**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to provide residents with a safe environment and failed to perform visual checks, at least every two hours for one of three sampled residents (Resident 1) to prevent Resident 1 from eloping (when a resident who is cognitively, physically, mentally, emotionally, and/or chemically impaired wanders away, walks away, runs away, escapes, or otherwise leaves a care-giving facility or environment unsupervised, unnoticed, and/or prior to their scheduled discharge) from the facility on 3/18/2023. Resident 1 had impaired cognition with diagnosis including Alzheimer ' s disease (a progressive mental deterioration that destroys memory and other important mental functions), dementia (a group of thinking and social symptoms that interferes with daily functioning), schizophrenia (a disorder that affects a person ' s ability to think, feel, and behave clearly), anxiety (intense, excessive, and persistent worry and fear about everyday situations), cognitive communication deficit (impairment in organization/thought organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), dysphagia (difficulty swallowing foods or liquids), and chronic obstructive pulmonary disease [(COPD) a group of lung diseases that block airflow and make it difficult to breathe]. Resident 1 was assessed as moderate risk for elopement. It was unknown how Resident 1 left the facility with his wheelchair and cane. As a result, Resident 1 left the facility unsupervised and was exposed to harsh environmental conditions including cold weather and rain, had a potential of being hit by a car, and had a potential for medical complications including malnutrition (lack of proper nutrition, caused by not having enough to eat, not eating enough of the right things, or being unable to use the food that one does eat), dehydration (a harmful reduction in the amount of water in the body), and death. There is a potential for Resident 1 to be without medications from 3/18/2023-3/28/2023, a total of ten (10) days. Resident 1 has still not been found on 3/29/2023. On 3/22/2023 at 10:44 a.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 (Admin) due to the facility ' s failure to closely monitor and document Resident 1 ' s whereabouts to prevent Resident 1 from leaving the facility unsupervised. On 3/24/202 at 9:51 a.m., the facility submitted an acceptable IJ removal plan ([IJRP] interventions to immediately correct the deficient practices). After verification of IJRP implementation through observation, interview, and record review, the IJ was removed on 3/24/23 at 1:20 p.m., in the presence of the DON. The IJRP included the following immediate actions: 1. After Resident 1 eloped from the facility on 3/18/23, the facility immediately conducted a head count on an hourly basis and implemented and documented on a head count log signed by Licensed nurses, Certified Nursing Assistance (CNAs) and department heads 2. The facility contacted the police department at approximately 8:00 am., to notify of Resident 1 disappearance. Facility has been searching since 3/18/23 exhaustively through today and will continue efforts to locate Resident 1. The facility ' s staff has contacted and kept a log of all hospitals and Emergency rooms (ERs) contacted daily, various neighborhoods in multiple counties, as well as visiting numerous homeless shelters, parks and tents, local shopping centers and stores. The Metro station was provided a description of Resident 1 to check all railways and buses. Resident 1 has not been located however facility is continuing to call and visit locations and neighborhoods. 3. Facility contacted an outside security agency to provide additional monitoring of the facility on 3/19/23. 4. The facility has hourly head count documented on a log since 3/18/23. The Director of Nursing (DON) and Director of Staff Development (DSD) provided in-service to all staff regarding the importance of conducting and documenting the head count hourly using the facility ' s daily census. Licensed nurses and CNAs continue to utilize the facility daily census in accounting each resident in the building during the hourly head count. Licensed nurses and CNAs, under the instruction of the DON, are responsible for conducting hourly rounds. The facility department managers, during their shift, will also conduct hourly rounds and ensure compliance. Licensed Nurses are primarily responsible to conduct and document hourly rounds on all shifts. Residents assessed to be moderate to severe risk for elopement will be identified to staff using a green sticker on their door tag. Residents identified as moderate to severe risk for elopement now have and continue to have a green sticker next to their name plate on the resident ' s door. An in-service was provided to all staff regarding the green sticker notification by the DSD and DON on 3/22/23. The DON provided in-services on 3/22/23 to all department heads (Administrator, Director of Staff Development, Minimum Data Sheet Nurse, Social Services Designee, Medical Records Director, Rehab coordinator, Activities Director, Dietary Supervisor, Business Office Manager) to visually check residents with a green sticker on their door tag during rounds. 