**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide immediate cardiopulmonary resuscitation (CPR - emergency lifesaving procedure, consisting of a combination of chest compressions, mouth- to-mouth, or mechanical breathing [using a device to help someone breathe], performed when the heart stops beating or beats ineffectively to restore breathing) to one of two sampled residents (Resident 1), who was a full code (when the resident's heart stops beating and/or the resident stops breathing, the resident or their representative's wishes to perform all lifesaving procedures to keep the resident alive, a full code is the default status for all patients unless they have explicitly discussed other wishes with their medical provider). On [DATE], Certified Nursing Assistant 1 (CNA 1), Licensed Psychiatric Technician (LPT 1) and Licensed Vocational Nurse 1 (LVN 1) did not provide CPR immediately when Resident 1 was found unresponsive in Resident 1's room as indicated in the facility's Policy and Procedures (P&P) titled Advance Directives [AD, legal document that provides instructions regarding medical care according to the resident's wishes and only goes into effect if the resident can no longer communicate their wishes]./Individual Health Care Instructions and Emergency Response Policy and Procedure. As a result, on [DATE] at 6:49 am, Resident 1 was pronounced expired after the paramedics (emergency medical technicians [EMT] who provide emergency medical services) performed unsuccessful CPR to Resident 1. On [DATE], while onsite at the facility, the California Department of Public Health (the Department) identified an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident) regarding the facility's failure to provide immediate CPR to Resident 1 when Resident 1 was found unresponsive on [DATE], by failing to ensure CNA 1, LPT 1, and LVN 1 performed CPR immediately when Resident 1 was found unresponsive. The surveyor notified the Administrator (ADM), the Director of Nursing (DON), and the Quality Assurance Nurse (QAN) of the IJ situation on [DATE] at 3:22 pm. On [DATE], the facility submitted an acceptable IJ Removal Plan (IJRP, plan that includes interventions to immediately correct the deficient practices). While onsite at the facility, the surveyor determined the IJ situation was no longer present and confirmed/verified the facility's full implementation of the IJRP through observations, interviews, and record review. The IJ was removed on [DATE] at 5:02 pm in the presence of the QAN, and the Program Director (PD). The IJPR included the following immediate actions: On [DATE], 1.The Director of Nursing (DON) and ADM provided in-service education to all nursing staff on duty, this included 3 licensed staff and 10 CNAs. The in-service education lesson plan focused on the protocol for providing CPR to an unresponsive Resident. 2. In-service training included: o Nursing staff first on scene of the unresponsive resident will begin to administer CPR while calling for a Code Blue [an emergency code that used to indicate a patient/resident requiring immediate cardiopulmonary resuscitation] and the location of the resident. o Staff not administering CPR will call 911 immediately. o Nursing staff first on scene will not discontinue CPR until another nursing staff member that is CPR certified takes over doing CPR or paramedics arrive; whichever is first. o Staff is not to leave the unresponsive resident until expiration has been verified by paramedics. Identifying other residents at risk: on [DATE], the DON reviewed all 94 current residents' code status [a type of emergent treatment a person would or would not receive if their heart or breathing were to stop] and documentation of no advanced directive by responsible party was all residents' charts. All 94 current residents are full code status. Root Cause Analysis: on [DATE], the ADM, the DON, and the QAN conducted a root cause analysis, including: 1. Review of interviews with involved staff (CNA 1, LPT 1, LVN 1, HK [housekeeping] 1) 2. Review of facility policies and procedures related to emergency response and CPR. 3. Review of all 75 nursing staff working the floor (20 licensed staff, 51 CNA's, 4 nursing aids) to ensure all were CPR certified, 75 out of 75 nursing staff were CPR certified. The root cause analysis revealed: 1. Lack of clear understanding among all staff regarding their role in initiating CPR. 2. Insufficient emphasis on the immediacy required in emergency situations. Systemic Changes and Preventive Measures: 1. On [DATE], the facility updated its Emergency Response Policy to clearly state that any staff member who discovered an unresponsive resident must immediately alert the nearest nursing staff and remain with the resident. 2. On [DATE], the DON conducted in-service training to 3 licensed staff, 1 nursing aid, and 18 CNA's. There were 40 nursing staff that were not present for in-service training on [DATE] - [DATE], the staff not present will be in-serviced immediately upon return to the facility. 3. Code Blue Drills will be conducted randomly by the DON on a quarterly basis on various shifts to ensure proficient and competent knowledge of Emergency Response Procedures. Monitoring and Evaluation Plan: 1. The Staff Developer will conduct weekly audits of 10% of staff (across all departments when applicable) to assess knowledge of emergency response procedures and CPR protocol weekly for 3 months. 2. Emergency Response Procedures will be a part of orientation training for all new nursing staff. 3. The QAN will review all emergency response incidents within 24 hours of occurrence for proper adherence to protocol. The Staff Developer will report the monitoring plan results quarterly [during the] QAA (Quality Assessment and Assurance, a committee that meets quarterly to develop and implement appropriate plans of action to correct identified quality deficiencies) [meeting]. The QAA committee will review the effectiveness of the interventions and make any necessary adjustments to the plan. Monitoring will be on an ongoing basis until sustained compliance is achieved, as evidenced by three consecutive months of 100% compliance in all audits and drills. The administrator is responsible for full compliance. Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on [DATE] with diagnoses that included paranoid schizophrenia (mental disorder characterized by abnormal social behavior and failure to understand what is real), bipolar disorder (a serious mental illness that causes unusual shifts in mood, periods of depression and periods of elevated mood) unspecified, and obesity (a chronic health condition that involves excess body fat that may impair health). During a review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated [DATE], the MDS indicated Resident 1's cognition (ability to understand and process information) was intact, had clear speech, and had the ability to understand and be understood (ability to express ideas and wants) by others. The MDS indicated Resident 1 did not have any impairments (an injury, illness, or a condition where part of your body or brain does not work as it normally should) on the upper extremities (shoulder, elbow, wrist, hand) and lower extremities (hip, knee, ankle, foot). During a review of Resident 1's Emergency Medical Technician ( EMT, trained medical professional who provides emergency medical care to people outside of a hospital) Fire Department run report (a standard document used by emergency medical service care providers), dated [DATE], timed at 6:36 am, the report indicated EMTs arrived at the facility on [DATE] at 6:43 am and were at Resident 1's bedside to evaluate Resident 1 at 6:44 am. The report indicated the EMTs found Resident 1 on the floor, unresponsive, and pulseless (without a pulse). The report's narrative indicated CPR was given to Resident 1and Resident 1's first monitored heart rhythm (electrical activity of the heart seen on a screen) was asystole (no heartbeat). The report's narrative indicated Resident 1 was dead (expired) prior to the EMTs arrival and the EMTs called a time of death (TOD) at 6:49 am. The report indicated staff alleged had seen Resident 1 ten minutes prior to the EMT's arrival but Resident 1 had rigor (fourth stage of death, recognizable sign of death characterized by stiffening of the limbs caused by chemical changes in the muscles and can occur as soon as four hours after death) and lividity (bluish purple discoloration of the skin after death). During a review of Resident 1's Progress Note (PN) written by LPT 1, dated [DATE], timed at 8:29 am, the PN indicated at 6:25 am, [CNA 1] alerted LPT 1 to check on Resident 1. The PN indicated Resident 1 was found bent over in the corner, between the bed and the closet [in Resident 1's room]. The PN indicated LPT 1 tapped Resident 1 on the back, but there was no response from Resident 1. The PN indicated Resident 1 had no vital signs (measuring the basic functions of your body