Every finding on record at Belvedere Nursing and Rehabilitation Center, LLC

Based on observations, interview, record review, and facility policy review, it was determined the facility failed to have adequate interventions in the resident's care plan, for non-compliant behaviors, with a resident with a history of nicotine dependence (Resident #9) out of 4 residents reviewed for accidents and adequate individualized care plans.Based on observations, interview, record review, and facility policy review, it was determined that the facility failed to develop and implement a comprehensive care plan for one (Resident #9) out of four residents reviewed. Specifically, to ensure the resident's care plan addressed non-compliant behaviors related to a history of nicotine dependence and bringing electronic cigarettes (vapes) into the facility. The findings include: Review of Resident #9's admission Record revealed the facility admitted Resident #9 on 03/17/2026 with diagnoses which included malignant neoplasm of the brain, anxiety, pneumonia, and nicotine dependence with withdrawal. Review of Resident #9's admission Minimum Data Set (MDS) with an Assessment Reference Date of 03/30/2026, revealed Resident #9 had a Brief Interview of Mental Status score of 13 which indicated Resident #9 was cognitively intact. Review of Resident #9's electronic health record did not reveal a smoking assessment that would indicate the resident had been assessed as being able to safely utilize electronic cigarettes (vapes). During an observation and concurrent interview on 05/04/2026 at 4:21 PM, Resident #9 was lying in bed, and this surveyor observed Resident #9 searching the bed and covers. Resident #9 stated they were looking for a black vape. Medication Aide-Certified (MAC) #1 entered the room and assisted Resident #9 to search for the black vape. MAC #1 indicated that the black vape was not charged, placed the black vape onto a charger, and handed Resident #9 an orange-colored vape device. The MAC #1 indicated that the device was an actual vape. Review of Resident #9's Care Plan initiated on 03/17/2026, revealed Resident #9 was nicotine dependent and was at risk for complications from nicotine, but the resident's history of repeatedly being found in possession of electronic cigarettes (vapes) was not addressed. Specifically, there were no interventions providing guidance to staff on how to address noncompliant behaviors related to the facility's smoking policy (such as educating the resident/resident's family or confiscating such devices). Information on the continued practice of Resident #9's family bringing vapes into the facility, or the need for increased scrutiny in ensuring unsafe devices were identified and removed as needed to eliminate accident hazards. During an interview on 05/06/2026 at 9:20 AM, Certified Nurse Aide (CNA) #2 indicated that the facility was non-smoking, which included electronic cigarettes (vapes) and denied knowledge of Resident #9 having a vape. CNA #2 also indicated that if she were to find a vape, she would notify the nurse and/or Director of Nursing (DON), because the vape should not be in Resident #9's possession. During an interview on 05/06/2026 at 9:38 AM, Licensed Practical Nurse (LPN) #3 indicated that Resident #9's spouse would frequently bring the resident vape devices. During an interview on 05/06/2026 at 4:20 PM, Social Services (SS) indicated that the facility was a non-smoking facility and residents in the building should not have vapes. SS also indicated that staff should not be assisting residents with vapes and should instead report the vape(s) to the Administrative team so the vape(s) could be confiscated. During an interview on 05/07/2026 at 9:23 AM, the MDS Coordinator indicated she was ultimately responsible for adjusting care plans. The MDS Coordinator added that staff knew how to care for a resident by reviewing the closet care plan, located inside a resident's closet door, that was formed from the care plan located in a resident's electronic medical record. The MDS Coordinator reviewed Resident #9's care plan and could not locate interventions regarding vaping, or the non-compliant behaviors of Resident #9 in relation to vaping in the care plan. During an interview on 05/07/2026 at 11:10 AM, the DON indicated that the facility was a non-smoking facility, which included vapes. The DON stated, interventions related to vaping do not need to be in the Care Plan since it is a non-smoking facility. The DON also indicated that instead of MAC #1 assisting Resident #9 with the vape devices, the devices should have been reported to the nurse on the floor and then confiscated. During an interview on 05/07/2026 at 11:36 AM, the Administrator indicated that the facility was a non-smoking facility, which included vapes. The Administrator also stated that interventions related to behaviors with non-compliance of vaping should be in a resident's Care Plan, if there was a tendency for vapes to be brought in by family/significant others, like Resident #9. During a follow-up interview and observation on 05/07/2026 at 12:05 PM, the Administrator exhibited a box of vape devices that contained four black-colored vape devices, one orange-colored vape device, and one green-colored vape device. The Administrator stated that all of the vape devices had been confiscated from Resident #9. The Administrator was able to show that the devices had a place to plug in a charger. Review of a Staff In-Service performed following the surveyor's observations, dated 05/05/2026, revealed, if a vape is found in a resident's room, please notify your nurse, social, DON, or Associate Director of Nursing (ADON). No resident is allowed to have a vape or smoke in facility. Review of an excerpt from a facility admission Packet undated revealed Smoking is not permitted in the Facility and The Resident and/or Responsible Party accept full responsibility and absolves the Facility, its personnel, and the attending physician of responsibility for any fires, burn, or other accidents occurring as a result of the Resident smoking while the Resident is in bed, in the Resident's room, or in any other areas in the Facility.

Based on observation, record review, and interview, the facility failed to ensure staff followed care planned interventions requiring one staff member to perform transfers with gait belt to promote resident safety and prevent injury for 1 (Resident #2) of 3 sampled residents who required one-person transfers with a gait belt. This failed practice resulted in actual harm for Resident #2, who was transferred without the use of a gait belt and sustained a dislocation of the shoulder, proximal humerus fracture, ligamentous injury, and clavicle injury. The findings are: 1. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/26/2025, revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 11 (8-12 indicated the resident had moderate cognitive impairment). Resident #2 had diagnoses of age-related osteoporosis, osteoarthritis of hip, other chronic pain, vitamin D deficiency, displaced fracture of surgical neck of left humerus, closed fracture. a. Resident #2 ' s Care Plan with a revision date of 12/20/2023, indicated, Focus: (Resident #2) has an ADL self-care performance deficit related to impaired mobility; Intervention: Transfer: (Resident #2) requires extensive assist of 1 staff and a gait belt for transfers between surfaces b. The Closet Care Plan Form dated 09/14/2023, for Resident #2 that was observed in Resident #2 ' s closet on 03/13/2025 indicated that resident needed assistance of one [staff member] and instructed staff to utilize a gait belt with all transfers. c. A form titled Witness Statement Form completed by Certified Nursing Assistant (CNA) #1 on 01/08/2025 at 5:55 PM, indicated Certified Nursing Assistant (CNA) #1 assisted Resident #2 to bed. Resident #2 was in [Resident #2] wheelchair beside the bed. CNA #1 did not use a gait belt and grasped Resident #2's left upper arm. CNA #1 lifted Resident #2 and transferred the resident to the bed supporting part of the resident ' s weight by their left arm and pivoted the resident to the bed. CNA #1 indicated that Resident #2's arm popped while transferring resident. CNA #1 indicated that Resident #2 complained a little about their arm hurting so she ran and got the nurse. d. A form titled Witness Statement Form completed by Licensed Practical Nurse (LPN) #1, on 01/08/2025 at 5:55 PM, indicated Licensed Practical Nurse (LPN) #1 was passing meds when CNA #1 alerted him that Resident #2 complained of shoulder pain after hearing a loud pop during transfer. LPN #1 assessed Resident #2 shoulder and determined that it was necessary to notify the on-call provider. LPN #1 indicated that Resident #2's shoulder popped when moving the arm and the movement caused the resident 7/10 pain, resident indicated that the pain was minimal when not moved. e. A form titled Witness Statement Form for Resident #2 was written by LPN #1 on 01/08/2025 at 10:00 PM, LPN #1 took Resident #2 ' s statement as to how resident ' s arm/shoulder was hurt. Resident #2 indicated that CNA #1 was helping me out of my wheelchair. Resident #2 indicated that CNA #1 was not going slow, but did not know how to explain it. Resident #2 indicated that ' it ' (shoulder) popped and began to hurt immediately. Resident #2 indicated that CNA #1 went to get help after that. f. A form titled Emergency Department [Named], date 01/08/2025, Medical Decision Making: Differential diagnosis includes dislocation of the shoulder, proximal humerus fracture, ligamentous injury, clavicle injury. X-ray of the shoulder is pending to further evaluate g. A form titled Emergency Department [Named] Imaging Services dated 01/08/2025, indicated findings: Mildly displaced transverse fracture through the surgical neck of the humerus. h. A form titled Academy: CARE Academy with a completion date 08/29/2024, For CNA #1 shows CNA #1's Skill Assessments were completed on 08/29/2024, Return demonstration - Transfers and Gait Belt, progress 100 percent. i. Undated [NAME] Belt, Use of Policy provided by the Administrator on 03/14/2025, indicated gait belts will be utilized for any resident transfers. j. The Undated Care Plan Policy provided by the Administrator on 03/14/2025, indicated, facility will develop and review the care plan of each resident. k. On 03/12/2025 at 12:03 PM, this surveyor spoke with Resident #2. Resident #2 indicated they could tell their shoulder was injured after the improper transfer. Resident #2 stated, The girl (CNA #1) was kind of rough with me and she does not work here anymore. Resident #2 indicated that [Resident #2] had heard they were having a lot of complaints about the CNA that hurt [Resident #2]. This surveyor asked Resident #2 where they were when CNA #1 helped the resident up and caused the injury. Resident #2 indicated [Resident #2] was in [Resident #2 ' s] wheelchair in [Resident #2 ' s] room and wanted to go to bed. Resident #2 indicated that CNA #1 did not use a gait belt and grabbed [Resident #2] under the arm and then it popped and hurt. Resident #2 demonstrated that CNA #1 grabbed their upper arm (left) under the shoulder, and then stated, it got a little broke. Resident #2 stated She (CNA #1) was helping me from the wheelchair to the bed and she (CNA #1) was rough. If she would have been careful it would not have happened. l. On 03/13/2025 at 9:25 AM, CNA #4 was asked how they know a resident needs one person or two-person assistance with transfers. CNA #4 indicated staff utilized the closet care plan. CNA #4 was asked how often the closet care plan was checked. CNA #4 stated Every day, because it can change. CNA #4 was asked if she had been in-serviced on transfers. CNA #4 stated Yes, less than 6 months ago. CNA #4 was asked how a resident that needed one person assistance should be transferred. CNA #4 stated With a gait belt. m. On 03/13/2025 at 9:38 AM, CNA #5 was asked how they know what care a resident might need. CNA #5 stated, I check the closet care plan in the resident ' s closet. CNA #5 was asked how they would know if a person needed one or two-person assistance with transfers. CNA #5 stated, Closet care plan. CNA #5 was asked how often she checked the closet care plan. CNA #5 stated Every day, because it can change. CNA #5 was asked if she had been in-serviced on transfers. CNA #5 stated Yes, a few months ago. CNA #5 was asked how a resident who needs one person assistance should be transferred. CNA #5 stated, With a gait belt. n. On 03/13/2025 at 9:50 AM, CNA #6 was asked how they would know what care a resident might need. CNA #6 stated Check the closet care plan. CNA #6 was asked how they would know if a resident needed one or two-person assistance. CNA #6 stated, By their care plan. CNA #6 was asked how often they checked a resident's closet care plan. CNA #6 stated, Every day, because it may change. CNA #6 was asked how a resident who needed one person assistance should be transferred. CNA #6 stated With a gait belt. CNA #6 was asked if she had been in-serviced on transfers recently. CNA #6 stated Yes, I think it was within the last month. o. On 03/13/2025 at 10:10 AM, CNA #3 was asked how much assistance Resident #2 needed with transfers. CNA #3 stated two-person assistance due to [Resident #2 ' s] arm. CNA #3 was asked how they would know what care a resident may need. CNA #3 stated I check the closet care plan. CNA # 3 was asked how often she checked the closet care plan. CNA #3 stated Every time I go into the resident's room, at least once a day. CNA #3 was asked if she had received any training recently. CNA #3 indicated that she had just been in-serviced on transfers a few weeks ago. p. On 03/13/2025 at 10:20 AM, CNA #2 was asked how much assistance Resident #2 needed with transfers. CNA #2 stated Resident #2 ' s plan says one, but if the resident was weak that day I will ask for more help. CNA #2 was asked how you should transfer a resident that is one person assistance. CNA #2 stated, With a gait belt. CNA #2 was asked if she had been in-serviced on transfers recently. CNA #2 stated, Maybe a week or two ago. q. On 03/13/2025 at 1:21 PM, the Director of Nursing (DON) was interviewed and indicated she started on 01/27/2025. The DON was asked how staff know what care a resident needed. The DON indicated staff had the closet care plan in the room to refer to, they are in each resident room. The DON was asked how they [staff] find that out (to utilize the closet care plans). The DON indicated staff were trained when hired to always refer to closet care plan. The DON was asked who updated the closet care plans. The DON indicated that the Assistant Director of Nursing (ADON) did, anytime a change was made. The DON was asked when staff should check a closet care plan, and indicated before any care was given to a resident. The DON was asked how much assistance Resident #2 needed for transfers. The DON indicated that Resident #2 needed 1 person assistance, then indicated it was based on a resident ' s care plan. The DON also indicated that she had the department supervisors go around each day and check 5 closet care plans per day to audit and make sure the closet care plans were current and in place. The DON was asked who determined if a resident was a one person or two-person transfer. The DON indicated Physical Therapy. The DON indicated that she monitored ten transfers a day to make sure they are done correctly. r. On 03/13/2025 at 3:15 PM, the Administrator (AD) indicated that he was advised of the situation with Resident #2 by phone. The AD indicated that his on-call supervisor called him, but he could not remember who was on-call that night. The AD indicated that he was told a resident was hurt due to an improper transfer. The AD indicated that he called his consultant and then he went to the facility. The AD indicated that CNA #1 self-reported that she transferred Resident #2 without a gait belt. The AD indicated that he called the police and notified the family and the doctor. The AD indicated that he watched the cameras to see if he could observe anything. He indicated that cameras were in the halls but not in the rooms and that he did not see anything. The AD indicated that the DON started abuse and neglect in-services that night. The AD indicated that CNA #1 was suspended immediately that night, pending investigation. He indicated that there was no need to just suspend CNA #1, due to her self-reporting that she transferred resident improperly without using a gait belt, so she was terminated that night. s. On 03/13/2025 at 3:18 PM, the Nurse Consultant (NC), advised that the previous Director of Nursing (PDON) had started a monitoring program for transfers, right after this incident and she checked as of 03/11/2025, it was still in place with the current DON. The NC also indicated that they had done a QAPI (Quality Assurance and Performance Improvement) on the improper transfer and injury. The facility provided the following evidence of corrective actions that were initiated after the incident, but prior to the Complaint Survey: 1. Record of in-service dated 01/09/2025, titled Abuse, Neglect, Misappropriation and Exploitation with attached policy Abuse, Neglect, Misappropriation and Exploitation Investigation & Reporting Policy attached for staff to read. 2. Form titled Transfers provided by the DON, showing where transfers have been monitored since 01/09/2025 to make sure they are being done correctly. 01/08/25 - 01/23/25 30 transfers a day were observed. 01/24/35 - 02/06/25 20 transfers a day were observed. 02/07/25 - 03/14/25 10 transfers a day were observed. 3. Quality Assurance and Performance Improvement (QAPI) meeting minutes for 01/31/2025 were provided by the DON. It shows that the Reportable was discussed and monitoring system had begun for monitoring system of proper gait belt transfer with CNA's weekly. 4. Employee Timesheet for CNA #1 was provided by the Administrator to show that CNA #1 was not showing time after 01/08/2025. It shows CNA #1 clocked out at 10:15 PM on 01/08/25.

