**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 1), who was on a [NAME]-Petris-Short (LPS, a California law enacted in 1969 that regulates the involuntary commitment of individuals with mental health disorders) conservatorship (a legal process where a court appoints a person to make certain decisions for an individual who was deemed gravely disabled [unable to provide for basic needs] due to a mental health disorder), did not elope (the act of leaving a facility unsupervised and without prior authorization) from a secure facility (a building, institution, or location designed and operated with features that physically restrict unauthorized access or the movement of individuals to prevent people from leaving or others from entering) on 7/28/2025 at 9:27 PM by failing to ensure,1. Certified Nursing Assistant (CNA) 1 reported to Licensed Vocational Nurse (LVN) 1 (charge nurse), CNA 1 found Resident 1, unsupervised, past a locked gate and in the facility's parking lot on 7/28/2025 at 9 PM (the parking lot was an unauthorized area to residents at 9 PM) as indicated in the facility's protocol titled, Supervision Level Protocol and Guidelines.2. Adequate supervision was provided to Resident 1 and failing to ensure Resident was placed on one-to-one supervision (1-1 supervision, one staff supervises one resident) on 7/28/2025 at 9 PM, after Resident 1 was found in the parking lot as indicated in the facility's protocol titled, Supervision Level Protocol and Guidelines, the facility's Policy and Procedures (P&P) titled, Elopements, and Safety of Residents.These failures resulted in Resident 1's elopement on 7/28/2025 at 9:27 PM, Resident 1 was not found until 7/29/2025 at 11 PM. Resident 1 was transferred to the General Acute Care Hospital (GACH) on 7/30/2025 at 10:27 AM for an evaluation. Resident 1 tested positive for amphetamines (a class of powerful and addictive stimulant drugs that speed up the central nervous system [the body's processing center: brain and spinal cord], can significantly affect safety by impairing judgement and physical coordination) at the GACH. Resident 1 was at risk for serious harm and injury when Resident 1 tested positive for amphetamines and did not receive regularly scheduled psychotropic, (prescription drugs that affect brain activity and are used to treat mental health conditions) anticonvulsant (prescription drugs used to prevent or treat seizures [sudden, uncontrolled electrical disturbance in the brain which can cause changes in behavior, movements, feelings, and consciousness]and mood disorders), and anticholinergic (prescription drugs used to treat and regulate bodily functions) medications.On 8/12/2025 at 4:35 PM, while onsite at the facility, the California Department of Public Health (CDPH, 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) situation. The IJ was called in the presence of the Administrator (ADM), the Director of Nursing (DON), and the Program Director (PD) due to the facility's failure to ensure Resident 1 did not elope from the facility on 7/28/2025.On 8/13/2025 at 3:30 PM, the ADM provided an acceptable IJ Removal Plan (IJRP, a detailed plan that includes interventions to immediately correct the deficient practices in the IJ). While onsite at the facility, the surveyor verified and confirmed the facility's full implementation of the IJRP through observations, interviews, and record review, and determined the IJ situation regarding Resident 1's elopement was no longer present. The surveyor removed the IJ on 8/13/2025 at 6 PM in the presence of the ADM, the DON, the PD, the [NAME] President of Operations (VPO), the Behavioral Health Consultant (BHC), the Medical Director for Behavioral Health Services (MD), and the Clinical Resource Nurse.The acceptable IJRP included the following summarized actions:A. Immediate Corrective Action:1. On 7/28/2025 @ 10:15 PM, LVN 1 noticed resident 1 missing and immediately initiated the Elopement protocol (procedures implemented in the healthcare setting to prevent and manage resident elopement) by conducting a resident headcount and alerted all staff to search for Resident 1 inside and outside the facility. Resident 1 was not located inside the facility and staff started driving around the area.2. On 7/28/2025 @ 10:25 PM, LVN 1 called the police department (PD) to make a missing persons' report. The PD came to the facility, met with the ADM who provided a description of Resident 1, Resident 1's face sheet, medical history, current medication regimen, a picture, and camera footage of Resident 1 [to the PD]. 