**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 10), who was admitted to the facility from a General Acute Care Hospital (GACH) on [DATE], was not administered Baclofen (a medication that relaxes the muscles to relieve spasm, tightness, and cramps) due to a known side effect of confusion, when: 1. Registered Nurse (RN) 1 did not review Resident 10's entire Discharge Instructions dated [DATE] and [DATE] for accuracy, prior to transcribing the orders in Resident 10's chart. 2. RN 1 did not review and clarify conflicting instructions outlined in the GACH's Discharge Instructions dated [DATE] which indicated do not use Baclofen since caused confusion versus the Discharge instructions dated [DATE], which indicated Medications to Continue to Take with no Change which indicated Baclofen 10 milligrams ([mg] metric unit of measurement, used for medication dosage and/or amount) give 0.5 tablet three times daily, with Resident 10's physician. 3. RN 1 administered 5 doses of Baclofen 5 milligrams ([mg] metric unit of measurement, used for medication dosage and/or amount) to Resident 10 without reconciling the orders with Resident 10's physician. 4. RN 1 did not follow the facility's Policy and Procedure (P/P), titled, Medication Orders Non-Controlled Medication Order Documentation revised 8/20219, which indicated nurses are to verify the GACH's order with attending physician before medication (Baclofen) was transcribed for administration. These deficient practices resulted in Resident 10 receiving Baclofen 5 mg from [DATE] through [DATE] (a total of six doses), experiencing shortness of breath (SOB), elevated blood pressure (BP), generalized weakness and increased confusion. Resident 10 was transferred to a GACH, where he was diagnosed with acute toxic encephalopathy (a condition characterized by sudden and severe brain dysfunction caused by exposure to toxic substances) and was dialyzed (treatment to remove waste products and excess fluid from the blood when the kidneys are unable to do so). On [DATE] at 3:28 p.m., an Immediate Jeopardy ([IJ] a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was called in the presence of the facility's Administrator (ADM), the Interim Chief Clinical Officer (CCO) and the Senior Nurse Executive (SNE) due to the facility's failure to recognize a discrepancy in the GACH's discharge instructions and follow up with Resident 10's attending physician to clarify discharge/transfer orders prior to transcribing Baclofen for administration to Resident 10. On [DATE], the facility submitted an acceptable IJ Removal Plan ([IJRP] interventions to immediately correct the deficient practices). After onsite verification of the facility's IJRP's implementation through observation, interview, and record review, the IJ was removed on [DATE] at 3:40 p.m., in the presence of the facility's DON and ADM. The facility's IJRP included the following immediate actions: 1. On [DATE], Resident 10 was discharged to a GACH and was readmitted to the facility on [DATE] the admitting nurse verified the admissions orders with the attending physician. A medication error report for Baclofen was completed on [DATE] for the [DATE] admission orders and was reported to the attending physician and Resident 10's family. Resident 10 was discharged home on [DATE]. 2. On [DATE] the Interim Chief Clinical Officer (CCO)/ Designee provided a 1:1 (a personalized, process where an experienced person works directly with a learner to teach a specific task, process, or skill) in-service training to RN 1 on reviewing discharge orders, reconciling and verifying orders with attending physicians prior to carrying out the orders, the facility's P/P titled, Medication Orders Non-Controlled Medication Order Documentation which requires the licensed nurses to verify the GACH's order with attending physician before medications (Baclofen) are transcribed for administration. 3. On [DATE], a random audit of all in-house patients was completed by Health Information Manager (HIM) and the Interim CCO/designee. A total of 12 residents who were receiving Baclofen were identified and there were no concerns. On [DATE], a random audit of all newly admitted residents in the past 24 hours was conducted by the HIM and Interim CCO/designee. A total of 10 residents identified and their physicians ‘orders were reviewed, reconciled with their attending physicians, no concerns were found. 4. On [DATE] the DSD/ Clinical Trainer provided re-training beginning to licensed nurses on entering orders into Electronic Treatment Administration Record ([eMAR/eTAR]) prior/pending confirmation, reconciliation and verification of orders. Licensed Nurses who are on leave, vacation, out sick or newly hired nurses will be educated prior to the start of their shift. 5. On [DATE], the DSD and the Clinical Trainer conducted an in-service training for licensed nursing staff on the facility's P/P titled, Medication Orders Non-Controlled Medication Order Documentation which requires the licensed nurses to verify the GACH's order with attending physician before medications is transcribed for administration. The training will continue until all licensed nursing staff have attended the training by [DATE]. Licensed Nurses who are on leave, vacation, out sick or newly hired nurses will be educated prior to the start of their shift. 5. On [DATE] during the ad hoc (created or done for a particular purpose when necessary or needed) QAPI (Quality Assurance/Quality Assurance and Performance Improvement-a data driven proactive approach to improvement used to ensure services are meeting quality standards) Committee meeting, a root cause analysis (RCA) revealed multiple system-level factors that contributed to the medication reconciliation error. RN 1, who was not the facility's regular admitting nurse, did not follow the reconciliation policy and bypassed physician verification, reflecting a knowledge gap in high-risk medication reconciliation requirements. Although the facility had a policy in place (Medication Orders Non-Controlled Documentation), it was not consistently applied, and there was no structured admission process to support nurses unfamiliar with admissions. Leadership oversight was also limited, with QAPI audits not consistently addressing reconciliation compliance and no real-time monitoring system to ensure medication reconciliation was completed upon admission. The RCA identified the root cause as the absence of a medication reconciliation process that ensured physician verification, standardized documentation, and active leadership oversight. 6. Team Members: Medical Director, Executive Director, Chief Clinical Officer, Director of Staff Education, Regulatory Compliance Nurse. Each member will perform the following: i. Medical Director: will monitor the system, recommend changes, and oversee corrective action plans. This role includes identifying and implementing medical interventions to reduce medication errors. ii. Executive Director (ED): will oversee all corrective actions initiated on [DATE] and continue monthly reviews during QAPI meetings. iii. Chief Clinical Officer (CCO): will oversee the investigation, reporting, and resolution of medication reconciliation audit, ensuring patient safety and regulatory compliance. The CCO will implement corrective actions, conduct audits, monitor staff adherence to policies, and collaborate with the DSD to provide ongoing training, reinforcing best practices in medication management. iv. Regulatory Compliance Nurse: This role entails staying updated on regulatory changes, collaborating with the interdisciplinary team to update policies, and ensuring staff adherence to these policies. It includes participating in quality improvement initiatives, analyzing compliance data, assisting with corrective actions, identifying risks, and investigating incidents to prevent recurrence. This role involves planning, developing, organizing, implementing, coordinating, and directing the quality assurance and assessment program designed to enhance the quality of resident care, in accordance with current rules, regulations, and guidelines that govern the facility. v. Director of Staff Development: This role involves educating staff and plays a critical role in addressing medication reconciliation audits by providing targeted training and education to licensed nursing staff, ensuring compliance with facility policies and regulatory standards. The role includes conducting in-service sessions on proper medication administration, overseeing competency evaluations, and implementing corrective action plans to prevent future errors while promoting a culture of accountability and continuous improvement.Findings: During a review of Resident 10's admission Record (Face Sheet), the Face Sheet indicated Resident 10 was admitted to the facility on [DATE] with diagnosis including osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage, end stage renal disease ([ESRD] irreversible kidney failure and was dependent on hemodialysis. During a review of Resident 10's Minimum Data Set ([MDS] a resident assessment tool) dated [DATE], the MDS indicated Resident 10 was