Based on observation, record review, interview, and facility record review, the facility failed to ensure the central bath and soiled utility room on 300 Hall were locked to prevent resident access to dirty linens, chemicals, and wet floors to prevent accidents and injuries. The facility failed to ensure the mechanical lift was in good working order to prevent accidents and injuries to 1 (Resident #49) of 1 sampled resident reviewed for accidents and injuries. Findings include: 1. a. On 11/04/24 at 10:34 AM, the surveyor observed the central bath door on 300 hall was unlocked. A clear bottle of blue fluid labeled [named] disinfectant cleaner was observed sitting just inside the door resting on a bedside chair. The bottle says hazardous to humans and animals, avoid contact with eyes and clothes and includes an emergency toll free number to call. A blue plastic container on the bedside commode contained anti-perspirant and [named] hygiene and barrier foam. b. On 11/05/24 at 10:36 AM, a deep bathtub, moist floor, shower area with 2 [named] fragrance body spray, and shampoo were observed in the central bath. The body spray was labelled as flammable, and not for underarm use. A low hanging cabinet observed not locked containing perineal skin cleanser, shave cream, and [named] hygiene and barrier foam. c. On 11/05/24 at 10:45 AM, the door to the soiled utility room opened easily and revealed two closed laundry bags, and two open containers of soiled linens. There were 2 containers of [named] sanitizing wipes displaying on the containers to call poison control for treatment resting on the cabinet. d. On 11/05/24 at 10:46 AM, Certified Nursing Assistant (CNA) #3 presented to the soiled utility room and stated the soiled utility room is supposed to stay locked so residents can not touch the soiled linens and harm themselves. CNA #3 stated that is why we have a separate room to store dirty linens, and it has a lock. CNA #3 was asked if the central bath is supposed to be locked, and why. CNA #3 confirmed the shower room should be locked due to chemicals, wet flooring, and stated residents could fall in the shower, or into the tub. e. During an interview with Director of Nursing (DON) on 11/07/24 at 8:40 AM, the DON was asked if bathrooms, and soiled utility rooms were to be locked, and why. The DON stated the central bath and soiled utility rooms are to remain locked and that is why there is a key code on the door to prevent residents from having access to dirty linens, chemicals, and wet floors that could cause residents to slip or fall. The DON stated maintenance was responsible for making sure the battery was changed in the key code lock, so they were in good working order. The Surveyor requested any policy or procedure, and maintenance logs showing the procedure for maintaining key coded doors. f. On 11/07/24 at 9:30 AM, the DON confirmed there was no policy or procedure addressing keeping the central bath or soiled utility rooms locked, and there was no log provided showing where maintenance checked the working order of doors with a key code to prevent resident access. 2. A review of Medical Diagnosis revealed Resident #49 had diagnoses of stroke, type II diabetes, and seizure disorder. a. The admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/06/2024 indicated Resident #49 had a Brief Interview for Mental Status (BIMS) score of 15 (13-15 indicated cognitively intact). Section GG suggest resident requires maximum assistance for bathing. b. On 11/05/24 at 2:40 PM, the surveyor observed Certified Nursing Assistant (CNA) #4 and CNA #5 removing the mechanical lift from Resident #49 with a clip missing from the right side on the 1st hook, and where the hang bar is attached to the mechanical lift there is a large piece of plastic missing at the top, exposing the metal bar. CNA #5 confirmed 3 times the lift pad is always connected to the 1st and 3rd hook and never the middle hook on the arm of the lift. CNA #5 stated she did not know what the metal clips were for, but assumed it was a safety feature to keep the lift pad from coming off the hook. CNA #4, and CNA #5 both stated they contacted maintenance, and he is coming to fix the mechanical lift, but they used it anyway because Resident #49 wanted to shower before getting a visitor. c. On 11/06/24 at 2:44 PM, Licensed Practical Nurse (LPN) #6 was asked the procedure for using a mechanical lift if a clip was missing and pointed out the broken plastic connecting the hanger bar to the mechanical lift. LPN #6 stated she would not use the lift if it was missing a clip for safety reasons. CNA #5 stated there was a risk that Resident #49 could have fallen by using a lift with a missing clip. d. On 11/05/24 at 3:45 PM, the DON provided a document from [named] Durable Medical Equipment (DME) service company showing the mechanical lift was serviced on 10/26/2024 and passed inspection. e. On 11/06/24 at 9:21 AM, Assistant Administrator provided a procedure titled Two Person Lift, revised 11-22-2016 that does not apply to the mechanical lift. e. On 11/06/24 at 9:30 AM, the Assistant Administrator provided a manual titled Hydraulic/Electric Patent Lift Warning Label Kit, revealing staff should check to see if the sling is properly attached to the hooks of the hanger bar, and if any attachments are not in place the resident should be lowered back to a stationary position. Part of maintenance is checking for missing hardware. f. On 11/07/24 at 8:35 AM, the DON was asked what process staff was expected to do before using a mechanical lift to transfer a resident. The DON revealed that durable medical equipment (DME) should be inspected to make sure everything is there or in good working condition before use. Maintenance should be notified, and the equipment removed from service, and the equipment should not return to service until it has been repaired. The DON was asked with the missing plastic and metal hook clip missing, should the mechanical lift been used. The DON stated the mechanical lift should have been pulled back and not used on Resident #49. g. On 11/07/24 at 9:30 AM, DON provided a copy of their medical equipment service agreement showing they provide service to durable medical equipment (DME) and other products.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure dietary staff washed their hands before handling clean equipment or food items when contaminated; 1 of 1 ice machines was maintained in a clean and sanitary condition, and cold dairy products were maintained at 41 degrees Fahrenheit or below for one meal observed. The findings are: 1. On 11/06/24 at 10:12 AM, Dietary Aide (DA) #7 opened the refrigerator, removed a pan of cookies, and placed it on the counter. Then DA #7 removed gloves from the glove box and placed them on her hands. Using her gloved hands, which were now contaminated, DA #7 picked up each piece of cookie from the pan placed them individually into separate bags to be served to the residents for lunch meal 2. On 11/06/24 at 10:22 AM, the following leftover dairy products were in a cooler by the steam table: a. There were 5 cartons of leftover whole milk, 2 cartons of chocolate ice cream, 4 cartons of sherbets and one carton of vanilla ice cream. The Assistant Dietary Manager was asked if she could check the temperature of the milk and check if the ice cream had thawed. She stated the milk temperature on the first carton was 43 degrees Fahrenheit and the second carton of milk temperature was 45 degrees Fahrenheit. After opening the cartons of ice cream and sherbets, the Assistant Dietary Manager confirmed the ice cream and sherberts had melted and should have been pulled from the cooler and put in the freezer at 8:50 AM, and she didn't know if staff checked the temperature on dairy products or if the ice cream had melted before putting them back in the freezer. 3. On 11/06/24 at 10:28 AM, the ice machine panel had wet black residue on it. The Surveyor asked the Assistant Dietary Manager to wipe the area, and the residue easily transferred to the tissue. The Assistant Dietary Manager stated it was dirty with black residue on the tissue, and the Certified Nursing Assistants (CNA) use it to fill beverages served to the residents at mealtimes and fill water pitchers in the resident's rooms and clean it every week. 4. On 11/06/24 at 11:05 AM, Dietary Aide (DC) #8 walked out of the restroom with tissue on his hands. Then, DA #8 picked up tray cards and placed them on the counter. Without washing his hands, he picked up napkins and placed them on the trays for the residents to use to wipe their mouths when eating. DA #8 was asked what the napkins were used for. DA #8 stated they use them to wipe their mouths while eating and he should have washed his hands. 5. A review of facility policy titled, In-Service Manual, initiated 2/92024, provided by the Assistant Dietary Manager on 11/7/2024 indicated, before, during, and after food preparation employees and after engaging in other activities that contaminate hands.

Based on observation and record review, the facility failed to develop and implement a comprehensive person-centered care plan for 1 (Resident #11) of 1 resident residing in the Memory Unit, related to identification of the medications the resident was receiving related to the Resident's medical needs. The findings are: 1. On 11/05/24 at 9:18 PM, a review of the Resident's Care Plan, Physician's Orders, and the Minimal Data Set (MDS) for Resident #111 identified Resident #111's Care Plan did not identify the following medications ordered for Resident #111: a. Risperidone oral tablet 0.25 milligram (MG), the resident was given 1 tablet by mouth two times a day for severe dementia with agitation. b. Trazodone oral tablet 150 MG, the resident was given 1 tablet by mouth at bedtime related to the resident's sleep disorder. c. Duloxetine oral capsule delayed release particles 60 MG resident was given 1 capsule by mouth two times a day related to major depressive disorder. d. Mirtazapine oral tablet 7.5 MG, resident was given 1 tablet by mouth at bedtime related to moderate protein-calorie malnutrition. e. Quetiapine Fumarate oral tablet 25 MG resident was given 1 tablet by mouth at bedtime related to dementia with agitation. f. Clonazepam oral tablet 0.5 MG a controlled drug, resident was given 1 tablet by mouth at bedtime for agitation related to Dementia with agitation. 2. Review of an admission MDS with an Assessment Reference Date (ARD) of 09/16/2024 revealed Resident #111 had a Brief Interview for Mental Status (BIMS) of 3, indicating severe cognitive impairment. 3. On 11/06/24 at 10:40 AM, MDS Coordinator #1 confirmed Resident #111 was ordered Duloxetine on 9/10/24, Trazodone on 9/10/24, Risperidone on 9/10/24, Quetiapine on 10/11/24, Mirtazapine on 9/10/24, and Clonazepam on 9/10/24. MDS Coordinator #1 confirmed the resident's care plan does not address these medications. MDS Coordinator #1 said Resident #111's care plan should identify the medications the resident is prescribed so the care plan shows the most current status of the resident.