3. On 7/28/2025 at 11:30 PM, the ADM and LVN 2 contacted Resident 1's family member (FM) 1 regarding Resident 1's elopement. The ADM gave the next of kin the ADM's cellphone number and requested FM 1 to contact the ADM if Resident 1 got in touch with FM 1 or if Resident 1 showed up at FM 1's house.4. On 7/29/2025 the ADM suspended CNA 1 pending the investigation of the incident regarding CNA 1 failing to report to LVN 1 that Resident 1 was in the parking lot unsupervised [no adequate staff supervision, can lead to potential harm, injury, or exposure to danger].5. On 7/29/2025 at 10 PM, LVN 3 searched for the area, at a local gas station, LVN 3 spoke to the gas station attendant and the attendant stated he had seen Resident 1 at a homeless encampment [located] across the street from the gas station. LVN 3 recognized Resident 1 and when called Resident 1's name, Resident 1 ran away from LVN 3 but LVN 3 provided crisis communication [structured process for managing high-stress situations involving patients, their families, and staff by delivering clear, empathetic, and timely messages to de-escalate emotions and facilitate problem-solving]. Resident 1 complied with LVN 3's verbal redirection and voluntarily returned to the facility.6. On 7/29/2025 at 11 PM, LVN 3 placed Resident 1 in a safe and appropriate environment by putting Resident 1 on 1-1 supervision for personal safety. Resident 1 was assessed, and no injuries were found. Resident 1 was provided with food, shower, and clean clothing. LVN 3 initiated a Change of Condition (COC, a sudden clinically important deviation in the resident's health or functioning that requires further assessments and interventions). 7. On 7/30/2025 LVN 3 contacted the physician (Medical Doctor [MD] 2) who ordered Resident 1 to be transferred to the GACH to obtain medical clearance.8. On 7/30/2025, 3 staff accompanied Resident 1 to the emergency room for evaluation. Resident 1 returned to the facility on 7/29/2025 at [11] PM.9. On 07/30/2025 at 3:07 PM an Interdisciplinary Team (IDT, a team of health care professionals who work together to establish plans of care for residents) was conducted to discuss appropriate interventions and plan of care for Resident 1. The IDT determined Resident 1 required a more secure environment and contacted LA County DMH (Department of Mental Health) liaison to request a transfer to a more secure [place].10. On 8/12/2025, the Clinical Resource Nurse, [NAME] President of Operations, the DON, and the ADM developed the Protocol for Supervision of Residents at Risk for Elopement. The Protocol provides guidelines to staff for increased supervision and support of residents at risk for Elopement.B. Identification of other residents potentially affected:1.On 8/12/2025, the DON conducted a re-evaluation of all 43 residents in the facility to determine the Risk of Elopement. 43 residents had the potential to be affected by the alleged deficient practice. 1 of 43 residents (Resident 2) was identified as being at risk for elopement, the protocol for residents with high-risk for elopement was initiated for Resident 2. Resident 2's Care Plan (CP) for AWOL [absent without leave or permission]/ /Elopement was revised and resolved as appropriate.C. Measures put in place to sustain compliance: 1. On 8/12/2025 the Director of Staff Development (DSD) initiated in-service to facility staff (Registered Nurses [RNs], LVNs, CNAs, Program counselors, Behavioral specialists, and the SSD) on the P&Ps titled, Increased Level of Supervision, Elopement, Protocol for Supervision of Residents at Risk for Elopement, and Head Count of Residents. The following [staff] completed the in-services: LVN - 13, CNA - 15, RN - 3, Primary Counselor - 7, Behavior Specialist - 3.2. On 8/12/2025, the DSD began to validate the competency/posttest of facility staff with the facility's P&Ps Increased Level of Supervision, Elopement, and Head Count of Residents, through a post-test to 5 random facility staff weekly for 3 months or until substantial compliance is achieved. Starting 8/12/25, the DSD is expected to report the monthly findings at the Quality Assessment and Assurance Meeting (QAA, a committee that meets quarterly to develop and implement appropriate plans of action to correct identified quality deficiencies). The following staff have received the in-services and completed post- tests: 12 of 19 LVNs, 16 of 22 CNAs, 4 of 7 RNs, 6 of 8 Primary Counselors, and 3 of 4 Behavior Specialist.3. The facility staff who have not been in-serviced due to leave of absence or on vacation have been scheduled to be in-serviced prior to the start of their next scheduled shift.4. On 8/12/2025 at approximately 8 PM, the DSD was informed by the ADM that all new