Every finding on record at Laurel Court

Based on interview and record review, the facility failed to incorporate the recommendations from the PASARR Level II determination and the PASARR evaluation report into a resident's assessment, care planning, and transitions of care services for 1 of 3 residents (Resident #1) reviewed for PASARR.The facility failed to submit a request through the Simple LTC portal for occupational therapy for Resident #1 within the time frame set by PASARR.This failure could affect residents who required a specialized PASARR service for occupational therapy.Findings included:Record review of Resident #1's face sheet dated 01/15/26 revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included autistic disorder (lifelong brain based condition that affects how a person communicates), dementia (decline in mental ability severe enough to interfere with activities of daily living), and cognitive communication deficit (difficulties with speaking, listening, reading with underlying problems with thinking skills like memory).Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed under section C0700 the resident had memory problems. Further review revealed Resident #1 needed extensive total care for all ADLs.Record review of Resident #1's care plan initiated dated 09/16/25 and revised on 10/16/25 revealed Resident #1 had been identified as having PASRR positive status related to an intellectual disability. Intervention: Nursing facility would provide habilitative OT services 5X per week: begin date 02/02/26 and end date 07/31/26 completed.Record review of Resident #1's PASRR Comprehensive Service Plan Form from a meeting dated 03/30/25 revealed the LAR accepted the PASRR SS of habilitation coordination. The LA-IDD agreed and wrote . The LAR requested Resident #1 be re-evaluated for OT to see about possibly starting OT again. It also marked number 2, which meant new for specialized assessment occupational therapy and specialized occupational therapy.Record review of Resident #1's 08/15/25 Form Activity from the Simple LTC portal revealed the facility completed an OT assessment on 07/07/25, and on 07/30/25 it read pending state review.During an interview on 03/19/26 at 1:31 p.m., the MDS coordinator and DOR were interviewed. The MDS coordinator said she was not in the facility when the PASARR care plan IDT meeting was held. She said after the meeting, the facility had 20 days to enter NFSS in the portal. The MDS coordinator said it was an oversight, and they would have plans in place to prevent this incident from happening again. The MDS coordinator said Resident #1 would not get the OT services because it was not entered in the portal timely.The DOR said she did not attend the PASARR IDT care plan meeting on 03/30/25 where OT was marked as new. She said the staff from the facility were the DON, former MDS coordinator, Resident #1, RP, PASARR representative, and insurance representative. She said the facility had 20 days to turn in the NFSS, which meant the therapy department would assess Resident #1, document all the necessary information, get the physician to sign, and then enter the information into the portal within 20 days, but it was not done. The DOR said Resident #1 would not get the OT services if it was approved because it was not entered in the portal in a timely manner.During an interview on 03/19/26 at 3:09 p.m., the DON said she attended the PASARR care plan meeting and answered any questions related to Resident #1's nursing clinicals. The DON said she did not know how many days were allowed to enter the information in the portal after the meeting and said it was the MDS coordinator's responsibility. She said Resident #1 would not get the OT services needed if the required information was not entered in the portal. She said the facility would review the process, identify where the breakdown occurred, and implement plans to prevent it from happening again.During an interview on 03/19/26 at 3:25 p.m., the Administrator said she was never invited to PASARR IDT meetings. She said PASRR staff should have coordinated with the facility so the meeting would have been a full IDT meeting. The Administrator said during the PASRR meeting it was determined Resident #1 needed OT therapy. She said the facility staff had to complete an OT assessment for Resident #1, fill out all necessary documentation, have it signed by the physician, and upload it into the portal within 20 days after the meeting. The Administrator said Resident #1 could have had upper body function decline because she did not receive services. The Administrator said the facility would schedule a full meeting with PASRR to prevent this from happening again.Record review of the facility policy on Resident assessment - coordination with PASARR program, implemented 12/20/25, read in part: .This facility coordinated assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition received care and services in the most integrated setting appropriate to their needs.

Based on interview and record review, the failed to ensure that its residents are free of any significant medication error for 1 (CR#1) of 5 residents reviewed for medication administration.CR#1 was ordered to receive 600 MG of Gabapentin in the evening for pain on 10/16/25 and 10/17/25 but was administered 300 MG both evenings by MA B.MA B failed to follow physician orders or consult with a nurse for order clarification.These failures could place residents at risks for increased pain, discomfort, and a diminished quality of life.Findings include: Record review of CR#1's face-sheet reviewed 10/21/25, revealed a seventy-six year old woman who was admitted to the facility on [DATE]. Her admitting diagnoses were a Type II Dens fracture (a break in the odontoid process, the peg-like structure that connects the second vertebra (axis) to the first vertebra (atlas) in the cervical spine), elevated white blood cell count, cervicalgia (pain in the neck region), pain, and adult failure to thrive. Record review of CR#1's Pain Management Team Encounter notes dated 10/16/25 stated that she was AAO x2-3. CR#1 had unspecified pain and treatment goals were directly therapeutic and were incorporated to provide improvement and/or prevention of progression of the condition, while providing a reasonable expectation of recovery. Record Review of CR#1's care plan reviewed 10/21/25, displayed a focus on pain management initiated on 10/16/25. Interventions stated to screen for pain on admission and daily. Assess to determine if experiencing pain. If pain was present, conduct, and document pain assessment particularly location, nature, intensity, and duration of pain. Record review of CR#1's orders dated 10/15/25 documented that CR#1 was to receive: 1. Gabapentin Capsule 300 MG Give 1 capsule by mouth three times a day for nerve pain. 2. Gabapentin Capsule 300 MG Give 1 capsule by mouth two times a day for nerve pain equals 600mg for AM and PM doses. Record review of CR#1's MAR dated October 2025 revealed the medications were administered as follows: 1- 300MG Gabapentin capsule by mouth two times a day (a.m. and p.m. doses that equaled 600 MG) for nerve pain. * 10/16/25 at 9:00 a.m. dose was marked administered by MA A *10/16/25 at 9:00 p.m. dose was marked administered by MA B. *10/17/25 at 9:00 a.m. dose was marked administered by MA A *10/17/25 at 9:00 p.m. doses was marked administered by MA B. * 10/18/25 at 9:00 a.m., dose was marked administered by the ADON. 1- 300 MG Gabapentin capsule to be given by mouth three times a day for nerve pain. *10/16/25 at 9:00 a.m. dose was marked administered by MA A, *10/16/25 at 3:00 p.m. and the 9:00 p.m. doses were marked administered by MA B. *10/17/25 at 9:00 a.m. dose was marked administered by MA A *10/17/25 at 3:00 p.m. and the 9:00 p.m. doses were marked administered by MA B *10/18/25 at 9:00 a.m., was marked administered by the ADON. In total, 5 Gabapentin 300 MG capsules should be administered to CR#1 daily and a total of 12 capsules should have been administered from 10/16/25 to 10/18/25 at 9:00 a.m. Record review of CR#1's progress notes on 10/18/25 at 11:42 a.m. inputted by ADON stated CR#1 had a change in condition where she was unresponsive. Nursing observation documented: ADON was called to room due to change in condition. NP notified and orders given to send out via 911 to hospital for further evaluation. Resident left with EMS at 11:54 a.m. via stretcher. In an interview and observation on 10/21/25 at 12:14 p.m., MA A, stated she worked at the facility since 2020 and had stepped into the role as a medication aide in March 2025. She worked from 6 a.m. to 2 p.m. and only remembered giving medications to CR#1 twice. She explained when she gave medication, she would verify the orders by checking the resident's name with the picture, asking the resident to verify their first and last name, and making sure the blister pack matched the orders. MA A took the Surveyor to the medication cart and she reviewed CR #1's orders. She stated she saw there was one order to give 1 tab of 300 MG of Gabapentin 3xs a day and another to give 1 tab of 300 MG of Gabapentin 2xs a day. On her shift of 6 a.m. to 2 p.m., she was ordered to give CR#1 2 capsules of Gabapentin. Reviewing the time stamps in the MAR, she administered this medication on 10/16/25 at 10:34 a.m. and on 10/17/25 at 10:22 a.m. She stated although she saw two separate orders in the MAR, she did not feel like it was inputted by accident, and she followed the orders as written. MA A stated she did not notice any adverse effects or any changes in her behavior. She explained that if she suspected there was an overlap in medications or a discrepancy, she would consult with one of the nurses. Inside the medication cart, there was one bottle of Gabapentin 300 MG filled on 10/15/25 for 60 capsules for CR#1. A blister pack was also found for Gabapentin 300 MG filled on 10/16/25 for 70 capsules. MA A recalled that she administered medication from the Gabapentin bottle initially, but she switched over to the blister pack once it was delivered on 10/17/25. MA A counted the amount of medication remaining from both the pack and the bottle that equaled a total of 130 capsules, 8 capsules 300 MG Gabapentin were missing from the count. In an interview with MA B on 10/21/25 at 12:55 p.m., she stated that she had worked at the facility for 1 year and she worked either the 6-2 a.m. shift or the 2-10 p.m. shift. On 10/16/25 and 10/17/25, she worked the 2-10 p.m. shift. She was familiar with CR#1 and after reviewing the MAR, she confirmed that she administered 300 MG of Gabapentin on 10/16/25 at 3:18 p.m. and 9:54 p.m. as well as on 10/17/25 at 3:40 p.m. and 9:02 p.m. She explained that she noticed that there were two orders of 300 MG of Gabapentin, but she figured it was an entry error because she was admitted with the bottle and the blister pack was delivered the next day. She stated that the combined orders of Gabapentin instructed to give CR#1 600 MG in the morning and 600 MG in the evening. She explained that she thought that this was too much and a medication error, so she decided to follow the order that stated to give CR#1 300 MG of Gabapentin 3xs a day and disregard the additional order that instructed this medication also be administered 2xs a day. MA B explained that for CR#1's evening medication passes, she only administered 1 300 MG capsule of Gabapentin and marked that it was given on the other order although she only passed 1 capsule. She stated she did not ask any of the nurses about CR#1's order but she stated that she was supposed to report it to the nurse if there were any kind of suspected medication errors. She stated that the reason she did not report it to a nurse was because she was working both halls and she forgot. In an interview on 10/22/25 at 9:43 a.m. with CR#1 in the hospital, she was in bed wearing her neck brace while she grimaced and moaned in a lot of pain. She stated that while she was in the nursing facility she was given a lot of medication, but she did not remember what it was. She stated she did not feel any pain while she was there, and the nurses were nice to her but was not feeling well enough to answer additional questions. In an interview on 10/22/25 at 4:43 p.m. with the NP, she stated the last time she saw CR#1 was on 10/17/25 and she was demented but alert and oriented x2. She explained she consulted with the facility's pain management team regarding her pain medications. She stated she saw there were two orders of 300 MG of Gabapentin orders in the system where one was to be given 3xs a day and the others was to be given 2xs a day. She stated for both morning and evening administration, CR#1 was to receive 600 MG of Gabapentin. Two orders were documented into the system for the medication because sometimes the system made them input each order in separately for it to populate when to administer it in the MAR. She stated these doses of Gabapentin were normal doses and could still be increased if needed. NP stated that she was unaware that CR#1 had not gotten her doses as she had ordered and she did not receive any questions from facility nurses or staff regarding confusion with the two 300 MG Gabapentin orders. She stated that nurses always contacted her if they were confused and no one should ever administer medication unless they have full understanding of the orders. In an interview with the DON on 10/23/25 at 10:55 a.m. she was informed that MA B had not given CR#1 her 300 MG of Gabapentin medication as ordered. She explained if an aide had confusion with the orders, they should have reached out to a nurse for clarification. If the nurse had a question, they should reach out to the physician. All orders were to be followed as documented in the computer. She explained the harm in CR#1 not receiving her medication as ordered would be increased pain for CR#1. Record review of MA B's employee file documented that she was hired at the facility on 08/19/24 as a certified medication aide. Her essential functions in this role were to administer medications as ordered by a physician under the supervision of a licensed nurse in accordance with any state and federal regulations and consistent with facility policy, record the administration of medications appropriately, and demonstrate knowledge of the five rights (right patient, right drug, right dose, right route, and right time). Record review of the facility's policy titled Adverse Consequences and Medication Errors revised April 2014 stated: A medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services. Examples of medications errors include: a. Omission - a drug is ordered but not administered; b. Unauthorized drug - a drug is administered without a physician's order; c. Wrong dose (e.g., Dilantin 12 mL ordered, Dilantin 2 mL given); d. Wrong route of administration (e.g., ear drops given in eye); e. Wrong dosage form (e.g., liquid ordered, capsule given); f. Wrong drug (e.g., vibramycin ordered, vancomycin given); g. Wrong time; and/or h. Failure to follow manufacturer instructions and/or accepted professional standards (e.g., failure to shake medication that is labeled shake well, crushing a medication on the d