Based on observation, interview, and facility policy review, it was determined that the facility failed to ensure proper hand hygiene was performed during peri care to reduce the risk of cross contamination, and the spread of infection for 1 sampled (Resident #55) resident reviewed for bowel and bladder. Findings include: Review of an in-service was provided titled Return Demonstration-Peri Care, revealing the dates of in-servicing of staff was done on 03/13/2024, 06/05/2024, and 07/01/2024, but no educational information was provided. A policy/procedure was provided titled Perineal/Catheter Care, revised 11/22/2016, revealing after perineal care gloves should be changed before placing a clean brief under resident and replacing the bedspread and giving resident the call light. On 11/04/2024 at 11:30 AM, during perineal care Certified Nursing Assistant (CNA) #2, and CNA #3 were observed cleaning Resident #55 of urine and stool without changing their gloves or washing hands prior to placing a clean brief and lift pad under the resident, pulling Resident #55's clothing up, and looking in the resident's bedside table. On 11/04/2024 at 11:40 AM, CNA #2 revealed she thought hand hygiene was supposed to be done at the beginning of perineal care, and when finished. CNA #2 confirmed hand hygiene should have been done after cleaning residents perineal area before dressing her and touching the environment. CNA #3 revealed she should have performed hand hygiene or changed her gloves after cleaning stool from resident's buttocks before dressing her and placing a clean lift pad under Resident #55 to avoid cross contamination. During an interview with Director of Nursing (DON) on 11/07/24 at 8:30 AM, the DON stated staff should wash their hands prior to beginning perineal care and should use one hand to hold the perineal area, and a clean hand should be used for wiping. The DON was asked if staff used both hands to clean a resident, if they are expected to do anything before dressing the resident. The DON stated staff should wash their hands before touching anything clean to prevent the spread of bacteria and prevent the harboring of infection.

Based on observation, record review, and interview, the facility failed to implement interventions for previous falls as indicated from the care plan to decrease the potential for future falls with injuries which resulted in a fall with a fracture for 1 (Resident #53); This failed practices had the potential to affect 23 residents who were at risk for falls according to a list provided by the Assistant Director of Nursing on 12/21/23 at 10:39AM. The facility failed to ensure residents who were at risk for fluid aspiration had the correct thickened consistency per physician's orders for 2 of 2 (#85 and #89). The Findings are: 1a. Resident #53 had a fall on 08/02/23 resulted in a radius fracture, ulnar fracture, seventh and eight rib fractures. b. Resident #53 had a fall on 08/21/23 which resulted in a knot to the right side of her head. c. Resident #53 had a fall on 08/26/23 resulted in a right femur fracture. d. Resident #53 had a fall on 10/30/23 with no injuries. e. On 12/19/23 at 7:00 PM review of Resident #53's electronic showed Nursing-I&A Note Effective Date:8/26/2023 15:30:00 written by Licensed Practical Nurse Created Date: 8/26/2023 19:18:30: Advanced Practice Nurse (APN) contacted at 1541. Family contacted at 1559. Incident Description: This nurse was alerted to noise and then a resident yelling she fell . Stood up from nurses' station to see resident laying on her right side in foyer to courtyard. Approached resident and wheelchair was noted to be at end of her body near her feet. Asked resident what happened, and she said she got up to go pee and fell . Resident reported some tenderness to right leg but was able to move leg. Resident was assisted by two staff members out of floor and into wheelchair. CNA [Certified Nursing Assistant] educated that one CNA is to be in common area at all times to watch the residents. Immediate Intervention: Staff educated that an CNA is to be in common area watching resident at all times. Nursing Note on effective Date: 8/21/2023 10:39:00 created by Licensed Practical Nurse Date:8/21/2023 10:42:23 Physician Contacted and Family Contacted Resident went into another resident's room, and it appears that she went to the restroom by herself and then somehow fell backwards, hitting her head on the wall on the way down. She has a knot on the right side of her head and states its sore. I tried calling Power of Attorney, but no answer so I left a voice nail. I spoke with [physician contact: name] and we started neuro checks, assessed for other injuries, helped her back to her wheelchair. Immediate Intervention: non-slip socks wheelchair alarm Nursing Note on Effective Date: 8/2/2023 05:40:00 Created Date: 8/2/2023 05:43:43 physician at 4:30 AM multiple attempts have been made to reach family but she still has not answered as of 5:45 AM. Incident Description: Resident found lying in her bathroom floor on her right side. Her head was sticking out of the bathroom doorway and could be seen from the common area. Resident was partially dressed and barefooted. Immediate Intervention: Resident assessed for injury. Resident's left arm appeared deformed, and Resident was guarding it in pain. ROM [range of motion] performed on other 3 extremities. Resident assisted out of floor and into w/c [wheel chair] with gait belt x 3 people. Telehealth call performed with on call and n/o [no orders] received to send resident to ER [emergency room ] for possible arm fx [fracture] with uncontrollable pain. h. On 12/20/23 at 9:08 AM after being observed for 3 days the Surveyor asked Licensed Practical Nurse (LPN) #3 if she could locate the following interventions from previous falls, shoes with back closures, rear tilted wheelchair seat, (measured front and back of wheel chair seat to the ground and noted 17 inches observed by LPN#3 and Certified nurse aide # 3), a seat belt, high back broad, anti-rollbacks. LPN #3 confirmed that none of the planned interventions were in place. During interview, the Surveyor asked LPN #3 was asked if the interventions should have been in place. LPN #3 stated, yes. The Surveyor asked LPN #3 was asked how the Certified Nursing Assistant (CAN)s knew how to care for the residents. LPN #3 stated, They have a closet care plan (CCP). The Surveyor asked show the surveyor the CCP. On the CCP were interventions that were not implemented. i. On 12/20/23 at 9:39 AM, the Director of Nursing (DON) was asked if she expected her staff to follow the interventions explicitly Resident # 53. The DON stated Yes, they should be in place every day. 3.a On 11/03/23 at 3:00PM, Resident #85 had orders for thickened liquids. Nectar Thick Liquids every shift. b. A care plan dated 11/3/23 documented change to mech soft, diet changed to puree, nectar thick liquids, date Initiated: 12/20/2021 with a revision date on 11/13/23. c. On 12/21/23 at 8:56AM the Surveyor asked CNA #3 to observe the thickened liquids and explain what was wrong. CNA #3 stated, I'm not sure. The Surveyor asked CNA #3 if there was a possibility Resident #85 could get any kind of liquids that the Resident might ingest that she shouldn't. CNA #3 stated, Oh yes, she can drink the melted ice. CNA #3 stated, She can aspirate and that can cause death. d. An order dated 09/13/23 at 3:00 PM an order for Honey Thick Liquids Every shift was documented in the Physicians Orders. e. On 08/02/23 the Care plan documented Diet changed to mech soft, honey thick liquids. f. On 12/18/23 at10:13 AM Resident #89's honey thick liquids were sitting at bedside in ice in a face pan. The ice was melting. g. On 12/19/23 at 9:15 AM, a warm ice pack with a small amount of thin water in pan at bedside with honey thick liquids floating in the water was observed. h. On 12/19/23 at 2:43 PM Resident # 89's thickened liquids from yesterday were in a pan of small amount of water with a warm ice pack on top of them at bedside. i. On 12/20/23 at 08:40 AM resident #89s thickened liquids were sitting in a pan of ice from Monday. The ice was melting and was 1/3 full of water. j. On 12/21/23 at 9:05AM, LPN #3 was asked to observe the thickened liquids and explain what was wrong. LPN #3 stated, The ice is melting, and she can drink it, aspirate fluids in her lungs and die. 4.a. On 12/18/23 at10:13 AM, Resident #89's honey thick liquids were sitting at bedside in ice in a face pan. The ice was melting. b. On 12/19/23 at 9:15 AM, a warm ice pack with a small amount of thin water in pan at bedside with honey thick liquids floating in the water was observed. c. On 12/19/23 at 2:43 PM Resident # 89's thickened liquids from yesterday were in a pan of small amount of water with a warm ice pack on top of them at bedside. d. On 12/20/23 at 8:40 AM, Resident #89's thickened liquids were sitting in a pan of ice from Monday. The ice was melting and was 1/3 full of water. e. On 12/21/23 at 9:05AM, LPN #3 was asked to observe the thickened liquids and explain what was wrong. LPN #3 stated, The ice is melting, and she can drink it, aspirate fluids in her lungs and die. g. On 12/20/23 at 4:26 the Assistant Director of Nurses (ADON) provided a form titled, Incident and Accident Policy. This policy isn't pertinent to the concern. h. On 12/21/23 at 10:39 AM, the Assistant Director of Nursing was asked to observe the thickened liquids sitting in thin water and explain what she observed. The ADON stated, The ice should be changed out more often to keep the consistency per physicians orders because if they drink the thin liquid they could aspirate and possibly die.

Based on observation, interview and record review, the facility failed to ensure medications were not left in a resident's room for one Resident (R#97) of one sampled resident. The findings are: 1. Resident #97 had a diagnosis of dementia. The Quarterly Minimum Data Set [MDS] with an assessment reference date [ARD] of 12/05/2023 documented a brief interview of mental status [BIMS] of 14 which indicates cognitively intact. a. On 12/18/23 at 10:39 AM, R #97 was observed lying in bed watching tv, on top of an overbed table to the right of Resident's bed there was a medication containing 7 calcium carbonate chewable tablets. Another medication cup was sitting at beside on the table with a thick white substance in it. When questioned about the medication cups, R #97 said it was her pain cream, she uses it for the arthritis in her hands. b. Review of R #97's Physician's orders did not document an order for calcium carbonate and documented an order for Voltaren 1% topical gel every 6 hours as needed. c. On 12/20/2023 Licensed Practical nurse [LPN] #2 was asked, Should medications be left at bedside? LPN #2 confirmed that it should not. d. On 12/20/2023 at 2:00 PM, the Surveyor asked the Director of Nursing [DON], should medication be left in a resident's room at beside and why or why not? The DON stated, No, you wouldn't know if the resident is taking them and when or they (the resident) may store them which can cause many problems. On 12/20/2023 at 3:30 PM, the Surveyor asked if R #97 had an assessment for self-administration of medication and the DON confirmed they did not. e. On 12/20/2023 at 3:30 PM, the surveyor asked for a policy on medication storage, at 4:26 PM the Assistant Director of nurses [ADON] stated, The facility does not have a policy on medication storage. f. Review of the facility Self-Administration of Medications documented.A resident may be permitted to administer or retain medication in his/her room under the following conditions: Assessment and approval by the interdisciplinary team .order is obtained from physician f. Review of the facility Self-Administration of Medications documented.A resident may be permitted to administer or retain medication in his/her room under the following conditions: Assessment and approval by the interdisciplinary team .order is obtained from physician

Based on observation, record review and interview, the facility failed to ensure a resident's care plan was individualized to address the residents hearing loss to ensure appropriate care was received for one Resident (#41) of one sampled resident with hearing loss. The findings are: 1. Resident #41 had a diagnosis of dementia, no diagnosis of hearing loss. The minimum data set [MDS] with an assessment reference dated [ARD] of 12/10/2023 documented a brief interview of mental status [BIMS] of 08 which indicates a moderately impaired cognitive status. The MDS also documented highly impaired hearing, able to understand others. a. On 12/18/23 at 11:05 AM, during interview with Resident #41 the Resident was unable to hear what was being said. Resident #41 kept repeating stating what. Resident #41's relative stated, Yeah, she is hard of hearing. My uncle bought her some hearing aids a before, but she refused to use them. I think she may be a little [NAME]. b. Review of diagnosis list, physician orders, and care plan did not document a hearing loss for Resident #41. c. On 12/20/2023 at 11:30 AM, the Surveyor asked Licensed Practical Nurse [LPN] #2, How do you communicate with Resident #41, with her hearing loss? LPN #2 stated, Sometimes it takes a few times repeating to get her to understand, I get down to eye level and she sometimes can read your lips. d. On 12/20/2023 at 11:45 AM, the Surveyor interviewed the MDS Coordinator. The Surveyor asked the MDS Coordinator How does staff communicate with Resident #41? The MDS Coordinator stated, The family had stated she has some hearing issues, but you can communicate if you get down to eye level with her. We have an audiologist that comes, the social worker sets that up. The Surveyor asked the MDS Coordinator to review the Residents plan of care to see if hearing loss was addressed. After looking at the care plan, MDS Coordinator said it is not on there. The Surveyor asked why is it important to ensure the care plan is accurate? The MDS Coordinator stated, So we can meet the resident's needs, to ensure the proper care and treatments are being done. e. The facility care plan policy documented, .After completing the MDS .the IDT (interdisciplinary team) must evaluate the information gained to develop a care plan that addresses those findings to the context of the resident's strengths, problems and needs .