able to make decisions that were reasonable and consistent. The MDS indicated Resident 10 required a one person assist to complete her activities of daily living ([ADLs] routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 10's GACH's Discharge summary dated [DATE] and timed at 2:09 p.m., the Discharge Summary indicated to discharge Resident 10 to the facility with the following instructions. a. Do not use Baclofen since the medication caused confusion b. Administer Baclofen 10 mg, give 0.5 tablet, three times daily. During a review of the GACH's discharge instructions, dated [DATE] and timed 8:44 a.m., the Discharge Instructions indicated administer Baclofen 10 mg, give 0.5 tablet, three times daily During a review of Resident 10's Clinical Record there was no written documentation to indicate the admitting nurse (RN 1) notified Resident 10's physician to clarify conflicting instructions to determine if Baclofen should or should not be administered to Resident 10. During a review of Resident 10's Physician's Order Summary, the Physician Order Summary dated [DATE] indicated to administer Resident 10 Baclofen 10 mg, give 0.5 tablet three times a day for muscle spasms. During a review of Resident 10's Medication Administration Record ([MAR] a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) dated 8/2025, the MAR indicated Resident 10 was administered six doses of Baclofen 5 mg from [DATE] to [DATE]. During a review of Resident 10's Change of Condition Evaluation (COC) dated [DATE] and timed at 8:04 a.m., the COC indicated Resident 10 was observed with SOB, weakness, confusion and drowsiness, with a BP of 180/110 millimeters of mercury (mmhg-unit of measurement) and an oxygen saturation ([O2 Sat] oxygen level in the body that indicates the body has enough oxygen supply, normal range of 95 to 100%) rate of 92% to 94 % on room air. The COC indicated Resident 10's physician was notified of Resident 10's COC on [DATE] at 8:45 a.m., and an order was obtained to transfer Resident 10 to the GACH by paramedics. During a review of the Resident 10's Physician's Order Summary, dated [DATE], the Physician's Order Summary indicated to call 911 for Resident 10 because of SOB, elevated blood pressure and generalized weakness. During a review of the GACH's Emergency (ED) Note dated [DATE] and timed at 10:28 a.m., the ED Note indicated Resident 10 was brought to the emergency room by the paramedics because of dizziness, fatigue, and nausea with a BP of 182/69. During a review of the GACH's History and Physical dated [DATE] and timed at 5:08 p.m., the H&P indicated Resident 10 presented at the emergency room (ER) with new onset altered mental status ([AMS] a person not as awake, alert or able to understand or respond to their surroundings as they normally would be), dizziness, nausea and weakness after confirmed administration of Baclofen at the facility. The H&P indicated a few weeks ago, Resident 10 was hemodialyzed at another GACH (date unknown) related to Baclofen toxicity (the extent to which a substance is poisonous and harmful to living thing).The H&P indicated Resident 10 might have received a second unintentional dose of Baclofen and was placed on delirium precautions (simple actions used to help a confused person to stay calm and oriented), frequent reorientation, and admitted for acute encephalopathy, likely due to Baclofen toxicity. During a review of the GACH's Nephrology (a branch of medicine that focuses on the diagnosis, treatment, and management of kidney diseases) Consultation Notes dated [DATE] and timed at 6:49 p.m., the Nephrology Consultation Notes indicated Resident 10 will undergo hemodialysis due to Baclofen toxicity. During a review of the GACH's Discharge summary dated [DATE] and timed at 2:44 p.m., the Discharge Summary indicated a diagnosis of acute toxin encephalopathy. During a review of Resident 10's Skilled Nursing Facility History and Physical (SNF H&P) dated [DATE] and timed at 12:45 p.m., the H&P indicated the facility's nursing department restarted Resident 10's home medications including Baclofen, The H&P indicated Resident 10's medications were started (transcribed and ordered) and administered to Resident 10, without clarifying the discharge medication list with the primary care physician (PCP). During a telephone interview on [DATE] at 12:23 p.m., Resident 10's Family Member (FM) 1 stated Resident 1 was transferred to the facility from a GACH on [DATE] with instructions not to give Resident 10 Baclofen because it made Resident 10 feel weak and confused. FM 1 stated on [DATE] Resident 10 called her complaining she did not feel well, and the facility had given her Baclofen. FM 1 stated she arrived at the facility at 10 a.m., and Resident 10 had been transferred to a GACH due to dizziness, fatigue, SOB and hallucinations. FM 1 stated when she arrived at the GACH, the GACH had not been informed by the facility that Resident 10 was given Baclofen or that it caused Resident 10 confusion. FM 1 stated she notified the GACH and the GACH immediately performed dialysis on Resident 10. FM 1 stated Resident 10 could have died because Resident 10's kidneys no longer functioned. During an interview on [DATE] at 4:11 p.m., RN 1 stated when she received Resident 10's admission papers from the GACH on [DATE], she determined Resident 10 was not allergic to any medication and transcribed the discharge medications listed on the GACH's Discharge Instructions. RN 1 stated she did not call Resident 10's physician to verify and/or clarify Resident 10's discharge medications or instructions because the physicians at the GACH normally prepare the discharge instructions and the primary care physician at the facility could see the orders in Resident 10's medical record. During a interview on [DATE] at 11:57 a.m., RN 1 stated after reviewing the Discharge summary dated [DATE], she did not see the instructions indicating Baclofen should not be given to Resident 10 due to confusion. RN 1 stated had she read the Discharge Summary, compared the GACH's discharge instructions, discharge medication list, and called Resident 10's physician to clarify the instructions, Resident 10 would never have been given Baclofen that caused a COC. During a telephone interview on [DATE] at 12:32 p.m., RN 3 stated on [DATE] during the 7 a.m. to 3 p.m. shift, she received endorsement from the outgoing nurse (11 p.m. - 7 a.m.) that Resident 10 was feeling weak and dizzy. RN 3 stated she assessed Resident 10 at the start of her shift (7 a.m. - 3 p.m.), and Resident 10 complained of right buttock pain, rated at 3 out of 10 on an eleven point scale (0=no pain, 1-3=mild pain, 4-6=moderate pain, and 7-10=severe pain, and 10=worst imaginable pain) and she (RN 3) applied a lidocaine patch (a topical adhesive patch containing lidocaine, used for pain) to the affected site and gave Resident 10 5 mg of Baclofen. RN 3 stated at approximately 8:30 a.m., Resident 10 still felt weak, dizzy, had become more lethargic (a state of decreased consciousness such as fatigue, drowsiness or sleepiness) and was not talking, her B/P was high, she was SOB, and her O2 Sat was 92% on O2 (liters of O2 unknown). RN 3 stated she administered an anti-hypertensive medication to Resident 10, but her BP remained high, she (RN 3) then called Resident 10's physician and was given an order to call the paramedics. During an interview on [DATE] at 12:47 p.m., the SNE stated the admission process included checking the discharge papers from the GACH including the doctor's discharge summary, discharge instructions and the medication list. The SNE stated it was the responsibility of the admitting nurse to call Resident 10's physician to verify and/or reconcile the residents' medications to ensure the residents' prescribed medications were accurate. During a telephone interview on [DATE] at 1 p.m., the facility's Pharmacist stated Baclofen causes central nervous system depression (a condition when the brain and the spinal cord slow down, and the body cannot function properly), dizziness and confusion. The Pharmacist stated physicians should be aware of the side effects of this medication and adjust the dose and/or stop the medication based on the residents' kidney function, response and/or tolerance to the medication. The Pharmacist stated Baclofen cannot be excreted (eliminate or discharge wastes from the body) well from the body when the kidneys are impaired and could increase a resident's risk of side effects associated with the use of the medication. During a telephone interview on [DATE] at 2:51 p.m., the on-call physician, who covered for Resident 10's attending physician, stated the admitting nurse should have contacted the Resident's attending physician to discuss the residents' discharge summary and discharge medications to identify and/or resolve any inconsistencies and discrepancies. During a telephone interview on [DATE] at 4:28 p.m., the GACH's Nephrologist stated Baclofen was not nephrotoxic (poisonous to the kidneys), but it could accumulate in the blood when the kidneys were impaired and cause a resident to have an altered level of consciousness ([ALOC] a change in a