Based on interview and record review, the failed to ensure that its residents are free of any significant medication error for 1 (CR#1) of 5 residents reviewed for medication administration. CR#1 was ordered to receive 600 MG of Gabapentin in the evening for pain on 10/16/25 and 10/17/25 but was administered 300 MG both evenings by MA B. MA B failed to follow physician orders or consult with a nurse for order clarification. These failures could place residents at risks for increased pain, discomfort, and a diminished quality of life. Findings include:Record review of CR#1's face-sheet reviewed 10/21/25, revealed a seventy-six year old woman who was admitted to the facility on [DATE]. Her admitting diagnoses were a Type II Dens fracture (a break in the odontoid process, the peg-like structure that connects the second vertebra (axis) to the first vertebra (atlas) in the cervical spine), elevated white blood cell count, cervicalgia (pain in the neck region), pain, and adult failure to thrive. Record review of CR#1's Pain Management Team Encounter notes dated 10/16/25 stated that she was AAO x2-3. CR#1 had unspecified pain and treatment goals were directly therapeutic and were incorporated to provide improvement and/or prevention of progression of the condition, while providing a reasonable expectation of recovery. Record Review of CR#1's care plan reviewed 10/21/25, displayed a focus on pain management initiated on 10/16/25. Interventions stated to screen for pain on admission and daily. Assess to determine if experiencing pain. If pain was present, conduct, and document pain assessment particularly location, nature, intensity, and duration of pain. Record review of CR#1's orders dated 10/15/25 documented that CR#1 was to receive: 1. Gabapentin Capsule 300 MG Give 1 capsule by mouth three times a day for nerve pain.2. Gabapentin Capsule 300 MG Give 1 capsule by mouth two times a day for nerve pain equals 600mg for AM and PM doses. Record review of CR#1's MAR dated October 2025 revealed the medications were administered as follows: 1- 300MG Gabapentin capsule by mouth two times a day (a.m. and p.m. doses that equaled 600 MG) for nerve pain. * 10/16/25 at 9:00 a.m. dose was marked administered by MA A *10/16/25 at 9:00 p.m. dose was marked administered by MA B. *10/17/25 at 9:00 a.m. dose was marked administered by MA A*10/17/25 at 9:00 p.m. doses was marked administered by MA B.* 10/18/25 at 9:00 a.m., dose was marked administered by the ADON. 1- 300 MG Gabapentin capsule to be given by mouth three times a day for nerve pain. *10/16/25 at 9:00 a.m. dose was marked administered by MA A, *10/16/25 at 3:00 p.m. and the 9:00 p.m. doses were marked administered by MA B. *10/17/25 at 9:00 a.m. dose was marked administered by MA A*10/17/25 at 3:00 p.m. and the 9:00 p.m. doses were marked administered by MA B*10/18/25 at 9:00 a.m., was marked administered by the ADON. In total, 5 Gabapentin 300 MG capsules should be administered to CR#1 daily and a total of 12 capsules should have been administered from 10/16/25 to 10/18/25 at 9:00 a.m. Record review of CR#1's progress notes on 10/18/25 at 11:42 a.m. inputted by ADON stated CR#1 had a change in condition where she was unresponsive. Nursing observation documented: ADON was called to room due to change in condition. NP notified and orders given to send out via 911 to hospital for further evaluation. Resident left with EMS at 11:54 a.m. via stretcher. In an interview and observation on 10/21/25 at 12:14 p.m., MA A, stated she worked at the facility since 2020 and had stepped into the role as a medication aide in March 2025. She worked from 6 a.m. to 2 p.m. and only remembered giving medications to CR#1 twice. She explained when she gave medication, she would verify the orders by checking the resident's name with the picture, asking the resident to verify their first and last name, and making sure the blister pack matched the orders. MA A took the Surveyor to the medication cart and she reviewed CR #1's orders. She stated she saw there was one order to give 1 tab of 300 MG of Gabapentin 3xs a day and another to give 1 tab of 300 MG of Gabapentin 2xs a day. On her shift of 6 a.m. to 2 p.m., she was ordered to give CR#1 2 capsules of Gabapentin. Reviewing the time stamps in the MAR, she administered this medication on 10/16/25 at 10:34 a.m. and on 10/17/25 at 10:22 a.m. She stated although she saw two separate orders in the MAR, she did not feel like it was inputted by accident, and she followed the orders as written. MA A stated she did not notice any adverse effects or any changes in her behavior. She explained that if she suspected there was an overlap in medications or a discrepancy, she would consult with one of the nurses. Inside the medication cart, there was one bottle of Gabapentin 300 MG filled on 10/15/25 for 60 capsules for CR#1. A blister pack was also found for Gabapentin 300 MG filled on 10/16/25 for 70 capsules. MA A recalled that she administered medication from the Gabapentin bottle initially, but she switched over to the blister pack once it was delivered on 10/17/25. MA A counted the amount of medication remaining from both the pack and the bottle that equaled a total of 130 capsules, 8 capsules 300 MG Gabapentin were missing from the count. In an interview with MA B on 10/21/25 at 12:55 p.m., she stated that she had worked at the facility for 1 year and she worked either the 6-2 a.m. shift or the 2-10 p.m. shift. On 10/16/25 and 10/17/25, she worked the 2-10 p.m. shift. She was familiar with CR#1 and after reviewing the MAR, she confirmed that she administered 300 MG of Gabapentin on 10/16/25 at 3:18 p.m. and 9:54 p.m. as well as on 10/17/25 at 3:40 p.m. and 9:02 p.m. She explained that she noticed that there were two orders of 300 MG of Gabapentin, but she figured it was an entry error because she was admitted with the bottle and the blister pack was delivered the next day. She stated that the combined orders of Gabapentin instructed to give CR#1 600 MG in the morning and 600 MG in the evening. She explained that she thought that this was too much and a medication error, so she decided to follow the order that stated to give CR#1 300 MG of Gabapentin 3xs a day and disregard the additional order that instructed this medication also be administered 2xs a day. MA B explained that for CR#1's evening medication passes, she only administered 1 300 MG capsule of Gabapentin and marked that it was given on the other order although she only passed 1 capsule. She stated she did not ask any of the nurses about CR#1's order but she stated that she was supposed to report it to the nurse if there were any kind of suspected medication errors. She stated that the reason she did not report it to a nurse was because she was working both halls and she forgot. In an interview on 10/22/25 at 9:43 a.m. with CR#1 in the hospital, she was in bed wearing her neck brace while she grimaced and moaned in a lot of pain. She stated that while she was in the nursing facility she was given a lot of medication, but she did not remember what it was. She stated she did not feel any pain while she was there, and the nurses were nice to her but was not feeling well enough to answer additional questions. In an interview on 10/22/25 at 4:43 p.m. with the NP, she stated the last time she saw CR#1 was on 10/17/25 and she was demented but alert and oriented x2. She explained she consulted with the facility's pain management team regarding her pain medications. She stated she saw there were two orders of 300 MG of Gabapentin orders in the system where one was to be given 3xs a day and the others was to be given 2xs a day. She stated for both morning and evening administration, CR#1 was to receive 600 MG of Gabapentin. Two orders were documented into the system for the medication because sometimes the system made them input each order in separately for it to populate when to administer it in the MAR. She stated these doses of Gabapentin were normal doses and could still be increased if needed. NP stated that she was unaware that CR#1 had not gotten her doses as she had ordered and she did not receive any questions from facility nurses or staff regarding confusion with the two 300 MG Gabapentin orders. She stated that nurses always contacted her if they were confused and no one should ever administer medication unless they have full understanding of the orders. In an interview with the DON on 10/23/25 at 10:55 a.m. she was informed that MA B had not given CR#1 her 300 MG of Gabapentin medication as ordered. She explained if an aide had confusion with the orders, they should have reached out to a nurse for clarification. If the nurse had a question, they should reach out to the physician. All orders were to be followed as documented in the computer. She explained the harm in CR#1 not receiving her medication as ordered would be increased pain for CR#1. Record review of MA B's employee file documented that she was hired at the facility on 08/19/24 as a certified medication aide. Her essential functions in this role were to administer medications as ordered by a physician under the supervision of a licensed nurse in accordance with any state and federal regulations and consistent with facility policy, record the administration of medications appropriately, and demonstrate knowledge of the five rights (right patient, right drug, right dose, right route, and right time). Record review of the facility's policy titled Adverse Consequences and Medication Errors revised April 2014 stated: A medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services.Examples of medications errors include:a. Omission - a drug is ordered but not administered;b. Unauthorized drug - a drug is administered without a physician's order;c. Wrong dose (e.g., Dilantin 12 mL ordered, Dilantin 2 mL given);d. Wrong route of administration (e.g., ear drops given in eye);e. Wrong dosage form (e.g., liquid ordered, capsule given);f. Wrong drug (e.g., vibramycin ordered, vancomycin given);g. Wrong time; and/orh. Failure to follow manufacturer instructions and/or accepted professional standards (e.g., failure to shake medication that is labeled shake well, crushing a medication on the do not crush list without an order).

Based on observations, interviews, and record review, the facility failed to ensure that each resident who was incontinent of bowel/bladder and each resident with an indwelling catheter received appropriate treatment and services to prevent urinary tract infections, for 1 of 6 residents (Resident #95) reviewed for incontinent care and for indwelling urinary catheters. The facility failed to ensure Resident #95's indwelling catheter (a tube into the bladder to drain urine) securement device used to stabilize the catheter was in place. This failure could place the residents at risk for pain, dislodgement, or infection. Findings included:Record review Resident #95's (undated) face sheet revealed a [AGE] year-old female readmitted to the facility on [DATE]. Her diagnoses included chronic kidney disease, acute kidney failure, and neuromuscular dysfunction of bladder disorder (condition that affects the muscles and nerves that controls the bladder). Record review of Resident #95's quarterly MDS assessment dated [DATE] revealed a BIMS was scored as 11, which indicted moderately impaired cognition. Resident #95's self-care assessment revealed she required substantial/maximal assistance with toileting, showering, lower body dressing, and putting on/taking off footwear. She was also noted to be incontinent to both bowel and bladder. Record review of Resident #95's care plan revealed she had a Foley catheter related to neuromuscular dysfunction of the bladder with a goal to remain free from catheter related trauma. Resident #95's interventions included positioning the catheter bag and tubing below the level of the bladder and away from the entrance room door, checking tubing for kinks each shift, monitoring and documenting pain/discomfort due to catheter, and monitoring/recording/reporting s/sx of UTI to MD. Record review of Resident #95's physician orders dated 07/11/25 indicated to change Foley catheter anchor every night shift starting on the 15th and ending on the 15th every month. During an observation on 07/16/2025 at 9:31 AM Resident #95 did not have a strap or device to secure the catheter tube to the resident's thigh. Resident #95 was alert and oriented, and said she never had a Foley securement device. During an interview on 07/16/2025, at 9:35 AM, CMA K, who was at Resident #95's bedside, said residents are supposed to wear a leg strap to secure their catheter. She said she did not know why the resident did not have a leg strap and referred the surveyor to Resident #95's nurse. During an interview on 07/16/2025 at 10:13 AM, LVN V said Resident #95's catheter should have been secured in place with a leg strap. She said the nurses and CNAs were responsible for ensuring the catheter was properly secured. LVN V said the risk of the catheter tubing not being secured was the tube could be pulled out and cause injury to the resident's urethra. During an interview on 07/17/2025 at 1:10 PM, the DON stated LVN V informed her that Resident #95 did not have a strap to secure the tubing. The DON said Resident #95's catheter strap should be on her thigh, per physician's orders. The DON said the risk of not having the strap was the tubing could cause injury/trauma and/or infection . During an interview on 07/18/2025 at 1:03 PM, the Administrator said she expected all residents with catheters to have leg straps or a securing device to prevent the catheter tube from pulling. The administrator said the risk could cause injury, pain, and/or lead to an infection. Record review of the facility policy titled Catheter Care, Urinary, revised September 2014 read in part: . Steps in the Procedure 18. Secure catheter utilizing a leg band .

Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 6 residents (Resident #6) reviewed for infection control practices. 1. The facility failed to ensure CNA J applied enhanced barrier precautions while providing incontinent/catheter care to Resident # 6. 2. The facility failed to ensure that CNA J sanitized their hands when providing incontinent/catheter care to Resident #6. These failures could place residents at risk of cross-contamination and infections leading to illness. Findings included: Record review of Resident #6's undated face sheet indicated the resident was a 66-year- old male who was readmitted to the facility on [DATE] with diagnoses of hemiplegia and hemiparesis affecting right dominant side (paralysis or severe weakness on one side of the body), Benign prostatic hyperplasia (prostate gland enlargement that can cause urinary difficulty), and Neuromuscular Dysfunction of Bladder (condition that affects the muscles and nerves that controls the bladder). Record review of Resident #6's MDS assessment, dated 4/07/2025, revealed a BIMS summary score of 12, indicating cognitively intact. The MDS also indicated Resident #6 required maximal/substantial assistance with showering, lower body dressing, personal hygiene, and removing lower body dressing. Record review of Resident #1's care plan initiated on 4/04/2025, indicated Resident #6 had a catheter. The goal was for Resident #6 to show no s/sx of urinary infection. Interventions included checking for kinks, monitoring and documenting for pain/discomfort due to catheter, and monitoring/recording/reporting too MD for s/sx of a UTI. Record review of physician's orders dated 06/11/25 revealed Resident #6 was also on enhanced barrier precautions (infection control interventions designed to reduce transmission of multidrug-resistant organism). During an observation on 7/17/2025 at 9:43 AM, enhanced barrier precautions signage was posted on the outside door, and PPE was noted outside the room. CNA J was observed performing incontinent/Catheter Care on Resident #6 without wearing proper personal protective equipment (gown). The resident was lying on his right side, and she was observed cleaning stool on the resident's buttocks using the same soiled gloves that held the dirty wipes to reenter the multi-wipe package. She continued to use the soiled gloves and applied a new brief to the resident. She doffed her gloves and left the room to retrieve soap, water, and new linen for catheter care, without sanitizing her hands. She returned to the resident's room, sanitized her hands, applied new gloves, and proceeded to start catheter care. She cleaned the resident's penis per policy and began wiping the catheter tubing from the urethra opening downward per policy; however, she did not doff gloves, sanitize hands and don new gloves after handling the soiled towels. She used the same soiled gloves and applied a new brief. She doffed her gloves and sanitized her hands after applying the new brief and adjusting Resident #6's linen and bed. She was observed using the same gloves throughout the entire Cath care procedure. During an interview on 7/17/2025 at 10:04 AM, CNA J said she forgot to put on her protective personal equipment (PPE) before performing incontinent/catheter care. The CNA said she was aware that she was supposed to wear PPE when performing incontinent care for Resident #6, based on previous infection control in-services/training and the signage posted on the door. CNA J also said she should have changed her gloves after discarding the dirty brief. She said she should have sanitized her hands and donned new gloves before applying the new brief or touching his linen and bed remote. She said the risk of not wearing PPE or not performing hand hygiene could spread germs and lead to infection. During an interview on 7/17/2025 at 10:04 AM, LVN V said all staff had been in-serviced on enhanced barrier precautions (EBP). She said PPE should be worn when providing direct care by wearing gowns and gloves. She said all staff should change gloves and sanitize their hands before, during, and after incontinent/catheter care. LVN V said the risk of not following EBP and not sanitizing hands could cause a cross-contamination and lead to a UTI. During an interview on 7/17/2025 at 1:10 PM, the DON said the facility had frequently in-serviced staff on enhanced barrier precautions (EBP) and infection control. The DON said she expected her staff to wear proper PPE when providing care, as per protocol. She also said her expectation was for staff to wash their hands before, during and after incontinent/Cath care. She said the risk was cross contamination and infection. During an interview on 7/18/2025 at 1:03 PM, the Administrator said she expected the nurses and staff to adhere to the enhanced barrier precautions/infection control policy. The Administrator said the risk of not following the infection control policy puts staff and residents at risk of spreading infection, which could lead to a decline in a resident's health. Record review of a policy titled Enhanced Barrier precautions dated August 2024, read in part . Policy: EBP are used as an infection prevention and control intervention to reduce the spread of multi-drug-resistant organisms to residents. 3. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: dressing, bathing/showering transferring providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc., and wound care any skin opening requiring a dressing .

Based on interview and record review, the facility failed to ensure individuals with mental health disorders were provided an accurate Preadmission Screening and Resident Review (PASRR) Screening for 1 (Resident #81) of 4 residents reviewed for resident assessments. The facility failed to ensure Resident #81 had a PASRR on file for his bipolar and depression diagnoses. This failure could place residents with mental disorders and developmental disabilities at risk of not receiving specialized PASRR services which could contribute to a decline in physical, mental, psychosocial well-being and quality of life. Findings included: Record review of Resident #81's face sheet revealed a [AGE] year-old male admitted on [DATE]. His diagnoses were bipolar disorder (A serious mental illness characterized by extreme mood swings), and depression. Record review of Resident #81's Quarterly MDS assessment dated [DATE] noted Resident #81 had a BIMS score of 5 out of 15 which indicated he was cognitively severely impaired. Section, Active Diagnoses noted the resident with bipolar disorder and depression. Section, Antipsychotic medications noted the resident was on antipsychotic medication. Record review of Resident #81's care plan dated 03/11/24 reflected Resident #81 had not been care planned for his bipolar disorder. Record review of Resident #81's medical record revealed one PASRR Level 1 Screening dated 03/11/24 with negative results for mental illness. There was no evidence a new screening was performed when Rresident #81 was admitted with a diagnosis of bipolar disorder. During an interview on 06/05/24 at 11:18 AM with the MDS Coordinator, he said he had been in his position for a little over a year. He said he was responsible for reviewing and completing the PASRRs and ensuring that all residents with a mental illness diagnoses were referred for PASRR evaluation for services. He said he must have overlooked this Rresident #81's mental illness diagnosis. He said the risk of not having and accurate PASRR Screening and evaluation was the resident was not receiving service such as and community services that they qualify for. Interview with the DON on 06/06/24 at 12:20 PM, she said the Resident #81's PASRR was completed upon admission on 3/11/2024. She reported she was unaware an additional PASRR needed to be completed. She reported the MDS Coordinator was responsible for PASRR's. She said she was unaware of risk or negative effects of not completing the correct PASRR screening or PASRR evaluation. Interview on 6/6/2024 at 12:26 PM with the Administrator, she said PASRR screening was completed prior to admission to the facility. She reported they followed the Texas Health and Human Services guidelines for PASRR screenings. She said the risk to the resident of not having an accurate PASRR screening and assessment would be that the resident would not receive mental health services to which they are entitled. Record review of Record review of the facility's Detailed Item by Item guide for referring entities to complete the PASRR Level 1 Screening policy dated 6/2023 read in part . Purpose. The PL1 screening form is designed to identify individuals who are suspected of having a mental illness (MI), intellectual disability (ID), or developmental disability((DD). All people who are confirmed as having MI ID RTD's are identified as PASRR positive. Administering the PE helps to ensure that PASRR positive individuals are placed in the most integrated residential setting of their choice, where they can receive the specialized services needed to improve and maintain the best level of functioning .