Based on observation, interview and record review, the facility failed to ensure catheter output bags were concealed in a privacy bag to protect the resident's dignity for 2 (Resident's #39, and #62) of 3 sampled residents who had an indwelling catheter on 300 hall. The findings are: 1. On 12/18/23 at 10:02 AM, the Surveyor observed Resident #39 sitting up in chair with the output catheter bag one quarter full of yellow liquid, attached to a trash can, facing the door, visible from the doorway and to visitors. a. On 12/18/23 at 12:54 PM, the Surveyor observed Resident #39, sitting up in chair with the output catheter bag 1/4 full of yellow liquid, hanging on a trash can, facing the door, visible from doorway and to visitors. b. On 12 /19/23 at 08:22 AM, the Surveyor observed Resident #39 up in chair with the output catheter bag 1/8 full of amber colored liquid, attached to a trash can, facing the door, visible from doorway entrance for visitors to see. c. Resident #39's physician order documented .APRN to change Super Pubic Foley 16fr(French)/5cc(cubic centimeters)- Change every month on first and PRN. Active 12/01/2023 . 2. On 12/18/23 at 11:29AM, the Surveyor observed Resident #62 lying in bed with the output catheter bag 1/4 full of amber colored liquid, attached to the bedrail facing the door, visible from the doorway and to visitors. a. On 12/18/23 at 1:04 PM, the Surveyor observed Resident #62 lying in bed with the output catheter bag 1/3 full of amber colored liquid, attached to the bed rail facing the door, visible from the doorway and to visitors. b. R #62 physician order documented .Foley Catheter: 16/FR 10ml(milliliters) balloon change night shift on 19th and ending on 20th every month. 3. On 12/20/23 at 2:58 PM, the Surveyor interviewed Certified Nursing Assistant (CNA), #1, and asked when are your resident's foley catheters checked? CNA #1 confirmed, every shift. The Surveyor asked what should be attached to the foley bag? CNA#1 confirmed, a privacy bag. 4. On 012/20/23 at 3:02 PM, the Surveyor asked Licensed Practical Nurse (LPN) #1 when are catheters checked? LPN #1 confirmed every shift. The Surveyor asked, what should be attached to the foley bag? LPN #1 confirmed it should have a privacy bag covering it. 5. On 12/20/23 at 11:50 AM, the Surveyor asked the Director of Nursing (DON), what does a foley catheter bag need to have over it. The DON confirmed a privacy bag, and said it's a dignity issue. 6. The facility policy titled Resident Rights provided by the DON on 712/20/23 at 3:37 PM documented .34. To be treated with consideration, respect and full recognition of dignity and individuality .

Based on observation, interview and record review, the facility failed to ensure a physician's order was in the electronic health record prior to administration of oxygen for 1 Resident (d#44) of 5 sampled residents; the facility failed to ensure oxygen tubing and nebulizer mouthpieces were stored in a sanitary manner to prevent the spread of bacteria for 2 Residents (#44 and #270) of 8 sampled residents. The findings are: 1.a. On 12/18/2023 at 11:43 AM, Resident# 44 was lying in bed wearing a nasal cannula attached to an oxygen concentrator that was providing oxygen at 2.5 Liters per minute. b. On 12/18/2023 at 2:15 PM, Resident# 44 was lying in bed wearing a nasal cannula attached to an oxygen concentrator that was providing oxygen at 2.5 Liters per minute. c. On 12/20/2023 at 9:42 AM, Resident# 44 was lying in bed wearing a nasal cannula attached to an oxygen concentrator that was providing oxygen at 2.0 Liters per minute. 2.a. On 12/18/23 at 11:01 AM, Resident #270 was sitting up in wheelchair with the nasal cannula tubing rolled up and hanging on the wheelchair handle connected to the E-tank, tubing was not bagged. The nebulizer mouthpiece and tubing were laying on nebulizer machine on top of nightstand and the mouthpiece and tubing was not bagged. b. On 12/18/23 at 1:41 PM, Resident #270's nebulizer mouthpiece and tubing was laying on top of nightstand. The mouthpiece and tubing was not bagged. c. On 12/19/23 at 8:46 AM, Resident #270's nebulizer mouthpiece and tubing were laying on top of nightstand. The mouthpiece and tubing was not bagged. 3. On 12/20/2023 at 10:00 AM, the Surveyor asked Licensed Practical Nurse (LPN) #4, once an order is received for oxygen what is the next process? LPN #4 stated, Inform the resident and Power of Attorney, get supplies, hook them up, tell about the oxygen use on the 24 hour report. The Surveyor asked, does Resident #44 receive oxygen therapy? Can you show me the order? LPN #4 stated, The Resident has had oxygen, I do not see an order for oxygen. The Surveyor asked, should there be an oxygen order? LPN #4 stated, Yes, there should be an oxygen order. The Surveyor asked, Why should there be an order? LPN #4 stated, If there is not an active order then the resident should not be receiving it if not. The Surveyor asked, how should a nebulizer and oxygen tubing be stored? LPN #4 started, In a bag with name, date, and time. The Surveyor asked, why should the tubing be stored in a bag? LPN #4 stated, To prevent infections. 4. On 12/20/2023 at 10:04 AM, the Surveyor asked Director of Nurses (DON), what is your process for oxygen administration? The DON stated, Get an order first, evaluate, and apply as needed The Surveyor asked, why should there be an oxygen order? The DON stated, To apply the oxygen as needed so the resident doesn't go into respiratory distress. The Surveyor asked, how should nebulizer and oxygen tubing be stored? The DON replied, In a bag with date and changed weekly. The Surveyor asked, why should the tubing be stored in a bag? The DON stated, sanitary reasons. 5. On 12/20/2023 at 11:30 AM the Assistant Director of Nurses provided a policy titled Oxygen Safety which stated, .Oxygen therapy is administered to the resident only upon the written order of a licensed physician .

49071 Based on observation, interview and record review, the facility failed to ensure resident's individualized care plan were updated to ensure appropriate care was received for two Residents (R #33 and R#99) of 2 sampled residents. This failed practice had the potential to affect all 119 residents who reside in the facility. The findings are: 1. Resident #33 had a diagnosis of Alzheimer. The Annual Minimum Data Set [MDS] with an assessment reference date [ARD] of [DATE], had a brief interview of mental status [BIMS] of 5 (0-7 indicates severely impaired) and documented that R #33 required extensive assistance of staff with activities of daily living and fed self after set up. a. On 12/18/23 at 11:50 AM Resident #33 was observed sitting in a positioning chair at a table in the dining area, which is used for residents who need assistance, leaning to the left without any positioning devices in place. b. The care plan with a revision date of 05/04/2020 documented that resident was able to turn and position self, dress self, self-perform personal hygiene, transfer self, use a walker to ambulate, bathed and fed self with minimal assistance. c. On 12/20/23 at 10:18 AM, during interview certified nursing assistant [CNA] #2 confirmed she responsible for the care of R #33. The Surveyor asked CNA #2, What can R #33 do for herself? CNA #2 responded, Sometimes she can feed herself, but usually she is assisted with eating, but we do all her other care. CNA #2 confirmed that R #33 required two-person assist with turning, transfers (using a lift), bathing, incontinent care, dressing and personal hygiene. d. On 12/20/2023 at 11:25 AM, the MDS Coordinator was asked if R #33's care plan accurately reflects R #33's needs. After reviewing R# 33's care plan, the M DS coordinator stated, No, that's not right, (R #33) doesn't do any of their own care, they feed themselves at times, but no its not accurate. I don't know how that didn't update. e. On 12/20/2023 at 11:30 AM, the MDS Coordinator observed R #33's closet care plan. The closet care plan in place was dated 09/07/2022 and documented, one person assist with transfers and toileting, and ambulated with a rolling walker and non-skid strips at bedside which was incorrect. 2. On 12/18/23 at 10:04 AM, the Surveyor observed an isolation sign on R #99's door, and 3 drawer isolation cart was out in front by R #99's door. a. On 12/20/23 at 2:30 PM, during record review Surveyor observed R #99's care plan had not been updated with any information related to isolation or antibiotics. b. On 12/20/23 at 4:26 PM a policy received from the Director of Nurses (DON), titled, Care Plan Completion showed the following: .Nursing homes should also evaluate the appropriateness of the care plan after each Quarterly assessment and modify the care plan on an ongoing basis, if appropriate.

Based on record review and interview, the facility failed to ensure the Quality Assurance and Performance Improvement program (QAPI) Committee developed and implemented appropriate plans of action to prevent repeated deficiencies with updating care plans and initiating a care area on the care plan. These failed practices had the potential to affect all 119 residents. The findings are: 1. A Recertification Survey was conducted on 09/28/2022 at the facility. During this survey, the team identified concerns with development and implementation of care plans and care plan revision. 2. There was no Plan of Correction noted from the previous survey. 3. A Recertification Survey was conducted on 12/18/23 at the facility. During this survey, the team identified concerns with care plans not having implementation of care areas and no revision. 4. A policy titled, Quality Assessment and Assurance (QAA) Quality Assurance and Performance Improvement (QAPI), provided by the Administrator on 12/21/2023 at 12:10 PM documented, .1. The facility will develop, implement, monitor, evaluate, and maintain a QAPI program that is effective, data driven, comprehensive, and will focus on performance indicators as well as high-risk, high-volume, or problem-prone areas, as well as resident safety, choice, autonomy, and quality of care. 2. The plan describes the process for identifying and correcting adverse events and problems . 5. On 12/21/2023 at 11:15 AM, the Surveyor asked the Administrator, How does the QAA Committee know when an issue arises in any department? Administrator , stated, We bring it to the daily meeting and review it then to see if it can wait till the big QA [Quality Assurance] meeting or take care of it now The Surveyor asked, how does the QAA Committee know when a deviation from performance or a negative trend is occurring? The Administrator stated, Through tracking and trending, morning meetings, and communication with staff. The Surveyor asked, How does the QAA Committee decide which issues to work on? The Administrator stated, We prioritize of need with resident safety being first The Surveyor asked, How long will the QAA Committee monitor an issue that it has been corrected? The Administrator answered, Three to six months The Surveyor asked, Is the QAA Committee aware of repeated survey deficiencies? The Administrator answered, yes. The Surveyor asked, If aware, did the Committee implement corrective action? The Administrator answered, yes. The Surveyor asked, Is the Committee monitoring to ensure corrective action has been implemented? The Administrator answered, yes.

Based on observation, interview and record review, the facility failed to store the ice scoop in a closed container to ensure the infection prevention and control program was followed to provide a safe and sanitary environment to help prevent the transmission of communicable diseases and infection. The findings are: 1. On 12/18/2023 at 10:11 AM, in 100 hall hydration room the ice chest containing ice for residents' water pitchers contained the handheld ice scoop laying directly on top of the ice. 2. On 12/18/2023 at 10:12 AM, the Surveyor asked Certified Nursing Assistant (CNA) #4 is the ice scoop supposed to be inside the ice chest? CNA #4 confirmed It is supposed to be in the side container. The Surveyor asked CNA #4 what is the reason for the ice scoop to be in the side container? CNA #4 confirmed to keep it clean. 3. On 12/18/2023 at 10:14 AM, the Surveyor asked Licensed Practical Nurse (LPN) #2 where is the ice scoop to be kept? LPN #2 confirmed in the container on the side of ice chest. The Surveyor asked LPN #2 what is the reason for the ice scoop to be in the side container? LPN #2 confirmed if left in there I guess it can be considered cross-contamination. 4. On 12/20/2023 at 10:04 AM the Surveyor asked Director of Nursing (DON) where are the ice scoops to the ice chests are to be kept? The DON confirmed the scoop is to be kept in compartment with a lid. The Surveyor asked what is the reason for the ice scoop to be kept in the side container? The DON confirmed for infection control sanitary reasons. 5. A policy provided by the Assistant Director of Nursing (ADON) on 12/20/2023 at 11:30 AM titled Infection Prevention and Control Program states .Facility will utilize standard and transmission-based precautions to prevent spread of infections .

Based on record review and interview, the facility failed to complete a Significant Change in Status Minimum Data Set (MDS) after a decline in two or more Activities of daily living (ADL) for 1 (Resident #53) of 1 sampled resident whose MDSs were reviewed. This failed practice had the potential to affect all 119 residents in the facility. Findings are: 1. Resident #53 had a decline in 3 areas of ADLs according to the last 2 Quarterlies dated 6/6/23-and 9/1/23. a. The Minimum Data Set (MDS) a Quarterly Assessment with an Assessment Reference Date (ARD) of 6/6/23 documented that the resident required, bed mobility ext. assist of 1 person, eating supervision with set up, transfers ext. assist of 1 person, toileting ext. assist of 1 person. b. The Minimum Data Set a Quarterly Assessment with an Assessment Reference Date of 9/1/23 documented, bed mobility ext. assist of 2 person, eating supervision with set up, transfers ext. assist of2-personn, toileting ext. assist of 2 person. c. On 12/20/23 at 9:25AM, the Surveyor asked the MDS Coordinator (MDSC) to review the last 2 Minimum Data Sets for Resident #53. MDSC stated, There is a decline in 2 or more areas between the 2 MDSs. The Surveyor asked the MDSC what should have been done. The MDSC stated, I missed it; it should have had a significant change done. The Surveyor asked the MDSC what negative outcome could occur from a missed MDS. The MDSC stated, She could fall. d. On 12/20/23 at 9:35 AM, the Director of Nurses (DON) was asked if she expected the MDSC to complete all required MDSs. She stated, I can get with [named] ADON to see, but anytime there is a decline, you should do a MDS. The Surveyor asked the DON what is a possible negative outcome for missing a significant change MDS. The DON stated, I'm not sure, they might realize something like a further decline and don't communicate it. e. The ADON provided a form titled, Long - Term Care Facility Resident Assessment Instument 3.0 User's Manual. - Version 3.0 April 2012 which documented, A significant Change is a decline or improvement in a resident's status that: will not normally resolve itself without intervention .2. Impacts more than one area of the resident's health status . A significant change is appropriate if there are either two or more areas of improvement or decline .

