30/2022, the NPNs indicated there was no documented evidence staff monitored Resident 1 for elopement and wandering behaviors as care planned. During a review of Resident 1's NPN, dated 12/30/2022 and timed at 3:05 p.m., the NPN indicated Resident 1 was not in his room at the beginning of the shift (3 p.m.) on 12/30/2022 and a search was initiated, and staff were unable to locate the resident. Code [NAME] was called, and all rooms were searched. According to the NPN, the ADM and the DON were made aware, and the police was called at 9:23 a.m. on 12/30/2022. During a concurrent observation and interview with the director of staff development (DSD) on 1/3/2023 at 2:15 p.m., the DSD stated the facility had six exit doors within the facility and all alarms were working. When the exit doors were opened the alarms activated loudly. The DSD stated there was one exit door in the facility, in the vicinity Resident 1's room, which was leading to a balcony with stairs to the ground floor which had a door that was locked with an alarm in place. During an interview with Licensed Vocational Nurse (LVN 1) on 1/3/2023 at 2:45 p.m., LVN 1 stated he starts his shift at 7 a.m. LVN 1 stated the nurses stated Resident 1 usually goes to breakfast at 7:30 a.m. but did not show up at 7:30 a.m. on 12/30/2022. LVN 1 stated at about 8:15 a.m. on 12/30/2022 the staff did a head count and could not find Resident 1. During a concurrent observation and interview with CNA 2 on 1/3/2023 at 3 p.m., CNA 2 stated she has taken care of Resident 1 many times. CNA 2 stated on the morning of 12/30/2022 (time unknown) while she was in the middle of another resident care, a Code [NAME] was announced. CNA 2 stated on 12/30/2022 the facility was short-staffed. CNA 2 stated she did not know Resident 1 was at risk for elopement. During an interview with the ADM on 1/3/2023 at 4:25 p.m., the ADM stated the surveillance camera (a camera used for the purpose of observing an area) that monitors the facility was not working and he needed to get it repair. The ADM stated, Resident 1 was a runner and had heard the resident elopes all the time. The ADM stated, The alarms in the facility are loud, so he probably did not use the doors, maybe hopped the fence. The ADM stated they were still looking for Resident 1. During a subsequent interview with LVN 1 on 1/4/2023 at 10:31 a.m., LVN 1, who was Resident 1's primary charge nurse, stated he did not know the resident was an elopement risk. LVN 1 stated had he known Resident 1 was an elopement risk, he would have had someone to watch him closely. During a telephone interview with Resident 1's Physician 1 on 1/9/2023 at 12:03 p.m., Physician 1 stated she was familiar with Resident 1 as he has been in and out of the hospital under her care. Physician 1 stated she has treated Resident 1 while in the hospital prior to admission to the facility due to his dual diagnosis of psychiatric illness and alcohol abuse with poor judgement. Physician 1 stated she was called on 12/29/2022, after Resident 1 hit a staff member and she told the DON to place the resident on 1:1 close monitoring (as a telephone order) until he was transferred to the hospital and to call the police. Physician 1 stated the DON did not transcribe her order and place the resident on continuous 1:1 monitoring as she order until the resident was transferred to the hospital. Physician 1 stated Resident 1 was an elopement risk and should have been monitored closely, as the resident was not ready for discharge. An interview with the DON was attempted regarding Physician 1's telephone order, but the DON was not available, as she resigned from the facility on 1/4/2023, per the administrator. During a telephone interview on 1/5/2023 at 7:15 a.m. with LVN 3, LVN 3 stated on 12/29/2022, Resident 1 was staying to himself (not social with others), while talking to himself, screaming at times; and punching in the air in an aggressive manner. LVN 3 stated Resident 1 hit a staff on 12/29/2022 during the 3 p.m.-11p.m. shift and it was the first time he was aware of the resident hitting anyone. LVN 3 stated Resident 1 was placed on 1:1 monitoring. LVN 3 stated Resident 1 was in bed at night when he came to work on 12/29/2022 at 11 p.m. LVN 3 stated the police was called but could not take the resident because of his diagnosis and the hospital had no available beds. LVN 3 stated the staff placed Resident 1 on 1:1 monitoring, as a standing order (an instruction or prescribed procedure in force permanently or until changed or canceled), because he hit a female nurse, and he was the elopement risk. LVN 3 stated the resident was monitored every two hours. LVN 3 stated, I did not have a male CNA that night (12/29/2022 on 11 p.m. shift), that is why I did not put Resident 1 on 1:1 monitoring on the night shift. LVN 3 stated Resident 1 eloped after 4 a.m., because he saw Resident 1 around 4 a.m. on 12/30/2022. LVN 3 stated he did not check on Resident 1 at 6 a.m. on 12/30/2022 because he was busy passing medications. LVN 3 stated Resident 1 had a history of eloping from facilities and should have been monitored closely. During a review of the facility's undated policy and procedure (P/P) titled, 'Physician Orders and Telephone Orders dated 1/2004, the P/P indicated Physician's order shall be obtained prior to the initiation of any treatment from the person lawfully authorized to prescribe for and treat human illness. All orders must be specific and complete, and no standing orders be accepted. The P/P indicated Telephone orders shall be signed in a timely manner or at least by the next routine visit by the physician. Telephone orders shall be noted promptly, all orders must include the date and time received and must be noted by the professional staff taking the order (e.g., licensed nurse).