temperature, blood pressure, pulse, and respirations) and [the staff] called for help, called a code blue, and CPR was started (no time specified). The note indicated paramedics arrived at the facility around 6:30 am (per the EMT report, EMT arrival time was 6:43 am), Resident 1 was pronounced expired, and the coroner's (a person who examines the circumstances surrounding a death) office was called. During a telephone interview on [DATE] at 1:28 pm, with LPT 1, LPT 1 stated CNA 1 informed LPT 1 to check on Resident 1after CNA 1 found Resident 1 unresponsive. LPT 1 stated, LPT 1 was assigned to care for Resident 1 on [DATE] during the night shift. LPT 1 stated during the shift, nothing was triggered and LPT 1 just walked by Resident 1's room. LPT 1 stated at 2 am and 4 am, LPT 1 passed by Resident 1's room and LPT 1 did not see anything unusual. LPT 1 stated, during LPT 1's shift, LPT 1 did not see Resident 1 come outside of Resident 1's room. LPT 1 stated in the early morning (no recall of exact time) LPT 1 entered Resident 1's room and saw Resident 1 faced down on the floor between the bed and closet. LPT 1 stated LPT 1 tapped Resident 1 but Resident 1 was unresponsive. LPT 1 stated LPT 1 left Resident 1's room, walked to the door leading to the east unit and instructed CNA 4 to notify LVN 1 there was an emergency. LPT 1 stated he and LVN 1 went back to Resident 1's room and started performing CPR. During a review of the facility's CPR certifications, from the International CPR Institute (a company that offers first aid certification-training and CPR training), LPT 1's certificate indicated LPT 1 successfully completed a three-hour CPR course on [DATE] (LPT 1 was able to perform CPR). According to the American Red Cross Training Services, undated, for a person who was found unresponsive and not breathing CPR should be started and an AED (automated external defibrillator, portable electric device that automatically diagnose life threatening cardiac arrhythmias [irregular heartbeat]) should be used immediately. https://www.redcross.org/take-a-class/resources/learn-first-aid/unresponsive-and-breathing-person During an interview on [DATE] at 1:48 pm with Housekeeper 1 (HK 1), HK 1 stated, today at around 6:30 am when HK 1 entered Resident 1's room, HK 1 saw Resident 1 on the floor next to Resident 1's bed and HK 1 told Resident 1 to get up and go to Resident 1's bed. HK 1 stated Resident 1's hands were blue, and HK 1 did not see Resident 1's face because it was tucked in Resident 1's chest. HK 1 stated Resident 1's bottom was facing up. HK 1 stated HK 1 told CNA 1 to check on Resident 1 because Resident 1 did not move [unresponsive] when HK 1 said anything [to Resident 1] and, something was wrong [with Resident 1]. HK 1 stated HK 1 did not touch Resident 1. During an interview on [DATE] at 1:56 pm, the DSD stated, on [DATE] at 6:25 am, the DSD went to the nurse's station to put up the [staff] assignment when CNA 1 called the DSD and told the DSD CNA 1 needed help. The DSD stated the DSD went to Resident 1's room, LPT 1 and LVN 1 were inside Resident 1's room and Resident 1 was [on the floor] kneeling toward Resident 1's head of the bed and was slumped over. The DSD stated Resident 1 was blue, not a normal color and Resident 1 had no pulse. The DSD stated LPT 1 and LVN 1 were standing next to Resident 1's body checking Resident 1, and the DSD instructed LPT 1 and LVN 1 to start CPR (to time recall of the time CPR was started) while the DSD ran outside Resident 1's room to get an oxygen [O2, colorless, odorless gas] tank, and instructed someone else (unidentified) to call 911. The DSD stated housekeepers were not CPR certified (not mandatory). During an interview on [DATE] at 2:17 pm, HK 2 stated HK 2 went inside Resident 1's room with HK 1 to clean Resident 1's restroom. HK 2 stated HK 1 started mopping Resident 1's room and HK 2 heard HK 1 talking to Resident 1 but Resident 1 was not responding. HK 2 stated HK 2 came out of the restroom to check the situation, saw Resident 1 in a baby position, and HK 2 only saw Resident 1's back. HK 2 stated HK 2 was not CPR trained-certified (unable to perform CPR). During a concurrent observation and interview on [DATE] at 2:20 pm with the DSD in the Administrator's (ADM) office desk, the DSD and surveyor watched the facility's surveillance video, dated [DATE] from 5:42 am to 7:08 am. The video showed the following sequence of events, on [DATE]: - At 6:28:00 am - HK 1 entered Resident 1's room. - At 6:28:35 am - CNA 1 entered Resident 1's room. - At 6:28:37 am - HK 1 was at Resident 1's doorframe talking to Housekeeping Supervisor (HKS). - At 6:29:02 am - CNA 1 exited Resident 1's room and walked towards the nurse's station. - At 6:29:03 am - HK 1 and HKS entered Resident 1's room. - At 6:29:33 am - CNA 1 entered Resident 1's room. - At 6:29:44 am -LPT 1 entered Resident 1's room. - At 6:30:09 am - CNA 1 exited Resident 1's room and walked down the hall. - At 6:30:20 am - HK 1 exited Resident 1's room. - At 6:30:25 - LPT 1 exited Resident 1's room. - From 6:30:25 am to 6:30:59 am - LPT 1 was pacing the hallway, then opened the east unit's door and entered the unit (to notify LVN 1). - At 6:31:05 am - CNA 1 returned and entered Resident 1's room. - At 6:31:08 am - HKS exited Resident 1's room. - At 6:31:09 am - LPT 1 entered Resident 1's room. - At 6:31:21 am - LPT 1 exited Resident 1's room and walked toward the east unit. - At 6:31:31 am to 6:31:35 am - CNA 4 and LPT 1 walked out of the east unit, walked toward Resident 1's room, and entered Resident 1's room. - At 6:32:01 am - LVN 1 entered Resident 1's the room. CNA 4 exited Resident 1's room and walked toward to east unit. - At 6:33:00 am - CNA 5 entered Resident 1's room, exited at 6:33:22 am, entered at 6:33:30 am, exited at 6:33:40 am, and entered again at 6:33:28 am. - At 6:33:27 am - the DSD entered Resident 1's room. - At 6:33:40 am - the DSD exited Resident 1's room and ran toward the nurse's station. - At 6:34:03 am - CNA 1 exited Resident 1's room. - At 6:34:12 am - LVN 1 exited Resident 1's room and walked down the hallway. - At 6:34:25 am - LPT 1 entered Resident 1's room. - At 6:34:41 am - LPT 1 walked out of Resident 1's room and stood in the hallway. - At 6:35:01 am - LPT 1 and LVN 1 walked back into Resident 1's room. - At 6:35:19 am - the Infection Preventionist (IPN) entered Resident 1's room. - At 6:35:48 am - the IPN walked out of Resident 1's room. - At 6:36:25 am - the DSD entered Resident 1's room. - At 6:36:40 am - a staff member (unidentified) brought an 02 tank into Resident 1's room. - At 6:41:51 am - LVN 1 left Resident 1's room, walked toward CNA 1, and spoke with CNA 1 in the hallway. - At 6:42:15 am - LVN 1 returned and entered Resident 1's room. - At 6:42:28 am - the DSD and LVN 1 exited Resident 1's room. - At 6:43:54 am - the EMTs entered Resident 1's room. - At 6:44:04 am - Los Angeles Fire Department (LAFD) arrived and entered Resident 1's room. - At 7:08:46 am - the police department arrived. During this interview, the DSD stated when the DSD entered Resident 1's room at 6:33 am, the DSD instructed LPT 1 and LVN 1 to start CPR because neither one had started CPR (CNA 1 found Resident 1 unresponsive at 6:28 am). The DSD stated CPR should have been started by CNA 1 because CNA 1 was the first staff member at the scene. The DSD stated CPR was important because it was the first action that had to be done after checking for breathing and checking for a pulse. During an interview on [DATE] at 4:19 pm, CNA 1 stated on [DATE] around 6:30 am, HK 1 told CNA 1 to check Resident 1 and when CNA 1 entered Resident 1's room, CNA 1 saw Resident 1 on the floor. CNA 1 stated CNA 1 called Resident 1's name three times and Resident 1 did not respond, CNA 1 left Resident 1's room to inform LPT 1. CNA 1 stated CNA 1 did not perform CPR and did not touch Resident 1 because CNA 1 did not know if Resident 1 fell or had any injuries. CNA 1 stated this was the first time CNA 1 found an unresponsive resident. CNA 1 stated CNA's (in general) were trained to provide CPR and stated when finding an unresponsive resident: CNAs needed to provide CPR by checking a pulse, starting chest compressions, and needed to call a code 99 (activated when there is a medical emergency that requires a response from clinical staff). During a review of the facility's CPR certifications, the review indicated CNA 1 had Basic life Support (BLS, a level of medical care used for patients with life-threatening condition of cardiac arrest, performed until they can be given full medical care by advanced life support providers) certification from the American Heart Association, issue date [DATE], renew by 4/2025. During a follow-up interview on [DATE] at 4:38 pm with LPT 1, LPT 1 stated when LPT 1 entered Resident 1's room and saw Resident 1 on the floor, in a fetal position (curled up into a ball while laying on one side with legs and arms bent), the situation looked like an emergency and LPT 