Based on record review and interview, the facility failed to complete a comprehensive assessment using the Resident Assessment Instrument (RAI) process within regulatory time frames for 2 (Resident #70, and #277) of 2 sampled residents whose MDS were reviewed. The findings are: 1. On 12/19/23 at 11:31 AM the Electronic Record was reviewed for resident #70. The Admission MDS (Minimum Data Set) with an Assessment Reference Date (ARD) of 08/04/23 was completed. There were no other MDSs indicating no MDS for 120 days. 2. On 12/19/23 at 11:46 AM the Electronic Record (Electronic Record) was reviewed for Resident #277. The MDS Quarterly with An ARD of 8/7/23 was completed. There were no other MDSs. 3. On 12/20/23 at 9:25 AM, the Surveyor asked the MDS Coordinator (MDSC), how often is a MDS required? The MDSC stated, Every 3 months. The MDSC looked in the ER and stated Resident # 70 and #277 both should have had a quarterly done last month. That's my mistake. 4. On 12/20/23 at 9:35AM, the Surveyor asked the Director of Nurses how often regulatory MDSs are required. The DON stated, I'm not sure, I can get with [named] ADON(Assistant Director of Nursing). The DON was asked if she thought there should have been a MDS done since August. The DON stated, I'll have to ask [named}ADON. 5. On 12/20/23 at 4:20PM, the ADON provided CMS's RAI version 3.0 Manual . 05 Quarterly Assessment. The Quarterly Assessment is an OBRA non-comprehensive assessment for a resident that must be completed at least every 92 days following the previous OBRA assessment of any type .Assessment Management Requirements .: Federal Requirements dictate that, at a minimum, three Quarterly assessments be completed in each 12-month period .

Based on record review and interview, the facility failed to develop and implement a water management program to prevent the likelihood of waterborne illnesses caused by opportunistic pathogens such as Legionella. This failed practice had the potential to affect all 114 residents in the facility based on the Midnight Census Report which was provided by the Administrator on 10/4/23 at 10:15 a.m. These findings were determined to be Immediate Jeopardy. The Surveyor provided the State Operations Manual Appendix Q Immediate Jeopardy template to the Administrator and informed of the Immediate Jeopardy on 10/5/23 at 2:43 PM. The findings are: Review of a chest x-ray report for Resident #1 dated 9/16/23 showed, the chest x-ray had significantly worsened from 9/6/23 and may represent multifocal infectious processes to include a viral agent. Review of a lab report dated 9/18/23 for Resident #1 showed the specimen was positive for Legionella AG. Review of a chest x-ray report for Resident #2 dated 9/30/23 showed possible chronic lung disease or mild superimposed pulmonary edema. Review of a lab report dated 9/28/23 for Resident #2 showed the specimen was positive for Legionella AG. Review of a Physician's Order for Resident #2 dated 10/2/23 showed an order for Levofloxacin, an antibiotic for Legionnaires' Disease. On 10/4/23 at 1:40 p.m. review of the Nosocomial Infection Report for September 2023 revealed 10 upper respiratory infections during the month and no lower respiratory infections. A review of the color-coded Infection Control Log revealed 10 upper respiratory infections colored blue on the log. A review of the facility map with color code revealed the100 hall had 2 respiratory illnesses, 200 hall had 1 respiratory illness, 300 hall had 2 respiratory illnesses, 400 hall had 1 respiratory illness. Two of the residents on the log were Resident #1 and #2. On 10/4/23 at 1:50 p.m. seven legionella urine test results that were performed on 9/19/23 were reviewed. Only one (Resident #8) resident tested was documented on the Infection Control log as having respiratory symptoms during the month of September 2023. On 10/4/23 at 12:00 p.m. the Maintenance Director provided water temperature logs from August 2023. Water temperatures ranged from 106 degrees to 112 degrees consistently with the 112 degrees being in the laundry eye wash station. On 10/5/23 at 8:15 a.m. The Maintenance Director provided the water temperature logs from September 2023. Water temperatures ranged from 105 degrees to 109 degrees consistently. Review of the facility water testing results with a collection date of 9/27/23 showed Legionella > 2272.6. During an interview on 10/4/23 at 10:05 a.m. Infection Preventionist (IP) #1 said the facility was notified of positive legionella tests for two residents who were hospitalized . IP #1 said all residents who had respiratory symptoms were tested for legionella, which were all negative. IP #1 said the housekeepers started leaving water dripping, all the fountains have been turned off and the Maintenance Director has a water management plan that is followed. Review of the document, Developing a Water Management Program, revealed the page titled Identifying Buildings at Increased Risk was not completed. On 10/4/23 at 10:15 AM the Administrator confirmed the facility used the document as the water management program policy and procedure. On 10/4/23 at 10:30 a.m., the Maintenance Director was asked, what actions did the facility take when residents tested positive for Legionella? The Maintenance Director said, I heard about it and the Health Department came last Thursday and tested our water. We will have the results tomorrow. They said our water temperatures were fine. There was a little more chlorine in the cold water than there was in the hot water. The city tests our domestic water for lead and chlorine, but they do not test for Legionella. We have never had this issue before. The Surveyor asked, when was the last time the city tested your water? They came 2 or 3 months ago. I think they come quarterly. They do not give us a report. If there was an issue they would probably say so. The Surveyor asked, what was the facility doing in the way of water management prior to the two positives? He answered, housekeepers run water in the rooms for ten minutes while they are cleaning. We have a circulating system to ensure the hot water travels through the pipes at all times. The Surveyor asked, does the facility have a fountain or water feature? We have one, but it's turned off. It is decorative. There is no water in it. The Surveyor asked, does the facility have a boiler? No. Each hall has an independent hot water heater. The Surveyor asked, tell me about your sprinkler system? They are tested quarterly but there is no outlet for the water unless there is a fire. The Surveyor asked, do you have a flow diagram of the water systems? We have a blueprint that we provide to contractors. The Surveyor asked who is on the water management team? Just me, and I guess the housekeepers. This is new to me. I had never heard of legionella. On 10/4/23 at 11:30 a.m., the Surveyor asked the Maintenance Director, prior to the two residents testing positive for legionella, had the facility assessed the water system or used diagrams to determine where waterborne pathogens can grow or spread? I have diagrams of how our water flows in. There is no standing water. The Surveyor asked, have you assessed the water system after the two residents tested positive? There is no telling where the legionella came from. Our water is constantly being circulated. The Surveyor asked, prior to the two residents testing positive for legionella, what were the control measures in place to prevent growth of waterborne pathogens? Just with our normal cleaning, running water, aerators are cleaned, shower heads sanitized. The Surveyor asked what are the measures in place now? Normal cleaning, run water for 10 minutes, sanitize shower hoses quarterly. The Surveyor asked prior to the two residents testing positive for Legionella, how did you monitor the measures that you had in place? I tested the water temps. I check the water temps in three rooms a week in various areas in the building. Nothing else written down specifically. The Surveyor asked, how do you monitor now? Same thing. He was shown the incomplete Page 2 of the Water management program and asked do you have a completed copy of this page in your water management program documentation? Let me go see what I have. On 10/4/23 at 11:45 a.m. The Maintenance Director provided an undated packet titled, Infection Control Assessment and Response (ICAR) Tool for General Infection Prevention and Control (IPC) Across Settings which showed, has a facility water infection control risk assessment been performed to identify potential issues arising from water exposures - Yes. If yes, when was the last assessment performed 9/23. He was asked, do you have the risk assessment from last year? No. On 10/4/23 at 12:15 p.m., the Surveyor asked IP #1 and #2 how long after exposure would symptoms present for legionella? IP #2 said anytime from 2 to 10 days. The Surveyor asked, are you on the water management team and do you have meetings to discuss the water management program? We meet weekly to discuss all infections and prior to this we never had to discuss it because there never was a positive. On 10/4/23 at 12:30 p.m., the Surveyor asked the Administrator if your waterborne pathogens risk assessment from 2022 included in the facility assessment? No. I just came here a few months ago and I'm not sure where the previous administrator kept it. I haven't seen one. A review of the Facility Assessment Tool did not reveal a risk assessment for water borne pathogens. On 10/4/23 at 2:15 p.m., the Surveyor asked IP nurse #1 of the 10 respiratory illnesses in September with 2 having positive legionella tests, were the other residents tested for legionella? No. The Surveyor asked why did you perform tests on the 7 residents on 9/19/23? IP #1 answered, they all lived on the 100 hall where the first positive resident lived. We were trying to determine if there was something wrong on that hall. The second positive just happened a few days ago. The hospital tested her because there may be something going on with the city water. On 10/5/23 at 8:00 a.m. the Surveyor asked the Administrator do you have a risk assessment that may have been done prior to September 2023 with diagrams of the water flow? I will look in the previous Administrator's files and see if I can find anything. On 10/5/23 at 8:15 a.m., the Surveyor asked the Maintenance Director, do you have any documentation of a water management program risk assessment that may have been done prior to September 2023? I purge my files after a survey, and I do not have one that was done prior to 9/23. On 10/5/23 at 9:15 a.m., the Surveyor asked the Administrator if he had a copy of the most recent city water testing. He stated, I have that. They come once a year. He provided the report titled, 2022 Annual Drinking Water Quality Report. Review of the report showed Chlorine level detected was average: 1.0 (Range 0.09 - 108) parts per million and the public health goal is 4.0. On 10/5/23 at 11:45 a.m. the Administrator said the preliminary test was positive for legionella. On 10/5/23 at 12:05 p.m., the Administrator said the State Agency instructed the facility to turn the water heaters up to 140 degrees and let the water circulate. The Administrator said the contractor scheduled to perform the super chlorination on Monday, then the state agency will return to retest. On 10/5/23 at 2:43 p.m. the Administrator was asked to provide the facility's Emergency Preparedness plan. On 10/5/23 at 4:50 p.m., the Administrator did not provide the facility's Emergency Preparedness plan. On 10/6/23 at 10:50 p.m., personnel from the remediation company arrived on site. On 10/13/23 the facility received negative results for Legionella and the plan of removal was accepted on 10/13/23 at 5:02 PM.

Based on record review and interview, the facility failed to ensure a cognitively impaired resident was adequately supervised when drinking hot liquids which resulted in an injury for 1 (Resident #5) and failed to supervise a cognitively impaired resident who got a hot curling iron from behind the nurses station for 1 (Resident #4) of 5 (Residents #1, #2, #3, #4 and #5) sampled residents who resided on the Secure Unit. This failed practice had the potential to affect all 23 residents residing on the Secure Unit as documented on the Census provided by the Administrator on 11/28/22 at 10:18 a.m. The findings are: 1. Resident #5 had diagnosis of Vascular Dementia. The Quarterly MDS with an ARD of 09/06/22 documented the resident scored 2 (0-7 indicates severely cognitively impaired) on a BIMS and required supervision and set up help with eating. a. The Care Plan with an initiated date of 09/02/22 documented, .is at risk for burns from hot liquids due to confusion and frequently attempts to dump her coffee or other hot liquids into her oatmeal, or into her plate. Also had a spill today of her coffee into her lap . b. The Incident and Accident Report (I&A) dated 09/03/22 documented, .Incident Description Nursing Description: Resident was at the dining room table and was drinking a cup of coffee and dropped it in her lap. Resident Description: Oops, I dropped it . Immediate Action Taken Description: Resident taken to her room and cold water was applied. Skin assessment performed with slight redness to the skin on the thighs radiating between the inside of the legs. 0 [no] blistering noted at this time . c. The Hot Liquid assessment dated [DATE] at 2:48 PM documented, .Hot Liquids Material Management History 1. Can the resident manage coffee cup on their own? No. 2. Does the resident require cup with a lid? No. 3. Does the resident require a cup with two handles? No. 4. Does the resident require a weighted cup No. 5. Does resident have a history of hot liquid spills? Yes. 6. Has resident experienced burn from spills? Yes . 2. Resident #4 had a diagnosis of Cognitive Communication Deficit. The Quarterly MDS with an ARD of 10/11/22 documented the resident scored 1 (0-7 indicates severely cognitively impaired) on a BIMS and required extensive physical assistance of two plus persons with transfers, limited physical assistance of one person with locomotion on and off the unit and extensive physical assistance of one person with personal hygiene. a. The Incident and Accident Report dated 11/03/22 documented, .Incident Description Nursing Description: resident was found behind nursing station holding in her hand a warm curling iron. No injuries . Resident Description: she said she didn't know that it was warm, she just wanted to take it to her room . Immediate Action Taken Description: NO curling irons left behind the nurses station. Immediate Intervention: items not be left where resident have access to them. b. The Progress Note dated 11/04/22 at 2:49 AM documented, .Hot Rack Charting: Resident was holding a warm curling iron on previous shift. 0 c/o [complaints of] pain or discomfort to residents hands. 0 s/s [signs and or symptoms] of burns, redness, or swelling noted at this time. Resident in bed resting with eyes closed. Call light, fluids and bedside table within reach . 3. On 11/29/22 at 9:41 a.m., the Surveyor asked Certified Nursing Assistant (CNA) #3 How did [Resident #4] obtain a hot curling iron on the Secure Unit? CNA #3 stated, I don't know anything about it. The Surveyor asked, Who is responsible for ensuring a hot curling iron isn't available? She stated, Each staff member who uses them should replace them in the shower room cabinet. The nurse should check behind. 4. On 11/30/22 at 8:20 a.m., the Surveyor asked the Director of Nursing (DON), When did you start? The DON stated, I began after Labor Day. The Surveyor asked the DON to review the I&A for Resident #5. The Surveyor asked, Did the spilled coffee result in an injury as documented? The DON stated, Slight redness not a burn, but just in case she treated it with cool water to proactively treat the area in case a burn came up.