staff are required to take the competency skills posttest on Elopement, Head Count, and Increased level Supervision. The DSD/designee was informed by the ADM that all newly hired facility staff should receive the skills competency on P&P on Elopement, Head Count, and Increased Level of Supervision as part of the orientation process.5. On 8/12/2025 at 9 PM, the DSD/designee was informed by the ADM to audit the competency skills/posttests starting 08/13/25 will audit once weekly for 4 weeks, once monthly for two months until 11/10/25 and then quarterly.6. On 8/13/2025 at 11 AM, a camera was installed in the administration building that will provide surveillance over the parking lot area. A sensor flood light was also installed on the west side of the garage building that turns on when motion is detected along with a loud alarm to alert any movement in the area.7. On 8/13/2025 the assigned CNA floater will be responsible for watching/looking over the front patio area to ensure residents are not near the exit gates or near the wall barrier. CNA is instructed to alert additional staff if needed.D. Monitoring Performance:1. Starting 8/12/2025, the DON/designee is expected to report findings related to results from the elopement assessment to the QAA committee for further recommendations monthly for 3 months or until substantial compliance is achieved.2. Starting 8/12/2025, the DSD is expected to report findings based on the P&P on Elopement, Head Count, and Increased Level of Supervision, post-test from the facility staff to the QAA committee for further recommendations monthly for 3 months or until substantial compliance is achieved.3. Starting 8/12/2025, the DSD/designee is expected to report findings of new hire completion of the in-service on the P&Ps on Elopement, Head Count, and Increased Level of Supervision, and the skills competency/posttest to the QAA committee for further recommendations monthly for 3 months or until substantial compliance is achieved.Findings:During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 11/7/2024 with diagnoses including paranoid schizophrenia (a mental illness characterized by hallucinations [false perception of objects or events involving the senses] and delusions, leading to a distorted perception of reality) and diseases of the musculoskeletal system and connective tissue (illnesses that affect the parts of the body that aid in movement and support). The AR indicated Resident 1's Responsible Party (RP) was a conservator (a public official appointed by the court to care for an individual who was deemed unable to care for his/herself).During a review of Resident 1's History and Physical (H&P), dated 11/8/2024, the H&P indicated Resident 1 did not have the capacity to make decisions.During a review of Resident 1's CP, initiated 11/7/2024, the CP indicated, Resident [1] is at risk for elopement related to being in an open placement setting. The CP's goal indicated, [Resident 1] will maintain 0 [zero] AWOL gestures (actions or behaviors that indicate someone is absent without permission) by [the] next review.During a review of Resident 1's Physician Progress Note (PN) dated 7/24/2025, the progress note indicated Resident 1 was an LPS conservatee (a person deemed incapable of managing his/her own affairs by a court and placed under the care of a conservator).During a review of Resident 1's PN, dated 7/24/2025, timed at 10:20 PM, the PN indicated, at approximately 7:10 p.m., on 7/24.2025, [Resident 1] was seen by staff jumping [the] exterior wall near [the] gate [ an unauthorized area]. The PN indicated [Resident 1] appeared to be moving towards [the] facility trailer and facility staff (unidentified) were able to redirect [Resident 1] and brought [Resident 1] back to [a] secure area of facility. The PN indicated [Resident 1] was placed on [every]15 [minute] monitoring.During a review of Resident 1's PN- Interdisciplinary Team Meeting (IDT, a team of health care professions who work together to establish plans of care for residents) notes, dated 7/29/2025, timed at 3:09 PM, the notes indicated, On 7/28/2025.at [9 pm] [Resident 1] took [Resident 1's] last medication for the day, then [CNA 1] was walking to the parking lot and noticed [Resident 1] was in an unauthorized area. At [10:15 PM LVN 1] was not able to account for [Resident 1] while [LVN 1] was doing rounds. At [10:26 PM] via video footage, [Resident 1] was seen leaving [the] facility.During a review of Resident 1's PN- Change of Condition (COC, a sudden clinically important deviation in the resident's health or functioning that requires further assessments and interventions), dated 7/30/2025, timed at 1:52 AM, the PN-COC indicated, [Resident 1] was returned to the facility by [LVN 2] post AWOL.