5. As of 3/19/23, the facility has 24 hours/7 days a week security personnel monitoring the facility. In the event staff calls off, the outgoing security personnel will stay while awaiting a replacement or until the agency can provide a security personnel. In the event staffing proves challenging, a department head will be called in to monitor until the contracted security agency provides a replacement to ensure 24 hours monitoring. During the daily huddle on each shift licensed nurses will document and inform CNAs which residents are at risk for elopement for additional oversight and monitoring of those residents. The DON provided in-services to licensed nurses on 3/19/23 and will ensure sustained compliance during daily rounds. Security personnel during their rounds document on each shift ensure alarms are tested and functioning and documented on a log, in-services provided on 3/22/23 by DON and DSD. Maintenance Supervisor, weekly checks alarms to ensure functioning and in good working order. Should alarm malfunction the maintenance supervisor will be immediately notified, and the supervisor will change alarm with extra new alarms kept in the maintenance office. 6. All residents assessed to be at moderate to severe risk for elopement will have individualized care plans with interventions in place upon admission and reviewed quarterly and as needed by the Minimum Data Set ([MDS] an assessment and care screening tool) nurse and DON. During daily huddle, each shift licensed nurses will discuss with CNAs interventions and identify residents at risk for elopement. The facility will continue to provide education to the residents regarding the risks of leaving the facility. The facility will develop a care plan for residents when verbalizing they want to leave the facility, and their physicians will be notified for further interventions. Findings: During a review of Resident 1 ' s Face Sheet (admission record), dated 3/20/2023, the face sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnosis including Alzheimer ' s disease (a progressive mental deterioration that destroys memory and other important mental functions), dementia (a group of thinking and social symptoms that interferes with daily functioning), schizophrenia (a disorder that affects a person ' s ability to think, feel, and behave clearly), anxiety (intense, excessive, and persistent worry and fear about everyday situations), cognitive communication deficit (impairment in organization/thought organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), dysphagia (difficulty swallowing), cognitive communication deficit, protein -calorie malnutrition (low energy intake, weight loss, loss of subcutaneous fat [a type of fat that's stored under the skin], loss of muscle mass, fluid accumulation, and decreased hand grip strength), and Chronic Obstructive Pulmonary Disease ([COPD] a group of lung diseases that blocks airflow and make it difficult to breathe). During a review of Resident 1 ' s general acute care hospital (GACH) Psychiatric Initial Evaluation (Psych Eval), dated 2/10/2023, the GACH Psych Eval indicated Resident 1 was admitted to the GACH on 2/10/2023 with psychosis (a severe mental disorder in which thought, and emotions are so impaired that contact is lost with external reality). and suicidal ideation ([SI] when someone thinks about killing themselves) by overdosing on medication. During a review of Resident 1 ' s GACH History and Physical (H&P), dated 2/10/2023, the H&P indicated Resident 1 was placed on AWOL (absent without leave)/Assaultive/Suicidal Precautions. During a review of Resident 1 ' s, H&P from the facility, dated 2/16/2023, the H&P indicated Resident 1 could make his needs known but could not make medical decisions. During a review of Resident 1 ' s MDS, dated [DATE], the MDS indicated Resident 1 was able to understand and be understood by others. The MDS indicated Resident 1 required limited assistance (staff provided non-weight-bearing assistance) activities of daily living (ADLs) such as transferring, walking, and moving in the unit. The MDS indicated Resident 1 required extensive assistance (staff provided weight bearing support) for dressing and toilet use. The MDS also indicated Resident 1 used a wheelchair for movement. The MDS indicated Resident 1 used an antipsychotic (medication primarily used to manage psychosis [mental disorder