Based on record review and interview, the facility failed to ensure a thorough investigation was conducted after an allegation of staff-to-resident physical abuse, to include interviewing other staff and residents to determine if abuse occurred and whether any other residents may have been affected for 2 (Residents #1 and #2) and failed to ensure an injury due to a hot coffee incident was thoroughly investigated and protective measures were immediately implemented to prevent further potential injuries for 1 (Resident #5), and an incident with a hot curling iron was thoroughly investigated and protective measures were immediately implemented to prevent potential injuries for 1 (Resident #4) of 5 (Residents #1, #2, #3, #4 and #5) sampled residents who resided on the Secure Unit. These failed practices had the potential to affect all 23 residents on the Secure Unit as documented on the Census Report provided by the Administrator on 11/28/22 at 10:28 a.m. The findings are: 1. Resident #1 had a diagnosis of Alzheimer's Disease with Late Onset. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/01/22 documented the resident scored 0 (0-7 indicates severely cognitively impaired) on a Brief Interview for Mental Status (BIMS). a. The Arkansas Department of Health and Human Services Division of Medical Services (DMS) Office of Long Term Care Incident & (and) Accident (I&A) Next Day Reporting Form (DMS-7734) dated 11/16/22 documented, .Date of I & A [Incident and Accident ]: 11/16/2022 . [Resident #1] .Status of Alleged Perpetrator: Facility Employee . Type of Incident: Abuse: .Physical .SUMMARYOF INCIDENT .On 11/16/2022 at 11 am I returned the call of OLTC [Name] who said she had allegations to report to me. She stated that a person by the name of [Facility Employee Name] had sprayed water in the face of a resident named [Resident #1] about 4 weeks ago on the unit. Investigation immediately began at this time. 2. Resident #2 had a diagnosis of Unspecified Dementia. The Quarterly MDS with an ARD of 10/25/22 documented the resident scored 0 (0-7 indicates severely cognitively impaired) on a BIMS. a. The DMS-7734 dated 11/16/22 documented, .Date of I & A: 11/16/22 . [Resident #2] . Status of Alleged Perpetrator: Facility Employee . Type of Incident: Abuse: . Physical . SUMMARYOF INCIDENT . On 11/16/2022 at 11 am I returned the call of OLTC [Name] who said she had allegations to report to me. She stated that week someone by the name of [Facility Employee Name] had slapped a resident by the name of [Resident #2] on the hands in the unit. Investigation immediately began at this time. 3. Resident #5 had diagnosis of Vascular Dementia. The Quarterly MDS with an ARD of 09/06/22 documented the resident scored 2 (0-7 indicates severely cognitively impaired) on 2 on a BIMS. a. The Incident and Accident Report dated 09/03/22 documented, .Incident Description Nursing Description: Resident was at the dining room table and was drinking a cup of coffee and dropped it in her lap. Resident Description: Oops, I dropped it . Immediate Action Taken Description: Resident taken to her room and cold water was applied. Skin assessment performed with slight redness to the skin on the thighs radiating between the inside of the legs. 0 blistering noted at this time . b. As of 11/29/22 at 2:00 p.m., there were no resident witness statements after the allegation for Resident #5 to the Administrator for a comprehensive investigation. 4. Resident #4 had a diagnosis of Cognitive Communication Deficit. The Quarterly MDS with an ARD of 10/11/22 documented the resident scored 1 (0-7 indicates severely cognitively impaired) on a BIMS and required extensive physical assistance of two plus persons with transfers, limited physical assistance of one person with locomotion on and off the unit and extensive physical assistance of one person with personal hygiene. a. The facility Incident and Accident Report dated 11/03/22 documented, .Incident Description Nursing Description: resident was found behind nursing station holding in her hand a warm curling iron. No injuries . Resident Description: she said she didn't know that it was warm, she just wanted to take it to her room . Immediate Action Taken Description: NO curling irons left behind the nurses station . b. The Progress Note dated 11/04/22 at 2:49 AM documented, .Hot Rack Charting: Resident was holding a warm curling iron on previous shift. 0 c/o [complaints of] pain or discomfort to residents hands. 0 s/s [signs and or symptoms] of burns, redness, or swelling noted at this time. Resident in bed resting with eyes closed. Call light, fluids and bedside table within reach . c. As of 11/29/22 at 2:00 p.m., there were no body audits and resident/staff interviews after the allegation for Resident #4 to the Administrator for a comprehensive investigation. 5. On 11/28/22 at 11:02 a.m., the Surveyor asked Certified Nursing Assistant (CNA) #1, What are the abuse types? CNA #1 stated, Abuse, neglect. The Surveyor asked, When is abuse reported? She stated, Right when it happens. The Surveyor asked, To whom is abuse reported to? She stated, The person at that time who is in charge. The Surveyor asked, Did you ever hear of a resident's face being sprayed with water? She stated, No. The Surveyor asked, Did you ever see or hear of someone slapping a resident? She stated, No. 6. On 11/28/22 at 11:03 a.m., the Surveyor asked CNA #2, What are the abuse types? CNA #2 stated, Physical, neglect, verbal. The Surveyor asked, When is abuse reported? She stated, Immediately. The Surveyor asked, To whom is abuse reported to? She stated, To the charge nurse, follow the chain of command. The Surveyor asked, Did you ever hear of a resident's face being sprayed with water? She stated, No. The Surveyor asked, Did you ever see or hear of someone slapping a resident? She stated, No. 39316 7. On 11/29/2022 at 8:49 a.m., the Surveyor asked the Director of Nursing (DON), When are body audits performed on the residents? The DON stated, Weekly. The Treatment Nurse does weekly body audits. The Surveyor asked, Why should a body audit be performed after an allegation of abuse and neglect? The DON stated, Assess the resident and protect the residents. The Surveyor asked, When are witness statements obtained from the residents? The DON stated, They are obtained when they are being obtained from the staff. The Surveyor asked, How are residents protected if staff are not reporting allegations of abuse? The DON stated, Staff have to be in-serviced. If something is brought to light, we start then. I can't speak for what happened before, but I know what we are doing now can protect them. The Surveyor asked, How is an allegation of abuse fully investigated, if there are no body audits and witness statements from the residents? The DON stated, We found out when the state called us. Nothing was brought up to me, and the Administrator wasn't here. The Surveyor asked, What are your expectations from your staff regarding following the facilities policy and procedure and following the Centers for Medicare and Medicaid (CMS) guidelines? The DON stated, That they follow them. 8. On 11/29/22 at 9:41 a.m., the Surveyor asked CNA #3, Did a staff member notify you about a staff member running water in [Resident #1's] face? CNA #3 stated, No. The Surveyor asked, Did a staff member notify you about a staff member hitting [Resident #2's] hands? She stated, No. 9. On 11/30/22 at 9:38 a.m., the Surveyor asked the Administrator, How long have you been here? He stated, I started 11/09/22. The Surveyor asked, When was the date and time you were notified of the alleged abuse? He replied On 11/16/22 at 11:00 a.m. The Surveyor asked who he was notified by. He stated, The Office of Long Term Care. The Surveyor asked, Why should allegations of abuse be reported immediately? He stated, For protection of the residents. The Surveyor asked, How do you monitor for potential or actual reported allegations of abuse? He stated, You talk to your staff, make rounds, you look for signs and symptoms of abuse, you listen to your residents. The Surveyor asked, When is abuse reported? He stated, Immediately. The Surveyor asked, To whom is it reported to? He stated, Immediate Supervisor, Director of Nursing or Administrator. The Surveyor asked, How long does a facility have to notify the OLTC? He stated, Two hours. The Surveyor asked, What are your expectations from your staff regarding following the facility policy and procedures and CMS guidelines? He stated, For them to follow the follow the rules. 10. The facility policy titled, Abuse, Neglect, Misappropriation and Exploitation Investigation & Reporting Policy, provided by the Administrator on 11/28/22 at 2:54 PM documented .All alleged, witness, or suspected resident abuse shall be immediately reported to Administrant or immediate supervisor and investigated by facility management. The Administrator or the Administrators Designee will report events required by State law or regulation .