patient's state of awareness [ability to relate to self and the environment] and arousal [alertness]) During a telephone interview on [DATE] at 1:20 p.m., the facility's Medical Director stated it was the facility's policy and common practice for the doctors and the licensed nurses to conduct a thorough reconciliation of the residents' discharge medications and review of discharge instructions including the discharge summary to clarify and/or decide the residents' treatment and medications. The Medical Director stated licensed nurses were not to transcribe any medication order without the approval of the primary care physician to ensure the residents were free from inappropriate medications that could affect their safety and wellbeing. During an interview on [DATE] at 11 a.m., the CCO stated Resident 10's COC and the life threatening complications could have been prevented if the admission process was followed. During an interview on [DATE] at 12:33 p.m., the Administrator (ADM) stated the failure to reconcile the medications with Resident 10's physician should not have happened because the facility has ongoing policies and procedures related to admission medication reconciliation. According to Mayo Clinic (a non-profit medical group practice that provides comprehensive and integrated healthcare services renowned for its expertise in cardiology, cancer care, neurology, orthopedics and transplant medicine), BACLOFEN (Oral Route)- Side effects and Dosage dated [DATE], Baclofen was used to help relax the muscles to relieve spasms and cramping by acting on the central nervous system to produce muscle relaxant effects. This medication must be prescribed and used with caution if anyone has an allergy or unusual reaction to it and limit use in elderly because of age-related kidney, liver or heart problems that may likely cause side effects of hallucination, confusion, mental depression, and severe drowsiness. The presence of a medical problem such as a kidney disease may increase the effects of the medication because of slower removal of medicine form the body and should be avoided because of increased risk of serious brain problems such as encephalopathy (a medical condition of the brain affected by some agent or condition such as toxins in the blood). https://www.mayoclinic.org During a review of the facility's P/P titled, Medication Orders Non Controlled Medication Order Documentation revised 8/2019, the P/P indicated the written transfer orders (sent with a resident by a hospital or other healthcare facility) shall be verified with the current order attending physician before medications are administered and the nurse who transcribes the orders must document in the admission form the date, time and by whom the orders were noted.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the facility's Rehabilitation (Rehab) room equipment was not readily accessible for unauthorized use by residents and/or visitors or used as a weapon to hit for one of four sampled residents (Resident 1). The facility failed to: 1. Ensure the Rehab room and equipment located in the Rehab room was secured and supervised at all times to prevent unauthorized access by residents and/or visitors. 2. Ensure Resident 1 did not gain access to a Dowel (a pole or rod used in rehabilitation to improve shoulder mobility and strength) from the facility's Rehab room without staff knowledge. 3. Ensure Resident 1 did not use a Dowel to physically assault Resident 2 and Resident 3. 4. Ensure staff followed the facility Policy and Procedure (P&P) titled, Safety and Supervision of Residents dated 7/2017, which indicated, the facility has individualized resident centered approach to safety, addresses safety and accident hazards for individual residents. The interdisciplinary care team ([IDT] a group of health care professionals with various areas of expertise who work together toward the goals of the residents) shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents. The care team shall target interventions to reduce individual risks related to hazards in the environment. These deficient practices resulted in Resident 1 obtaining a Dowel (used to improve range of motion ([ROM] the direction a joint can move to its full potential), strength, and coordination, particularly for upper body movements like the shoulder and the hand) from the facility's Rehab room without staff knowledge or consent and using the Dowel to hit Resident 2 on her left arm on 2/24/2025 and Resident 3 on her right arm, right shoulder, and face then pushing Resident 3 to the floor on 4/19/2025. Resident 3 sustained a fracture (a break in a bone) to the mid sacrum (a triangular bone located at the base of the spine [back]) and was transferred to a General Acute Care Hospital (GACH) on 4/22/2025. These deficient practices placed residents' and/or visitors at risk for serious harm and death. On 5/8/2025, at 5:27 p.m., an Immediate Jeopardy ([IJ]) a situation in which the facility's noncompliance with one or more requirements of participation caused, or was likely to cause, serious injury, harm, impairment, or death to a resident) was called in the presence of the facility's Administrator (ADM) and Director of Nursing (DON) due to the facility's failure to keep the Rehab room equipment secured at all times and not accessible to Resident 1 or any other resident without supervision. On 5/9/2025, the facility submitted an acceptable IJ Removal Plan ([IJRP] an intervention to immediately correct the deficient practices). After onsite verification of the facility's IJRP implementation through observation, interview, and record review, the IJ was removed on 5/9/2025 at 5:23 p.m., in the presence of the facility's ADM and DON. The IJRP included the following: 1. Corrective and appropriate actions to be implemented for the affected residents identified in the deficiencies. a. Immediate Action: On 4/19/2025, Resident 1 and Resident 3's incident was reported to the California Department of Public Health (CDPH) with final investigation of the report completed on 4/25/2025 and submitted. Following the resident-to-resident incident on 4/19/2025, Resident 1 and Resident 3 were immediately separated from each other on 4/19/2025. b. Immediate action: Resident 3 was transferred to another room in a different wing of the building with ongoing monitoring by staff of Resident 3's psychosocial wellbeing. Resident 3 was transferred to the hospital on 4/22/2025 for additional assessment related to an acute fracture of the mid sacrum and was returned to the facility on the same day with no new orders. Resident 3's care plan was updated by the assigned licensed nurse on 4/22/2025 to include a resident-to-resident altercation. c. Immediate action: Resident 1's care plan for behaviors was reviewed and updated on 4/19/2025 to include physical aggressive behavior. On 4/22/2025, Resident 1 was referred to a psychiatric mental health Nurse Practitioner (NP) but refused to meet with a mid-level practitioner (NP). On 4/23/2025 the Interdisciplinary Team ([IDT] a group of health care professionals with various areas of expertise who work together toward the goals of the residents) met with Resident 1 and her family member who agreed to intervene to assist Resident 1 to be seen by a psychiatrist. Resident 1 was sent out to General Acute Care Hospital (GACH) on 4/28/2025 for in-patient psychiatric evaluation related to physical aggression. Resident 1 returned on 4/29/2025 with a diagnosis of a urinary tract infection ([UTI] an infection in the bladder/urinary tract) and an order for antibiotics. Resident 1's care plan and IDT note was updated on 5/09/25 to address Resident 1's use of a dowel during the episode of aggressive behavior on 4/19/2025. d. Immediate Action: Effective 5/8/2025 a tracking system was implemented requiring Rehab staff to sign weighted dowels, free weights, and ankle weights in and out, noting their location and assigned user. If any item is found missing, staff must immediately notify the Rehab Manager and complete an incident log to initiate a prompt search and resolution process. e. Immediate Action: On 5/7/2025, the Executive Director was assigned to the Rehab Manager to ensure that weighted dowels, free weights, and ankle weights were properly locked and secured at the end of each treatment day. A log was created on 5/8/2025 to document and verify daily compliance with this security measure. f. Immediate action: On 5/8/2025, the Executive Director designated the Rehab Manager to ensure that access to the Rehab room is secured when staff were not present to supervise the gym. A log was created on 5/8/2025 to document daily compliance and serve as evidence of adherence to this protocol with rehab staff assigned with responsibility of documenting the time the room was secured and verification that no residents remain inside, to prevent unauthorized and unsupervised access. 