Based on observations, interviews, and record reviews, the facility failed to ensure each resident was free from neglect for 1 of 11 residents (CR #1) reviewed for neglect. The facility failed to initiate safety interventions/monitoring or provide psychiatric services for CR #1, who had a documented history of depression and suicidal ideations. The physician ordered an urgent psychiatric consultation ([DATE]) after he expressed suicidal ideations and attempted to elope from the facility several times, which resulted in an actual suicide attempt on [DATE]. The facility failed to refer CR #1 for psychiatric services as recommended when he was discharged from an acute care hospital on [DATE]. LVN A failed to notify the DON and Administrator when CR #1 initially expressed suicidal ideations on [DATE] and inform them that CR #1's physician ordered an urgent psychiatric consultation. The facility failed to notify CR #1's physician when he expressed suicidal ideations a second time on [DATE]. An Immediate Jeopardy (IJ) situation was identified on [DATE] at 1:25 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at the severity level of actual harm with a scope identified as pattern due to the facility's need to evaluate the effectiveness of the corrective systems. These failures placed residents with a history of depression or suicidal ideations at risk of experiencing emotional distress, psychiatric episodes, and possible death from not receiving adequate care, interventions, and psychiatric services. Findings include: Record review of CR #1's face sheet dated [DATE] revealed he was an [AGE] year-old male who was admitted to the facility on [DATE]. His admitting diagnoses included with Parkinson's Disease (a disease of the central nervous system that affects movement, often including tremors), rhabdomyolysis (a breakdown of muscle tissue that releases a damaging protein into the blood), acute kidney failure (a condition in which the kidneys suddenly cannot filter waste from the blood), weakness, repeated falls, depression (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and dementia (a condition characterized by progressive or persistent loss of intellectual functioning). CR #1 was also diagnosed with suicidal ideations (often called suicidal thoughts or ideas, is a broad term used to describe a range of contemplations, wishes, and preoccupations with death and suicide). CR #1 was transferred to a local acute care hospital on [DATE]. Record review of CR #1's MDS dated [DATE] revealed he had a BIMS score of 7 (severe cognitive impairment); he felt down, depressed, or hopeless between ,d+[DATE] days; he did not experience hallucinations or delusions; he rejected care daily; he wandered daily which placed him at significant risk of getting to potentially dangerous places; he required supervision with no physical assistance for bed mobility, transfers, walking, dressing, and bathing; he required supervision with setup assistance with eating and personal hygiene; he ambulated independently with a walker; he was always continent of bowel and bladder; he experienced coughing or choking during meals or when swallowing medications; and he was prescribed antidepressant medication. Record review of CR #1's care plan updated [DATE] revealed the following: -CR #1 had potential for elopement as evidenced by exit seeking behavior ([DATE] exited out the front door). Goals included: Maintain the least restrictive environment while providing safety. Interventions included: Have activities involved with favorite past times. Music. Exercise. Photo in Elopement risk book. All staff to be made aware of CR #1's risk status via staff sign-in book and verbal reports. If possible, have family or volunteers visit on a regular basis. Keep doctor and family informed. SW to make regular visits. Reorient/Redirect as needed. Reassess as needed. SW to obtain detailed prior routine of CR #1. -CR #1 was taking psychotropic medications for Depression (Sertraline). Goals included: CR #1 will not experience adverse side effects. Interventions included: Monitor and record any displayed behavior or mood problems. Encourage appropriate behavior, discourage inappropriate behavior. Monitor effectiveness of psychotropic medications. Monitor for involuntary movements and repetitive behaviors and report to doctor. Review medications every three months for possible dose reduction. Allow CR #1 to express feelings. Protect CR #1 from self-harm or harm to others. Monitor for weight loss. Psych consult as needed. -CR #1 had behavioral symptoms not directed toward others ([DATE]- CR #1 attempted to harm himself by wrapping a phone cord around his neck- 911 was called- will re-evaluate interventions upon return. Goals included: Incidents of self-harm will be decreased. Interventions included: Gently remind CR #1 that behavior is not appropriate. Provide medication as ordered. Record behaviors on Behavior Tracking form. Monitor pattern of behavior (time of day, precipitating factors, specific staff, or situations). Head to toe assessment completed to check for any injuries (no injuries noted). 1 on 1 monitoring until EMS arrived. -CR #1 exhibited wandering behaviors. Goals included: Current level of mobility will be maintained. Interventions included: Assess potential causes for wandering (need for toilet, water, food, pain relief). Provide diversional activities. Record behaviors on Behavior Tracking form. Redirect CR #1's behavior/activity when wandering is observed. -CR #1 had other behavioral symptoms not directed toward others (refusal of care, threatening to break windows. Goals included: Incident will be decreased. Interventions included: Gently remind CR #1 that behavior is not appropriate. Provide medication as ordered. Record behaviors on Behavior Tracking form. Remove from situation; allow time to calm down. -CR #1 was at risk for falls as evidenced by cognitive impairment, fall history, weakness, unsteady gait, and rhabdomyolysis. Goals included: Dignity will be maintained. CR #1 will not experience falls or injuries from falls. Interventions included: Encourage CR #1 to ask for assistance of staff. Ensure call light is in reach, answer promptly. Therapy to evaluate and treat per orders. Anticipate needs, provide prompt assistance. Assure lighting is adequate and areas are free of clutter. Observation and interview of CR #1 at a psychiatric hospital on [DATE] at 9:00 a.m. revealed he was alert, oriented and ambulated independently with a walker. CR #1 said they went by the rules at the facility. He said he sneaked out the front door and tried to go to Whataburger. He said he did not like living there because there was no place to go, and he was the type of guy who liked to go places. He said they (he did not say who they were) would not let him go sit outside because he had a fall outside. He said he wanted to get some fresh air, but the nurses caught him. CR #1 said he did not do anything but sit at the facility because there were no activities he liked. He said two of the nurses stood at the door and would not let him out. He said he was going to get out one way or the other, either they would let him walk out, or kill himself and let the undertaker carry him out. He said the cops picked him up from the facility when he tried to kill himself. CR #1 said he wrapped a telephone cord around his neck. He said he had not been home in a very long time, and he wanted to go home. He said they gave him more medication and he felt better now. He said he did not want to kill himself anymore, he wanted to go home. Record review of CR #1's hospital records dated [DATE] revealed he was admitted to a local acute care hospital via the emergency roiagnom on [DATE] after he fell in his home and was on the floor several hours. The document read in part, . Patient states, 'You're wasting your time- I want to die . I don't have any family- They should have left me on the floor' . Precautions: Falls, Depressed state/ reports, 'I want to die' . Discharge Recommendations: Continue Rehab, Psych Consult. Precautions: Fall, Anxiety/Depression - Recommend Psych Consult . Home Medications: . Sertraline (Zoloft) 50 MG tablets daily . Record review of CR #1's hospital records dated [DATE] revealed he was transported to the emergency room by EMS on [DATE]. The records read in part, . presenting with EMS after possible strangulation attempt, patient was reported to have been found with a telephone cord around his neck, cyanotic (bluish or grayish color of the skin) appearing face, removed telephone cord and transported to hospital hemodynamically (how your blood flows through your arteries and veins and the forces that affect your blood flow) stable in route. When asked about this, patient reports he was just playing around with cord, had no suicidal intention. Patient would like to leave, does not know why is here, does not want to go back to the facility . patient with history of suicidal ideation . Assessment: Suicidal Attempt . Plan: Admit to floor . Sitter 1:1 . CR #1 was discharged to an inpatient psychiatric hospital on [DATE]. Record review of CR #1's physician's orders for [DATE] revealed he was prescribed Sertraline, 50 mg tablets once daily for depression. Start date: [DATE]. Record review of CR #1's MAR for [DATE] revealed he received Sertraline daily as ordered from [DATE] until [DATE]. Record review of CR #1's referral for a psychiatry consultation dated [DATE] revealed CR #1's physician gave LVN A verbal orders to refer CR #1 for the consultation on [DATE]. The order was electronically signed by LVN A on [DATE] at 8:12 p.m. Record review of CR #1's physician progress notes dated [DATE] revealed, . Chief Complaint: New skilled nursing patient seen and examined for admission visit. Patient sitting on side of bed in no apparent distress. Pleasantly confused. States he lives alone. No suicidal ideation today. States he is ready to go home and wants to go home . Physical Exam: . Psychiatric: Judgement/insight: Poor . Summary of Plans: . Consults: Psychiatry to follow . Diagnosis and Assessment: . Dementia - . Has tried to exit seek multiple occasions since admission . Depression - Consult psych. Continue Zoloft 50 mg daily. Per report, suicidal ideation yesterday. None today. Plan: . Urgent consult on psych to evaluate and treat. Recent history of suicidal ideation. None noted today. States he wants to go home and not be in a nursing home . Record review of CR #1's physician progress notes dated [DATE] revealed, Chief Complaint: Skilled nursing patient seen and examined in follow-up . Per staff, patient was found outside of the facility walking along the sidewalk stating that he wanted to go home . Record review of CR #1's progress notes for [DATE] revealed the following: *On [DATE] at 8:05 p.m. (incident occurred at 5:15 p.m.), LVN A wrote, Resident was being evaluated by ST for swallowing issues that were reported. ST was introducing a mechanical soft diet. Resident stated he did not want to change diets. Asked ST 'What for?' He verbalized to ST that he wanted to die instead because he was tired. Will notify MD and refer resident for Psych evaluation. *On [DATE] at 12:24 p.m., LVN B wrote, . Resident wanders throughout facility via walker. He attempted to exit x2 despite redirection . *On [DATE] at 5:52 a.m., LVN C wrote, During rounds resident was noted to be sitting on the bed and asked this writer to come here. Resident thanked this writer for providing care to him and that he will be leaving today. Asked resident was family coming to get him, he stated no, 'I'm walking. I would walk now but it is dark.' Educated resident on the importance of staying at the facility, resident stated, 'I will think about it .' *On [DATE] at 9:54 a.m., LVN B wrote, . This shift, he eloped out of front door and started to walk down the sidewalk. This nurse and other nurses on duty spoke with resident and attempted to provide redirection. After some time, resident agreed to come back inside. Resident still upset, threatening to break windows. Administrator speaking with RP at this time to make a discharge decision. *On [DATE] at 3:33 a.m., LVN C wrote, . Resident is in bed resting quietly at this time, sitter is sitting outside of door . *On [DATE] at 8:10 p.m., LVN C wrote, Resident is walking around asking staff to help him leave, staff redirects resident. Currently resident is in his room stating that he is leaving as soon as he finds a window to go out of. All staff notified to keep an eye on resident due to him stating he is going to leave. *On [DATE] at 2:31 a.m. (incident occurred [DATE] at 8:50 p.m.), LVN C wrote, This writer seen resident going towards the back door. This writer and another began to stand between resident and the door. Resident asked staff if we could move so he could leave. Asked resident where he was going, he stated, home to his bed because he had things to do. This writer explained to resident that I could not let him leave and I was responsible for his wellbeing. Resident stepped closer to staff and asked resident to please step back, he did. Resident continued to stand at the door. Resident then stated that he was going to leave one way or another, resident made a cutting sign (gesture) towards his neck. Asked resident what that was, he stated, 'Could you just let me leave?' Call placed to Administrator, advised resident that he would have to go to his room, or I will call 911, orders given from management. Aide offered popcorn, resident stated he guessed he would go brush his teeth and go to bed. Administrator called and asked if I could interview resident to see if he was a danger to himself. When interviewing resident, he could not recall making a cutting sign at his throat, resident also stated that he will never hurt himself, notified Administrator, resident is currently in bed resting quietly . rounds are made every 2 hours. *On [DATE] at 10:12 a.m. (incident occurred at 9:15 a.m.), LVN A wrote, Receptionist was walking towards nursing station when she noted resident sitting in library. When she attempted to approach resident sitting in library, she noted that the resident had the phone cord wrapped around him and attempting to tighten it harder. Receptionist stated that the resident was turning blue when she ran in to intervene and remove the cord from the resident's neck. The Receptionist called for help and LVN E reached out to me on the way to assist resident and Receptionist. *On [DATE] at 10:16 a.m., LVN A wrote, . Assessed resident. Resident stabilized after removing cord from neck and having to sit down. Stated wanted to leave. Asked if he was attempting to kill himself and he stated, 'If that's the only way out then, yes?' Called 911 to have resident transferred to hospital for psych evaluation . RN D spoke with family and advised that resident was being sent out to hospital for Psych evaluation due to suicide attempt. Family stated that it was not the first time the resident has attempted suicide . Record review of CR #1's, Elopement Risk assessment dated [DATE] revealed LVN F determined CR #1 was a moderate risk for elopements based on his cognitive impairment and wandering behaviors. Action included, Implement Elopement Risk care plan; Implement Frequent Monitoring Form (form was not completed) to determine elopement risk or until Interdisciplinary Team reviews and makes recommendation. Record review of CR #1's, Elopement Risk assessment dated [DATE] revealed RN G determined CR #1 was an imminent risk for elopements based on his ambulation status, wandering behaviors, and his intentional or unintentional attempts to leave the community. Action included, Implement Elopement Risk care plan; Implement Frequent Monitoring Form (form was not completed) to determine elopement risk or until Interdisciplinary Team reviews and makes recommendation. In an interview with the DON and the Regional Director of Clinical Services on [DATE] at 9:45 a.m., the Regional Director of Clinical Services stated the DON was new to the facility and regional staff was not always in the building. The Regional Director of Clinical Services stated, based on what they knew, CR #1 had no previous suicidal ideations. The Regional Director of Clinical Services said CR #1's wife passed away in the facility many years prior and he had no other family other than a neighbor who helped him out prior to admission. The Regional Director of Clinical Services said CR #1's neighbor stated he (CR #1) previously talked about wanting to die. The DON stated to their (administration) knowledge, CR #1 spoke with the ST and referenced dying. The DON said CR #1's physician was notified and ordered an urgent referral for psychiatric services, but psych services was not able to see CR #1 before the suicide attempt. The Regional Director of Clinical Services stated CR #1's physician spoke with LVN A and that is where it ended. The Regional Director of Clinical Services stated LVN A was educated because something like that (suicidal ideations) should be escalated to the top (DON and Administrator). The Regional Director of Clinical Services said LVN A did not let anybody else know about the conversation between CR #1 and the ST. The Regional Director of Clinical Services said CR #1's physician documented his suicidal ideations and that she wanted an urgent psych consult. The Regional Director of Clinical Services said the incident was not communicated to the top (administration), so they did not have an opportunity to follow-up on the referral. The facility's elopement policy was requested, but the wandering policy was provided. In an interview with the VP of Clinical Operations on [DATE] at 11:00 a.m., she stated the facility did an emergency QAPI on [DATE], after CR #1 attempted suicide. She said all staff involved were counseled and in-serviced. She said nursing staff talked to each resident who could speak and used a special psychiatric tool given to them by a psych provider to interview about depression and suicide. She said the residents who could not talk were assessed head to toe to insure nothing was out of the ordinary for them. She said the Administrator was suspended because their investigation found he may have known about CR #1's prior history of depression. In a telephone interview with the Administrator on [DATE] at 11:45 a.m., he stated he knew CR #1 kept saying he wanted to go home because he wanted to shampoo his carpet at home. He said it was not out of the ordinary for residents to express desires to go home. The Administrator said CR #1 had previously been admitted to the facility for rehab and he (CR #1) wanted attention, that was it. The Administrator said CR #1 was not depressed and he just wanted to go home and do chores. The Administrator said CR #1's depression, suicidal ideations, or behaviors were never brought to his attention prior to admission, and he never spoke to CR #1's family before or after his admission. The Administrator said the night before the suicide attempt ([DATE]), LVN C called him around 10:00 p.m. He said he thought LVN C texted him, or he missed her call and then she texted saying CR #1 was trying to leave the building and that he wanted to kill himself. The Administrator said he sent LVN C a text to call 911, but she sent a text or called him, saying CR #1 was doing fine after they gave him popcorn. The Administrator said he called the LVN C back and she said CR #1 was fine and brushing his teeth. The Administrator said he told LVN C he needed to know what CR #1's state of mind was. He said LVN C said CR #1 could not even recall what he said earlier. He said he told LVN C to put CR #1 on monitoring (no monitoring was documented) and notify him if anything changed. He said he did not receive any more calls that night until incident on Saturday, [DATE] when LVN A called and said CR #1 tried to hurt himself. In a telephone interview with LVN A on [DATE] at 11:59 a.m., he stated he was a charge nurse and he only worked weekends. He said on [DATE], the ST approached him and said CR #1 had difficulty swallowing and she wanted to down grade his diet (to a mechanical soft diet). He said the ST told him CR #1 refused the food she used to assess him and said he (CR #1) was tired and wanted to die. LVN A said he went to follow-up with CR #1 in his room and asked about his diet. LVN A said he wanted CR #1 to say in his own words how he felt, but he did not express a desire to die to him. LVN A said he did not ask CR #1 about what he said to the ST. LVN A said he called CR #1's doctor and got an order for a psych consultation and he documented the situation. LVN A said the order was not an urgent order. He said orders for psychiatric services were usually turned in to the SW. LVN A said he slipped the referral under the SW's door on Sunday, [DATE], and he did not hear anything else about CR #1's referral after that. He said he did not relay this information to the DON, the Administrator, or anybody else. He said he did not know the SW was on vacation, but had he known, he would have taken the referral order to someone else. He said no special monitoring or intervention was initiated for CR #1. LVN A said that next weekend, [DATE], CR #1 said he wanted to go home, but that was nothing out of ordinary from his usual agitation. He said on [DATE], he heard another nurse call his name and he ran to the library room and saw CR #1 there with the Receptionist. He said by the time he got to the library, other staff had removed the phone cord from CR #1's neck and he (CR #1) was just shaking. He said he got someone to stay with CR #1 while he called his doctor for an order to send him out and he called CR #1's family and the Administrator. LVN A said the police arrived while he was assessing CR #1 and CR #1 told the officer, Oh, I tried to kill myself, but it was nothing big. LVN A said the officer asked CR #1 again if he wanted to kill himself and CR #1 said yes. LVN A said he did not assign CR #1 a sitter the previous weekend when he initially expressing suicidal ideations. He said RN D called CR #1's family (after the suicide attempt) who said CR #1 had a history of suicidal ideations and had done this (attempted suicide) before. He said CR #1's family never mentioned prior to him having the cord around his neck that he had a history of suicide attempts. LVN A said after he was in-serviced (after CR #1's suicide attempt), he realized he should have expedited the information about the suicidal ideations and referral to the DON or management to let them know what was stated. In a telephone interview with CR #1's NP on [DATE] at 12:33 p.m., she stated she visited CR #1 on [DATE], after he was admitted on [DATE]. She said she was notified about CR #1's suicidal ideations on [DATE] and when she saw him on [DATE], she asked him about the day before. She said she asked him if he still wanted to harm himself and he said no, he just wanted to go home and did not want to be in the facility. The NP said she documented in her notes that she put in an urgent request for psych services. The NP said the order was urgent based on CR #1's history of depression. She said she was familiar with the facility's referral process and the request had to be submitted to the SW then sent thru the referral portal. She said the process took a little while, so it was urgent to be done timely. She said she knew the psych provider saw patients at the facility on Mondays, so she knew CR #1 probably would not have been seen Monday, [DATE]. She said she was not aware CR #1's discharging facility recommended he be evaluated by psych services. She said had CR #1 exhibited behaviors, the facility staff could have notified psych for medication if needed. The NP said she had no prior knowledge of CR #1's history of suicidal ideations. She said she saw CR #1 again on [DATE] and staff notified her CR #1 had eloped. She said she was not notified of any other incident of suicidal ideations. She said had staff notified her or the on-call doctor that CR #1 made a throat cutting motion (on the morning of [DATE]), she would have sent him out to the hospital at that time. In an interview with the SW on [DATE] at 1:00 p.m., she stated, usually, the NP or doctor would write an order and the nurse would print the order and give it to her. She said she sent an email to the psychiatric provider and made the referral. The SW said the process usually only took one day and the provider came on Mondays. She said she never received a referral or request for CR #1 to receive psych services. She said she was on vacation [DATE] - [DATE]. She said when she returned from vacation, she did not see any request for CR #1 under her door. The SW said nobody ever asked her about any referral for CR #1. She said the facility's nurses could do the referrals if she was not here. The SW said if the psych provider was in the building and the nurses let them know someone needed to be seen, psych would have evaluated CR #1 even without the referral. She said if the referral was already in their computer system, they could have given it to him (psych) and he could have sent the referral to his (psych) office. The SW provided a copy of CR #1's order for psych services from the computer system and said the order did not say anything about urgency. She said she never saw a psych referral mention urgency. She said that ([DATE]) was the first time she saw CR #1's referral for psych services. Observation of the facility on [DATE] at 1:30 p.m. revealed the library was located in a room (not open to the rest of the building) between the reception desk (front entrance) and the nurse's station. Further observation revealed someone would have to pass the entrance to the library to see if anyone was inside the library. There was a telephone with a cord on a small table next to a chair. In a telephone interview with LVN C on [DATE] at 1:22 p.m. revealed she usually worked the 2:00 p.m. - 10:00 p.m. and 10:00 p.m. - 6:00 a.m. shift, but she rarely worked on weekends. She said one night (she could not recall the date), she was about to pass medications and CR #1 thanked her for caring for him and said he was leaving, but it was dark. LVN C said she asked CR #1 if his family was coming, but he said no, he was leaving. She said she told CR #1 he was there for therapy and that was it, he went back to sleep. LVN C said on another night (she could not recall the day), CR #1 said he was leaving, and she (LVN C) called his RP (he was his own RP, but he did have an emergency contact), but she did not answer. LVN C said earlier on that day, another staff told her CR #1 had gotten outside (eloped) so, that night CR #1 was assigned a sitter (a facility housekeeper and maintenance staff). LVN C said to her knowledge, that was the only night he had a sitter. LVN C said the night he made the cutting motion was the same night she called CR #1's RP. She said they had to watch CR #1 because he would try to elope, and she noticed he went towards one of the doors. LVN C said CR #1 said they (the nurses) would not let him out the front, so he would get out one way or another, then he made cutting motion across his throat. LVN C said she asked CR #1 if that meant he would cut himself, and he said, If you think that's what I'm saying. LVN C said she told CR #1 if that was what he was saying, she would have to call the police. LVN C said CR #1 told her he would go brush his teeth. She said the Administrator said to go talk to CR #1 and ask if he was going to harm himself. LVN C said CR #1 acted like he did not recall doing that (making the cutting motion) or anything that happened that night. LVN C said CR #1 said he was going to bed. LVN C said she did not have the DON's phone number at that time. LVN C said she did not call CR #1's doctor because, to be honest, it slipped her mind. LVN C said she waiting to see if CR #1 would react or do anything else. She said now, she probably would have called the doctor. She said she was not aware of any referral for psych services for CR #1. In a telephone interview with RN D on [DATE] at 1:34 p.m., she stated she was the weekend supervisor and she only worked weekends. She said she interacted with CR #1 on weekends quite a bit. RN D said CR #1 kept wanting to go home and tried to elope several times. RN D said she was never made aware of CR #1's suicidal ideations the weekend before ([DATE]) his suicide attempt and she worked 6:00 a.m. - 10:00 p.m. RN D said she worked on the weekend the ST worked ([DATE]) but she was never made aware of CR #1 saying he wanted to die. RN D said CR #1 did not seem depressed and he had dementia but was able to have a conversation and express his feelings. RN D said on [DATE], CR #1 made his usual attempts to elope and kept trying. She said eventually, she heard someone calling for a nurse to check on CR #1 and she followed afterwards. RN D said when she got to the library, CR #1 was in there sitting on a chair and LVN A was assessing him. She said she was not made aware that CR #1 had a referral for psych services. RN D said on weekends, they contact the primary care doctor or NP for a referral order and then they contact the provider they refer to. She said they could make a referral over the phone and then fax it in. She said she had never done a referral over the weekend and unless it was an emergency, they would wait until following week to do it. She said if the situation was emergent, she would do the referral or send the resident out. She said if she felt there was an active plan for suicide, she would notify the doctor and keep the resident on 1:1 monitoring until the doctor determined their next step. In an interview with the DON on [DATE] at 2:00 p.m., she said the Administrator called her on [DATE] after CR #1 made the cutting motion across his throat. She said the Administrator told her about CR #1 making the cutting motion, and she asked him if CR #1 had a plan and some other questions. The DON said the Administrator said he would call the facility back to ask those questions and call back if there was anything else. The DON said when the nurse went back in to talk to CR #1, he was no longer expressing suicidal ideations. The DON said in hindsight, she probably should have called CR #1's doctor just in case she wanted her to do anything different. The DON said she had in serviced the nurses on when to communicate with physicians. The DON said she did not know if CR #1's referral was ever sent off to the psych provider. She said the SW handled all referrals and she did not know who to contact about referrals at their psych services provider. She said she believed the Administrator was handling referrals when the SW went on vacation. In a follow up telephone interview with the Administrator on [DATE] at 2:25 p.m., he stated if the SW was out, he would have done referrals but, he was never made aware of CR #1's order or referral. He said CR #1's referral was never sent out. In a telephone interview with the ST on [DATE] at 2:31 p.m. She said CR #1 did not have suicidal ideations. She said CR #1 told her his wife died at the facility ,d+[DATE] years prior and then he said, I guess I'm going to die here too. The ST said it was not an ideation. She said she was working with him and sho [TRUNCATED]

Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 11 residents (CR #1) reviewed for accidents and supervision. The facility failed to provide adequate supervision and monitoring for CR #1 when he expressed suicidal ideations and attempted to elope from the facility several times which resulted in actual elopements on [DATE] and [DATE] and an actual suicide attempt on [DATE]. An Immediate Jeopardy (IJ) situation was identified on [DATE] at 1:25 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at the severity level of actual harm with a scope identified as pattern due to the facility's need to evaluate the effectiveness of the corrective systems. This failure placed residents with a history of suicidal ideations and exit seeking behaviors at risk of serious harm and possible death from not receiving adequate supervision/monitoring and safety interventions. Findings include: Record review of CR #1's face sheet dated [DATE] revealed he was an [AGE] year-old male who was admitted to the facility on [DATE]. His admitting diagnoses included with Parkinson's Disease (a disease of the central nervous system that affects movement, often including tremors), rhabdomyolysis (a breakdown of muscle tissue that releases a damaging protein into the blood), acute kidney failure (a condition in which the kidneys suddenly cannot filter waste from the blood), weakness, repeated falls, depression (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and dementia (a condition characterized by progressive or persistent loss of intellectual functioning). CR #1 was also diagnosed with suicidal ideations (often called suicidal thoughts or ideas, is a broad term used to describe a range of contemplations, wishes, and preoccupations with death and suicide). CR #1 was transferred to a local acute care hospital on [DATE]. Record review of CR #1's MDS dated [DATE] revealed he had a BIMS score of 7 (severe cognitive impairment); he felt down, depressed, or hopeless between ,d+[DATE] days; he did not experience hallucinations or delusions; he rejected care daily; he wandered daily which placed him at significant risk of getting to potentially dangerous places; he required supervision with no physical assistance for bed mobility, transfers, walking, dressing, and bathing; he required supervision with setup assistance with eating and personal hygiene; he ambulated independently with a walker; he was always continent of bowel and bladder; he experienced coughing or choking during meals or when swallowing medications; and he was prescribed antidepressant medication. Record review of CR #1's care plan updated [DATE] revealed the following: -CR #1 had potential for elopement as evidenced by exit seeking behavior ([DATE] exited out the front door). Goals included: Maintain the least restrictive environment while providing safety. Interventions included: Have activities involved with favorite past times. Music. Exercise. Photo in Elopement risk book. All staff to be made aware of CR #1's risk status via staff sign-in book and verbal reports. If possible, have family or volunteers visit on a regular basis. Keep doctor and family informed. SW to make regular visits. Reorient/Redirect as needed. Reassess as needed. SW to obtain detailed prior routine of CR #1. -CR #1 was taking psychotropic medications for Depression (Sertraline). Goals included: CR #1 will not experience adverse side effects. Interventions included: Monitor and record any displayed behavior or mood problems. Encourage appropriate behavior, discourage inappropriate behavior. Monitor effectiveness of psychotropic medications. Monitor for involuntary movements and repetitive behaviors and report to doctor. Review medications every three months for possible dose reduction. Allow CR #1 to express feelings. Protect CR #1 from self-harm or harm to others. Monitor for weight loss. Psych consult as needed. -CR #1 had behavioral symptoms not directed toward others ([DATE]- CR #1 attempted to harm himself by wrapping a phone cord around his neck- 911 was called- will re-evaluate interventions upon return. Goals included: Incidents of self-harm will be decreased. Interventions included: Gently remind CR #1 that behavior is not appropriate. Provide medication as ordered. Record behaviors on Behavior Tracking form. Monitor pattern of behavior (time of day, precipitating factors, specific staff, or situations). Head to toe assessment completed to check for any injuries (no injuries noted). 1 on 1 monitoring until EMS arrived. -CR #1 exhibited wandering behaviors. Goals included: Current level of mobility will be maintained. Interventions included: Assess potential causes for wandering (need for toilet, water, food, pain relief). Provide diversional activities. Record behaviors on Behavior Tracking form. Redirect CR #1's behavior/activity when wandering is observed. -CR #1 had other behavioral symptoms not directed toward others (refusal of care, threatening to break windows. Goals included: Incident will be decreased. Interventions included: Gently remind CR #1 that behavior is not appropriate. Provide medication as ordered. Record behaviors on Behavior Tracking form. Remove from situation; allow time to calm down. -CR #1 was at risk for falls as evidenced by cognitive impairment, fall history, weakness, unsteady gait, and rhabdomyolysis. Goals included: Dignity will be maintained. CR #1 will not experience falls or injuries from falls. Interventions included: Encourage CR #1 to ask for assistance of staff. Ensure call light is in reach, answer promptly. Therapy to evaluate and treat per orders. Anticipate needs, provide prompt assistance. Assure lighting is adequate and areas are free of clutter. Observation and interview of CR #1 at a psychiatric hospital on [DATE] at 9:00 a.m. revealed he was alert, oriented and ambulated independently with a walker. CR #1 said they went by the rules at the facility. He said he sneaked out the front door and tried to go to Whataburger. He said he did not like living there because there was no place to go, and he was the type of guy who liked to go places. He said they (he did not say who they were) would not let him go sit outside because he had a fall outside. He said he wanted to get some fresh air, but the nurses caught him. CR #1 said he did not do anything but sit at the facility because there were no activities he liked. He said two of the nurses stood at the door and would not let him out. He said he was going to get out one way or the other, either they would let him walk out, or kill himself and let the undertaker carry him out. He said the cops picked him up from the facility when he tried to kill himself. CR #1 said he wrapped a telephone cord around his neck. He said he had not been home in a very long time, and he wanted to go home. He said they gave him more medication and he felt better now. He said he did not want to kill himself anymore, he wanted to go home. Record review of CR #1's hospital records dated [DATE] revealed he was admitted to a local acute care hospital via the emergency roiagnom on [DATE] after he fell in his home and was on the floor several hours. The document read in part, . Patient states, 'You're wasting your time- I want to die . I don't have any family- They should have left me on the floor' . Precautions: Falls, Depressed state/ reports, 'I want to die' . Discharge Recommendations: Continue Rehab, Psych Consult. Precautions: Fall, Anxiety/Depression - Recommend Psych Consult . Home Medications: . Sertraline (Zoloft) 50 MG tablets daily . Record review of CR #1's hospital records dated [DATE] revealed he was transported to the emergency room by EMS on [DATE]. The records read in part, . presenting with EMS after possible strangulation attempt, patient was reported to have been found with a telephone cord around his neck, cyanotic (bluish or grayish color of the skin) appearing face, removed telephone cord and transported to hospital hemodynamically (how your blood flows through your arteries and veins and the forces that affect your blood flow) stable in route. When asked about this, patient reports he was just playing around with cord, had no suicidal intention. Patient would like to leave, does not know why is here, does not want to go back to the facility . patient with history of suicidal ideation . Assessment: Suicidal Attempt . Plan: Admit to floor . Sitter 1:1 . CR #1 was discharged to an inpatient psychiatric hospital on [DATE]. Record review of CR #1's physician's orders for [DATE] revealed he was prescribed Sertraline, 50 mg tablets once daily for depression. Start date: [DATE]. Record review of CR #1's MAR for [DATE] revealed he received Sertraline daily as ordered from [DATE] until [DATE]. Record review of CR #1's referral for a psychiatry consultation dated [DATE] revealed CR #1's physician gave LVN A verbal orders to refer CR #1 for the consultation on [DATE]. The order was electronically signed by LVN A on [DATE] at 8:12 p.m. Record review of CR #1's physician progress notes dated [DATE] revealed, . Chief Complaint: New skilled nursing patient seen and examined for admission visit. Patient sitting on side of bed in no apparent distress. Pleasantly confused. States he lives alone. No suicidal ideation today. States he is ready to go home and wants to go home . Physical Exam: . Psychiatric: Judgement/insight: Poor . Summary of Plans: . Consults: Psychiatry to follow . Diagnosis and Assessment: . Dementia - . Has tried to exit seek multiple occasions since admission . Depression - Consult psych. Continue Zoloft 50 mg daily. Per report, suicidal ideation yesterday. None today. Plan: . Urgent consult on psych to evaluate and treat. Recent history of suicidal ideation. None noted today. States he wants to go home and not be in a nursing home . Record review of CR #1's physician progress notes dated [DATE] revealed, Chief Complaint: Skilled nursing patient seen and examined in follow-up . Per staff, patient was found outside of the facility walking along the sidewalk stating that he wanted to go home . Record review of CR #1's progress notes for [DATE] revealed the following: *On [DATE] at 8:05 p.m. (incident occurred at 5:15 p.m.), LVN A wrote, Resident was being evaluated by ST for swallowing issues that were reported. ST was introducing a mechanical soft diet. Resident stated he did not want to change diets. Asked ST 'What for?' He verbalized to ST that he wanted to die instead because he was tired. Will notify MD and refer resident for Psych evaluation. *On [DATE] at 12:24 p.m., LVN B wrote, . Resident wanders throughout facility via walker. He attempted to exit x2 despite redirection . *On [DATE] at 5:52 a.m., LVN C wrote, During rounds resident was noted to be sitting on the bed and asked this writer to come here. Resident thanked this writer for providing care to him and that he will be leaving today. Asked resident was family coming to get him, he stated no, 'I'm walking. I would walk now but it is dark.' Educated resident on the importance of staying at the facility, resident stated, 'I will think about it .' *On [DATE] at 9:54 a.m., LVN B wrote, . This shift, he eloped out of front door and started to walk down the sidewalk. This nurse and other nurses on duty spoke with resident and attempted to provide redirection. After some time, resident agreed to come back inside. Resident still upset, threatening to break windows. Administrator speaking with RP at this time to make a discharge decision. *On [DATE] at 3:33 a.m., LVN C wrote, . Resident is in bed resting quietly at this time, sitter is sitting outside of door . *On [DATE] at 8:10 p.m., LVN C wrote, Resident is walking around asking staff to help him leave, staff redirects resident. Currently resident is in his room stating that he is leaving as soon as he finds a window to go out of. All staff notified to keep an eye on resident due to him stating he is going to leave. *On [DATE] at 2:31 a.m. (incident occurred [DATE] at 8:50 p.m.), LVN C wrote, This writer seen resident going towards the back door. This writer and another began to stand between resident and the door. Resident asked staff if we could move so he could leave. Asked resident where he was going, he stated, home to his bed because he had things to do. This writer explained to resident that I could not let him leave and I was responsible for his wellbeing. Resident stepped closer to staff and asked resident to please step back, he did. Resident continued to stand at the door. Resident then stated that he was going to leave one way or another, resident made a cutting sign (gesture) towards his neck. Asked resident what that was, he stated, 'Could you just let me leave?' Call placed to Administrator, advised resident that he would have to go to his room, or I will call 911, orders given from management. Aide offered popcorn, resident stated he guessed he would go brush his teeth and go to bed. Administrator called and asked if I could interview resident to see if he was a danger to himself. When interviewing resident, he could not recall making a cutting sign at his throat, resident also stated that he will never hurt himself, notified Administrator, resident is currently in bed resting quietly . rounds are made every 2 hours. *On [DATE] at 10:12 a.m. (incident occurred at 9:15 a.m.), LVN A wrote, Receptionist was walking towards nursing station when she noted resident sitting in library. When she attempted to approach resident sitting in library, she noted that the resident had the phone cord wrapped around him and attempting to tighten it harder. Receptionist stated that the resident was turning blue when she ran in to intervene and remove the cord from the resident's neck. The Receptionist called for help and LVN E reached out to me on the way to assist resident and Receptionist. *On [DATE] at 10:16 a.m., LVN A wrote, . Assessed resident. Resident stabilized after removing cord from neck and having to sit down. Stated wanted to leave. Asked if he was attempting to kill himself and he stated, 'If that's the only way out then, yes?' Called 911 to have resident transferred to hospital for psych evaluation . RN D spoke with family and advised that resident was being sent out to hospital for Psych evaluation due to suicide attempt. Family stated that it was not the first time the resident has attempted suicide . Record review of CR #1's, Elopement Risk assessment dated [DATE] revealed LVN F determined CR #1 was a moderate risk for elopements based on his cognitive impairment and wandering behaviors. Action included, Implement Elopement Risk care plan; Implement Frequent Monitoring Form (form was not completed) to determine elopement risk or until Interdisciplinary Team reviews and makes recommendation. Record review of CR #1's, Elopement Risk assessment dated [DATE] revealed RN G determined CR #1 was an imminent risk for elopements based on his ambulation status, wandering behaviors, and his intentional or unintentional attempts to leave the community. Action included, Implement Elopement Risk care plan; Implement Frequent Monitoring Form (form was not completed) to determine elopement risk or until Interdisciplinary Team reviews and makes recommendation. In an interview with the DON and the Regional Director of Clinical Services on [DATE] at 9:45 a.m., the Regional Director of Clinical Services stated the DON was new to the facility and regional staff was not always in the building. The Regional Director of Clinical Services stated, based on what they knew, CR #1 had no previous suicidal ideations. The Regional Director of Clinical Services said CR #1's wife passed away in the facility many years prior and he had no other family other than a neighbor who helped him out prior to admission. The Regional Director of Clinical Services said CR #1's neighbor stated he (CR #1) previously talked about wanting to die. The DON stated to their (administration) knowledge, CR #1 spoke with the ST and referenced dying. The DON said CR #1's physician was notified and ordered an urgent referral for psychiatric services, but psych services was not able to see CR #1 before the suicide attempt. The Regional Director of Clinical Services stated CR #1's physician spoke with LVN A and that is where it ended. The Regional Director of Clinical Services stated LVN A was educated because something like that (suicidal ideations) should be escalated to the top (DON and Administrator). The Regional Director of Clinical Services said LVN A did not let anybody else know about the conversation between CR #1 and the ST. The Regional Director of Clinical Services said CR #1's physician documented his suicidal ideations and that she wanted an urgent psych consult. The Regional Director of Clinical Services said the incident was not communicated to the top (administration), so they did not have an opportunity to follow-up on the referral. The facility's elopement policy was requested, but the wandering policy was provided. In an interview with the VP of Clinical Operations on [DATE] at 11:00 a.m., she stated the facility did an emergency QAPI on [DATE], after CR #1 attempted suicide. She said all staff involved were counseled and in-serviced. She said nursing staff talked to each resident who could speak and used a special psychiatric tool given to them by a psych provider to interview about depression and suicide. She said the residents who could not talk were assessed head to toe to insure nothing was out of the ordinary for them. She said the Administrator was suspended because their investigation found he may have known about CR #1's prior history of depression. In a telephone interview with the Administrator on [DATE] at 11:45 a.m., he stated he knew CR #1 kept saying he wanted to go home because he wanted to shampoo his carpet at home. He said it was not out of the ordinary for residents to express desires to go home. The Administrator said CR #1 had previously been admitted to the facility for rehab and he (CR #1) wanted attention, that was it. The Administrator said CR #1 was not depressed and he just wanted to go home and do chores. The Administrator said CR #1's depression, suicidal ideations, or behaviors were never brought to his attention prior to admission, and he never spoke to CR #1's family before or after his admission. The Administrator said the night before the suicide attempt ([DATE]), LVN C called him around 10:00 p.m. He said he thought LVN C texted him, or he missed her call and then she texted saying CR #1 was trying to leave the building and that he wanted to kill himself. The Administrator said he sent LVN C a text to call 911, but she sent a text or called him, saying CR #1 was doing fine after they gave him popcorn. The Administrator said he called the LVN C back and she said CR #1 was fine and brushing his teeth. The Administrator said he told LVN C he needed to know what CR #1's state of mind was. He said LVN C said CR #1 could not even recall what he said earlier. He said he told LVN C to put CR #1 on monitoring (no monitoring was documented) and notify him if anything changed. He said he did not receive any more calls that night until incident on Saturday, [DATE] when LVN A called and said CR #1 tried to hurt himself. In a telephone interview with LVN A on [DATE] at 11:59 a.m., he stated he was a charge nurse and he only worked weekends. He said on [DATE], the ST approached him and said CR #1 had difficulty swallowing and she wanted to down grade his diet (to a mechanical soft diet). He said the ST told him CR #1 refused the food she used to assess him and said he (CR #1) was tired and wanted to die. LVN A said he went to follow-up with CR #1 in his room and asked about his diet. LVN A said he wanted CR #1 to say in his own words how he felt, but he did not express a desire to die to him. LVN A said he did not ask CR #1 about what he said to the ST. LVN A said he called CR #1's doctor and got an order for a psych consultation and he documented the situation. LVN A said the order was not an urgent order. He said orders for psychiatric services were usually turned in to the SW. LVN A said he slipped the referral under the SW's door on Sunday, [DATE], and he did not hear anything else about CR #1's referral after that. He said he did not relay this information to the DON, the Administrator, or anybody else. He said he did not know the SW was on vacation, but had he known, he would have taken the referral order to someone else. He said no special monitoring or intervention was initiated for CR #1. LVN A said that next weekend, [DATE], CR #1 said he wanted to go home, but that was nothing out of ordinary from his usual agitation. He said on [DATE], he heard another nurse call his name and he ran to the library room and saw CR #1 there with the Receptionist. He said by the time he got to the library, other staff had removed the phone cord from CR #1's neck and he (CR #1) was just shaking. He said he got someone to stay with CR #1 while he called his doctor for an order to send him out and he called CR #1's family and the Administrator. LVN A said the police arrived while he was assessing CR #1 and CR #1 told the officer, Oh, I tried to kill myself, but it was nothing big. LVN A said the officer asked CR #1 again if he wanted to kill himself and CR #1 said yes. LVN A said he did not assign CR #1 a sitter the previous weekend when he initially expressing suicidal ideations. He said RN D called CR #1's family (after the suicide attempt) who said CR #1 had a history of suicidal ideations and had done this (attempted suicide) before. He said CR #1's family never mentioned prior to him having the cord around his neck that he had a history of suicide attempts. LVN A said after he was in-serviced (after CR #1's suicide attempt), he realized he should have expedited the information about the suicidal ideations and referral to the DON or management to let them know what was stated. In a telephone interview with CR #1's NP on [DATE] at 12:33 p.m., she stated she visited CR #1 on [DATE], after he was admitted on [DATE]. She said she was notified about CR #1's suicidal ideations on [DATE] and when she saw him on [DATE], she asked him about the day before. She said she asked him if he still wanted to harm himself and he said no, he just wanted to go home and did not want to be in the facility. The NP said she documented in her notes that she put in an urgent request for psych services. The NP said the order was urgent based on CR #1's history of depression. She said she was familiar with the facility's referral process and the request had to be submitted to the SW then sent thru the referral portal. She said the process took a little while, so it was urgent to be done timely. She said she knew the psych provider saw patients at the facility on Mondays, so she knew CR #1 probably would not have been seen Monday, [DATE]. She said she was not aware CR #1's discharging facility recommended he be evaluated by psych services. She said had CR #1 exhibited behaviors, the facility staff could have notified psych for medication if needed. The NP said she had no prior knowledge of CR #1's history of suicidal ideations. She said she saw CR #1 again on [DATE] and staff notified her CR #1 had eloped. She said she was not notified of any other incident of suicidal ideations. She said had staff notified her or the on-call doctor that CR #1 made a throat cutting motion (on the morning of [DATE]), she would have sent him out to the hospital at that time. In an interview with the SW on [DATE] at 1:00 p.m., she stated, usually, the NP or doctor would write an order and the nurse would print the order and give it to her. She said she sent an email to the psychiatric provider and made the referral. The SW said the process usually only took one day and the provider came on Mondays. She said she never received a referral or request for CR #1 to receive psych services. She said she was on vacation [DATE] - [DATE]. She said when she returned from vacation, she did not see any request for CR #1 under her door. The SW said nobody ever asked her about any referral for CR #1. She said the facility's nurses could do the referrals if she was not here. The SW said if the psych provider was in the building and the nurses let them know someone needed to be seen, psych would have evaluated CR #1 even without the referral. She said if the referral was already in their computer system, they could have given it to him (psych) and he could have sent the referral to his (psych) office. The SW provided a copy of CR #1's order for psych services from the computer system and said the order did not say anything about urgency. She said she never saw a psych referral mention urgency. She said that ([DATE]) was the first time she saw CR #1's referral for psych services. Observation of the facility on [DATE] at 1:30 p.m. revealed the library was located in a room (not open to the rest of the building) between the reception desk (front entrance) and the nurse's station. Further observation revealed someone would have to pass the entrance to the library to see if anyone was inside the library. There was a telephone with a cord on a small table next to a chair. In a telephone interview with LVN C on [DATE] at 1:22 p.m. revealed she usually worked the 2:00 p.m. - 10:00 p.m. and 10:00 p.m. - 6:00 a.m. shift, but she rarely worked on weekends. She said one night (she could not recall the date), she was about to pass medications and CR #1 thanked her for caring for him and said he was leaving, but it was dark. LVN C said she asked CR #1 if his family was coming, but he said no, he was leaving. She said she told CR #1 he was there for therapy and that was it, he went back to sleep. LVN C said on another night (she could not recall the day), CR #1 said he was leaving, and she (LVN C) called his RP (he was his own RP, but he did have an emergency contact), but she did not answer. LVN C said earlier on that day, another staff told her CR #1 had gotten outside (eloped) so, that night CR #1 was assigned a sitter (a facility housekeeper and maintenance staff). LVN C said to her knowledge, that was the only night he had a sitter. LVN C said the night he made the cutting motion was the same night she called CR #1's RP. She said they had to watch CR #1 because he would try to elope, and she noticed he went towards one of the doors. LVN C said CR #1 said they (the nurses) would not let him out the front, so he would get out one way or another, then he made cutting motion across his throat. LVN C said she asked CR #1 if that meant he would cut himself, and he said, If you think that's what I'm saying. LVN C said she told CR #1 if that was what he was saying, she would have to call the police. LVN C said CR #1 told her he would go brush his teeth. She said the Administrator said to go talk to CR #1 and ask if he was going to harm himself. LVN C said CR #1 acted like he did not recall doing that (making the cutting motion) or anything that happened that night. LVN C said CR #1 said he was going to bed. LVN C said she did not have the DON's phone number at that time. LVN C said she did not call CR #1's doctor because, to be honest, it slipped her mind. LVN C said she waiting to see if CR #1 would react or do anything else. She said now, she probably would have called the doctor. She said she was not aware of any referral for psych services for CR #1. In a telephone interview with RN D on [DATE] at 1:34 p.m., she stated she was the weekend supervisor and she only worked weekends. She said she interacted with CR #1 on weekends quite a bit. RN D said CR #1 kept wanting to go home and tried to elope several times. RN D said she was never made aware of CR #1's suicidal ideations the weekend before ([DATE]) his suicide attempt and she worked 6:00 a.m. - 10:00 p.m. RN D said she worked on the weekend the ST worked ([DATE]) but she was never made aware of CR #1 saying he wanted to die. RN D said CR #1 did not seem depressed and he had dementia but was able to have a conversation and express his feelings. RN D said on [DATE], CR #1 made his usual attempts to elope and kept trying. She said eventually, she heard someone calling for a nurse to check on CR #1 and she followed afterwards. RN D said when she got to the library, CR #1 was in there sitting on a chair and LVN A was assessing him. She said she was not made aware that CR #1 had a referral for psych services. RN D said on weekends, they contact the primary care doctor or NP for a referral order and then they contact the provider they refer to. She said they could make a referral over the phone and then fax it in. She said she had never done a referral over the weekend and unless it was an emergency, they would wait until following week to do it. She said if the situation was emergent, she would do the referral or send the resident out. She said if she felt there was an active plan for suicide, she would notify the doctor and keep the resident on 1:1 monitoring until the doctor determined their next step. In an interview with the DON on [DATE] at 2:00 p.m., she said the Administrator called her on [DATE] after CR #1 made the cutting motion across his throat. She said the Administrator told her about CR #1 making the cutting motion, and she asked him if CR #1 had a plan and some other questions. The DON said the Administrator said he would call the facility back to ask those questions and call back if there was anything else. The DON said when the nurse went back in to talk to CR #1, he was no longer expressing suicidal ideations. The DON said in hindsight, she probably should have called CR #1's doctor just in case she wanted her to do anything different. The DON said she had in serviced the nurses on when to communicate with physicians. The DON said she did not know if CR #1's referral was ever sent off to the psych provider. She said the SW handled all referrals and she did not know who to contact about referrals at their psych services provider. She said she believed the Administrator was handling referrals when the SW went on vacation. In a follow up telephone interview with the Administrator on [DATE] at 2:25 p.m., he stated if the SW was out, he would have done referrals but, he was never made aware of CR #1's order or referral. He said CR #1's referral was never sent out. In a telephone interview with the ST on [DATE] at 2:31 p.m. She said CR #1 did not have suicidal ideations. She said CR #1 told her his wife died at the facility ,d+[DATE] years prior and then he said, I guess I'm going to die here too. The ST said it was not an ideation. She said she was working with him and showing him how to swallow safer and he said, Lady, why do you care so much, just let me die. She said CR #1 had diagnosis of depression already, but for her, the words he said to her were resistance from him to do the swallowing exercises and he had a lack of desire to get better. She said she told the charge nurse (LVN A) about it. In an interview with the Regional Director of Clinical Services on [DATE] at 2:52 p.m., he stated had CR #1's referral been escalated to the appropriate staff like it should have been, CR #1 would have received th [TRUNCATED]