1 decided LPT 1 needed help from LVN 1 who was more experienced. LPT 1 stated LPT 1 left Resident 1's room to the east unit and told CNA 4, who was close to the door located between west and the east unit, to notify LVN 1 there was an emergency. LPT 1 stated if Resident 1 was not breathing and had no pulse, LPT 1 needed to check Resident 1's airway, breathing, circulation, check Resident 1's pulse, and start CPR immediately. LPT 1 stated CPR could save a life and it was the last defense for Resident 1 to get oxygen and pump [blood to] the heart. During an interview on [DATE] at 6:21 am, CNA 1 stated on [DATE], CNA 1 was assigned to care for Resident 1 (11 pm to 7 am). CNA 1 stated the last time CNA 1 saw Resident 1 was at the start of CNA 1's shift at 11 pm. During this time, Resident 1 was laying on Resident 1's bed, sleeping, and snoring. CNA 1 stated CNA 1 did not see Resident 1 after 11 pm. CNA 1 stated on [DATE] CNA 1 visually checked residents assigned to CNA 1 by sitting in the hallway located two rooms away from Resident 1's room but did not actually observe Resident 1 while the resident was inside the room. During a review of Resident 1's Follow Up Question Report (hourly location of Resident 1), dated [DATE], the log indicated CNA 1 documented Resident 1 was inside Resident 1's room from [DATE] at 9 pm to [DATE] at 6 am. During an interview on [DATE] at 8:25 am, with CNA 3, CNA 3 stated it was around 6:30 am when CNA 3 was returning from the laundry area and heard CNA 1 call for help. CNA 3 entered Resident 1's room and CNA 3 saw LPT 1, LVN 1, and Resident 1 lying on the floor. CNA 3 stated LVN 1 tapped Resident 1 and LVN 1 asked Resident 1, Are you okay? CNA 3 stated CNA 3 left the room when LPT 1 and LVN 1 started to turn Resident 1 on his back and CNA 3 saw the Director of Staff Development (DSD) on the DSD's way to Resident 1's room. During an interview with the Quality Assurance Nurse (QAN), on [DATE] at 11:30 am, the QAN was asked for Resident 1's POLST (a written medical order from a physician, nurse practitioner, or a physician assistant which specifies what a patient's lifesaving treatment wishes are). The QAN stated Resident 1 did not have a POLST and stated all residents residing at the facility were considered full codes unless there was an AD. The QAN stated Resident 1 did not have an AD. During a telephone interview on [DATE] at 1:30 pm, LVN 1 stated, on [DATE], LVN 1 went to Resident 1's room when LVN 1 was notified [by CNA 4] there was a medical emergency. LVN 1 stated LVN 1 saw Resident 1 on the floor with Resident 1's face down and told Resident 1 to get up but Resident 1 did not respond. LVN 1 stated Resident 1 had no pulse, was not breathing, and LVN 1 instructed the staff who were inside the room (unidentified) to call 911. LVN 1 stated Resident 1 was turned over and there was yellowish, clear liquid (approximately half a cup) with small spots of blood underneath Resident 1. LVN 1 stated the DSD came to Resident 1's room and instructed them (LVN 1 and LPT 1) to start CPR and Resident 1 was turned on Resident 1's back. LVN 1 stated LVN 1 initiated CPR but could not recall what time LVN 1 initiated CPR. LVN 1 stated it was around 6:30 am when CNA 4 informed him there was a medical emergency. During an interview on [DATE] at 2:49 pm, with the Director of Nursing (DON), the DON stated the facility staff needed to check responsiveness by calling the resident's name and if there was no response, staff needed to tap the resident, if there was still no response, staff needed to check for airway, breathing, and circulation. The DON stated if there was no pulse and no breathing, staff needed to call a code blue and start CPR to restart circulation and keep the heart beating. During a review of the facility's undated P&P titled, Advance Directive/Individual Health Care Instructions, the P&P indicated each resident will receive and the facility must provide the necessary care and services to attain or maintain the highest possible practicable physical, mental, and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care by providing basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advance directive. During a review of the facility's P&P titled, Emergency Response Policy and Procedure dated 9/2024, the P&P indicated the facility will provide basic life support, including (Cardiopulmonary Resuscitation) CPR, to all residents requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advanced directives. The P&P indicated all residents of [the facility] are full code status unless otherwise indicated in an advanced directive that is given to the facility by the resident's responsible party.

Based on observation, interview, and record review, the facility failed to have a system in place to ensure safeguarding of all prescribed medications including controlled medications (medications with a high potential for abuse) for 17 of 17 Resident (Residents 18, 20, 25, 27, 28, 34, 37, 45, 51, 55, 57, 71, 84, 97, 148, 150, and 151) by failing to: 1. Maintain accountability records for all controlled substances/medications that were disposed of or destroyed with the unused supply between 1/1/2024 through 8/8/2024 and ensure each resident's individual controlled drug record (CDR, any Schedule 2 through Schedule 5 controlled drugs [potential for abuse and/or addiction] received or supplied by a pharmacy) for each controlled medication was used for accurate accountability of controlled medications for 6 of 6 sampled Residents (Residents 34, 71,97, 148, 150 and 151). Controlled medications included lorazepam and clonazepam (medications used to treat anxiety, a mental disorder characterized by persistent feelings of worry, nervousness, or unease strong enough to interfere with daily activities), zolpidem (medication used to treat insomnia, difficulty falling asleep), lacosamide and clobazam (medication used to treat seizures, a sudden rush of abnormal electrical activity in your brain). 2. Ensure medication carts and cabinets contained controlled medications and biologicals, were maintained locked, and not left unattended when not in use to prevent the potential for unauthorized access to medications that included noncontrolled medications stored in medication carts in two of two nursing stations (West Nursing Station Medication Cart and East Nursing Station Medication Cart) for 11 of 11 sampled Residents (Residents 18, 20, 25, 27, 28, 37, 45, 51, 55, 57 and 84). 3. Ensure the access keys were not the same keys to access other medications and controlled medications and were not stored inside the medication carts and failed to ensure licensed nurses (all licensed nurses) maintained possession of the keys to controlled medications and the keys were not left inside of an unlocked medication cart in the East Nursing Station. These deficient practices resulted in a facility wide system failure to secure and accurately account for and reconcile controlled medications for Residents 18, 20, 25, 27, 28, 34, 37, 45, 51, 55, 57, 71, 84, 97, 148, 150 and 151. The failure placed the facility at risk for medication errors, residents to receive more or less medication than prescribed, adverse reactions (harmful or unpleasant reaction, resulting from an intervention related to the use of a medication) such as: falls, hospitalizations, harm, and inability to readily identify the loss or drug diversion (illegal distribution of abuse of prescription drugs or their use for unintended purposes) of controlled medications. On 8/8/2024, while onsite at the facility, the California Department of Public Health (the Department) identified an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident) regarding the facility's failure to ensure safeguarding of controlled medications. The survey team notified the Administrator (ADM), the Director of Nursing (DON), the Registered Nurse Supervisor (RNS), the Quality Assurance Nurse (QAN), the Social Services Designee (SSD), the Director of Staff Development (DSD), and the Infection Preventionist (IP) of the IJ situations on 8/8/2024, at 3:07 PM due to the facility failure to maintain countability for controlled medications for Residents 34, 71, 97, 148, 150 and 151, and failure to keep controlled medications locked/secured for Residents 18, 20, 25, 27, 28, 37, 45, 51, 55, 57 and 84. On 8/9/2024, the facility submitted an acceptable IJ Removal Plan (IJRP, plan that includes interventions to immediately correct the deficient practices). While onsite at the facility, the survey team determined the IJ situation was no longer present and confirmed/verified the facility's full implementation of the IJRP through observations, interviews, and record review. The IJ was removed on 8/9/2024 at 7:13 PM in the presence of the ADM, the DON, the QAN, and the DSD. The IJPR included the following immediate actions: 1. All controlled medications for the 17 sampled residents were immediately secured in a locked box within the medication cart. 2. A routine count sheet was created for each resident that received controlled medications. 