2. Governing Body -Quality Assurance Performance Improvement (QAPI) committee a. Immediate Action: The IDT was in-serviced on 5/8/2025 by the Senior Nurse Executive (SNE) to review how to conduct an IDT meeting when reviewing resident to resident incidents. b. Immediate Action: An ad hoc (created or done for a particular purpose as necessary) QAPI Committee meeting was scheduled for 5/9/2025 to conduct a root cause analysis (RCA) to determine key issues stemming from the recent resident to resident altercation to determine process breakdowns, including communication breakdowns, inconsistent documentation, and training gaps in high-risk monitoring protocols/interventions. c. The Executive Director (ED) will oversee corrective actions initiated on 5/8/2025 and monthly thereafter during QAPI meetings which were based on the results of the RCA and plan of corrections for the findings during the survey. Any corrective actions not meeting the 100% compliance benchmark, as determined by medical record audits, such as IDT, care plan and change of condition audits as well as safety equipment monitoring of rehab equipment random audits will be reviewed and revised with the QAPI Committee for revision, further evaluation, and recommendations, with a designated IDT member assigned to each corrective action. d. Any new issues found during medical record audits on resident to resident altercation will be presented to the IDT members for immediate action. The Chief Clinical Officer (CCO) will monitor the immediate actions for implementation of monitoring/audit needs at least monthly for the next 3 months or until compliance is 100% or is achieved. 3. Specific staff involved in implementing the corrective actions. a. Team Members: Medical Director, Executive Director, Chief Clinical Officer, Director of Staff Education, and Regulatory Compliance Nurse. Each member will perform: i. Medical Director: Through the QAPI committee, the Medical Director will monitor the system, recommend changes, and oversee corrective action plans. This role includes identifying and implementing medical interventions related to injuries resulting from resident-to-resident altercation. ii. Executive Director (ED): The ED will oversee all corrective actions initiated on 5/8/2025 and continue monthly reviews during QAPI meetings. iii. Chief Clinical Officer: Leading the IDT, the Chief Clinical Officer will regularly review at-risk residents who have physical aggression behaviors and assess intervention effectiveness and adjust care plans as needed. This role also ensures that abuse prevention practices are standardized, monitors staff compliance, coordinates equipment maintenance, educates staff, oversees data analysis, and conducts reviews to recommend preventive measures. iv. Regulatory Compliance Nurse/ Designee: This role entails staying updated on regulatory changes, collaborating with the interdisciplinary team to update policies, and ensuring staff adherence to these policies. It includes participating in quality improvement initiatives, analyzing compliance data, assisting with corrective actions, identifying risks, and investigating incidents to prevent recurrence. v. Director of Staff Education: This role involves educating staff on care planning, documentation, and protocols for abuse prevention and management, covering incident reporting, preventive measures, and emergency responses. Responsibilities include training new hires on resident safety, conducting competency assessments, and ensuring accurate documentation related to resident-to-resident altercation. 4. Identification of other residents who may need to be included (who may have been affected by the deficient practice: a. All residents were identified as potentially affected by the deficient practice. b. There are 4 independent residents who can walk 10 to 50 feet. Out of these 4 residents, 3 can walk 150 ft and above. Out of these residents 1 resident with physical aggression - Resident 1. 5. Systemic Changes and Measures: a. Immediate Action: The Interdisciplinary Team (IDT) in-service on 5/8/2025 by the Senior Nurse Executive (SNE) to review how to conduct an interdisciplinary team meeting when reviewing resident to resident incidents. b. System Change: A log was created on 5/08/2025 to document and verify daily compliance with securing weighted dowels, free weights, and ankle weights and locking the rehab room when no staff were present to supervise. Beginning 5/09/2025, the Activity Director and/or designee will use a monitoring tool to document compliance of logs created by the Rehab Department. Audits will be conducted daily for three days, then weekly for two weeks, and monthly thereafter. The issues found will be referred to the ED for further review and revision of the action plan and/or to determine any further training needed for staff involved. c. System Change: Starting 5/9/2025, the Medical Records Department will use a monitoring tool to audit the documented IDT and care plan for change of conditions related to any resident-to-resident altercations. Audits will be conducted daily for three days, then weekly for two weeks, and monthly thereafter. Any issues found will be referred to the Chief Clinical Officer (CCO) immediately for further review and revision of the action plan and/or to determine any further training needed for staff involved. 6. Training and Education Started on 5/08/2025 by Senior Nurse Executive and/or Designee. a. Immediate action: Inservice training for staff license nurses was started on 5/8/2025 on updating comprehensive care plans for residents that have been identified with physical aggression. A total of 16 nurses have been trained. The facility will continue training until all staff nurses have attended by 5/10/2025. b. Immediate action: Inservice training for IDT was started on 5/8/2025 on updating comprehensive care plan and interdisciplinary team investigation and documentation for residents that have been identified with physical aggression and those with resident-to-resident altercations. A total of 4 IDT members have been trained and will continue training until all IDT members have attended by 5/10/2025. c. Immediate action: Inservice training for rehab staff was started on 4/25/2025 on how to secure weighted dowels, free weights, and ankle weights and the rehab room door when no staff are present in the gym to supervise, as well as additional in-service initiated on 5/09/2025 on how to track and sign equipment in and out, noting its location and assigned user. A total of 10 rehab staff have been trained and will continue training until all Rehab staff have attended by 5/10/2025. Findings: During a review of Resident 1's Face Sheet (the front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including anxiety disorder (a mental health condition characterized by excessive worry and fear that significantly interferes with daily life) and unspecified signs and symptoms (s/s) involving cognitive function decline (changes in thinking, memory, or attention that are not clearly categorized as a specific type of cognitive deficit) following a cerebral infarction ([stroke] loss of blood flow to a part of the brain)). During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool), dated 2/23/2025, the MDS indicated Resident 1's cognition was intact (able to make independent and reasonable decisions), and she could walk 150 feet. During a review of Resident 2's admission Record, (Face Sheet), the Face Sheet indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted [DATE] with diagnoses including mild cognitive impairment (a brain condition that causes noticeable but mild memory and thinking problems) unspecified dementia (a progressive state of decline in mental abilities without behavioral disturbance, psychotic disturbance (a state where a person's thinking, perception, and behavior are significantly altered, leading to a loss in contact with reality), mood disturbance (a serious mental illness that causes persistent and intense changes in a person's mood, energy, and behavior), and anxiety. During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2's cognition was intact. During a review Resident 3's admission record (Face sheet), the Face Sheet indicated Resident 3 was admitted to the facility on [DATE], with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness or inability to move on one side of the body) following a cerebral infarction affecting Resident 3's left non dominant side. During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3 's cognition was intact. The MDS indicated Resident 3 used a walker (a device used to assist with walking) for mobility. During a review of Resident 3's H&P dated 2/19/2025, the H&P indicated Resident 3 was alert and able to make decisions regarding routine medical decisions and her immediate needs. During a review of Resident 1's Progress Note, dated 2/24/2025, the Progress Note indicated Resident 2 reported that Resident 1 hit her with a cane on her left arm. During a review of Resident 1's Change in Condition (COC) Evaluation, dated 2/24/2025, the COC indicated at 10:43 p.m., Resident 2 reported that Resident 1 struck her with a stick. During a review the facility's Investigation of Resident 2's allegation dated 2/24/2025, the Investigation indicated the cane/stick was not located and there were no witnesses who saw