Based on observation, interview, and record review, the facility failed to ensure a resident who displayed or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder, received appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being for 1 of 11 residents (CR #1) reviewed for psychosocial concerns. The facility failed to initiate safety interventions or provide CR #1 with psychiatric services after his physician ordered an urgent consultation when he expressed suicidal ideations and attempted to elope from the facility several times and resulted in an actual suicide attempt on [DATE]. The facility failed to review and follow recommendations from CR #1's discharging facility for a psychiatric consultation. An Immediate Jeopardy (IJ) situation was identified on [DATE] at 1:25 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at the severity level of actual harm with a scope identified as pattern due to the facility's need to evaluate the effectiveness of the corrective systems. These failures placed residents with a history of depression or suicidal ideations at risk of experiencing emotional distress, psychiatric episodes, and possible death from not receiving adequate care, interventions, and psychiatric services. Findings include: Record review of CR #1's face sheet dated [DATE] revealed he was an [AGE] year-old male who was admitted to the facility on [DATE]. His admitting diagnoses included with Parkinson's Disease (a disease of the central nervous system that affects movement, often including tremors), rhabdomyolysis (a breakdown of muscle tissue that releases a damaging protein into the blood), acute kidney failure (a condition in which the kidneys suddenly cannot filter waste from the blood), weakness, repeated falls, depression (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and dementia (a condition characterized by progressive or persistent loss of intellectual functioning). CR #1 was also diagnosed with suicidal ideations (often called suicidal thoughts or ideas, is a broad term used to describe a range of contemplations, wishes, and preoccupations with death and suicide). CR #1 was transferred to a local acute care hospital on [DATE]. Record review of CR #1's MDS dated [DATE] revealed he had a BIMS score of 7 (severe cognitive impairment); he felt down, depressed, or hopeless between ,d+[DATE] days; he did not experience hallucinations or delusions; he rejected care daily; he wandered daily which placed him at significant risk of getting to potentially dangerous places; he required supervision with no physical assistance for bed mobility, transfers, walking, dressing, and bathing; he required supervision with setup assistance with eating and personal hygiene; he ambulated independently with a walker; he was always continent of bowel and bladder; he experienced coughing or choking during meals or when swallowing medications; and he was prescribed antidepressant medication. Record review of CR #1's care plan updated [DATE] revealed the following: -CR #1 had potential for elopement as evidenced by exit seeking behavior ([DATE] exited out the front door). Goals included: Maintain the least restrictive environment while providing safety. Interventions included: Have activities involved with favorite past times. Music. Exercise. Photo in Elopement risk book. All staff to be made aware of CR #1's risk status via staff sign-in book and verbal reports. If possible, have family or volunteers visit on a regular basis. Keep doctor and family informed. SW to make regular visits. Reorient/Redirect as needed. Reassess as needed. SW to obtain detailed prior routine of CR #1. -CR #1 was taking psychotropic medications for Depression (Sertraline). Goals included: CR #1 will not experience adverse side effects. Interventions included: Monitor and record any displayed behavior or mood problems. Encourage appropriate behavior, discourage inappropriate behavior. Monitor effectiveness of psychotropic medications. Monitor for involuntary movements and repetitive behaviors and report to doctor. Review medications every three months for possible dose reduction. Allow CR #1 to express feelings. Protect CR #1 from self-harm or harm to others. Monitor for weight loss. Psych consult as needed. -CR #1 had behavioral symptoms not directed toward others ([DATE]- CR #1 attempted to harm himself by wrapping a phone cord around his neck- 911 was called- will re-evaluate interventions upon return. Goals included: Incidents of self-harm will be decreased. Interventions included: Gently remind CR #1 that behavior is not appropriate. Provide medication as ordered. Record behaviors on Behavior Tracking form. Monitor pattern of behavior (time of day, precipitating factors, specific staff, or situations). Head to toe assessment completed to check for any injuries (no injuries noted). 1 on 1 monitoring until EMS arrived. -CR #1 exhibited wandering behaviors. Goals included: Current level of mobility will be maintained. Interventions included: Assess potential causes for wandering (need for toilet, water, food, pain relief). Provide diversional activities. Record behaviors on Behavior Tracking form. Redirect CR #1's behavior/activity when wandering is observed. -CR #1 had other behavioral symptoms not directed toward others (refusal of care, threatening to break windows. Goals included: Incident will be decreased. Interventions included: Gently remind CR #1 that behavior is not appropriate. Provide medication as ordered. Record behaviors on Behavior Tracking form. Remove from situation; allow time to calm down. -CR #1 was at risk for falls as evidenced by cognitive impairment, fall history, weakness, unsteady gait, and rhabdomyolysis. Goals included: Dignity will be maintained. CR #1 will not experience falls or injuries from falls. Interventions included: Encourage CR #1 to ask for assistance of staff. Ensure call light is in reach, answer promptly. Therapy to evaluate and treat per orders. Anticipate needs, provide prompt assistance. Assure lighting is adequate and areas are free of clutter. Observation and interview of CR #1 at a psychiatric hospital on [DATE] at 9:00 a.m. revealed he was alert, oriented and ambulated independently with a walker. CR #1 said they went by the rules at the facility. He said he sneaked out the front door and tried to go to Whataburger. He said he did not like living there because there was no place to go, and he was the type of guy who liked to go places. He said they (he did not say who they were) would not let him go sit outside because he had a fall outside. He said he wanted to get some fresh air, but the nurses caught him. CR #1 said he did not do anything but sit at the facility because there were no activities he liked. He said two of the nurses stood at the door and would not let him out. He said he was going to get out one way or the other, either they would let him walk out, or kill himself and let the undertaker carry him out. He said the cops picked him up from the facility when he tried to kill himself. CR #1 said he wrapped a telephone cord around his neck. He said he had not been home in a very long time, and he wanted to go home. He said they gave him more medication and he felt better now. He said he did not want to kill himself anymore, he wanted to go home. Record review of CR #1's hospital records dated [DATE] revealed he was admitted to a local acute care hospital via the emergency roiagnom on [DATE] after he fell in his home and was on the floor several hours. The document read in part, . Patient states, 'You're wasting your time- I want to die . I don't have any family- They should have left me on the floor' . Precautions: Falls, Depressed state/ reports, 'I want to die' . Discharge Recommendations: Continue Rehab, Psych Consult. Precautions: Fall, Anxiety/Depression - Recommend Psych Consult . Home Medications: . Sertraline (Zoloft) 50 MG tablets daily . Record review of CR #1's hospital records dated [DATE] revealed he was transported to the emergency room by EMS on [DATE]. The records read in part, . presenting with EMS after possible strangulation attempt, patient was reported to have been found with a telephone cord around his neck, cyanotic (bluish or grayish color of the skin) appearing face, removed telephone cord and transported to hospital hemodynamically (how your blood flows through your arteries and veins and the forces that affect your blood flow) stable in route. When asked about this, patient reports he was just playing around with cord, had no suicidal intention. Patient would like to leave, does not know why is here, does not want to go back to the facility . patient with history of suicidal ideation . Assessment: Suicidal Attempt . Plan: Admit to floor . Sitter 1:1 . CR #1 was discharged to an inpatient psychiatric hospital on [DATE]. Record review of CR #1's physician's orders for [DATE] revealed he was prescribed Sertraline, 50 mg tablets once daily for depression. Start date: [DATE]. Record review of CR #1's MAR for [DATE] revealed he received Sertraline daily as ordered from [DATE] until [DATE]. Record review of CR #1's referral for a psychiatry consultation dated [DATE] revealed CR #1's physician gave LVN A verbal orders to refer CR #1 for the consultation on [DATE]. The order was electronically signed by LVN A on [DATE] at 8:12 p.m. Record review of CR #1's physician progress notes dated [DATE] revealed, . Chief Complaint: New skilled nursing patient seen and examined for admission visit. Patient sitting on side of bed in no apparent distress. Pleasantly confused. States he lives alone. No suicidal ideation today. States he is ready to go home and wants to go home . Physical Exam: . Psychiatric: Judgement/insight: Poor . Summary of Plans: . Consults: Psychiatry to follow . Diagnosis and Assessment: . Dementia - . Has tried to exit seek multiple occasions since admission . Depression - Consult psych. Continue Zoloft 50 mg daily. Per report, suicidal ideation yesterday. None today. Plan: . Urgent consult on psych to evaluate and treat. Recent history of suicidal ideation. None noted today. States he wants to go home and not be in a nursing home . Record review of CR #1's physician progress notes dated [DATE] revealed, Chief Complaint: Skilled nursing patient seen and examined in follow-up . Per staff, patient was found outside of the facility walking along the sidewalk stating that he wanted to go home . Record review of CR #1's progress notes for [DATE] revealed the following: *On [DATE] at 8:05 p.m. (incident occurred at 5:15 p.m.), LVN A wrote, Resident was being evaluated by ST for swallowing issues that were reported. ST was introducing a mechanical soft diet. Resident stated he did not want to change diets. Asked ST 'What for?' He verbalized to ST that he wanted to die instead because he was tired. Will notify MD and refer resident for Psych evaluation. *On [DATE] at 12:24 p.m., LVN B wrote, . Resident wanders throughout facility via walker. He attempted to exit x2 despite redirection . *On [DATE] at 5:52 a.m., LVN C wrote, During rounds resident was noted to be sitting on the bed and asked this writer to come here. Resident thanked this writer for providing care to him and that he will be leaving today. Asked resident was family coming to get him, he stated no, 'I'm walking. I would walk now but it is dark.' Educated resident on the importance of staying at the facility, resident stated, 'I will think about it .' *On [DATE] at 9:54 a.m., LVN B wrote, . This shift, he eloped out of front door and started to walk down the sidewalk. This nurse and other nurses on duty spoke with resident and attempted to provide redirection. After some time, resident agreed to come back inside. Resident still upset, threatening to break windows. Administrator speaking with RP at this time to make a discharge decision. *On [DATE] at 3:33 a.m., LVN C wrote, . Resident is in bed resting quietly at this time, sitter is sitting outside of door . *On [DATE] at 8:10 p.m., LVN C wrote, Resident is walking around asking staff to help him leave, staff redirects resident. Currently resident is in his room stating that he is leaving as soon as he finds a window to go out of. All staff notified to keep an eye on resident due to him stating he is going to leave. *On [DATE] at 2:31 a.m. (incident occurred [DATE] at 8:50 p.m.), LVN C wrote, This writer seen resident going towards the back door. This writer and another began to stand between resident and the door. Resident asked staff if we could move so he could leave. Asked resident where he was going, he stated, home to his bed because he had things to do. This writer explained to resident that I could not let him leave and I was responsible for his wellbeing. Resident stepped closer to staff and asked resident to please step back, he did. Resident continued to stand at the door. Resident then stated that he was going to leave one way or another, resident made a cutting sign (gesture) towards his neck. Asked resident what that was, he stated, 'Could you just let me leave?' Call placed to Administrator, advised resident that he would have to go to his room, or I will call 911, orders given from management. Aide offered popcorn, resident stated he guessed he would go brush his teeth and go to bed. Administrator called and asked if I could interview resident to see if he was a danger to himself. When interviewing resident, he could not recall making a cutting sign at his throat, resident also stated that he will never hurt himself, notified Administrator, resident is currently in bed resting quietly . rounds are made every 2 hours. *On [DATE] at 10:12 a.m. (incident occurred at 9:15 a.m.), LVN A wrote, Receptionist was walking towards nursing station when she noted resident sitting in library. When she attempted to approach resident sitting in library, she noted that the resident had the phone cord wrapped around him and attempting to tighten it harder. Receptionist stated that the resident was turning blue when she ran in to intervene and remove the cord from the resident's neck. The Receptionist called for help and LVN E reached out to me on the way to assist resident and Receptionist. *On [DATE] at 10:16 a.m., LVN A wrote, . Assessed resident. Resident stabilized after removing cord from neck and having to sit down. Stated wanted to leave. Asked if he was attempting to kill himself and he stated, 'If that's the only way out then, yes?' Called 911 to have resident transferred to hospital for psych evaluation . RN D spoke with family and advised that resident was being sent out to hospital for Psych evaluation due to suicide attempt. Family stated that it was not the first time the resident has attempted suicide . Record review of CR #1's, Elopement Risk assessment dated [DATE] revealed LVN F determined CR #1 was a moderate risk for elopements based on his cognitive impairment and wandering behaviors. Action included, Implement Elopement Risk care plan; Implement Frequent Monitoring Form (form was not completed) to determine elopement risk or until Interdisciplinary Team reviews and makes recommendation. Record review of CR #1's, Elopement Risk assessment dated [DATE] revealed RN G determined CR #1 was an imminent risk for elopements based on his ambulation status, wandering behaviors, and his intentional or unintentional attempts to leave the community. Action included, Implement Elopement Risk care plan; Implement Frequent Monitoring Form (form was not completed) to determine elopement risk or until Interdisciplinary Team reviews and makes recommendation. In an interview with the DON and the Regional Director of Clinical Services on [DATE] at 9:45 a.m., the Regional Director of Clinical Services stated the DON was new to the facility and regional staff was not always in the building. The Regional Director of Clinical Services stated, based on what they knew, CR #1 had no previous suicidal ideations. The Regional Director of Clinical Services said CR #1's wife passed away in the facility many years prior and he had no other family other than a neighbor who helped him out prior to admission. The Regional Director of Clinical Services said CR #1's neighbor stated he (CR #1) previously talked about wanting to die. The DON stated to their (administration) knowledge, CR #1 spoke with the ST and referenced dying. The DON said CR #1's physician was notified and ordered an urgent referral for psychiatric services, but psych services was not able to see CR #1 before the suicide attempt. The Regional Director of Clinical Services stated CR #1's physician spoke with LVN A and that is where it ended. The Regional Director of Clinical Services stated LVN A was educated because something like that (suicidal ideations) should be escalated to the top (DON and Administrator). The Regional Director of Clinical Services said LVN A did not let anybody else know about the conversation between CR #1 and the ST. The Regional Director of Clinical Services said CR #1's physician documented his suicidal ideations and that she wanted an urgent psych consult. The Regional Director of Clinical Services said the incident was not communicated to the top (administration), so they did not have an opportunity to follow-up on the referral. The facility's elopement policy was requested, but the wandering policy was provided. In an interview with the VP of Clinical Operations on [DATE] at 11:00 a.m., she stated the facility did an emergency QAPI on [DATE], after CR #1 attempted suicide. She said all staff involved were counseled and in-serviced. She said nursing staff talked to each resident who could speak and used a special psychiatric tool given to them by a psych provider to interview about depression and suicide. She said the residents who could not talk were assessed head to toe to insure nothing was out of the ordinary for them. She said the Administrator was suspended because their investigation found he may have known about CR #1's prior history of depression. In a telephone interview with the Administrator on [DATE] at 11:45 a.m., he stated he knew CR #1 kept saying he wanted to go home because he wanted to shampoo his carpet at home. He said it was not out of the ordinary for residents to express desires to go home. The Administrator said CR #1 had previously been admitted to the facility for rehab and he (CR #1) wanted attention, that was it. The Administrator said CR #1 was not depressed and he just wanted to go home and do chores. The Administrator said CR #1's depression, suicidal ideations, or behaviors were never brought to his attention prior to admission, and he never spoke to CR #1's family before or after his admission. The Administrator said the night before the suicide attempt ([DATE]), LVN C called him around 10:00 p.m. He said he thought LVN C texted him, or he missed her call and then she texted saying CR #1 was trying to leave the building and that he wanted to kill himself. The Administrator said he sent LVN C a text to call 911, but she sent a text or called him, saying CR #1 was doing fine after they gave him popcorn. The Administrator said he called the LVN C back and she said CR #1 was fine and brushing his teeth. The Administrator said he told LVN C he needed to know what CR #1's state of mind was. He said LVN C said CR #1 could not even recall what he said earlier. He said he told LVN C to put CR #1 on monitoring (no monitoring was documented) and notify him if anything changed. He said he did not receive any more calls that night until incident on Saturday, [DATE] when LVN A called and said CR #1 tried to hurt himself. In a telephone interview with LVN A on [DATE] at 11:59 a.m., he stated he was a charge nurse and he only worked weekends. He said on [DATE], the ST approached him and said CR #1 had difficulty swallowing and she wanted to down grade his diet (to a mechanical soft diet). He said the ST told him CR #1 refused the food she used to assess him and said he (CR #1) was tired and wanted to die. LVN A said he went to follow-up with CR #1 in his room and asked about his diet. LVN A said he wanted CR #1 to say in his own words how he felt, but he did not express a desire to die to him. LVN A said he did not ask CR #1 about what he said to the ST. LVN A said he called CR #1's doctor and got an order for a psych consultation and he documented the situation. LVN A said the order was not an urgent order. He said orders for psychiatric services were usually turned in to the SW. LVN A said he slipped the referral under the SW's door on Sunday, [DATE], and he did not hear anything else about CR #1's referral after that. He said he did not relay this information to the DON, the Administrator, or anybody else. He said he did not know the SW was on vacation, but had he known, he would have taken the referral order to someone else. He said no special monitoring or intervention was initiated for CR #1. LVN A said that next weekend, [DATE], CR #1 said he wanted to go home, but that was nothing out of ordinary from his usual agitation. He said on [DATE], he heard another nurse call his name and he ran to the library room and saw CR #1 there with the Receptionist. He said by the time he got to the library, other staff had removed the phone cord from CR #1's neck and he (CR #1) was just shaking. He said he got someone to stay with CR #1 while he called his doctor for an order to send him out and he called CR #1's family and the Administrator. LVN A said the police arrived while he was assessing CR #1 and CR #1 told the officer, Oh, I tried to kill myself, but it was nothing big. LVN A said the officer asked CR #1 again if he wanted to kill himself and CR #1 said yes. LVN A said he did not assign CR #1 a sitter the previous weekend when he initially expressing suicidal ideations. He said RN D called CR #1's family (after the suicide attempt) who said CR #1 had a history of suicidal ideations and had done this (attempted suicide) before. He said CR #1's family never mentioned prior to him having the cord around his neck that he had a history of suicide attempts. LVN A said after he was in-serviced (after CR #1's suicide attempt), he realized he should have expedited the information about the suicidal ideations and referral to the DON or management to let them know what was stated. In a telephone interview with CR #1's NP on [DATE] at 12:33 p.m., she stated she visited CR #1 on [DATE], after he was admitted on [DATE]. She said she was notified about CR #1's suicidal ideations on [DATE] and when she saw him on [DATE], she asked him about the day before. She said she asked him if he still wanted to harm himself and he said no, he just wanted to go home and did not want to be in the facility. The NP said she documented in her notes that she put in an urgent request for psych services. The NP said the order was urgent based on CR #1's history of depression. She said she was familiar with the facility's referral process and the request had to be submitted to the SW then sent thru the referral portal. She said the process took a little while, so it was urgent to be done timely. She said she knew the psych provider saw patients at the facility on Mondays, so she knew CR #1 probably would not have been seen Monday, [DATE]. She said she was not aware CR #1's discharging facility recommended he be evaluated by psych services. She said had CR #1 exhibited behaviors, the facility staff could have notified psych for medication if needed. The NP said she had no prior knowledge of CR #1's history of suicidal ideations. She said she saw CR #1 again on [DATE] and staff notified her CR #1 had eloped. She said she was not notified of any other incident of suicidal ideations. She said had staff notified her or the on-call doctor that CR #1 made a throat cutting motion (on the morning of [DATE]), she would have sent him out to the hospital at that time. In an interview with the SW on [DATE] at 1:00 p.m., she stated, usually, the NP or doctor would write an order and the nurse would print the order and give it to her. She said she sent an email to the psychiatric provider and made the referral. The SW said the process usually only took one day and the provider came on Mondays. She said she never received a referral or request for CR #1 to receive psych services. She said she was on vacation [DATE] - [DATE]. She said when she returned from vacation, she did not see any request for CR #1 under her door. The SW said nobody ever asked her about any referral for CR #1. She said the facility's nurses could do the referrals if she was not here. The SW said if the psych provider was in the building and the nurses let them know someone needed to be seen, psych would have evaluated CR #1 even without the referral. She said if the referral was already in their computer system, they could have given it to him (psych) and he could have sent the referral to his (psych) office. The SW provided a copy of CR #1's order for psych services from the computer system and said the order did not say anything about urgency. She said she never saw a psych referral mention urgency. She said that ([DATE]) was the first time she saw CR #1's referral for psych services. Observation of the facility on [DATE] at 1:30 p.m. revealed the library was located in a room (not open to the rest of the building) between the reception desk (front entrance) and the nurse's station. Further observation revealed someone would have to pass the entrance to the library to see if anyone was inside the library. There was a telephone with a cord on a small table next to a chair. In a telephone interview with LVN C on [DATE] at 1:22 p.m. revealed she usually worked the 2:00 p.m. - 10:00 p.m. and 10:00 p.m. - 6:00 a.m. shift, but she rarely worked on weekends. She said one night (she could not recall the date), she was about to pass medications and CR #1 thanked her for caring for him and said he was leaving, but it was dark. LVN C said she asked CR #1 if his family was coming, but he said no, he was leaving. She said she told CR #1 he was there for therapy and that was it, he went back to sleep. LVN C said on another night (she could not recall the day), CR #1 said he was leaving, and she (LVN C) called his RP (he was his own RP, but he did have an emergency contact), but she did not answer. LVN C said earlier on that day, another staff told her CR #1 had gotten outside (eloped) so, that night CR #1 was assigned a sitter (a facility housekeeper and maintenance staff). LVN C said to her knowledge, that was the only night he had a sitter. LVN C said the night he made the cutting motion was the same night she called CR #1's RP. She said they had to watch CR #1 because he would try to elope, and she noticed he went towards one of the doors. LVN C said CR #1 said they (the nurses) would not let him out the front, so he would get out one way or another, then he made cutting motion across his throat. LVN C said she asked CR #1 if that meant he would cut himself, and he said, If you think that's what I'm saying. LVN C said she told CR #1 if that was what he was saying, she would have to call the police. LVN C said CR #1 told her he would go brush his teeth. She said the Administrator said to go talk to CR #1 and ask if he was going to harm himself. LVN C said CR #1 acted like he did not recall doing that (making the cutting motion) or anything that happened that night. LVN C said CR #1 said he was going to bed. LVN C said she did not have the DON's phone number at that time. LVN C said she did not call CR #1's doctor because, to be honest, it slipped her mind. LVN C said she waiting to see if CR #1 would react or do anything else. She said now, she probably would have called the doctor. She said she was not aware of any referral for psych services for CR #1. In a telephone interview with RN D on [DATE] at 1:34 p.m., she stated she was the weekend supervisor and she only worked weekends. She said she interacted with CR #1 on weekends quite a bit. RN D said CR #1 kept wanting to go home and tried to elope several times. RN D said she was never made aware of CR #1's suicidal ideations the weekend before ([DATE]) his suicide attempt and she worked 6:00 a.m. - 10:00 p.m. RN D said she worked on the weekend the ST worked ([DATE]) but she was never made aware of CR #1 saying he wanted to die. RN D said CR #1 did not seem depressed and he had dementia but was able to have a conversation and express his feelings. RN D said on [DATE], CR #1 made his usual attempts to elope and kept trying. She said eventually, she heard someone calling for a nurse to check on CR #1 and she followed afterwards. RN D said when she got to the library, CR #1 was in there sitting on a chair and LVN A was assessing him. She said she was not made aware that CR #1 had a referral for psych services. RN D said on weekends, they contact the primary care doctor or NP for a referral order and then they contact the provider they refer to. She said they could make a referral over the phone and then fax it in. She said she had never done a referral over the weekend and unless it was an emergency, they would wait until following week to do it. She said if the situation was emergent, she would do the referral or send the resident out. She said if she felt there was an active plan for suicide, she would notify the doctor and keep the resident on 1:1 monitoring until the doctor determined their next step. In an interview with the DON on [DATE] at 2:00 p.m., she said the Administrator called her on [DATE] after CR #1 made the cutting motion across his throat. She said the Administrator told her about CR #1 making the cutting motion, and she asked him if CR #1 had a plan and some other questions. The DON said the Administrator said he would call the facility back to ask those questions and call back if there was anything else. The DON said when the nurse went back in to talk to CR #1, he was no longer expressing suicidal ideations. The DON said in hindsight, she probably should have called CR #1's doctor just in case she wanted her to do anything different. The DON said she had in serviced the nurses on when to communicate with physicians. The DON said she did not know if CR #1's referral was ever sent off to the psych provider. She said the SW handled all referrals and she did not know who to contact about referrals at their psych services provider. She said she believed the Administrator was handling referrals when the SW went on vacation. In a follow up telephone interview with the Administrator on [DATE] at 2:25 p.m., he stated if the SW was out, he would have done referrals but, he was never made aware of CR #1's order or referral. He said CR #1's referral was never sent out. In a telephone interview with the ST on [DATE] at 2:31 p.m. She said CR #1 did not have suicidal ideations. She said CR #1 told her his wife died at the facility ,d+[DATE] years prior and then he said, I guess I'm going to die here too. The ST said it was not an ideation. She said she was working with him and showing him how to swallow safer and he said, Lady, why do you care so much, just let me die. She said CR #1 had diagnosis of depression already, but for her [TRUNCATED]