Based on record review and interview, the facility failed to ensure staff reported an allegation of abuse immediately to the Administrator, the Office of Long-Term Care, and other authorities in accordance with state law, to prevent a delay in initiating an investigation and implementing protective measures for 2 (Residents #1 and #2) sampled residents and failed to report an injury due to a hot coffee incident was reported to the state agency for 1 (Resident #5) and an incident with a hot curling iron was reported to the state agency for 1 (Resident #4) of 5 (Residents #1, #2, #3, #4 and #5) sampled residents who resided on the Secure Unit. These failed practices had the potential to affect all 23 residents who resided on the Secure Unit as documented on the Census Report provided by the Administrator on 11/28/22 at 10:28 a.m. The findings are: 1. Resident #1 had a diagnosis of Alzheimer's Disease with Late Onset. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/01/22 documented the resident scored 0 (0-7 indicates severely cognitively impaired) on a Brief Interview for Mental Status (BIMS). a. The Arkansas Department of Health and Human Services Division of Medical Services (DMS) Office of Long Term Care Incident & (and) Accident (I&A) Next Day Reporting Form (DMS-7734) dated 11/16/22 documented, .Date of I & A [Incident and Accident ]: 11/16/2022 . [Resident #1] . Status of Alleged Perpetrator: Facility Employee . Type of Incident: Abuse: .Physical .SUMMARYOF INCIDENT .On 11/16/2022 at 11 am I returned the call of OLTC [Name] who said she had allegations to report to me. She stated that a person by the name of [Facility Employee Name] had sprayed water in the face of a resident named [Resident #1] about 4 weeks ago on the unit. Investigation immediately began at this time. 2. Resident #2 had a diagnosis of Unspecified Dementia. The Quarterly MDS with an ARD of 10/25/22 documented the resident scored 0 (0-7 indicates severely cognitively impaired) on a BIMS. a. The DMS-7734 dated 11/16/22 documented, .Date of I & A: 11/16/22 . [Resident #2] . Status of Alleged Perpetrator: Facility Employee . Type of Incident: Abuse: .Physical .SUMMARYOF INCIDENT .On 11/16/2022 at 11 am I returned the call of OLTC [Name] who said she had allegations to report to me. She stated that week someone by the name of [Facility Employee Name] had slapped a resident by the name of [Resident #2] on the hands in the unit. Investigation immediately began at this time. 3. Resident #5 had diagnosis of Vascular Dementia. The Quarterly MDS with an ARD of 09/06/22 documented the resident scored 2 (0-7 indicates severely cognitively impaired) on 2 on a BIMS. a. The Incident and Accident Report dated 09/03/22 documented, .Incident Description Nursing Description: Resident was at the dining room table and was drinking a cup of coffee and dropped it in her lap. Resident Description: Oops, I dropped it . Immediate Action Taken Description: Resident taken to her room and cold water was applied. Skin assessment performed with slight redness to the skin on the thighs radiating between the inside of the legs. 0 blistering noted at this time . 4. Resident #4 had a diagnosis of Cognitive Communication Deficit. The Quarterly MDS with an ARD of 10/11/22 documented the resident scored 1 (0-7 indicates severely cognitively impaired) on a BIMS and required extensive physical assistance of two plus persons with transfers, limited physical assistance of one person with locomotion on and off the unit and extensive physical assistance of one person with personal hygiene. a. The facility Incident and Accident Report dated 11/03/22 documented, .Incident Description Nursing Description: resident was found behind nursing station holding in her hand a warm curling iron. No injuries . Resident Description: she said she didn't know that it was warm, she just wanted to take it to her room . Immediate Action Taken Description: NO curling irons left behind the nurses station. b. The Progress Note dated 11/04/22 at 2:49 AM documented, .Hot Rack Charting: Resident was holding a warm curling iron on previous shift. 0 c/o [complaints of] pain or discomfort to residents hands. 0 s/s [signs and or symptoms] of burns, redness, or swelling noted at this time. Resident in bed resting with eyes closed. Call light, fluids and bedside table within reach . 5. On 11/28/22 at 11:02 a.m., the Surveyor asked Certified Nursing Assistant (CNA) #1, What are the abuse types? CNA #1 stated, Abuse, neglect. The Surveyor asked, When is abuse reported? She stated, Right when it happens. The Surveyor asked, To whom is abuse reported to? She stated, The person at that time who is in charge. The Surveyor asked, Did you ever hear of a resident's face being sprayed with water? She stated, No. The Surveyor asked, Did you ever see or hear of someone slapping a resident? She stated, No. 6. On 11/28/22 at 11:03 a.m., the Surveyor asked CNA #2, What are the abuse types? CNA #2 stated, Physical, neglect, verbal. The Surveyor asked, When is abuse reported? She stated, Immediately. The Surveyor asked, To whom is abuse reported to? She stated, To the charge nurse, follow the chain of command. The Surveyor asked, Did you ever hear of a resident's face being sprayed with water? She stated, No. The Surveyor asked, Did you ever see or hear of someone slapping a resident? She stated, No. 39316 7. On 11/29/2022 at 8:49 a.m., the Surveyor asked the Director of Nursing (DON), When any alleged abuse is reported, what is the facilities process for investigation? The DON stated, Immediately protect the resident, report to state, obtain witness, assess the resident involved, notify family, doctor and start in-services on abuse and neglect , and protecting the residents is suspending someone with an allegation. The Surveyor asked, Why wasn't there a reportable submitted for [Resident #4] for the incident and accident dated 11/3/2022, related to the hot iron incident? The DON stated, She wasn't injured, she had no injury, and we care planned it. The Surveyor asked, Was there a body audit performed? The DON stated, If they would have done one, it would have been scheduled that week. The Surveyor asked, Why wasn't there a reportable submitted for [Resident #5] for the incident and accident dated 9/2/2022 related to the incident involving the hot coffee? The DON stated, I didn't work then. I became the DON on 9/6/2022, the day after Labor Day. The Surveyor asked, How are residents protected if staff are not reporting allegations of abuse? The DON stated, Staff have to be in-serviced, if something is brought to light, we start then. I can't speak for what happened before, but I know what we are doing now can protect them. The Surveyor asked, What are your expectations from your staff regarding following the facilities policy and procedure and following the Centers for Medicare and Medicaid [CMS] guidelines? The DON stated, That they follow them. 8. On 11/29/22 at 9:41 a.m., the Surveyor asked CNA #3, Did a staff member notify you about a staff member running water in [Resident #1's] face? CNA #3 stated, No. The Surveyor asked, Did a staff member notify you about a staff member hitting [Resident #2's] hands? She stated, No. 9. On 11/30/22 at 9:38 a.m., the Surveyor asked the Administrator, How long have you been here? He stated, I started 11/09/22. The Surveyor asked, When was the date and time you were notified of the alleged abuse? He replied On 11/16/22 at 11:00 a.m. The Surveyor asked who he was notified by. He stated, The Office of Long Term Care. The Surveyor asked, Why should allegations of abuse be reported immediately? He stated, For protection of the residents. The Surveyor asked, How do you monitor for potential or actual reported allegations of abuse? He stated, You talk to your staff, make rounds, you look for signs and symptoms of abuse, you listen to your residents. The Surveyor asked, When is abuse reported? He stated, Immediately. The Surveyor asked, To whom is it reported to? He stated, Immediate Supervisor, Director of Nursing or Administrator. The Surveyor asked, How long does a facility have to notify the OLTC? He stated, Two hours. The Surveyor asked, What are your expectations from your staff regarding following the facility policy and procedures and CMS guidelines? He stated, For them to follow the follow the rules. 10. The facility policy titled, Abuse, Neglect, Misappropriation and Exploitation Investigation & Reporting Policy, provided by the Administrator on 11/28/22 at 2:54 PM documented .All alleged, witness, or suspected resident abuse shall be immediately reported to Administrant or immediate supervisor and investigated by facility management. The Administrator or the Administrators Designee will report events required by State law or regulation .