[Resident 1] had redness on bilateral eyes and states to [LVN 2] that [Resident 1] smoked something earlier but [Resident 1] was fine now.During a review of Resident 1's Physician Order (PO), dated 7/30/2025, timed at 9:11 AM, the PO indicated, May send [Resident 1] to [GACH] for further evaluation and treatment [related to] safety one time only for 1 day [manifested by] AWOL.During a review of Resident 1's GACH records, titled Emergency Trauma Documentation, dated 7/30/2025, the GACH record indicated, .The patient does confess to methamphetamine (a highly addictive lab-made stimulant that affects the central nervous, users are at high risk for psychosis [a state of detachment from reality that is a major safety hazard]) and alcohol use. The caregivers (facility staff who accompanied Resident 1 to the GACH) stated that the patient [Resident 1] jumped a large wall to elope from the facility. highly suspicious of schizophrenia and methamphetamine abuse given history of taking and clinical exam findings. The record indicated Resident 1's toxicology (a test that analyzes urine or blood to determine the presence of drugs, alcohol, or other substances) notable for amphetamines.During a review of Resident 1's GACH Toxicology report, dated 7/30/2025, the report indicated amphetamines were detected in Resident 1's urine.During a review of Resident 1's Order Summary Report (OSR), dated active as of 8/13/2025, the OSR indicated Resident 1 had the following physician orders:1. Valproic acid (medication used to treat certain types of seizures or used as a mood stabilizer) 750 milligrams (mg, unit of measurement) administered by mouth at bedtime for irritable affect (a state of being easily annoyed, frustrated, or provoked to anger) related to paranoid schizophrenia, start date of 11/11/2024.2. Zyprexa (medication used to treat certain mental disorders including paranoid schizophrenia) 15 mg administered by mouth two times a day for withdrawn behavior related to paranoid schizophrenia, start date of 11/11/2024.3. Haloperidol (medication used to treat certain mental disorders including paranoid schizophrenia) 15 mg administered by mouth in the morning and at bedtime manifested by responding to internal stimuli (RTIS-reacting to changes or signals originating within the body) related to paranoid schizophrenia, start date of 12/12/2024.4. Lexapro (medication used to treat anxiety [excessive and persistent worry, fear, and nervousness] and depression [a mental health disorder characterized by sadness, loss of interest, and other symptoms that impact daily life]) 5 mg administered by mouth one time a day for feelings of sadness and withdrawn behavior (a behavior characterized by isolating oneself and avoiding social interactions) related to paranoid schizophrenia, start date of 4/12/2025.5. Benztropine Mesylate (medication used to manage extrapyramidal symptoms [involuntary movements, tremors, and muscle stiffness] caused by antipsychotic medications) one mg administered by mouth at bedtime for tremors and stiffness of muscles, start date of 7/25/2025.The active orders did not indicate an order for 1-1 supervision for Resident 1.During a review of Resident 1's Medication Administration Record (MAR), dated July 2025, the MAR indicated:1. Resident 1 did not receive the 9 PM dose of Benztropine Mesylate 1 mg on 7/29/2025.2. Resident 1 did not receive the 11 AM and 9 PM dose of Haloperidol 15 mg on 7/29/2025.3. Resident 1 did not receive the 7 AM dose of Lexapro 5 mg on 7/29/2025.4. Resident 1 did not receive the 9 PM dose of Valproic Acid 750 mg on 7/29/2025.5. Resident 1 did not receive the 12 PM and 9 PM dose of Zyprexa 15 mg on 7/29/2025.During a review of Resident 1's rounding report (a visual confirmation of Resident 1's location) titled General Resident Supervision Rounds and Area Safety/Security Inspection Rounds, dated 7/28/2025, the rounding report indicated Resident 1 was observed hourly on 7/28/2025 from 12 AM to 10 PM.During a concurrent observation of the facility's surveillance video and interview on 8/12/2025 at 11:10 AM, with the ADM, the facility's surveillance video indicated that on 7/28/2025 at 9:27 PM Resident 1 moved and wheeled a trash can to the facility's locked gate. The video indicated Resident 1 climbed onto the wheeled trash can, climbed over the locked gate, and eloped from the facility. The ADM stated Resident 1 climbed over the locked gate and eloped from the facility. The ADM stated Resident 1 was found at a homeless encampment on 7/29/2025 by LVN 2. The ADM stated