Based on observation, interview and record review the facility failed to provide pharmaceutical services to meet the needs of each resident for 3 of 5 residents (Resident #56, Resident #69 and Resident #72) reviewed for pharmacy services. - The facility failed to ensure that the 200 Hall Nursing Cart did not contain expired insulin pens for Resident #56, Resident #69 and Resident #72. This failure could place residents at risk of not receiving the therapeutic benefit of medications, uncontrolled blood sugars and/or adverse reactions to medications. Findings Included Resident #69 Record review of Resident #69's Face Sheet dated 05/03/23 revealed, a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included: dementia, muscle weakness and type 2 diabetes. Record review of Resident #69's Admission MDS signed 09/05/22 revealed, use of corrective lenses, moderately impaired cognition as indicated by a BIMS score of 12 out of 15, supervision for most ADLs and occasionally incontinent of both bladder and bowel. Record review of Resident #69's undated Care Plan revealed, no care plan problem areas related to citation. The care plan did not include diabetes. Record review of Resident #69's Patient Medication Profile dated 05/03/23 revealed, HumaLOG Insulin- check blood sugar and follow sliding scale four times starting 03/17/23. Resident #56 Record review of Resident #56's Face Sheet dated 05/03/23 revealed, an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included: high cholesterol, pressure ulcer of the left heal and type 2 diabetes. Record review of Resident #56's Annual MDS signed 03/29/23 revealed, severely impaired cognition as indicated by a BIMS score of 04 out of 15, extensive assistance with most ADLs and always incontinent of both bladder and bowel. Record review of Resident #56's undated Care Plan revealed, problem- risk for high or low blood sugar episodes secondary to diabetes; interventions- medication as ordered. Record review of Resident #56's Patient Medication Profile dated 05/03/23 revealed, NovoLOG( Insulin Aspart)- check blood sugar and follow sliding scale four times a day starting 06/30/22. Lantus Insulin- 30 units under the skin two times daily starting 05/01/23. Resident #72 Record review of Resident #72's Face Sheet dated 05/03/23 revealed, a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included: irregular heartbeat, nicotine dependence and diabetes. Record review of Resident #72's Annual MDS signed 03/04/23 revealed, moderately impaired cognition as indicated by a BIMS score of 11 out of 15, occasionally incontinent of bladder, always continent of bowel and supervision for most ADLs. Record review of Resident #72's undated Care Plan revealed, no care plan problem areas related to citation. The care plan did not include diabetes. Record review of Resident #72's Patient Medication Profile dated 05/03/23 revealed, HumaLOG Insulin- check blood sugar and follow sliding scale under the skin four times day with start date 03/14/22. Lantus- inject 10 units under the skin two times daily. An observation and interview on 05/04/23 at 09:04 AM AM, inventory of the 200 Hall Nursing Cart with LVN A revealed: - 1 expired, open and in-use Insulin Lispro vial for Resident #69 with an open date of 03/28/23. - Expired, open and in-use Insulin Aspart (NovoLOG) and Lantus Insulin vials for Resident #56 with an open dates of 03/28/23. - Expired, open and in-use Insulin Lispro and Lantus Insulin vials for Resident #72 with an open dates of 03/28/23. LVN A said nursing staff are expected to check their carts daily as used for expired medications including insulin. She said the insulin pens should only be used for 30 days once opened (04/27/23) so they were expired and could no longer be used. LVN A said when insulin expires it loses it efficacy and use could place residents at risk for uncontrolled blood sugars. She said she would reorder the medication and then ask her ADON on the appropriate way to dispose of the expired insulin. In an interview on 05/03/23 at 11:00 AM, the ADON said nursing staff are expired to check their carts daily for expired medications. She said when insulin expires it is was not as effective so they should be discarded in the drug disposal bin in the medication room. The ADON said the use of expired insulin could place residents at risk of uncontrolled blood sugars. Record review of the facility's policy titled 'Storage of Medications' revised 04/2007 revealed, 4- the facility shall not use discontinued, outdated or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. Record review of the facility's policy titled 'Drug Destruction' dated 09/2013 revealed, expired medications shall be removed and disposed of through monthly drug destruction. Record review of the undated facility documents titled 'Medication Storage Review' revealed, check insulins and remove those open >28 days, except Levemir 42 days and Ozempic is 56 days. Date open must be on vial/pen, vial/pen must be in fully labeled bag/box/bottle.