3. All routine narcotic medications were moved to a locked box within the medication cart with individual counting sheets for each medication. 4. On 8/8/2024, the DON and the new Pharmacy Consultant (Pharm 3) conducted a facility-wide audit to identify all residents that received controlled medications. All 95 residents were considered at risk due to the systemic nature of the deficiency. The same immediate actions taken for the 17 sampled residents were implemented for all residents that received controlled medications. 5. On 8/08/2024, a root cause analysis was conducted, including interviews with nursing staff, review of medication administration records, and analysis of current policies and procedures. The analysis revealed: a. Lack of a robust system for controlled medication accountability b. Inadequate staff training on controlled medication management c. Insufficient security measures for medication storage 6. Effective 8/8/2024, a new controlled medication accountability system was implemented: a. Individual counting sheets for each resident's-controlled medication. b. Dual nurse sign-off (process that required two licensed nurses to approve or initiate a change) for waste (leftover or unused medications that were discarded) or refusal of controlled medications. c. Shift change audits of controlled medications. 7. On 8/08/2024, all controlled medications were stored in a locked box within a locked drawer in the medication cart. 8. As of 8/8/2024, narcotic keys were kept with the charge nurse and stored on their person until endorsed to the next licensed nurse during shift change. The DON would have a key to the discontinued medication box, and in the DON's absence, the RN supervisor would be the designated person to hold the key. 9. As of 8/8/2024, Licensed nurses would submit discontinued medications to the DON as soon as possible after the medication were discontinued or when the resident was discharged . If the discontinuation occurred during the weekend, the licensed nurse would hold the discontinued medications in the locked box and continue counting until submitted to the DON. 10. On 8/8/2024, the DON completed an inventory of all controlled medications currently on hand in the facility. 11. On 8/09/2024, discontinued controlled medications were stored in a locked box bolted inside a locked drawer in the DON's office 12. As of 8/9/2024, the DON would count discontinued controlled medications with the licensed nurse and document the receipt on the narcotic sheet. 13. On 8/9/2024, a new pharmacy consultant from the facility's pharmacy provided inservice training to all licensed staff on controlled medication management, storage, counting, documentation, and wasted controlled medication procedures. The staff that were not able to attend the in-service training would be in-serviced on 8/13/2024 at 11 AM by the new pharmacy consultant. The staff that were unable to attend and [reason] why would be indicated on the in-service training sign-in sheets attached. 19 licensed staff were able to attend [the] in-service training and 5 were out due to school, other jobs, vacation, and medical [leave]. On 8/9/2024 available licensed staff did return in-service training [regarding] shift change narcotic count sheets, the sheets should not be signed ahead of time, and controlled substances must follow a pour (placing/pouring the correct medication dose into a medication cup) and sign [sign off] protocol. The DON would do return in-service training every shift for licensed staff unable to attend on 8/9/2024 until all licensed staff [were] in-serviced. 14. On 8/9/2024, the facility would review policies on Medication Storage in the Facility, Medication Ordering and Receiving from Pharmacy, Controlled Medications, and Controlled Substance Prescriptions to reflect new procedures. The Monitoring and Evaluation Plan indicated: 1. Beginning 8/8/2024, the DON conducted audits of controlled medication management: a. Every shift for the next 48 hours (until 8/9/2024) b. Twice weekly for three weeks (until 8/31/2024) c. Weekly thereafter beginning 8/31/2024. The DON would review all discrepancies identified during the audits, notify the Medical Director and pharmacy as needed, and document the findings for Quality Assurance and Assessment (QAA, provides framework for evaluating a facility's systems to prevent deviation and to correct inappropriate care processes, responds to quality deficiencies identified in the facility) review. 2. Beginning 8/9/2024, the DON would oversee the disposal (discarding unused drugs) of discontinued controlled medications in collaboration with the facility's pharmacist. 3. Beginning on 8/9/2024, the destruction of medical records would be kept in accordance with Title 22 (state regulations). The Director of Nursing would report the monitoring plan results to the QAA Committee monthly. The QAA Committee would monitor on an ongoing basis until sustained compliance is achieved and report results in quarterly QAA meetings. Findings: 1. During a concurrent observation of the controlled medication storage inside the DON's office, and interview with the DON, on 8/7/2024 at 3:03 PM. The DON stated the DON's office was shared with the DSD and the IP. The DON stated controlled medications awaiting disposal were stored in a cabinet inside of the DON's office and the DSD kept the key to the cabinet. The cabinet was observed unlocked. The DON stated the DON placed the controlled medications, awaiting disposal, on top of a box inside of a cabinet. The DON stated the DON did not have a designated or secure location to store controlled medications awaiting disposal. During a concurrent interview with the DON and record review on 8/7/2024 at 3:08 PM, the CDR forms for Residents 34, 71, 97, 148, 150 and 151 indicated the following: a. Resident 34's CDR form with a pharmacy fill date of 2/7/2024, labeled for zolpidem tartrate 10 milligram (mg, unit of measurement) tablet, indicated a total of 30 tablets. The CDR form did not indicate signatures from licensed nurses to show the date, time, and quantity for each dose of zolpidem removed for administration to Resident 34. b. Resident 71's CDR form with a pharmacy fill date of 6/20/2024, labeled for lorazepam 1 mg, 1 tablet taken every 6 hours PRN (as needed), indicated a total quantity of 39 tablets and a disposed quantity of 36 tablets. The form indicated the DON and Pharm 1 signed on the bottom left of the form, dated 7/30/2024 for the disposal of 36 tablets. The CDR form did not indicate signatures from licensed nurses to show the date, time, and quantity for each dose of lorazepam removed for administration to Resident 71. c. Resident 97's CDR form with a pharmacy fill date of 1/24/2024, labeled for clonazepam 1 mg, indicated a total quantity of 75 tablets of clonazepam and a disposed quantity of 30 out of 75 tablets. The form indicated the DON and Pharm 1 signed on the bottom left of the form, dated 2/17/2024 for the disposal of 30 tablets. The CDR form did not indicate signatures from licensed nurses to show the date, time, and quantity for each dose of clonazepam removed for administration to Resident 97. d. Resident 148's CDR form with a pharmacy fill date of 1/10/2024, labeled for lorazepam 1 mg, indicated a total quantity of 90 lorazepam tablets and a disposed quantity of 30 tablets. The form indicated the DON and Pharm 1 signed on the bottom left of the form, dated 2/22/2024 for the disposal of 30 tablets. The CDR form did not indicate signatures from licensed nurses to show the date, time, and quantity for each dose removed for administration to Resident 148. e. Resident 150's CDR form with a pharmacy fill date of 4/17/2024, labeled lorazepam 1 mg, tablet with instructions to administer one tablet by mouth twice daily indicated there were 58 lorazepam tablets and the disposal quantity was 29 out of 58 tablets. The form indicated the DON and Pharm 1 signed the form, dated 5/21/2024, on the bottom left to indicate the disposal of 29 tablets. The CDR form included a handwritten note that indicated, given routinely. The form did not indicate signatures from licensed nurses to show the date, time, and quantity for each dose removed for administration to Resident 150. f. Resident 151's CDR forms with pharmacy fill date of 2/7/2024, labeled for lacosamide 200 mg, give one tablet by mouth twice a day, indicated a total quantity of 60 tablets. The CDR form did not indicate signatures for the disposal of the medications nor signatures from licensed nurses to show the date, time, and quantity for each dose of lacosamide removed for administration to Resident 15. During a concurrent interview with the DON and record review on 8/7/2024 at 3:08 PM, the DON stated the signatures on the bottom of the CDR forms belonged to the DON and Pharm 1. The DON stated discontinued and expired controlled medications were last destroyed on 