the cane/stick. During a review of Resident 3's Nurses Progress Note, dated 4/20/2025, the Nurse Progress Note indicated Resident 3 reported that Resident 1 pushed her down and hit her with a stick multiple times on 4/19/2025. The Nurses Progress Note indicated three Certified Nursing Assistants (CNA 2, 3 and 4) reported seeing Resident 1 walking away from Resident 3's bed with a stick wrapped in a white sheet. The Nurses Progress Note indicated Resident 1 reported that Resident 3 always disrespected her and would always close the sliding door in the room and the room was always hot. The Nurses Progress Note indicated Resident 1 reported today (4/19/2025) she (Resident 3) closed the sliding door, and she (Resident 1) opened it. During a review of Resident 1's Nurses Progress Note, dated 4/21/2025 and timed at 10:06 a.m., the Nurses Progress Note indicated Resident 3 requested an X-ray (a procedure used to generate images of tissue and structures inside the body) of her right shoulder and back. A subsequent Nurses Progress Note dated 4/21/2025 timed at 12 p.m., indicated the Nurse Practitioner (NP) ordered a STAT (immediately) X-ray for Resident 3. During a review of Resident 3's X-ray results dated 4/21/2025, the X-ray results indicated an acute fracture of the mid sacrum. During a review of Resident 3's Physician's Order, dated 4/22/2025, the Physician's Order indicated to transfer Resident 3 to the GACH for an X-ray of her lumbar spine (lower portion of the back) and sacrum. During a review of Resident 3's Nurses Progress Note, dated 4/22/2025 and timed at 2:40 p.m., the Nurses Progress Note indicated Resident 3 was transported to a GACH for evaluation due to an X-ray result that indicated a fracture of the mid sacrum. During a review of the GACH's Face Sheet, the Face Sheet indicated Resident 3 was admitted to the GACH on 4/22/2025. During a review of GACH's Radiology (the science dealing with X-rays for the diagnosis and treatment of disease) Results, dated 4/22/2025, the Radiology Results indicated Resident 3 sustained a non-displaced fracture (a broken bone where he bone fragments remain in their correct alignment after the break) of the mid sacrum. During a review of the GACH's Assessment and Plan, dated 4/22/2025, the Assessment and Plan indicated Resident 3 was given Percocet (no dosage indicated) and a Lidocaine patch (no dosage indicated) for pain management. During a review of Resident 1's IDT Conference Record, dated 4/23/2025, the IDT Conference Record indicated Resident 1 had poor impulse control and was easily angered. The IDT Conference Record indicated there was no reference to the Dowel Resident 1 used to strike Resident 3 or interventions to prevent access to the Dowel During an interview on 5/5/2025, at 3:40 p.m., Resident 3 stated, approximately two Saturdays ago (unsure of the date), Resident 1 was upset because the patio door, that was located near her (Resident 3) bed, was closed and locked. Resident 3 stated Licensed Vocational Nurse (LVN) 1 explained to Resident 1 that the door had to remain closed at 7 a.m., because it was cold. Resident 3 stated Resident 1 argued with LVN 1 about the door being closed but thought she finally accepted what LVN 1 said. Resident 3 stated she was lying in bed watching television (4/19/2025) when Resident 1 called her names using expletives (a swear word). Resident 3 stated, Resident 1 had a pole in her hand and walked over to her (Resident 3) bed and hit her (Resident 3) on her right arm, right shoulder, and the pole grazed the right side of her face. Resident 3 stated she stood up because she was afraid of what Resident 1 would do next. Resident 3 stated she screamed for help and that was when Resident 1 turned and pushed her and she (Resident 3) fell backwards, hitting a wheelchair and bedside table on her way to the floor. Resident 3 stated Resident 1 tried to hide the pole in a sheet, but a CNA (unknown) saw the pole and took it away from Resident 1. Resident 3 stated she does not feel safe; she can't sleep and is afraid Resident 1 will find her and harm her. During an interview on 5/5/2025, at 3:55 p.m., Resident 1 refused to speak about the alleged incident. During an interview on 5/5/2025, at 4:10 p.m., CNA 2, stated on 4/19/2025 she heard yelling and screaming coming from a room (Resident 1 and Resident 3's shared room) and when she entered the room, she saw Resident 3 on the floor against the wall and Resident 1 was standing over Resident 3 holding a pole in her hand and calling Resident 3 expletives. Resident 3 stated the pole that Resident 1 used to hit Resident 3 with, was approximately two to three feet long, wrapped in a sheet. During an interview on 5/6/2025, at 2:32 p.m., CNA 3, stated, around 10 p.m., (4/19/2025) she heard loud yelling coming from Resident 1's room. CNA 3 stated she, CNA 2, and CNA 4, who also heard the yelling, ran to Resident 1's room. CNA 3 stated when she arrived at the room, she saw Resident 1 holding a pole that was approximately three feet long, wrapped in a sheet, Resident 1 was standing over Resident 3 who was lying on the floor between the bed and the patio door in a fetal position (lying on one's side with knees pulled up towards the chest). During an interview on 5/6/2025, at 3:37 p.m., Registered Nurse Supervisor (RNS) 1 stated, a few months ago Resident 2, Resident 1's former roommate, accused Resident 1 of hitting her (Resident 2) with a stick. RNS 1 stated she looked everywhere for the stick but couldn't find it. During an interview on 5/7/2025, at 11:15 a.m., the Director of Rehabilitation (DOR) stated, when staff from the Rehab Department were not in the Rehab room, they close the door, but they don't lock it. The DOR stated, when the Rehab staff leave the facility, between 5 p.m. and 7 p.m., they (Rehab staff) lock the door. The DOR stated there were a total of 10 weighted dowels hanging on the wall in the Rehab room, and one of them was used by Resident 1 to hit Resident 3. The DOR stated the Dowel weighed two pounds. During an observation on 5/7/2025 (18 days after Resident 1 struck Resident 3 with the Dowel that was identified coming from the Rehab room), at 2:20 p.m., with the ADM and the DON present, in the rehabilitation room, Dowels and free weights of different weight and sizes were observed hanging unsecured on a wall in the Rehab room. During a concurrent observation and interview on 5/7/2025, at 2:57 p.m., the DOR showed the Dowel to Resident 2, Resident 2 confirmed that the Dowel looked like the object that Resident 1 hit her with on 2/24/2025. During a review of the facility's Policy and Procedure (P&P), titled, Safety and Supervision of Residents dated 7/2017, the P&P indicated, our individualized resident centered approach to safety addresses safety and accident hazards for individual residents. The interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents. The care team shall target interventions to reduce individual risks related to hazards in the environment. The P&P indicated Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure a resident, who was assessed at risk for wandering (moving around inside the facility without awareness of personal safety, potentially putting themselves in harm's way), did not elope (the act of leaving a facility unsupervised and without prior authorization) from the facility for one of nine sampled residents (Resident 1). The facility failed to: 1. Have a system in place to supervise and monitor Resident 1's whereabouts to prevent him from eloping from the facility. 2. Develop a care plan with interventions addressing Resident 1's risk for wandering, to ensure the resident's safety, and prevent him from eloping from the facility. 3. Ensure staff followed the facility's policy and procedure (P&P), titled Wandering Residents - No Facility Wide Wandering Notification System dated 11/2016, that indicated residents at risk for wandering shall have a care plan implemented with interventions appropriate to the resident to help prevent wandering out of the facility during the day. These deficient practices resulted in Resident 1 eloping from the facility on 10/30/2024 and was missing for over two hours before staff noticed he was gone. Resident 1 was placed at risk for exposure to harsh environmental conditions, including extremes in heat and/or cold, possible motor vehicle accidents, medical complications related to his diagnoses of diabetes mellitus ([DM] a disorder characterized by difficulty in blood sugar [b/s] control and poor wound healing), such as hyperglycemia (when b/s levels are too high [normal b/s levels range from 70 milligrams [mg]/deciliter [dl] a unit of measurement), hypoglycemia (when b/s levels are too low), and possible death. Resident 1 was eventually located on 11/6/2024 (eight days after he was found missing from the facility), in a towing yard, living in a van. On 11/6/2024 at 4:10 p.m. 