Based on observation, interview and record review the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 2 of 4 medication carts (300 Hall Nursing Cart and 400 Hall Nursing Cart) reviewed for medication storage. - The facility failed to ensure the 400 Hall Nursing Cart did not contain medications without pharmacy labels identifying the patients or medication administration instructions. - The facility failed to ensure the 300 Hall Nursing Cart did not contain insulin pens without open dates. This failure could place residents at risk of uncontrolled health conditions and adverse medication reactions. Findings Included: 400 Hall Nursing Cart An observation and interview on [DATE] at 09:08 AM, inventory of the 400 Hall Nursing Cart with LVN B revealed: - An Enoxaparin Sodium (a blood thinner) 40 mg/0.4 ml Injection without a pharmacy label. - A vial of Nitroglycerin (treatment of chest pain) 0.4mg tablets without a pharmacy label. LVN B said nursing staff are expected to check their carts daily for inappropriately labeled medications. She said all medications must have a pharmacy label with patient identifiers and prescription information. LVN B said since the Enoxaparin and Nitroglycerine had no labeling there could not be used and must be discarded in the drug disposal bin located in the medication room. She said the use of medications without the appropriate labels could place residents at risk for med errors because of the potential to give the medications to the wrong resident or administer the wrong dose. 300 Hall Nursing cart Resident #51 Record review of Resident #51's Face Sheet dated [DATE] revealed, a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included: repeated falls, anxiety disorder, high cholesterol and type 2 diabetes. Record review of Resident #51's Admission MDS signed [DATE] revealed, moderately impaired cognition as indicated by a BIMS score of 09 out of 15, extensive assistance with most ADLs and always incontinent of both bladder and bowel. Record review of Resident #51's undated Care Plan revealed, problem- risk of hyper or hypoglycemic episodes secondary to diabetes; interventions- medication as ordered. Record review of Resident #51's Patient Medication Profile dated [DATE] revealed, Insulin Glargine (Lantus)- Inject 25 units under the skin one time daily starting [DATE]. Resident #8 Record review of Resident #8's Face Sheet dated [DATE] revealed, an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of: anxiety disorder, heart failure and type 2 diabetes. Record review of Resident #8's Annual MDS signed [DATE] revealed, intact cognition as indicated by a BIMS score of 15 out of 15, extensive assistance with most ADLs, and occasionally incontinent of both bladder and bowel. Record review of Resident #8's undated Care Plan revealed, Problems- risk of hyper or hypoglycemic episodes secondary to diabetes. Medication: Lantus Insulin. Record review of Resident #8's Patient Medication Profile dated [DATE] revealed, Tresiba- 20 units under the skin one time daily starting [DATE]. An observation and interview on [DATE] at 09:14 AM inventory of the 300 Hall Nursing Cart with LVN C revealed: - An open an in-use vial of Insulin Glargine (Lantus) with pharmacy fill date of [DATE] for Resident #51 with no open date. - An open and in-use Tresiba Insulin Pen for Resident #8 with no open date. LVN C said nursing staff are expected to check their carts daily as used for inappropriately labeled medications. She said insulin pens/vials should be labeled with the date opened in order to track the expiration date. LVN C said when insulin expires it could become less effective and since the insulin found had no open date their expiration dates could not be determined so they must be discarded in the sharps container after they were reordered. She said the use of expired insulin could place residents at risk of uncontrolled blood sugars. In an interview on [DATE] at 11:00 AM, the ADON said nursing staff are expected to check their carts daily as used for inappropriately labeled medications. She said all prescription medications must have a pharmacy labeled with patient identifiers and drug information. The ADON said all multi-dose insulin containers [NAME] be labeled with the date opened in order to track their expiration since insulin could become less effective once expired. She said any insulin containers without open dates or inappropriately labeled medications must be discarded in the drug disposal bin located in the medication room since the expiration dates or patient information are unknown. The ADON said the use of medications without pharmacy identifiers or insulin containers with no open date could place residents at risk of uncontrolled blood sugars and adverse reactions. Record review of the facility's policy titled 'Storage of Medications' revised ,d+[DATE] revealed, 3- drug containers that have missing, incomplete, improper, or incorrect labels shall be returned to the pharmacy for proper labeling before storing. Record review of the facility's policy titled 'Administering Medications' revised ,d+[DATE] revealed, 12- expiration/beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container. Record review of the facility's policy titled 'Labeling of Medication Container' revised ,d+[DATE] revealed, 3- labels for individual resident medications include all necessary information such as: resident's name, prescribing physician, pharmacy contact information, the prescription number, the date the medication was dispensed, and the directions for use. Record review of the undated facility documents titled 'Medication Storage Review' revealed, check-multi dose containers for date open on container( . vials/pens for injectable meds and diluent fluid vials). Date open must be on vial/pen, vial/pen must be in fully labeled bag/box/bottle.