Complaint # (AR 690) was substantiated, all or in part, with these findings: Based on observation, record review and interview, the facility failed to ensure close supervision and monitoring were implemented and continued after a resident attempted or exhibited the intent to harm himself or commit suicide, failed to thoroughly assess the resident's environment to identify and address other items that could be used by the resident to repeat the attempt, after the resident wrapped a nebulizer cord around his neck in a failed suicide attempt, and failed to ensure all staff involved with the resident's care were aware of the resident's self-harm / suicidal behavior for 1 (Resident #1) of 1 resident who attempted to take his own life. The failed practice resulted in past noncompliance at the level of immediate jeopardy, which caused or could have caused serious harm, injury or death to Resident #1, who, after making the failed suicide attempt with the nebulizer cord, subsequently utilized the call light cord to commit suicide. The failed practice had the potential to cause more than minimal harm to 2 residents who had voiced the intent to harm themselves in the past 30 days, according to a list provided by the Director of Nursing (DON) on [DATE]. The Director of Nursing (DON) and Administrative Employee #1 were notified of the past immediate jeopardy condition on [DATE] at 1:09 p.m. The findings are: Resident #1 was admitted to the facility on [DATE] and had admitting [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] documented the resident scored 14 (,[DATE] indicates cognitively intact) on a Brief Interview for Mental Status (BIMS), required extensive assistance of 2-plus people for bed mobility and transfer, and exhibited verbal behaviors toward others / screaming at others / cursing at others on 4 to 6 of the last 7 days. a. The Admission assessment with Care Plan dated [DATE] documented, Bed mobility: extensive assistance, Transfer: extensive assistance, Dressing: extensive assistance, Toilet use: Supervision, Personal hygiene: total dependence and bathing: total dependence . b. The Comprehensive Care Plan dated [DATE] documented, Admit to Medicare part A Skilled bed Dx (diagnosis) [DIAGNOSES REDACTED] . Improve functional activity, tolerance and mobility . Resident asks staff for heroin. Resident is refusing therapies .resident drowsy and incoherent unable to talk or understand him. Administrator notified of suspected drug use . The Care Plan did not address the admission [DIAGNOSES REDACTED]. c. Progress Notes dated [DATE] at 07:06 a.m. by Licensed Practical Nurse (LPN) #3 documented, Type: Behavior note. Behavior Identified: Trying to climb out of bed and stating he is gonna call 911 and have (ambulance service) take him home. R (Resident) took nebulizer cord and tubing and wrapped it around his neck. Tubes and cords taken out of reach and resident monitored. R (Resident) then called staff to his room and stated he was sorry he was just being stupid and he would go to sleep. R (Resident) rested after that the rest of the shift. d. Progress Notes dated [DATE] at 11:06 a.m. by LPN #4 documented, Type: Nsg (Nursing) - General Note . Received in report that resident had put nebulizer cord around his neck, nurse went to talk to resident after receiving report of this, resident states 'I just got upset because they wouldn't let me get up and move around during the night and they were rude to me, I didn't mean anything I was just upset', when asked 'who is they' he stated, 'the people that work here'. Resident was calm and resident was asked if he had any intention of harming himself or anyone else and he stated, 'No I was just upset'. Resident was calm and ate breakfast. Resident was approached again by nurse, APN, (Advanced Practice Nurse) and Social Worker. The resident was asked again if he had thoughts of harming himself and stated 'No, I was just upset', resident again told APN and Social Worker that 'they would not let me up to go to the bathroom and they were rude to me, I was upset', Resident stated 'I know y'all (sic) would send me to the loony house if I did', resident was upbeat and smiling when staff were speaking to him, resident did c/o (complain of) not sleeping well at night and APN told resident she would address this. Resident also refused to have (Geriatric Psychology Services Provider) with a counselor, resident states 'I don't want to see them, they need more counseling than I do' . d. A written contract form dated [DATE] and written by the Social Worker documented, I (Resident #1) a short term Reanimation Resident at (Facility) voice that I have no intent with my words or actions in harming myself. I do verbalize out of anger and have no plans to carry through with my words or actions. I have been offered (Geriatric Psychology Service Provider) counseling and have declined. The contract was signed by Resident #1, the Social Worker and Certified Occupational Therapy Assistant (COTA) #1. f. Progress Notes dated [DATE] at 22:44 (10:44 p.m.) by LPN #2 documented, .Type: Nsg - General Note . around 2045 (8:45 p.m.) CNA #1 approached this nurse (LPN #1) and stated resident had asked for a knife. Myself and aid went to resident's room and asked what he needed. He asked for a knife. I asked resident why he needed a knife and he said 'because I need one'. I asked resident for what and he stated 'to cut this cord' as he held up the call light cord. I explained that it was electrical and could not be cut. I asked resident if he was in any pain and he said 'inside my head.' I administered Tylenol to resident. Around 2145 (9:45 p.m.) his call light went off. CNA answered call. I was right by resident's room and went in. I observed resident on L (left) side of bed, face down with cord around his neck. CNA started to remove cord and I ran for crash cart and another nurse. We entered resident's room and I helped remove the cord from neck. Resident was unresponsive to his name being called and no pulse was noted. We rolled resident onto his back. Resident was not breathing, purple/bluish in color with eyes fixed and dilated. I ran to check code status. Nurse started CPR (Cardiopulmonary Resuscitation) ambulance was notified and I administered O2 (oxygen). CPR was continued for 20 minutes until ambulance, police and fire rescue arrived. The coroner was contacted by emergency personnel. Officer took names and statements from staff. Time of death was called at 2210 (10:10 p.m.). This nurse attempted to contact resident's family multiple times and was unable to leave voicemail or reach family. (Facility) staff drove to the family on file's house and were unable to make contact with family . g. An Office of Long Term Care (OLTC) Incident and Accident Report (I&A), Division of Medical Services (DMS) form 7734 dated [DATE] at 2210 (10:10 p.m.) documented, (CNA #1) and (LPN #1) answered call light finding R (resident) face down on floor beside bed with call light cord wrapped around neck. CNA began unwrapping cord and (LPN #1) ran to Nurses Station to grab the crash cart and another (LPN #2) who went in room and assessed resident finding no pulse or breath sounds then began CPR. (LPN #1) called 911 and CPR was continued till EMS (Emergency Medical Service) arrived. EMS stopped coding resident and called the Coroner and the (City) Police. h. A Witness Statement dated [DATE] documented, .Witness Full Name, (Certified Nursing Assistant (CNA) #4) . State in your own words what you witnessed . (MONTH) 1 2019 Resident also kept talking about blood running down the walls, shadows, knocking sounds in the walls. Things about the war he asked for a candle to set himself on fire. He complained of pain often at night and wouldn't sleep. Didn't want his lights off. Throughout the night we answered the light every ,[DATE] minutes. R (resident) didn't sleep at night. i. On [DATE] at 3:56 p.m., LPN #3 was asked if she had taken care of Resident #1. She stated, Yes. He had been in the hospital; he'd fallen at one point. He was an alcoholic, and he was kind of confused at times. He didn't sleep much; he was generally a difficult resident. The LPN was asked what happened on [DATE] and stated, He was putting the call light on. He was saying 'Y'all have to do what I say'. He was mumbling. I left the room, and he would immediately turn the light on. Asked if he wanted to get up. He said 'No.' Around 2 to 3 a.m., the CNA called out and told me that he had gotten his nebulizer tubing around his neck. We removed the nebulizer tubing from the resident's neck. The resident stated that he wasn't going to harm himself. I posted a CNA to monitor him. The LPN was asked if she had reported this incident to anyone. The LPN stated, I didn't call anyone. I had called the APN about previous behavior, when he was saying inappropriate comments sexual nature, and talking about alcohol. She was asked, What was his condition after he had wrapped the nebulizer cord around his neck? The LPN stated, He had wrapped the nebulizer cord - there were no marks - it was not tight or anything like that. The LPN was asked if she had called the family. The LPN stated, No, I didn't talk to the family; he was his own responsible party. The LPN was asked if this was an important incident that should have been discussed with the Physician. The LPN stated, Yes, but I had spoken with the APN earlier due to his behavior. After the incident with the nebulizer cord, he later said, 'I'm fine, I'm done, y'all win, I'm stupid, I didn't mean it.' I posted the CNA outside his door, and he went to sleep. I had talked to APN prior to that, and we watched him, so I didn't call her back. The LPN was asked, when did you post the CNA outside his door? She stated, She (CNA) stayed in the hallway and checked on the resident frequently. I know now that I should have called the APN, even though we monitored him. The LPN was asked if she had ever dealt with a resident who had suicidal ideation. The LPN stated, No. The LPN was asked if she had received in-service training regarding suicide precautions since the incident involving Resident #1 and stated, Yes. j. On [DATE] at 2:06 p.m., CNA #1 was interviewed via telephone and was asked if she had provided care for Resident #1. The CNA stated [DATE] was the first day she had worked with Resident #1. The CNA was asked what information she had received regarding the care of this resident. The CNA stated, I was told he was extensive care and a little crazy. The CNA was asked to explain and stated, I guess crazy's not the word; he mumbled and was hard to understand. The resident made a statement that someone had been in his room; the bed was unmade. I explained that we had gotten him up for supper. I had a day shift CNA that stayed with me until 7:30 p.m. The day CNA, (CNA #4), didn't know much about him. Then the call light was on, and he asked for a knife; he needed to open something. I told him I could open it and he said, 'no, if you open, it will be the end of all of us'. I explained I couldn't give him a knife. The CNA was asked, Did you report this to the nurse. The CNA stated, Yes. It was I guess between 8:30 and 9:00 (p.m.), another CNA (CNA #3) and myself went in room with me, because the resident makes me uncomfortable. He needed everyone that was in the house to come in. The Nurse was giving meds (medications) and couldn't come in. I explained that I hadn't seen anyone and attempted to reassure him that I would watch to ensure that no one came in his room. He mumbled some things that I couldn't understand. The CNA was asked if she had reported this to the Nurse and stated, Yes, the nurse was outside the resident's room. It was around maybe a little after 9 (p.m.), the nurse went in with me, (LPN #1). The resident was asking for a knife again and gnawing on his call light cord and wanting to cut the call light cord. When I went to move the call light cord, he was holding onto it real tight. Resident complained of pain in his head. He said that, 'it was all in my head'. It was about 9:45 (p.m.), there were 2 call light going off, and I answered the first one, and then went in his room and called to the Nurse that he was on the floor. I stepped in the room and saw the cord around his neck and called for (LPN #1) and they, (LPNs #1 and #2) came in. She was asked, How many times was the (call light) cord around his neck? The CNA stated, Once around his neck, and the cord was wrapped around the side rail and stuck under the mattress. He was lying flat on the floor, face down, his face was blue and foaming at the mouth. I was in shock. I don't recall looking at anything else. The CNA was asked when CPR was started and stated, (LPN #2) asked if he was code and started CPR almost immediately. (LPN #1) left to check the chart, and the other Nurse stayed in the room. I don't know why I left the room with (LPN #1), I just did. The CNA was asked, have you had in-service training regarding suicide precautions since the incident involving (Resident #1)? The CNA stated, No, I haven't been back to work; I went in to work Sunday ([DATE]), and I was sent home due to being suspended. The CNA was asked why she had been suspended. The CNA stated, As part of the investigation. The CNA stated, (Resident #1) was extensive care and was not really with it. I was not aware of any suicidal issues. k. On [DATE] at 2:29 p.m. LPN #2 was interviewed via telephone and asked about Resident #1. The LPN stated she did accompany LPN #1 to the resident's room on the evening of [DATE], when the resident asked for a knife to cut the call light cord and, .we explained that he couldn't cut the cord. He complained of pain in his head. (LPN #1) gave him Tylenol. I was giving (LPN #1) a break, and she was coming back from break and threw her bag and said, 'we have an emergency'. I went to (Resident #1's) room. I asked (LPN #1) if he was a full code. I rolled him over and his lips and face were blue, I immediately started compressions. (LPN #1) went to check the code status (and) stated he was a full code. (LPN #1) called 911, got the ambu-bag and we continued with CPR 'til the EMS arrived. They took over, stopped the code and called the Coroner, and the Physician was called. The LPN was asked what she would do if a resident voiced that he was going to harm himself. She stated, Report immediately to Physician/DON, place resident on 1:1 and remove anything that he could harm himself. l. On [DATE] at 2:39 p.m., LPN #1 was interviewed via telephone and asked if she had provided care for and was familiar with Resident #1. The LPN stated, Yes. The LPN was asked if there were any issues or problems that she was aware of for Resident #1. The LPN stated, Resident was not mobile, required assistance, he was negative and pleasant personality. He was a glass half empty kind of guy. Problems, we had to watch his blood sugar real closely. The LPN was asked if there were any other issues. The LPN stated, I don't have his chart, so I don't know all the issues with all the residents. She was asked, Were you told of any issues that had occurred prior to Saturday [DATE]? The LPN stated, I was not aware of any issue with thoughts of suicide. The LPN was asked to explain the incident that had occurred on [DATE]. The LPN stated, The resident had asked around 8:45 p.m. for a knife, and I went and talked to him, and he said that he wanted the knife to cut the call light. I explained that you couldn't cut the cord, it was electric, and I talked to him that he had complained of pain inside his head and I gave him Tylenol. He had shaved his beard off this past week. He looked like a different person. When the light went off, (CNA #1) went in the room and stated that he was on the floor. The CNA and I went in the room; I instructed the CNA to get the call light cord off his neck. I went to the desk to get the crash cart and another Nurse. The CNA was in room with the resident, and (LPN #2) had begun CPR. The CPR was started in approximately 30 to 60 seconds. It's hard to remember exactly, it happened so fast; that's the first resident that I had lost on my shift. The LPN was asked if the resident had any behavioral issues and stated, He would hear things and ask us to, 'get them out of my room'. He was having this every weekend; this was his norm. The LPN was asked if she had documented the hallucinations anywhere. She stated, No. The LPN was asked if a resident having hallucinations was an important detail that should be documented. The LPN stated, It's hard to document every detail. The LPN stated, Yes, he was an alcoholic. The LPN was asked did anyone else report that he was having hallucinations. The LPN stated, Not that I'm aware of and I wasn't aware of any other incident that the resident had tried to harm himself. The LPN was asked, you weren't told of any incident involving the resident trying to harm himself? The LPN stated, No. The LPN was asked if she had received an in-service training regarding suicide precautions since the incident. The LPN stated, No, I haven't been back to work. m. On [DATE] at 4:12 p.m., the APN was interviewed via telephone and was asked about Resident #1. The APN stated, I was called on [DATE] that he (Resident #1) was having agitation and saying sexual inappropriate remarks to the staff. I had ordered [MEDICATION NAME] for the agitation. I didn't know about the nebulizer tubing incident until the next morning. I had spoken with the resident, explained that we take this very seriously, and he said he wasn't going to harm himself. I talked with him, and he wasn't at risk for harming himself, very pleasant, exhibiting no behaviors, and he complained that he had wanted to go to bathroom and he was constipated and having trouble sleeping. He was given something for sleep and I started him on [MEDICATION NAME] for sleep. The APN was asked if she had notified the physician of the nebulizer cord incident. The APN stated, No. I didn't feel that he was at risk for harming himself; he was very pleasant. She was asked, You didn't feel that the physician should have been notified? The APN stated, No, he (resident) didn't have any signs or thoughts or risk for harming himself. We offered (Geriatric Psychology Services Provider) services, and he didn't want to be sent to the loony bin, as he called it. I was not told at that time that he had wrapped the nebulizer cord around his neck; I was under the impression that he held it up to his neck. But at that point, I didn't feel that he was at risk for harming himself. I also saw him on Friday ([DATE]); he was not exhibiting any signs or expressed anything that he would harm himself, and he agreed to be started on [MEDICATION NAME] on Friday as well. The APN was asked if she was aware the resident had experienced hallucinations. The APN stated, No. That might have been helpful. He had a psych (psychiatric) evaluation prior to being discharged from the hospital and that he would say things when he was mad at staff that he would harm himself. The Physician stated that he did not require [MEDICAL CONDITION] care. I had spoken with him (resident), and he stated that he wasn't going to harm himself, he was very pleasant and signed a form that he wouldn't harm himself. n. On [DATE] at 3:06 p.m. CNA #3 was asked if she had provided care for Resident #1. The CNA stated, Yes, the resident was special; we really liked him. He had a real supportive family; they were here a lot. He didn't talk about his family. He had children, but didn't talk about them. The CNA was asked if there had been any behavioral issues with this resident and CNA stated, He had issues and problems with eating; there were no (other) issues. He was really weak. The CNA was asked, Are you aware of the resident attempting to harm himself? The CNA stated, No. The CNA was asked if she had worked on [DATE] and [DATE] and stated, Yes. The CNA was asked, You did not receive a report that the resident had attempted to harm himself? The CNA stated, No. I gave him a bath; I thought he was discouraged, but that happens a lot with rehab (rehabilitation) residents that don't want to do their therapy. The CNA was asked if there was any issue with the resident's behaviors. The CNA stated, No, not that would have set off alarms. The CNA was asked, If a resident verbalized or had an action that they were are going to harm themselves what do you do? The CNA stated, Report to the Nurse immediately. o. On [DATE] at 1:45 p.m., the Director of Nursing (DON) was asked how long the call light cords in resident rooms were. A call light cord package was provided; the label documented the call light cord was 10 feet in length. The DON stated, That is about right. The DON was asked about Resident #1's cause of death and stated, I called the Coroner. The report won't be ready for 2 to 3 months, but when the Coroner was here, he stated the cause of death was suicide. p. On [DATE] at 2:21 p.m. the DON was asked about interventions for Resident #1 after the nebulizer cord incident on [DATE]. The DON stated she had counseled the LPN and, She should have called the Physician or APN back. The DON was asked what intervention or monitoring were put in place after this incident and stated, The resident was with therapy that morning ([DATE]) and went to lunch and was around staff. The APN had spoken with the resident and cleared him that he wasn't at risk for harming himself. The facility felt that the APN had assessed the resident and that the resident was not at risk of harming himself. The Social Worker and the APN assessed the resident and the resident signed a contract that he wasn't going to harm himself . q. The facility removed the immediate jeopardy and corrected the failed practices on [DATE] when the facility initiated corrective actions, as evidenced by the following: 1.) A document titled, Suicide Precautions, received from the DON on [DATE], documented, .Any patient who expresses suicide intentions shall be placed on suicide precautions and the Physician notified immediately. Social Services shall obtain mental health referrals as soon as possible. 2. Suicide Precautions shall include: a. All items that could be harmful to the resident at this time will be removed from rooms. b. The patient shall be observed closely for any harmful behavior which shall be reported immediately to the Charge Nurse, the Director of Nursing and attending Physician. 3. The facility will communicate suicide precautions to staff. 4. Document observation of suicide precautions every shift in resident's medical record. 5. If necessary, request for transfer shall be made immediately. Reporting and Documentation; 1. Report any abnormal or unusual finding to the Charge Nurse. 2. Document the above . 2.) A Staff In-Service form dated [DATE] documented, Department: Nursing, In-Service by: (Director of Nursing), Topic: Anytime a resd (resident) makes any comments that appear to be suicidal, you must observe that resd 1:1 (one on one) and report it to your charge nurse, Charge nurse must assess resd notify DON, MD (Medical Doctor)/APN for further instructions, continue 1:1 monitoring til you are given further instructions. If resd is actively being suicidal keep resd 1:1 and call 911. This form was signed by 69 staff members, and a Suicide Precaution form was attached to the In-Service form. 3.) A Staff In-Service dated [DATE] documented, Department: Nursing, In-Service by (Director of Nursing), Topic: Suicide Precautions, Read and sign. This form was signed by 35 staff. 4.) A Staff In-Service dated [DATE] documented, Department: Department Heads, In-Service by (Director of Nursing), Topic: Suicide Precautions. This form was signed by 11 staff. 5.) A Staff In-Service dated [DATE] documented, Department: Therapy. This form was signed by 4 staff and the Suicide Precaution form was attached. 6.) On [DATE] at 1:45 p.m., the DON was asked if there had been any other residents who had voiced intentions to harm themselves. The DON stated, Yes, (Resident #2), who was immediately placed on one-on-one (1:1) and transported to the hospital for evaluation. According to an Untitled form with the resident's name and dated [DATE] from Resident #2's clinical record, there was a period of only 1 hour and 40 minutes from the time the resident made a comment about wanting to die and when the resident was sent to the hospital emergency room (ER). During the 1 hour and 40 minute period, the resident was placed on 1:1 monitoring, as follows: 10:50 (a.m.) - Resd stated to (Physical Therapy), 'He would rather be dead than do therapy' . 1:1 with ST (Speech Therapy) til 11:15 (a.m.) . 11:15 (CNA) sent to room . 11:30 Resident in bed (CNA) in room . 11:45 Resident lying in bed, (CNA) in room . 12:00 Resident lying in bed, (CNA) in room . 12:15 Resident lying in bed, (CNA) in room . 12:30 Resident sent to ER . 7.) On [DATE] at 2:06 p.m., CNA #1 was asked, have you had in-service training regarding suicide precautions since the incident involving (Resident #1)? The CNA stated, No, I haven't been back to work; I went in to work Sunday ([DATE]), and I was sent home due to being suspended. The CNA was asked why she had been suspended. The CNA stated, As part of the investigation.