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) was called in the presence of the facility's Executive Director (ED), Chief Clinical Officer (CCO), and RCN (RCN) due to the facility's failures to have a system in place to prevent Resident 1 from eloping from the facility and placing nine other residents, who were assessed at risk for elopement, to go missing. On 11/7/2024, the facility submitted an acceptable IJ Removal Plan ([IJRP] interventions to immediately correct the deficient practices). After onsite verification of the facility's IJRP's implementation through observation, interview, and record review, the IJ was removed on 11/7/2024 at 6:23 p.m. in the presence of the facility's ED, and the CCO. The facility's IJPR included the following immediate actions: 1. Corrective and appropriate actions to be implemented for the affected residents identified in the deficiencies. a. Immediate Action: On 10/30/2024 at approximately 4:30 p.m., the Certified Nursing Assistant (CNA) assigned to Resident 1 reported to the CCO and ED that Resident 1 was missing. Immediately a Code Orange (a message usually sent out via intercom to notify and prompt staff to search for a missing resident) was called, which initiated facility staff to conduct a thorough search within the premises of the facility and surrounding neighborhoods, but staff were unable to locate the resident. The facility also alerted local hospitals and shelters. The incident was reported to the local sheriff's office via telephone on 10/30/24 at 5:40 p.m., and notification was faxed to the California Department of Public Health (CDPH) on 10/31/24 at 3:00 p.m. The resident's roommate was interviewed and queried after staff were unable to locate Resident 1. The resident's roommate indicated that Resident 1 said he wanted to go to Pacific Coast Highway. A facility staff drove down Pacific Coast Highway to assist with locating Resident 1. An in-service for staff regarding Elopement Policy was completed on 11/1/2024. b. A door monitor (a person assigned to monitor the facility's entrance/exit doors) was assigned for the back door entrance initiated 10/30/24. The local Sheriff's office was also informed and assisted in looking for Resident 1. The local Sheriff's Office made multiple postings to social media and to other missing person's outreach. The Department of Motor Vehicle (DMV) was called to request if the facility could avail itself of any vehicle registered under Resident 1 to locate the resident and inform the sheriff's department. The DMV informed the facility that they were not allowed to disclose any vehicle information that was registered to Resident 1. The final investigation report was sent to CDPH on 11/5/2024 at 5:00 p.m. c. Immediate action: On November 6, 2024, at 2:00 p.m., the facility admission coordinator worked with the insurance case manager to locate information on a responsible party. The insurance case manager found details about Resident 1's daughter and her phone number from an entry made six months prior in their portal, related to a previous admission and discharge, which had not been relayed to the facility or included in Resident 1's current admission records. The RCN called the daughter at around 2.30 p.m. on 11/6/2024. The daughter stated she called the sheriff's office and the sheriff posted information on the patient on social media. Resident 1's daughter indicated Resident 1 did not want to stay with her but currently had a van that was parked in the lot of a towing company. On November 6, 2024, at 5:40 p.m., Resident 1 was located by the facility's RCN. The resident expressed a desire not to return to the facility, preferring to stay in his van, where he had been residing when not hospitalized or in a nursing home over the past year. Resident 1 mentioned that he had visited his doctor for an appointment earlier in the day and received his prescription. His van was parked at a towing company lot, where the owner of the towing company keeps an eye on him (Resident 1). Resident 1 reported having his own supply of food and medication and confirmed a recent visit to the social security office. Resident 1 also signed a discharge against medical advice (A.M.A) on 11/6/2024 since he insisted on not wanting to return to the facility. The Sheriff's department was notified on 11/6/24 that Resident 1 had been located and where Resident 1, they (the Sheriff's department) and also completed a wellness check on 11/7/24 and Resident 1 continued to not want to return to the facility. d. Immediate action: All exit doors are equipped with an alarm 24 hours and 7 days a week. Door monitors have been assigned to monitor two exit doors beginning 11/6/24 with the front door being monitored from 8 a.m. to 8 p.m. and the back door and back patio from 6:30 a.m. to 8 p.m. The alarms are activated after the door monitors leave for the day. 2. Governing Body (responsible for ensuring that the facility's Quality Assessment [QAPI] and Performance Improvement program is effective and ongoing) - QAPI committee a. Immediate Action: The Interdisciplinary Team ([IDT] a group of healthcare professionals with diverse specialties who collaborate closely to develop and implement a comprehensive care plan for each patient) convened on 11/6/24 to revise the wandering and elopement policy. The updated policy includes assessment updates, risk scoring with targeted interventions based on risk levels, elopement drills, and procedures to follow if a resident goes missing. Following the review and update of the policy, an ad hoc meeting of the Quality Assurance Performance Improvement (QAPI) Committee was held on 11/6/24 to review, update and approve the new wandering and elopement policy, including the wandering and elopement assessment. b. Immediate Action: During the ad hoc QAPI Committee meeting on 11/6/24, a root cause analysis (RCA) revealed key issues in the wandering and elopement process, including communication breakdowns, inconsistent documentation, and training gaps in high-risk monitoring protocols/interventions. Staff were found to lack clear guidance on monitoring frequency, specific elopement prevention protocols, and proper documentation of care plans for high-risk residents. These findings underscore the need for improved communication, consistent documentation, and targeted training to enhance care quality for residents at risk of elopement. c. The ED will oversee corrective actions initiated on 11/6/2024 and monthly thereafter during QAPI meetings which are based on the results of the RCA and plan of corrections for the findings during the survey. Any corrective actions not meeting the 100% compliance benchmark, as determined by medical records audits, wandering and elopement system audit will be reviewed and revised with the QAPI Committee for revision, further evaluation, and recommendations, with a designated person IDT member assigned to each corrective action. d. Any new issues found during medical record audits and wandering, and elopement system audit will be presented to the Wandering/Elopement IDT members for immediate action. The CCO will monitor the immediate actions for implementation of monitoring/audit needs at least monthly for the next 3 months or until compliance is 100% or is achieved. 3. Specific staff involved in implementing the corrective actions. a. Team. Members: Medical Director, ED, CCO, Director of Staff Education, and RCN. Each member will perform as follows: i. Medical Director: Through the QAPI committee, the Medical Director will monitor the system, recommend changes, and oversee corrective action plans. This role includes identifying and implementing medical interventions to reduce confusion and prevent wandering or elopement. ii. ED: The ED will oversee all corrective actions initiated on 11/6/2024 and continue monthly reviews during QAPI meetings. iii. CCO: Leading the Wandering and Elopement Team., the CCO will regularly review at-risk residents, assess intervention effectiveness, and adjust care plans as needed. This role also ensures that wandering management and elopement prevention practices are standardized, monitors staff compliance, coordinates equipment maintenance, educates staff, oversees data analysis, and conducts reviews to recommend preventive measures. iv. RCN: This role entails staying updated on regulatory changes, collaborating with the IDT to update policies, and ensuring staff adherence to these policies. It includes participating in quality improvement initiatives, analyzing compliance data, assisting with corrective actions, identifying risks, and investigating incidents to prevent recurrence. v. Director of Staff Education: This role involves educating staff on care planning, documentation, and protocols for elopement and wandering, covering incident reporting, preventive measures, and emergency responses. Responsibilities include training new hires on resident safety, conducting competency assessments, emphasizing risk assessment, and ensuring accurate documentation related to elopement and wandering prevention. 