7/30/2024 with Pharm 1. The DON stated the section for dispensed medications on the CDR forms labeled for individual residents were left blank. The DON stated the facility did not accurately account for the discontinued and expired controlled medications. During an interview with the DON on 8/7/2024 at 3:15 PM, the DON stated both the DON and Pharm 1 would not go back to compare Residents' (Residents 34, 71, 97, 148 150 and 151's) MARs with each CDR form to ensure all doses of controlled medications were administered as ordered by the physician and to address the discrepancy between the original quantity and the disposal of medications. The DON stated, the DON and Pharm 1 did not verify or account for the disposal/destruction of controlled medications for each dose of controlled medication that were not recorded on the CDR forms. The DON stated the licensed nurses did not document on the CDR forms when controlled medications were removed and administered to the residents. The DON stated when Pharm 1 came to the facility to dispose controlled medications with the DON, the DON and Pharm 1 did not go back to compare with the residents' MAR or any residents' medical records. The DON stated the facility did not have a system to ensure all doses of the controlled medications were administered to the residents or to reconcile or account for the discrepancy between the original quantity delivered to the facility and the quantity destroyed. The DON stated the facility did not have a system to account for each dose of controlled medication being wasted, refused, or not administered to a resident as prescribed. The DON stated there was no shift change audit (a controlled medication reconciliation document signed by two nurses during shift change) done between the oncoming nurse (nurse starting the shift) and the outgoing nurse (nurse leaving) to verify that all controlled medications inside the medication carts were accurate and accounted for before endorsing the medication carts from one nurse to the next nurse. During a concurrent observation of the medication cart in the [NAME] Nursing Station and interviews with LVN 3 and LVN 4 on 8/7/2024 at 3:40 PM, there were controlled medications stored together with noncontrolled medications in the medication cart. LVN 3 showed a large binder located on the [NAME] Nursing Station that was filled with CDR forms and had prescription labels from the facility's dispensing pharmacy. LVN 4 stated licensed nurses never filled the CDR forms out to account for each dose of controlled medications removed for administration to the residents. LVN 4 stated the licensed nurses did not count the controlled medications during shift change before endorsing the medication carts to the nurses from the next shift. During an interview on 8/7/2024 at 3:50 PM with LVN 3 and LVN 4, LVN 4 stated LVN 4 would not have any idea if controlled medications were missing, diverted for personal use, or if all the controlled medications for each resident were accounted for because nurses did not count the controlled medications between shifts. LVN 3 stated the licensed nurses would not know if controlled medications became missing or were misused because the medications were kept among the noncontrolled medications, and the controlled medications were not counted each day. During a telephone interview on 8/8/2024 at 8:19 AM with the DON and Pharm 1, Pharm 1 stated the facility's licensed nurses were supposed to document on the controlled drug count down sheet (CDR) each time they remove a controlled medication for resident administration. Pharm 1 stated the nurses were also expected to verify the controlled medications with two nurses during the change of shift to make sure the controlled medication count was accurate before the outgoing nurse endorsed (hands over the medication cart key) to the oncoming nurse, and if there were any discrepancies with the controlled medications, two nurses could work to resolve any concerns. Pharm 1 stated, that was the standard of practice for handling-controlled medications. Pharm 1 stated the controlled medication count down sheets (CDR) needed to be filed away as a permanent record to ensure controlled medication accountability. Pharm 1 was asked why Pharm 1 signed the blank (not filled in) CDR forms for Residents 34, 71, 97, 148, and 150 during controlled medication disposal when the original quantity was different from the quantity being destroyed for each resident-controlled medication, Pharm 1 stated Pharm 1 just destroyed what was presented to Pharm 1. Pharm 1 stated, I would not know if any medications [were] diverted or lost. Pharm 1 stated I am only documenting the narcotic medication I am disposing of right there. Pharm 1 stated I do not look at any other document to see or reconcile with the unused controlled medication that I am disposing of. Pharm 1 stated Pharm 1 had not provided any training to the facility's staff on medication storage or handling controlled medications. During an interview on 8/8/2024 at 8:50 AM with the DON, the DON stated the facility's practice was not using the CDR sheets during the removal of routine controlled medications since before the DON started working at the facility more than a year and half ago. During a telephone interview on 8/8/2024 at 9 AM with the DON and the facility's dispensing pharmacist (Pharm 2) Pharm 2 stated, Pharm 2 sent a CDR form for each resident's controlled medication to the facility. Pharm 2 stated, CDR forms were used to keep track of what was dispensed and administered to the residents. Pharm 2 stated, it was up to the facility's policy what process for keeping track of controlled medications the facility should follow. Pharm 2 stated it was the responsibility of the facility's Consulting Pharmacist (in general) to help keep the facility compliant with regulations. Pharm 2 stated Consulting Pharmacist needed to follow the facility's policy for handling controlled medications and ensuring the monitoring and accounting of controlled medications. Pharm 2 stated the facility must order controlled medications each time before a resident runs out of their medication by either calling the dispensing pharmacy or sending a faxed refill request. During a concurrent telephone interview with Pharmacist Technician (PhTech) from the facility's dispensing pharmacy, and record review on 8/8/2024 at 11:13 AM, the Controlled Medication Report dated from 1/1/2024 through 8/8/2024 were reviewed, the Controlled Medication Report indicated the facility received the following controlled medications from the dispensing pharmacy for 35 individual residents and the total number of doses for each medication delivered to the facility from 1/1/2024 through 8/8/2024 were as follow: 1. Lorazepam 0.5 mg - 951 tablets 2. Lorazepam 1 mg - 1,861 tablets 3. Clonazepam 0.5 mg - 210 tablets 4. Clonazepam 1 mg - 3,101 tablets 5. Clonazepam 2 mg - 472 tablets 6. Zolpidem 10 mg - 60 tablets 7. Lacosamide 50 mg - 402 tablets 8. Lacosamide 200 mg - 180 tablets During an interview on 8/8/2024 at 3:14 PM with the ADM and the DON, the DON stated Pharm 1 had been to the facility many times and had not identified any concerns with the facility's handling of controlled medications. 2. During a concurrent observation of the controlled medication storage inside the DON's office, and interview with the DON, on 8/7/2024 at 3:03 PM. The cabinet was unlocked. The DON stated the DON placed the controlled medications, awaiting disposal, on top of a box inside of the cabinet. The DON stated the DON did not have a designated or secure location to store controlled medications awaiting disposal. During an interview on 8/7/2024 at 3:27 PM with DON and the DSD inside of the DON's office, the DSD stated, the DSD had the key to the cabinet inside of the DON's office that contained discontinued and expired controlled medications awaiting disposal. The DSD stated the key to the cabinet was hung and stored on a wallboard located inside of the DON's shared office space. The DON stated the cabinet was not kept locked. During an observation of the [NAME] Nursing Station Medication Cart and the East Nursing Station Medication Cart with the DON on 8/7/2024 from 3:44 PM to 4:26 PM, the following resident medications were observed and stored mixed together with noncontrolled medications: West Nursing Station Medication Cart included the following controlled medications for: a. Resident 27 - two medication cards of clonazepam 0.5 mg, half of a tablet in each bubble pack (a card that packages doses of medication within small, clear, or light-resistant, amber-colored plastic bubbles). There were 17 remaining half tablets in one medication card and 15 half tablets in the second medication card. b. Resident 28 - two medication cards of clonazepam 1 mg, one medication card contained 20 tablets and the second medication card contained 21 tablets of clonazepam. c. Resident 20 - two medication cards of lorazepam 1 mg, one medication