Resident 1 was returned to the facility around 11 PM on 7/29/2025.During a telephone interview on 8/12/2025 at 12:30 PM with CNA 1, CNA 1 stated CNA 1 saw Resident 1 in the parking lot around 9 PM on 7/28/2025. CNA 1 stated residents (in general) were not allowed in the parking lot area without staff supervision. CNA 1 stated Resident 1 went through a locked gate to get into the parking lot. CNA 1 stated Resident 1 tried to hide from CNA 1 under a tree and CNA 1 stated CNA 1 asked Resident 1 how Resident 1 had made it to the parking lot past the locked gate. CNA 1 stated Resident 1 refused to answer. CNA 1 stated CNA 1 returned Resident 1 to Resident 1's room but did not report Resident 1 was found in an unauthorized area [parking lot] to other staff members including the assigned charge nurse (LVN 1).During an interview on 8/12/2025 at 4:44 PM with LVN 1, LVN 1 stated Resident 1 was on hourly supervision on 7/28/2025. LVN 1 stated LVN 1 was doing rounds (structured regular visits by staff to resident rooms to check on the resident's well-being, comfort, needs, and safety) on 7/28/2025 at 10:15 PM and LVN 1 couldn't find Resident 1. LVN 1 stated LVN 1 was unaware Resident 1 was found unsupervised in the parking lot earlier that evening [on 7/28/2015 at 9 PM].During an interview on 8/13/2025 at 5:45 PM with the ADM, the ADM stated the facility's parking lot area was an unauthorized area to all residents [due to the facility being a secure facility]. The ADM stated when Resident 1 was found in the parking lot on 7/28/2025 at 9 PM and Resident 1's behavior of being in an unauthorized area, CNA 1 needed to report the incident to the charge nurse because Resident 1's behavior indicated Resident 1 had a desire to elope from the facility. The ADM stated Resident 1 should have been placed on 1-1 supervision, on 7/28/2025, per the facility's increased level of supervision protocol.During a review of the facility's P&P titled, Safety of Residents, effective 6/27/2022, the P&P's purpose indicated, To provide a safe environment for residents.Upon admission, residents will be monitored for behavioral triggers including, but not limited to:.Increased pacing or wandering.Response to unsafe behavior: If a resident's behavior becomes.unmanageable in a way that compromises his or her safety. the Charge Nurse and the [Director of Nursing Services] DNS are notified immediately. The Charge Nurse will: .Maintain 1-1 supervision of the resident until the behavior has subsided.During a review of the facility's P&P titled, Elopements, revised 2/21/2025, the P&P indicated, The residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. Definitions: Wandering is random or repetitive locomotion that may be goal-directed (e.g., the person appears to be searching for something such as an exit), or non-goal directed or aimless. Elopement occurs when a resident leaves the premises or a safe area without authorization . and/or any necessary supervision to do so.The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary.The effectiveness of interventions will be evaluated, and changes will be made as needed.During a review of the facility's undated Protocol titled, Supervision Level Protocol and Guidelines, the protocol indicated, When residents are under general supervision, they are expected to stay in the building except when following standard policies for leaving (e.g. therapeutic pass (authorized outing), outings, appointments, and hospital stays). A staff member entering/exiting a secured resident area is responsible for detecting any resident who attempts to leave without permission. The staff member should verbally redirect the resident away from the area and alert other staff members for assistance so they can intervene to keep the residents safe. The protocol indicated, Increased supervision is provided to.residents whose .behavior .indicated an increased level of risk. The protocol indicated residents required 1-1 supervision when residents were actively seeking to elope or required constant observation. The protocol indicated 1-1 supervision is an emergency intervention that may be implemented by charge nurses or RNs with a doctor's order. The protocol indicated that a resident on 1-1 supervision will have dedicated staff assigned to have visual contact with the resident at all times, the assigned staff will have no other duties besides the 1 to 1 observation of the resident. The protocol's guidelines indicated a resident will be placed 1 to 1 supervision per doctor's orders for a maximum of 72 hours. The protocol indicated the IDT will reevaluate the necessity of continuing this level of supervision.