4. Identification of other residents who may need to be included (who may have been affected by the deficient practice: a. All residents who were identified as high risk for wandering/eloping were identified at risk for the identified deficient practice. A total of 5 residents were initially identified based on current assessment as high risk. All five residents were reassessed using the new wandering and elopement assessment approved by the QAPI Committee on 11/6/24. There was a total of 0 residents that scored significant/serious actual risk for wandering/elopement and 2 residents scored moderate actual risk. The care plan was updated based on the wandering/elopement assessment for frequency of routine checks for location will be as followed: i. Significant/Serious Actual Risk - frequency of routine monitoring will be every 15 minutes for location of the resident. ii. Moderate Actual Risk - frequency of routine monitoring will be every 2 hours for location of the resident. iii. Low Probable Risk - frequency of routine monitoring will be every 4 hours for location of the resident. 5. Systemic Changes and Measures: a. Immediate Action: The IDT convened on 11/6/24 to revise the wandering and elopement policy. The updated policy includes assessment updates, risk scoring with targeted interventions based on risk levels, elopement drills, and procedures to follow if a resident goes missing. Following the review and update of the policy, an ad hoc meeting of the QAPI Committee was held on 11/6/24 to review, update and approve the new wandering and elopement policy, including the wandering and elopement assessment. b. Immediate Action: The residents with identified risk will be added to the specific instructions on the Electronic Medical Record (EMR) banner for each resident beginning 11/6/24. c. System Change: The EMR's wandering, and elopement risk assessment was updated as well as the care plan library to include risk score intervention for frequency of routine checks for location on 11/7/2024 will be documented in either the Electronic Medication Administration Record (EMAR) or TASK section of the EMR and will be as followed: a. Significant/Serious Actual Risk - frequency of routine monitoring will be every 15 minutes for location of the resident. b. Moderate Actual Risk - frequency of routine monitoring will be every 2 hours for location of the resident. c. Low Probable Risk - frequency of routine monitoring will be every 4 hours for location of the resident. d. Immediate Action: The elopement/wandering binder that already contained the list of all the residents with moderate/ serious significant risk for wandering and elopement was reviewed on 11/6/24. The elopement binder will be updated at least weekly by each Unit Director of Nursing (DON) and/or with new admissions that meet the significant/serious risk score. The wandering/elopement binder will be audited for completion and verification of list of patients every week by Medical Records Designee and any inconsistencies from the list will be provided to CCO to update and make corrections. e. System Change: Wandering and elopement risk assessment and missing resident policy has been updated on 11/6/24. f. System Change: Starting November 7, 2024, the Medical Records Department will use a monitoring tool to audit the documented frequency of routine checks/location for residents identified with a risk for wandering or elopement, based on their established care plans. Audits will be conducted daily for three days, then weekly for two weeks, and monthly thereafter. Immediately after completion of the audit, the Medical Records Designee will submit the findings of the audits to the CCO. Issues found by the CCO will be referred to the Wandering and Elopement IDT for further review and revision of the action plan and/or to determine any further training needed for staff involved. g. System Change: The Wandering/Elopement IDT will review post elopement events within 24-72 hours of incident for any revision of assessment need and/or plan of care interventions. 6. Training and Education Started on 11/6/24 by Director of Staff Education and/or Designee. a. Immediate action: Inservice training for staff license nurses was started on 11/6/24 on updating comprehensive care plans for residents that have been identified as wandering/elopement risk. A total of 11 nurses have been trained and will continue training until all staff nurses have attended and will continue training until all staff nurses have attended by 11/08/24. b. Immediate action: Inservice training for staff nurses was started on 11/6/24 on how to assess residents with elopement/wandering risk. A total of 11 nurses have been trained and will continue training until all staff nurses have attended and will continue training until all staff nurses have attended by 11/08/24. c. Immediate action: Inservice training for staff nurses was started on 11/6/24 on how to determine frequent monitoring needs based on elopement/wandering episodes and how to document the monitoring in the electronic medical records. A total of 27 clinical staff have been trained and will continue training until all staff nurses have attended and will continue training until all staff nurses have attended by 11/08/24. d. Immediate action: Inservice training on staff nurses was started on 11/6/24 on how to recognize behaviors that place residents at risk for elopement and who to report and how to follow up with residents. A total of 27 clinical staff have been trained and will continue training until all staff nurses have attended and will continue training until all staff nurses have attended by 11/08/24. e. Immediate action: Inservice training for staff nurses was started on 11/6/24 on how to identify residents that are at high risk for wandering using an orange band (a band placed on residents' wrist to indicate they are at risk for wandering). A total of 27 nurses have been trained and will continue training until all staff nurses have attended and will continue training until all staff nurses have attended by 11/08/24. f. Immediate action: Inservice training for staff nurses was started on 11/6/24 on elopement drill and what to do for missing residents. A total of 27 clinical staff have been trained and will continue training until all staff nurses have attended and will continue training until all staff nurses have attended by 11/08/24. g. Immediate action: The assigned door monitors were provided in-service training on how to monitor residents based on elopement binder list on 11/7/24. A total of 2 have already been training and will continue until all have attended by 11/8/24. Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including wedge compression fracture (a break or crack in the spine that usually occurs from too much pressure) of the thoracic vertebra (the 12 bones in the middle section of the spine between the neck and the bottom of the ribs), DM, and mild cognitive (ability to think and reason) impairment. The Face Sheet indicated Resident 1 prior to admission to the facility was unsheltered/homeless (when someone's primary night time residence is in a place that is not designed for sleeping such as a car). During a review of Resident 1's Minimum Data Set ([MDS] a federally mandated resident assessment tool) dated 9/16/2024, the MDS indicated Resident 1's cognition (ability to think and reason) was mildly impaired. The MDS indicated Resident 1 had no functional limitations in range of motion ([ROM] the direction a joint can move to its full potential) to his upper or lower extremities (arms/legs) and he required moderate assistance (helper does less than half the effort) for showering and dressing the lower body and he required supervision for toileting hygiene. During a review of Resident 1's Wandering Risk Scale assessment dated [DATE], the Wandering Risk Scale Assessment indicated Resident 1 was at risk for wandering due to his diagnosis of cognitive impairment. During a review of the Care Plan section of Resident 1's clinical records, the Care Plan section indicated there was no care plan developed for Resident 1's risk for wandering, based on his Wandering Risk Scale Assessment conducted 9/7/2024 . During a review of Resident 1's Physician's Order dated 9/7/2024, the Physician's Order indicated Resident 1 was to receive Regular Insulin (a short-acting injected medication, used to treat DM, that helps the body metabolize sugar) subcutaneously (administered under the skin) before meals and at bedtime per a sliding scale (pre-meal insulin dosage based on the b/s level before set intervals) as follows: For a b/s of 121 mg/dl -150 mg/dl give one unit of Regular Insulin For a b/s of 151 mg/dl - 200 mg/dl give two units of Regular Insulin For a b/s of 201 mg/dl - 250 mg/dl give three units of Regular Insulin For a b/s of 301 mg/dl - 350 mg/dl give six units of Regular Insulin For a b/s of 351 mg/dl - 400 mg/dl give eight units of Regular Insulin For a b/s greater than 400 mg/dl give eight units of Regular Insulin and call the Medical Doctor (MD). During a review of Resident 1's Change in Condition (COC) Evaluation note dated 10/30/2024, the COC indicated on 10/30/2024 at 4:30 p.m., Resident 1 could not be located by facility staff and a Code Orange was called. During an interview on 11/1/2024 at 12:23 p.m., Certified Nursing Assistant (CNA 1) stated on 10/30/2024, she worked a double shift beginning 7 a.m. to 3 p.m., and continued 3 p.m. to 11 p.m., but