card contained 6 tablets and the second medication card contained 7 tablets of lorazepam. d. Resident 55 - two medication cards of lorazepam 0.5 mg, one medication card contained 6 tablets and the second medication card was contained 7 tablets of lorazepam. e. Resident 51 - one medication card of lorazepam 0.5 mg, the medication card contained 10 half tablets of lorazepam. East Nursing Station Medication Cart included the following controlled medications for: a. Resident 45 - one medication card of clonazepam 2 mg, the medication card contained 28 tablets of clonazepam. b. Resident 57 - three medication cards of clonazepam 1 mg, one medication card contained 28 tablets, the second medication card had 29 tablets, and the third medication card contained 29 tablets of clonazepam. c. Resident 18 - three medication cards of lorazepam 1 mg, one medication card contained 12 tablets, the second medication card contained 13 tablets, and the third medication card contained 13 tablets of lorazepam. d. Resident 25 - two medication cards of clonazepam 1 mg, one medication card contained 15 tablets and the second medication card was contained 14 tablets of clonazepam. e. Resident 37 - one tablet of lorazepam 0.5 mg, prescribed for single use prior to appointments until 10/30/2024. f. Resident 84 - one tablet of lorazepam 0.5 mg, prescribed for single use prior to appointments until 10/7/2024. During an interview with the DON on 8/7/2024 at 4:18 PM, the DON stated controlled medications were not stored in a double locked drawer in the medication carts. The DON stated routine controlled medications were stored together with regular noncontrolled medications. The DON stated the facility was not following the facility's policy for storage of controlled medications. The DON stated the access key for controlled medications inside of the medications cart was the same key used for noncontrolled medications. The DON stated both nursing stations (West Nursing Station medication carts and the East Nursing Station medication carts) stored controlled routine medications along with noncontrolled medications. During a telephone interview on 8/8/2024 at 8:19 AM with the DON and Pharm 1, Pharm 1 stated Pharm 1 provided pharmacy consultant services to the facility in accordance with federal and state regulations. Pharm 1 stated controlled medications should be stored in a separate locked drawer inside of the medication cart. Pharm 1 stated Pharm 1 did not check the facility's medication storage every month. During an interview on 8/8/2024 at 8:50 AM with the DON, the DON stated the controlled medications that were routinely administered had never been locked or stored separately from the noncontrolled medications since the DON started working at the facility over a year and a half ago. The DON stated, I do not know if any controlled medication has been diverted, loss, or misused. During a concurrent interview with LVN 4 and observation of two medication carts in the [NAME] Nursing Station on 8/8/2024 at 9:50 AM, LVN 4 opened the [NAME] Nursing Station Medication Cart and stated there were currently six residents receiving controlled medications on the [NAME] Nursing Station. LVN 4 pulled the medication cards that were mixed with the noncontrolled medications and stated there were 13 medication cards. LVN 4 left the [NAME] Nursing Station Medication room without locking the two medication carts located inside of the [NAME] Nursing Station Medication Storage Room. During an interview with LVN 4 on 8/8/2024 at 10:23 AM. LVN 4 stated the two medication carts on the [NAME] Nursing Station were unlocked and the medication cart should have been locked before LVN 4 left the medication storage room. 3. During a concurrent observation of two medication carts on the East Nursing Station and interview with LVN 4 on 8/8/2024 at 10:25 AM, LVN 4 unlocked and entered the East Nursing Station, the two East Nursing Station Medication Carts were unlocked, and no licensed nurse or staff were present upon the surveyor's arrival with LVN 4 to the East Nursing Station. LVN 4 stated the two medication carts inside of the East Nursing Station were left unlocked and the East Nursing Station Medication Cart was assigned to LVN 1. LVN 4 stated LVN 4 did not know where LVN 1 was. LVN 4 opened the unlocked medication cart and opened a drawer that contained keys to both medication carts and to the locked narcotic drawer inside of the unlocked medication cart. LVN 4 was able to use the key to unlock the narcotic drawer. LVN 4 used the keys to lock the two medication carts in the East Nursing Station. LVN 4 stated unauthorized staff that worked in the facility had access to the nursing station, which included, certified nurse assistants (CNAs), floor staff, counselors, and housekeeping. LVN 4 stated the unauthorized staff had access to the medications inside of the medication carts including controlled medications because the medication carts were not locked, and the keys were left available to be used by others. During an interview on 8/8/2024 at 11:04 AM with LVN 1, LVN 1 stated LVN 1 left the medication cart on the East Nursing Station unlocked and LVN 1 should have locked the medication cart because there was a lot of medications inside that could be removed while LVN 1 was away from the cart. LVN 1 stated the medication cart was not secured to ensure access was limited to the medications by authorized staff (licensed nurses). During a review of the facility's Policy and Procedures (P&P) titled, Controlled Substance Prescriptions, dated 5/2022, the facility's P&P indicated, Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances, and medications classified as controlled substances by state law, are subject to special ordering, receipt, and recordkeeping requirements in the facility, in accordance with federal and state laws and regulations. The Director of Nursing and the contracted pharmacist maintain the facility's compliance with federal and state law and regulations in the handling of controlled medications. Only authorized, licensed nursing and pharmacy personnel have access to controlled medication. Controlled substance medications are dispensed by the provider pharmacy in readily accountable quantities and containers designed for easy counting of contents. The pharmacy will provide an individual resident-controlled drug record (count sheet) for each controlled substance medication container dispensed to a resident. Controlled substance medications are stored at the facility under double lock on the medication cart separate from all other medications and counted at each change of custody. The access key to controlled medications is not the same key that allows access to other medications. The medication nurse on duty maintains possession of a key to controlled medications. During a review of the facility's P&P titled, Consultant Pharmacist Services Provider Requirements, dated 5/2022, the facility's P&P indicated, The consultant pharmacist provides consultation on all aspects of the provision of pharmacy services in the facility. In collaboration with facility staff, the consultant pharmacist helps to identify, communicate, address, and resolve concerns and issues related to the provision of pharmaceutical (relating to medical drugs, or the preparation use or sale of drugs) services. This includes, but is not limited to .Establishing a system of records for receipt and disposition of all controlled medications to enable an accurate reconciliation, and determining that drug records are in order and that an account of all controlled medications is maintained and periodically reconciled .Checking the medication storage areas at least monthly, and the medication carts at least quarterly, for proper storage and labeling of medications, cleanliness, and removal of expired medications. During a review of the facility's P&P titled, Controlled Substance Disposal, dated 5/2022, the facility's P&P indicated, Disposition is documented on the individual controlled substance accountability record/book .Accountability records for controlled substances that are disposed of or destroyed are maintained with the unused supply until it is destroyed or disposed of and then these records are stored for a period of time outlined per applicable law or regulation or facility policy. During a review of the facility's P&P titled, Storage of Medications, dated 5/2022, the facility's P&P indicated, Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes.) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow its policy and procedure (PP) titled, Q:15 (every 15) Minute Monitoring, and provide supervision every 15 minutes per the physician's order to prevent elopement (leaving the facility without notice) from the locked (equipped with secured locks or other functioning security devices) facility for one of four sampled residents (Resident 1) who was assessed as at risk for elopement by failing to: 1. Ensure Certified Nurse Assistant (CNA) 1 and CNA 2 monitored and kept Resident 1 in a clear and direct line of sight (within someone's view) every 15 minutes. 