characterized by a disconnection from reality], particularly in schizophrenia) for seven out of the seven days of the week. During a review of Resident 1 ' s physician ' s order dated 2/16/2023, the physician ' s order indicated Risperdal (medication used to treat certain mental/mood disorders such as schizophrenia), 1 milligram ([mg] unit of measurement), two times daily (BID), and Neurontin (medication used to relieve nerve pain) 200 mg, 1 capsule three times daily (TID) for polyneuropathy (a condition in which a person ' s peripheral nerves are damaged). During a review of Resident 1 ' s Elopement Risk Evaluation dated 2/16/2023, the evaluation indicated Resident 1 was at moderate risk for elopement and required care planning for elopement. Resident 1 ' s history of elopement from a previous facility and diagnosis of Alzheimer ' s disease, were not considered during the elopement risk assessment to place the resident at high risk for elopement. During a review of Resident 1 ' s care plan, titled Elopement Risk, dated 2/16/2023, the interventions indicated staff will encourage Resident 1 to notify the nurse if he had to leave the facility for any reason, assess/record/report to the doctor (MD) risk factors for potential elopement like wandering, repeated requests to leave facility, statements such as I am leaving and I wanna go home, attempt to leave the facility, elopement attempts from previous facility or hospital. The care plan intervention also indicated staff would observe Resident 1 ' s location with visual checks, at least every two hours. During a review of Resident 1 ' s Change in Condition (COC), assessment dated [DATE] and timed 6:30 a.m., the COC indicated Licensed Vocational Nurse (LVN) 1 noticed that on 3/18/2023 at 6:30 a.m., Resident 1 was not in his bed when LVN 1 was doing rounds. The COC indicated LVN 1 looked around the facility and gathered incoming staff to drive around the neighborhood to look for Resident 1 but did not find the resident. During an interview on 3/20/2023 at 2:14 p.m., with LVN 2, LVN 2 stated Resident 1 was alert and aware but had episodes of confusion and during those episodes of confusion, Resident 1 would say he had to go to work. LVN 2 stated she performed visual checks on Resident 1 ' s location at least every 2 hours during her shift but did not document anywhere in the resident ' s medical record that visual checks were done. LVN 2 stated, it was important to document all care given, to indicate it was done. During an interview on 3/20/2023 at 3:13 p.m., with the Director of Nursing (DON), the DON stated there were two security guards during the day in charge of monitoring residents. The DON stated at night, the nursing staff were supposed to monitor exit doors of the facility during rounds to prevent residents from leaving the facility unsupervised. The DON stated staff was to perform visual checks on Resident 1 at least every two hours and document on the resident ' s chart. The DON stated unfortunately, staff did not document. During an interview on 3/20/2023 at 3:45 p.m., with LVN 1, LVN 1 stated Resident 1 had dementia, was confused, and had sundowning syndrome (a state of confusion that can cause restlessness, agitation, irritability occurring in the late afternoon and lasting into the night). After dinner, Resident 1 would get up from his wheelchair and state he had to go to work. LVN 1 stated on 3/18/2023 she noticed Resident 1 was no longer in his room at 6:30 a.m. while she (LVN 1) was doing her final rounds. She was looking for Resident 1 and noticed his wheelchair and his cane were missing. LVN 1 stated she did not remember the last time she performed visual checks on Resident 1. LVN 1 stated she did not document Resident 1 ' s whereabouts in the resident ' s medical record. LVN 1 stated she did not hear the door alarms that night. LVN 1 said if the alarm on the doors were on, it would have sounded, if Resident 1 went through the doors. During an interview with the Administrator (Admin) on 3/21/2023 at 9:59 a.m., the Admin stated the facility ' s security footage was not available because the recordings reset every Sunday. The Admin stated he forgot to review the recordings before it reset. The Admin stated on 3/20/2023, he called the previous facility where Resident 1 resided prior to hospitalization and was told Resident 1 would repeatedly sign himself out and not come back to that facility. The Admin stated the facility was unaware of Resident 1 ' s previous behavior because the facility did not call Resident 1 ' s previous facility to inquire. During a concurrent interview and record review on 3/21/2023 at 12:27 p.m., with the DON, Resident 1 ' s Elopement Risk Evaluation dated 2/16/2023 was reviewed. The DON stated Resident 1 was admitted to the GACH for SI and feelings of