was only assigned to Resident 1 from 3 p.m. to 11 p.m. CNA 1 stated the last time she saw Resident 1 was in his room, lying in bed awake after lunch around 1 p.m. CNA 1 stated she did not see Resident 1 on her next shift when she started at 3 p.m. CNA 1 stated at 3:40 p.m., she spoke to Resident 1's roommate (Resident 4), who told her Resident 1 informed him (Resident 4) that Resident 1 was upset because his room was being deep cleaned (a cleaning process where all furniture is removed from the residents room). CNA 1 stated she believed Resident 1 left through the front exit because he liked to sit on the couch and hang out in the front lobby. CNA 1 stated Resident 1 was able to walk holding onto a wheelchair and pushing the wheelchair in front of him. CNA 1 stated she reported to the Assistant Director of Nursing (ADON) at 4:15 p.m., that Resident 1 was missing, and the ADON called a Code Orange at 4:45 p.m., but they were unable to locate Resident 1 after searching the facility. During an interview on 11/1/2024 at 3:02 p.m., CNA 2 stated on 10/30/2024 she was assigned to Resident 1 for the first time from 7 a.m. to 3 p.m. and was not told when she was given report that Resident 1 was a wandering risk. CNA 2 stated the last time she saw Resident 1 on 10/30/2024 was before lunch, around 11 a.m., in the front lobby near the front door of the facility. CNA 2 stated she normally made rounds three times on her eight-hour shift, between 7:30 a.m. to 8 a.m., 12:30 p.m. to 1 p.m. and at 2:45 p.m., before her shift ended at 3 p.m. CNA 2 stated on 10/30/2024 it was busier than usual, residents' rooms were being deep cleaned, including Resident 1's room, and she had to take residents to the facility's Halloween event after lunch. CNA 2 stated she was unable to stick to her normal routine and forgot to check on Resident 1. During an interview on 11/1/2024 at 3:30 p.m., the MDS Nurse (MDSN) 1 stated, the admitting nurse was responsible for creating an initial care plan for residents at risk for wandering, based on the resident's Wandering Risk Scale assessment, which was completed on admission. MDSN 1 stated the Wandering Risk Scale assessment was completed for all newly admitted residents and if a resident was determined to be at risk for wandering, a care plan should be created. MDSN 1 stated the nursing staff and MDS department does not specify on the care plan how often a resident who was at risk for wandering should be monitored. MDSN 1 stated in her professional opinion a resident with mild cognitive impairment should be monitored every 1 to 2 hours, and more frequently for a more confused resident. MDSN 1 stated nurses should have communicated that Resident 1 was at risk for wandering during their huddle (a meeting discussing residents). During an interview on 11/5/2024 at 9:40 a.m., Registered Nurse (RN 1) stated during admission, if a wandering risk assessment indicated a resident was at risk for wandering, a care plan should be created with interventions to monitor the resident at least once every 2 hours. RN 1 stated even if the resident does not exhibit wandering behaviors but was mildly confused, the resident could have impaired judgement and should be monitored. RN 1 stated during huddle, residents who need to be monitored closer due to wandering or confusion should be discussed amongst staff. During an interview on 11/5/2024 at 10:14 a.m., the Director of Staff Development (DSD) stated residents should be visually checked at a minimum of once every two hours and more as needed, which is determined by any licensed nurse. The DSD stated monitoring frequency for residents at risk for wandering was at the discretion of the licensed nurse who should communicate the frequency needed to monitor the resident to the CNAs during their huddle, then the licensed nurse should oversee the CNA to make sure the residents were being monitored. During an interview on 11/5/2024 at 10:59 a.m., Licensed Vocational Nurse (LVN 1) stated Resident 1 was ambulatory (able to walk) and would often walk through the facility pushing his wheelchair daily. LVN 1 stated Resident 1 was not in his room most of the day on the day he eloped from the facility (10/30/2024) because his room was being deep cleaned from 10:15 a.m. to 3 p.m. LVN 1 stated she last saw Resident 1 before lunch when she attempted to take Resident 1's b/s, and she assumed he was at the facility's Halloween event. LVN 1 stated Resident 1 was not discussed in their huddle at the beginning of the shift on 10/30/2024, she was not aware Resident 1 was at risk for wandering, and she was not sure if Resident 1 had a care plan related to his at risk for wandering. LVN 1 stated, normally CNAs make rounds to monitor residents three times on an eight-hour shift but for residents at risk for wandering she instructed the CNAs to do rounds every 1 to 2 hours. During an interview on 11/5/2024 at 11:59 a.m., the ADON stated the purpose of completing a wandering risk assessment was to identify residents who were at risk for elopement, and the purpose of creating a care plan, based on the wandering risk assessment, was to ensure all staff were aware to monitor the resident. The ADON stated charge nurses were responsible to familiarize themselves with a resident's care plan and communicate those needs to the CNAs. The ADON stated residents who were at risk for wandering should be monitored once an hour or more. The ADON stated care plans should be clear and not left open for interpretation so goals could be measured to know if the goals were being met or not. During an interview on 11/6/2024 at 12:38 p.m., the Director of Quality Assurance (DOA) stated the last time she saw Resident 1 was in the facility's front lobby near the front door at 2 p.m., on 10/30/2024. The DOA stated a wandering risk assessment should be completed for all residents, and a care plan should be created if a resident was at risk for wandering, in order to document the care needed for a resident and implement it. The DOA stated a care plan should have been created for Resident 1's risk of wandering by the admitting nurse. The DOA stated Resident 1 should have been monitored at least four times during an eight-hour shift based on his mild cognitive impairment and ability to walk. During an interview on 11/6/2024 at 10:36 a.m., the DON stated per their policy when a resident was assessed as a wandering risk, a care plan should be created to make everyone aware of the resident's specific care needs. The DON stated for residents at risk for wandering, monitoring should be done at least six times during an eight-hour shift. The DON stated the reason why a wandering/elopement care plan was not created for Resident 1 was because he did not exhibit any actual wandering behaviors. The DON stated different frequencies of monitoring were dependent on the resident. During an interview on 11/6/2024 at 1:22 p.m., the DON stated the purpose of a care plan was to identify appropriate care for residents based on their needs and preferences. The DON stated a care plan should have been developed to address Resident 1's risk for wandering and documentation should have been completed to monitor Resident 1's location to prevent him from eloping from the facility and potentially getting hurt. The DON stated Resident 1 was diabetic and required insulin depending on his b/s levels and could suffer a medical emergency if he did not get his medication as prescribed. The DON stated Resident 1 was living in his van prior to admission to the facility and he voiced wanting to be discharged from the facility to go back to his van, but the physician stated it was unsafe for him to leave at that time. During an interview on 11/12/2024 at 1:14 p.m., admission Nurse Assistant (ANA 1) stated she had been an ANA at the facility for six months and part of her duties included completing the wandering risk assessment for newly admitted residents. ANA1 stated she was not instructed to complete a care plan for residents who were assessed at risk for wandering. ANA 1 stated her understanding was that wandering care plans were to be completed by the MDS department. During a review of facility's P&P titled Wandering Residents - No Facility Wide Wandering Notification System dated 11/2016, the P&P indicated residents at risk for wandering shall have a care plan implemented with interventions appropriate to the resident to help prevent wandering out of the facility during the day. During a review of facility P&P titled Care Plans - Baseline and Summary dated 10/2024, the P&P indicated a baseline care plan should be developed for each resident within 48 hours of admission to provide instructions for the provision of effective and person-centered care to each resident, striking a balance between conditions and risks affecting the residents' health and safety. During a review of facility's P&P titled Routine Resident Checks dated 10/2024, the P&P indicated to ensure the safety and well-being of residents nursing staff shall make a routine resident check on each unit at least once per 8-hour shift, but frequency adjustments will be made according to individual needs.