2. Ensure CNA 1 and CNA 2 accurately monitored and documented Resident 1's whereabouts every 15 minutes. As a result of these failures, on 5/19/2024 at 10:15 am, Resident 1 entered the facility's unlocked Recreation Room without CNA 1 and CNA 2's supervision. On 5/19/2024 at 10:32 am, Resident 1 eloped from the facility through the patio from the Recreation Room. Resident 1 stacked chairs on top of a table in the patio, climbed onto the facility roof, walked to the southwest corner of the front of the facility building, climbed down using facility fencing, and walked southbound on the street and away from the facility. Resident 1 had not been found. These failures had the potential to put Resident 1 at risk for serious injury, harm, and/or death due to not receiving psychotropic medications (any drug that affected brain activities associated with mental processes and behavior), not having food and shelter, and being exposed to cold weather at night. On 5/21/2024 at 5:10 pm, while onsite at the facility, the surveyor identified an Immediate Jeopardy situation (IJ- a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). The surveyor called an IJ in the presence of the Administrator (ADM), Director of Nursing (DON), Quality Assurance Nurse (QAN), Director of Staff Development (DSD), Medical Records Director (MRD), and the facility's [NAME] President (VPL) due to the facility's failure to monitor and supervise Resident 1, under 42 Code of Federal Regulations Section 483.25(d) Accidents, including providing adequate (acceptable in quality or quantity) supervision to prevent accidents to Resident 1 who was at risk for elopement, and was on every 15-minute monitoring by CNA 1 and CNA 2. On 5/22/2024 at 4:54 pm, the facility submitted an acceptable Plan of Action (POA- a list of steps taken to correct the deficient practices). While onsite at the facility, the surveyor verified the facility installed a new lock on the Recreation Room's door, other residents do not have access to the Recreation Room and confirmed the facility's implementations of the POA through observation, interview, and record review. The surveyor determined an IJ situation was no longer present and removed the IJ while onsite at the facility on 5/22/2024 at 5:06 pm, in the presence of the ADM, DON, QAN, DSD, and MRD. The IJ removal plan, dated 5/22/2024 included the following: 1. The facility made every effort to locate Resident 1 in the community by doing the following: a. CNA 2, Mental Health Aide (MHA) 1, and CNA 6 completed a 1-mile parameter search around the facility. b. Licensed Psychiatric Technician (LPT) 1 conducted a search of the roof to determine if Resident 1 had injured himself or was unable to get off roof. c. LPT 1 and LPT 2 contacted Local Police Department and filed a missing person's report. d. The DON called local hospitals daily and asked if Resident 1 had been admitted . e. The QAN and Social Services Designee (SSD) updated County Public Guardian (an individual or entity appointed by the court to make decisions with respect to the personal affairs of an individual) daily and inquired if the County Public Guardian had any new information regarding Resident 1. 2. The facility would provide an environment, safe from hazards and bodily injury to Resident 1 once found. Staff (assigned staff) would supervise Resident 1 every 15 minutes for safety. Staff must visually see Resident 1 upon these checks. The facility ' s updated PP titled, Q:15Minute Monitoring, on 5/22/2024 to reflect the following changes: a. Facility staff (assigned staff) must have a clear line of sight of Resident 1. b. Facility staff must visually identify Resident 1. c. If facility staff exercised the use of a Walkie Talkie device (a small radio held in the hand, used for both sending and receiving messages) to locate Resident 1's whereabout, the staff who visually saw Resident 1 must document Resident 1's location in Resident 1's electronic clinical record under the Plan of Care (POC) portal. d. In documenting Resident 1's location in Resident 1's electronic clinical record, staff were to make an honest and accurate entry that staff visually saw and identified Resident 1. 3. All 95 Residents admitted to the facility would be safe in the environment and safe from hazards and bodily injury. Facility staff would supervise all residents on an hourly basis unless otherwise noted, every 15 minutes for safety. Staff must visually see the residents upon these checks. As per the facility ' s PP titled, Q:15 Minute Monitoring, updated on 05/22/2024, staff assigned to conduct the Q:15-minute checks would do the following: a. Facility staff must have a clear line of sight of the residents. b. Facility staff must visually identify the residents. c. If facility staff exercised the use of a Walkie Talkie device to locate the residents, the staff who visually saw the residents must document the residents' location in the residents' electronic clinical record under the POC portal. d. In documenting the resident's location in the resident's electronic clinical record under the POC portal, staff were to make an honest and accurate entry that staff visually saw and identified the residents. 4. To prevent future incidents of elopement of this likeness, the facility implemented the following: a. On 5/20/2024, the Maintenance Staff (MS) installed a self-locking door hardware on the Recreation Room door. b. On 5/20/2024, facility staff replaced white plastic chairs in the Recreation Room with plastic back and seat. c. ON 5/20/2024, the two staff (CNA 1 and CNA 2) responsible for failing to follow resident care documentation for the Q:15-minute check for Resident 1 were suspended. c1. CNA 1 was terminated on 05/22/2024. Report to the CNA Certification Board to follow. c2. CNA 2 will be terminated on 05/23/2024. Report to the CNA Certification Board to follow. d. On 5/21/2024, the MS had a consultation to have motion sensor cameras installed on the patio to detect any motion. e. On 5/21/2024 and 5/22/2024, all staff (85 staff) were in-serviced on safety and Q:15-minute supervision requirements. f. On 5/22/2024, the MS checked all doors in the facility for self-locking door hardware and replaced any non-self-locking door hardware with self-locking door hardware. This check included the following with the following interventions: f1. On 5/22/2024, the MS replaced the traditional locking doorknob on the roof access with a self-locking doorknob. f2. On 5/22/2024, the MS removed the traditional locking doorknob from the Recreation Room Sliding Door and installed a case lock (a device that kept the door locked and secured). f3. On 5/22/2024, the MS removed the traditional doorknob from the Dining Room and installed a self-locking doorknob. f4. On 5/22/2024, the MS removed the traditional doorknob from the Patio Access Door on [NAME] Unit and installed a self-locking doorknob. g. As of 05/22/2024, all staff would be required to unlock with key to exit onto the patio. h. As of 05/22/2024, all doors in the facility would be required to have a key to unlock for entry. 5. On 5/22/2024, the DSD carried out safety and Q:15-minute supervision in-service training to all staff. The DSD would conduct a safety and Q:15-minute supervision in-service training to all staff annually and upon hire. 6. On 5/22/2024, the Administrator carried out safety and Q:15-minute supervision in-service training to all social services staff (12 staff). Staff that were not able to attend the safety and Q:15-minute supervision in-service training due to being out on leave or being ill, would be in-serviced promptly upon return to work. 7. The QAN to review Q:15-minute documentation for accuracy. The Quality Assessment and Assurance (QAA- a continuous process based on identifying quality problems assessment of data collection and analysis) Committee to review compliance at Quarterly (every 3 months) QAA meeting. Cross Reference F842 Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 to the facility on [DATE], with diagnoses that included schizoaffective disorder (a mental disorder characterized by abnormal thought processes and an unstable mood), anxiety disorder (persistent feeling of dread or panic that can interfere with daily life), and major depressive disorder (common and serious illness that negatively affects how one feels, thinks and acts). During a review of Resident 1's Elopement Risk Assessment (ERA), dated 10/26/2023, the ERA indicated Resident 1 had a history of elopement from previous placements. The ERA indicated Resident 1 believed he did not need treatment for mental illness and shelter as he had been living in the streets. The ERA indicated staff were aware of Resident 1's wander (to move around or go to different places without having a particular purpose or direction) risk. During a review of Resident 1's untitled care plan (CP), initiated on 10/26/2023, the CP indicated Resident 1 had poor impulse control due to absent without official leave (AWOL- also known as elopement) related to schizoaffective disorder. The CP indicated Resident 1 had a history of AWOL from prior facilities. The CP indicated Resident 1 had an attempted AWOL on 1/1/2024 and had one AWOL episode on 1/26/2024. The CP interventions included to assist Resident 1 to identify/discuss feeling associated with impulsive behavior. During a review of Resident 1's Physician Order (PO), dated 1/8/2024, the PO indicated an order for staff to monitor Resident 1 Q:15 minutes, every shift related to safety. During a review of Resident 1's Minimum Data Set (MDS- a standardized resident assessment and care screening tool), dated 4/23/2024, the MDS indicated Resident 1 had moderately impaired cognition (ability to think, remember, and reason). The MDS indicated Resident 1 was independent (no help or staff oversight at any time) with eating, oral hygiene, toileting hygiene, and walking 10 to 150 feet (ft- unit of measurement). The MDS indicated Resident 1 required supervision or touching assistance (helper provided verbal cues and/or touching/steadying and/or contact guard assistance as resident completed the activity and may be provided throughout the activity or intermittently) with personal hygiene. During a concurrent interview and record review on 5/21/2024 at 10:42 am with the ADM, Resident 1's Location Monitoring Follow Up Question Report (LM Report) dated 5/19/2024 was reviewed. The ADM stated CNA 2 was the primary CNA assigned to monitor Resident 1 every 15 minutes on 5/19/2024. The ADM stated CNA 1 documented on the LM Report that Resident 1 was in Resident 1's room on 5/19/2024 at 10 am. The ADM stated CNA 1 documented on the LM Report that Resident 1 was in the hallway from 10:15 am to 10:30 am. The ADM stated CNA 2 documented on the LM Report that Resident 1 was in the hallway from 11:15 am to 11:45 am. The ADM stated facility staff (CNA 1 and/or CNA 2) did not document Resident 1's whereabouts at 10:45 am and 11 am. The ADM stated per the facility's investigation, Resident 1 entered the facility's Recreation Room at 10:15 am because the Recreation Room door was left unlocked. The ADM stated the Recreation Room's door opened to the patio. The ADM stated residents (all residents) were not allowed to be on the patio without staff supervision. The ADM stated Resident 1 was left unsupervised in the Recreation Room and on the patio (on 5/19/2024) from 10:15 am to 10:32 am. The ADM stated Resident 1 climbed onto the facility's roof from the patio and eloped from the facility. The ADM stated facility staff (CNA 1 and CNA 2) did not realize Resident 1 was missing until after lunch (1 pm), even though CNA 1 and CNA 2 were documenting Resident 1's whereabouts between 10:15 am to 11:45 pm. During a concurrent review of the facility's video surveillance and interview on 5/21/2024 at 11:57 am with the Program Director of Special Treatment Program (PD), the surveyor reviewed the facility's video surveillance, dated 5/19/2024 with the PD. The PD stated, the facility's video surveillance dated 5/19/2024, at 10:10:00 am, Resident 1 was in the hallway, standing adjacent to the facility's Beauty Parlor. The PD stated there were no staff visible in the (video surveillance's) frame. The PD stated at 10:15:22 am, Resident 1 was standing in the hallway across from the Recreation Room. The PD stated no staff were visible in the frame. The PD stated at 10:15:56 am, Resident 1 entered the Recreation Room. The PD stated at 10:30:32 am, Resident 1 climbed onto the roof from the patio using 5 stacked plastic chairs and plastic folding table that Resident 1 obtained from the Recreation Room and placed on the patio. The PD stated at 10:32:36 am, the video surveillance showed Resident 1 was outside of the facility fencing, walking south bound on the street and away from the facility. The PD stated no staff were visible in the frame. The PD stated there were no staff present to monitor and supervise Resident 1 while Resident 1 was in the Recreation Room and the patio. The PD stated the Recreation Room was supposed to remain locked for residents' safety. During a telephone interview on 5/21/2024 at 1:28 pm with CNA 1, CNA 1 stated (in general) when a resident was on Q 15-minute monitoring, CNA 1 was supposed to supervise a resident by checking on him/her. CNA 1 stated (on 5/19/2024) CNA 1 went on break from 10:20 am to 10:30 am. CNA 1 stated CNA 1 documented Resident 1's whereabouts (at 10 am, 10:15 am and 10:30 am) without knowing Resident 1's accurate location because no other staff had documented in Resident 1's record. CNA 1 stated CNA 1 documented the whereabouts of Resident 1 because CNA 1 wanted to ensure the charting (medical record) was complete. CNA 1 stated CNA 1 changed the documentation to indicate Resident 1 was AWOL once facility staff realized Resident 1 was missing after lunch time. CNA 1 stated it was important to know Resident 1's whereabouts and accurate location for Resident 1's safety. CNA 1 stated when CNA 1 documented she knew Resident 1's location even though she did not, Resident 1 could get hurt. During a telephone interview on 5/21/2024 at 1:37 pm with CNA 2, CNA 2 stated CNA 2 was the primary CNA assigned to Resident 1 on 5/19/2024. CNA 2 stated Resident 1 was supposed to be monitored every 15 minutes to ensure Resident 1's safety. CNA 2 stated CNA 2 documented Resident 1's whereabouts as being in the hallway at 11:15 am, 11:30 am, and 11:45 am on 5/19/2024 even though CNA 2 did not know Resident 1's accurate location. CNA 2 stated because CNA 2 did not monitor Resident 1's accurate whereabouts as directed; Resident 1 was able to elope from the facility. CNA 2 stated Resident 1 could get really hurt and have an accident being out on the streets. During an interview on 5/21/2024 at 4 pm with the DSD, the DSD stated staff (CNA 1 and CNA 2) completing the Q 15-minute monitoring of Resident 1 must locate and visualize Resident 1's actual whereabouts every 15 minutes for Resident 1's safety. The DSD stated staff blindly documenting Resident 1's whereabouts when Resident 1's actual whereabouts were not visualized put Resident 1 at risk for elopement and serious injury, or even death. The DSD stated Resident 1 should not be out in the community unsupervised because Resident 1 had moderately impaired cognition and Resident 1 was a danger to himself and others. During a concurrent interview and record review on 5/21/2024 at 4:29 pm with the DON, Resident 1's Elopement Risk Assessment (ERA) dated 10/26/2023 was reviewed. The DON stated Resident 1 was at risk for elopement. The DON stated Resident 1 was on monitoring for poor impulse control and for AWOL/elopement risk because Resident 1 had attempted to leave the facility in the past (1/1/2024 and 1/26/2024). The DON stated the facility's protocol for Q 15-minute monitoring was to check a resident's (Resident 1's) location every 15 minutes. The DON stated that (Q 15-minute monitoring) meant staff needed to visualize Resident 1 every 15 minutes and document Resident 1's accurate location. The DON stated the staff (CNA 1 or CNA 2) who visualized Resident 1 was supposed to document Resident 1's location to ensure Resident 1's location was accurate, and that Resident 1 was being appropriately monitored and supervised. The DON stated (in general) when a resident was not appropriately monitored or supervised like Resident 1, then like Resident 1, that resident could also leave the facility without staff knowing. The DON stated because Resident 1 eloped from the facility, Resident 1 was a danger to himself and others. The DON stated CNA 1 and CNA 2 falsified Resident 1's Q 15-minute monitoring report by documenting they monitored/supervised and knew Resident 1's whereabouts even though they did not visually see Resident 1's whereabouts. The DON stated this (falsification of record) prevented staff from knowing Resident 1's accurate location and intervening the moment Resident 1 was missing. The DON stated the consequence of CNA 1 and CNA 2 not monitoring Resident 1's whereabouts accurately was that Resident 1 may not be found. The DON stated Resident 1 could become seriously injured or even die. During a review of the facility's PP titled, Q:15 Minute Monitoring, dated 4/2024, the PP indicated the facility provided an atmosphere that was safe and secure for all residents and staff. The PP indicated a tool to assist in providing a safe and secure environment was Q:15-minute checks. The PP indicated the CNA assigned to the resident placed on Q:15-minute checks sought, found, and documented location and condition of the resident every 15 minutes during their shift and must be done in a timely manner. The PP indicated staff who implemented the Q:15-minute checks must maintain a clear and direct line of sight at time of documentation of Q:15-minute checks and document their location.