hopelessness on 2/9/2023. The DON stated an elopement risk evaluation was done for the resident on 2/16/2023 and a care plan written. The DON stated staff was supposed to perform visual checks on Resident 1 but were not required to document routine visual checks. The DON stated on weekends, the entrance to the facility was through the main entrance, ambulance entrance, and hallway exit. The DON stated the three main entrances/exits had alarms on the door. The DON also stated the facility did not know how Resident 1 eloped from the facility on 3/18/2023, because the wires of the facility ' s security cameras were damaged by the rain and did not work well. The DON stated there is a likelihood Resident 1 had not been medicated since eloping from the facility on 3/18/2023 because the resident had still not been located. During an interview on 3/21/2023 at 1:30 p.m., with the Maintenance Supervisor (MS), the MS stated all alarm doors were tested on Wednesdays every week. The MS stated if Resident 1 eloped from any of the exit doors, the alarms would have gone off and the staff would have been alerted to stop the resident from leaving the facility unsupervised. The MS stated there were no alarms on the windows, and that the windows could be opened from residents ' rooms including Resident 1 ' s room. During an interview on 3/21/2023 at 1:44 p.m., with the MS, the MS stated Resident 1 ' s room window can be opened from the resident ' s room. The MS stated Resident 1 could push the window open and get out through the window to the alley. During an interview on 3/21/2023 at 2:16 p.m., with LVN 2, LVN 2 stated Resident 1 would say he had to go to work. LVN 2 stated she did not document Resident 1 ' s statement and did not report it to the MD. LVN 2 stated Resident 1 had a history of suicidal ideation and should have been monitored or supervised more often than just every two hours, per the resident ' s elopement risk care plan, to prevent the resident from eloping. LVN 2 stated staff should have monitored Resident 1 every two hours because the resident stated he wanted to go to work. During a concurrent interview and record review on 3/21/2023 at 4:30 p.m., with LVN 1, Resident 1 ' s Elopement Risk care plan dated 2/16/2023, was reviewed. LVN 1 stated the care plan interventions indicated to document and report to the MD risk factors for wandering, such as Resident 1 stating he needed to go to work. LVN 1 stated she did not document Resident 1 saying that he had to go to work and did not report to the MD because she redirected Resident 1 successfully. LVN 1 stated that when Resident 1 stated he wanted to go to work, she should have educated the resident on the risk of leaving the facility. LVN 1 stated Resident 1 had Alzheimer ' s and was at risk for elopement. LVN 1 stated she was not concerned about the resident leaving the facility at the time because Resident 1 was redirectable. LVN 1also stated Resident 1 ' s Elopement Risk Evaluation was inaccurate because it scored the resident as a 15 instead of an 18 or more, considering Resident 1 ' s diagnoses of Alzheimer ' s and statement I want to go to work. During a telephone interview on 3/23/2023 at 10:45 a.m., with CNA 1, CNA 1 stated the last time she saw Resident 1 was on 3/18/2023 at 6 a.m., while she was doing her hourly rounds and Resident 1 was in his room in his wheelchair. CNA 1 stated she did not document anywhere when she saw Resident 1 because the charge nurse did not tell her to document Resident 1 ' s visual checks. CNA 1 stated she did not hear any alarms go off during that shift. CNA 1 stated the alarm was very loud and if it went off, everyone would have heard it. CNA 1 stated Resident 1 would talk about missing his wife and that his daughter was coming to see him. During a record review of the Accuweather forecast report for Los Angeles area from 3/18/2023 to 3/24/2023 Los Angeles, CA Monthly Weather | AccuWeather, the temperature was in the low 60's degree Fahrenheit ([°F] unit of measurement) to high 50's °F. It also indicated some days were, rainy, cloudy and with thunderstorms. During a record review of https://crimegrade.org/murder-90043, the Los Angeles city's overall crime grade for violent crimes for zip code 90043, where the facility was located, was an F grade (meaning most dangerous). During a review of the facility ' s policy and procedure (P&P) titled Gate Monitoring, dated 2/18/2018, the P&P indicated the facility will protect residents ' safety in the facility. During a review of the facility ' s P&P titled Elopement Risk Assessment, undated, the P&P indicated interventions for elopement include notification of physician for changes in behavior, such as increasing insistence or attempts to leave and environmental controls such as a functional alarm system for egresses.