Based on observation, interview, and record review the facility failed to have the resident's comprehensive care plan, reviewed, and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for 1 (Resident #27) of 6 residents reviewed for care plan timing and revision. The facility failed to review and revise the comprehensive care plan for Resident #27. This failure could place residents at risk of a diminished quality of life leading to a variety of emotional and physical problems/issues. Findings included: Record review of Resident #27's face sheet revealed a [AGE] year-old male who was admitted on [DATE]. His diagnosis was dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment), and cerebral infraction (occurs because of disrupted blood flow to the brain due to problems with blood vessels that supply it). Record review of resident #27's Comprehensive MDS dated [DATE] revealed Resident #27 had a BIMs score of 06 indicating the resident was severely cognitively impaired. The resident required extensive assistance with two persons physical assist with bed mobility. He required total dependence and one-person physical assistance for dressing, total dependence and two persons assistance for toilet use, supervision, and setup for eating, and total dependence and two persons assistance for transfer. He also requires total dependence and one-person assistance for personal hygiene. Record Review of resident #27's care plan, revision date not listed, revealed Resident #27 was not care planned for a low bed. Record Review of Resident #27's care plan, revision date not listed, revealed Resident #27's was care planned for falls that occurred on 7/21/2022, 7/24/2022, 9/15/2022, 4/07/2023, and 4/13/2023. His goals revealed he will demonstrate the ability to ambulate/transfer without fall related injuries over the next 90-day review period. The interventions revealed, place call bell/light within easy reach, remind [NAME] to call for assistance before moving from bed-to-chair and from chair to bed. Respond promptly to calls for assist to the toilet, footwear will fit properly and have non-skid soles, and provide reminders to use ambulation and transfer assist devices. Observation on 5/2/2023 at 10:55a.m., revealed Resident #27, lying down on a bed that was very low to the ground. His legs were touching the ground and his diaper was hanging off him. Interview on 5/2/2023 at 11:00a.m., with CNA A, said Resident #27 bed was low because he sometimes hangs his legs off the bed, and it keeps him from hurting himself. She said Resident #27 moved a lot which moved his diaper off him. She said Resident #27 had an indwelling catheter. Interview on 5/4/2023 at 9:34a.m., with Charge nurse/LVN P, said Resident #27 reposition himself when he was lying in bed. He said he will put his feet off the bed and when he was tired, he would put his feet back up. He said the bed was low because Resident #27 is a fall risk. Interview on 5/4/2023 at 1:32p.m., with LVN X, said whenever something has changed with a resident, it was important to write it in the care plan. She said the plan of care is in place to make sure everything was good with the resident. LVN X said she looked through the care plan and said the low bed for Resident #27 was not documented in his care plan. She said the nurse would usually tell her if they needed help with something and she would help them with the care plan. She said all the licensed nurses are responsible for putting things in the care plan. She said she edited and took things out of the care plan if it was no longer needed or when she does their next assessment. She said a nurse never shared with her that Resident #27's low bed needed to be documented in his care plan. She said the nurse working with Resident #27 on the hall would inform her of any changes with Resident #27. She said the PCC, ADON, the unit manager, and the treatment nurse does the care plans. Interview on 5/4/2023 at 1:52p.m., the ADON, said the importance of having a care plan was so they know how to care for the patient. She said anyone can go into the system and see what needed to be done for the patient. She said they have 24 hours reports that they use to write information regarding the residents, and they also use clinical notes and daily care guides on how to care for the residents. She said they have morning meetings and discuss the things that were needed or added to the care plan. She said the MDS was on top of things like that. She said if the nurses were lowering Resident #27's bed, it should be documented in the care plan. She said it could be a risk of the patient being off the low bed and having a risk for injury if it was not noted in the care plan. She said for accuracy of the care plans, it was normally done as a team, to ensure everyone was on the same page. She said the care plan should be update quarterly or as needed. Interview on 5/4/2023 at 2:15p.m., with unit manager LVN Y, said she tried to keep Resident #27's catheter on the bed, and if the bed is high, he will reposition himself and might pull the catheter. She said it was safer for the catheter to be near the bed. She said she knows that it is a low bed because it is a particular type of bed. She said Resident #27 has a low bed in his room. Record Review of the facility's policy titled Patient Care Management System, revised on 11/2017 read in part . Each care plan must be reviewed and updated by the interdisciplinary Care Plan team quarterly, upon each change in condition and upon re-admission.

Based on observation, interview and record review, the facility failed to dispose garbage and refuse properly for 1 of 1 dumpster reviewed for garbage disposal in that: -The facility's dumpster lids and door were not secured. This failure could affect residents and place residents, staff, and visitors at risk of infection from improperly disposed garbage. Findings include: Observation on 03-02-22 at 9:00 am, with the Dietary Manager the facility's dumpster area, which was in the lot behind the dietary department. The facility's commercial -size dumpster lids and door were open. Interview on 03-02-22 at 10:00 am, with the Dietary Manager she stated that the dumpster lids always must be closed to keep vermin, pests and insects out of the dumpster and from entering the facility. The dumpster lid was open overnight when the last staff that disposed garbage in the dumpster left the lid open. It is the responsibility of all facility staff who dispose garbage in the dumpster for ensuring the dumpster lid were closed after each use. Record review on 03-02-22 on policy and procedure on Waste Disposal dated November 03/2004 revealed: Policy: All waste shall be kept in leakproof, non-absorbent, fireproof containers that are kept covered that prevent cross contamination and properly disposed of in an external receptacle (dumpster) that is closed.

Based on interview, and record review the facility failed to ensure services were provided using proper safety techniques to prevent accidents for 2 of 6 residents (Resident # 1 and Resident #2) reviewed for accidents. --The facility did not provide a safe transfer on a slippery shower floor for Resident #1 who was identified as a 2-person assist that resulted in the CNA falling on top of Resident #1. --The facility did not provide Resident #2 with 2 people assist while receiving peri care and Resident's bed rail broke and he fell out of the bed. These failures could place residents at risk of falls, serious harm and improper transfer. Findings include: Record review of Resident #1's face sheet she was an [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included [CONDITION(S)], dementia without behavioral disturbance, malignant neoplasm of right breast, type 2 diabetes mellitus (blood sugar), hypertension (high blood pressure), [CONDITION(S)] (high cholesterol), muscle spasm, [CONDITION(S)] (not enough [CONDITION(S)]), [CONDITION(S)] (blood sugar low), and abnormality of gait and mobility. Record review of Resident #1's Care Plan updated 2/17/22 revealed ADL Functions required staff assistance daily with interventions being assist with transfer as needed. Resident was identified as being at risk for falls. As evidenced by general weakness and deconditioning, physical impairment, impaired cognition. Resident had actual fall on 2/17/22. Intervention was to encourage Resident #1 to ask for assistance. Record review of Resident #1's Annual MDS assessment dated [DATE] revealed a BIMS Summary score of 11 indicating moderately impaired cognition. Resident #1's Activities of Daily Living (ADL) Assistance for bed mobility, transfer, toilet use revealed extensive assistance needed with two staff assisting. Record review of Resident #1's accident/incident report dated 2/17/22 and signed by Charge Nurse A revealed CNA A needed Charge Nurse assistance in the spa area. Charge Nurse observed Resident #1 on the floor lying on her left side with her back pressed against her wheelchair. Record review of Resident #1's Occupational Therapy notes dated 6/30/21 revealed Resident #1 was able to engage in bed mobility two person assist, w/c mobility, and sit to stands at parallel bars. In an interview on 3/3/22 at 10:20 a.m. with PTA, she said Resident #1 has received therapy in the past, but she was not currently on their caseload. She was on service in July of 2021 and discharged to restorative nursing program. Resident #1 did not participate well therapy. It was just recently brought to their attention that she had a fall with nursing during a transfer. She was always a Hoyer or a 2-person transfer with nursing. Resident #1 was said to not be ambulatory. It happened in the shower during a transfer. She has a discharge summary for PT and OT showing her current level of what she was at the time from May 4 through July 1st, 2021. Record review of Physical Therapy Patient Discharge Summary dated 5/4/2021- 7/1/2021 revealed Resident #1 will safely perform functional transfers with Minimum (A) and 25% Verbal Cues for use of compensatory strategies and for use of upper extremity during push-off and for push up from arms of chair in order to decrease level of assistance from caregivers, facilitate increased participation with functional daily activities and increase performance skills with functional tasks. Resident #1's Transfers and bed mobility was identified as 35%. Resident #1's discharge recommendations were to receive assistance with ADL's, Assistive device for safe functional mobility, lifeline for safety and 24-hour care. In an interview on 3/3/22 at 10:33 a.m. with Resident #1 she said she had 3 falls in the shower. The Staff want her to stand up and they told her to grab hold of the rails. She was getting out of the shower and CNA A was standing up to take her from the shower chair back to her wheelchair and the aide slipped on a towel and CNA A fell on top of her. She did not have to go to the hospital. The showers are too slippery. Resident #1 said she was scared to get into the shower. Resident #1 said she has had 3 falls in the shower. The floor is slippery. Each time the fall happened because they wanted her to grab hold to the rails. She told them that she could not do it. That's why she wants her PT. Resident #1 said the Staff were not using the Hoyer lift. She has been trying to get strength in her legs. There is usually only 1 person assisting her. Sometimes they will call a 2nd person. After this fall, The Charge Nurse said she will put a note to have 2 people to get her out of the shower to put her in the shower chair. They usually only have 1 person with a Hoyer lift. In an interview on 3/3/22 at 11:28 a.m. with CNA B she said Resident #1 is a 2 person assist and she is a 2 person assist with the shower also. In an interview on 3/3/22 at 11:32 a.m. with DON she said CNA A was giving Resident #1 a shower and Resident #1 had an assisted fall. In a telephone interview on 3/3/22 at 11:37 a.m. with CNA A she said she helped the shower tech with Resident #1 with a shower. She said the Nurse went on a break and the shower tech went to make a bed. CNA A said she put a towel on the floor to prevent slipping and Resident #1's hips got stuck in the shower chair. CNA A said she transferred the resident by herself and they both fell down. CNA A said she fell on top of Resident #1, but she braced herself. Resident #1 said she did not want to wait to be transferred from the shower. CNA A said they usually have 2 people to assist Resident #1 and she put her in bed by herself for the last 2 weeks. Resident #1 said she could stand up, but lately she had not been standing too much. Resident #1's legs are really heavy. CNA A said they put a towel on the floor in the shower to prevent slipping. She said Charge Nurse told her that Resident #1 is a 2 person assist in the shower. In an interview on 3/3/22 at 11:47 a.m. with Charge Nurse she said Resident #1 was now a 2 person assist in the shower. Resident #1 came here for therapy and since then she has declined. The Charge Nurse said Resident #1 tells all the staff that she is a one person assist because she wants to be able to do it. She has always been a 2 person assist, but Resident #1 tells the staff that she can do it with 1 person. Her son tells her that whenever she can walk, she can come home. Therapy tried her pick her back up, she refuses it. Now, there some kind of stipulation because she refused it before. About a month or two ago they were supposed to evaluate her to see if they can get her in therapy. Resident has declined. Therapy will help her get the dexterity back. She was here for the fall Resident had. Resident #1 was in the shower and CNA A let her know she needed her. She went in the shower and Resident #1 was on the floor. Resident #1 was on the ground with her back against the wall. It took 4 staff to get her off the ground. Resident #1 said CNA A went to transfer her and they slid and they both went down. CNA A said her foot got caught on one of the chairs and they both went down. CNA A's foot got caught. She fell down on top of her. Resident did not have to go to the hospital. She had full range of motion, still in the shoulder. She called her son. She told Resident #1 that she could not talk staff out of being a 2 person assist. She started giving her a list of the people who could give her a 1-person transfer. Record review of Resident # 2 face sheet revealed he was a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnosis included acute [CONDITION(S)] with [CONDITION(S)] (breathing), dysphagia (difficulty swallowing), chronic embolism and [CONDITION(S)] of unspecified vein (blockage in artery for heart), dementia without behavioral disturbance, cognitive communication deficit, pericardial effusion, hypertension (High blood pressure), [CONDITION(S)], [CONDITION(S)] (irregular heartbeat), type 2 diabetes (blood sugar), chronic kidney disease and pressure ulcer of left ankle, stage 4. Record review of Resident # 2's Accident/Incident Report dated 2/7/22 at 10:30 a.m. by DON revealed CNA heard yelling for help. Nurse entered room to find resident in prone position. CNA stated she was changing him, and he rolled softly out of bed and did not hit his head Resident assisted back to bed X4. Record review of Resident #1's Care Plan dated 8/3/2021 revealed he was at risk for falls R/T general weakness and deconditioning, decreased mobility all extremities. Resident # 2 had actual fall on 2/7/2022, and ADL's requires staff care daily with interventions as assist with transfer as needed. Record review of Resident # 2's Significant change in status MDS dated [DATE] revealed a BIMS Summary Score of 2 indicating severe mental impairment. The functional Status revealed resident's transfer revealed activity occurred only once or twice and needing two-person physical assistance; resident's bed mobility, dressing, toilet use, and personal hygiene required total dependence and requiring two-person assistance. Residents' functional limitation in range of motion revealed impairment on both sides in upper and lower extremity. Record review of Resident # 2's Clinical Notes Report dated 2/7/22 a 10:41 a.m. signed by DON revealed Resident had a witnessed fall. Resident was being changed and rolled off of side of bed. Resident did not hit his head and CNA said it was a slow fall. In an interview on 3/3/22 at 12:45 p.m. with Resident #2 he said that he did not remember his fall. Resident #2 said sometimes there is 1 staff assisting him and sometimes there are 2 staff. In an interview on 3/3/22 at 1:10 p.m. with DON she said a CNA was changing Resident #2 and he fell off the side of the bed. The CNA was turning him. The CNA was CNA C and he rolled over too far. The DON said they were renting the bed and the rail was fixed immediately. In an interview on 3/3/22 at 1:22 p.m. with CNA C she said the Nurse walked out of the room and she was changing him by herself. He rolled over and he was holding the bed rail and it broke and they both fell over the side of the bed. It was a rental bed. This was on the Covid hall and this was her first time meeting him. She was working the Covid unit. Resident #2 was normally a 2 person assist. It was only her and a Nurse working the Covid hall that day. She was working 6 a.m. to 8 p.m. That same day they fixed the rail. Resident #2 was not hurt. Record review of Facility's policy on Transfers dated June 14, 2006 and revised on 07/2014 If for some reason a Patient is unable to bear weight on his legs, it will be necessary for two people to transfer him in and out of bed. Record Review of facility's policy on Resident Rights, not dated revealed, .You have the right to be free from abuse, neglect, and exploitation, be treated with dignity, courtesy, consideration, and respect .receive all care necessary to have the highest possible level of health .

Based on observation, interview, and record review the facility failed to ensure residents were free of significant medication errors for 1 (Resident #4) of 12 residents reviewed for medication errors. -MA A administered Resident # 4's morning medications at 1:25 p.m. instead of 7 a.m. (or 1 hour before or after). The medications included three high blood pressure pills, one diuretic (a medication used to reduce extra fluid in the body caused by a condition such as heart failure), one pain medication, and one diabetes medication. This failure could place residents at risk for inadequate therapeutic outcomes and decline in health. Findings included: Record review of Resident #4's face sheet revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . It's a group of medical problems that can happen when you do not control your high blood pressure), congestive heart failure, [CONDITION(S)] (a disease of the heart characterized by irregular and often faster heartbeat), hypertension (high blood pressure), gout, dementia, type 2 diabetes, depressive disorder, and [CONDITION(S)] (swelling caused due to excess fluid accumulation in the body tissues). Record review of Resident #4's quarterly MDS assessment dated [DATE], revealed a BIMS score of 7 out of 15 which indicated severe cognitive impairment. She required supervision and limited assistance of one staff for ADL care. Record review of Resident #4's care plan dated 4/20/21 revealed she was at risk for hyper or hypoglycemic episodes secondary to diabetes. Interventions included to take medication as ordered. Resident #4 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Her medication included [MEDICATION(S)], [MEDICATION(S)], losartan, and [MEDICATION(S)]. Interventions were to give medications per order. Record review of Resident #4's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] 1.[MEDICATION(S)] 40 mg one tablet two times daily, order date 4/27/21. 2.Losartan 50 mg one tablet two times daily, order date 4/27/21. 3.[MEDICATION(S)] 100 mg one tablet every 8 hours, order date 4/27/21. 4.[MEDICATION(S)] 100 mg one tablet two times daily, order date 4/27/21. 5.Tylenol-[MEDICATION(S)] #3 one tablet three times daily, order date 12/8/21. 6.[MEDICATION(S)] 500 mg one tablet two times daily, order date 1/5/22. Record review of Resident #4's March 2022 MAR revealed: 1.[MEDICATION(S)] 40 mg twice a day at 7:00 a.m. and 3:00 p.m. ICD-10: transfusion associated circulatory overload. 2.Losartan 50 mg twice a day at 7:00 a.m. and 7:00 p.m. ICD-10: hypertension; BP and/or pulse hold: diastolic blood pressure is < 60, pulse is < 60. 3.[MEDICATION(S)] 100 mg every 8 hours at 7:00 a.m., 3:00 p.m., and 11:00 p.m. ICD-10: hypertension; BP and or pulse hold: diastolic blood pressure is < 60, pulse is < 60, systolic blood pressure is < 110. 4.[MEDICATION(S)] 100 mg twice a day at 7:00 a.m. and 7:00 p.m. ICD-10: hypertension; BP and/or pulse hold: diastolic blood pressure is < 60, pulse is < 60, systolic blood pressure is < 110. 5.Tylenol-[MEDICATION(S)] #3 three times a day at 7:00 a.m., 3:00 p.m., and 11:00 p.m. ICD-10: pain. 6.[MEDICATION(S)] 500 mg twice daily at 7:00 a.m. and 5:00 p.m. ICD-10: type 2 diabetes. Observation and interview on 3/3/22 at 1:20 p.m. of the 400-hall medication aide cart with MA A, there was a medication cup filled with pills sitting in one of the locked compartments of the medication cart. There was no name on the cup. MA A said the medication belonged to Resident #4 and were due around 7 a.m. this morning. He said he tried to administer the medication to Resident #4 this morning, but she was asleep. The Surveyor and MA A compared the medications in the cup to Resident #4's MAR. The following medications were identified: [MEDICATION(S)] 500 mg, [MEDICATION(S)] 100 mg, [MEDICATION(S)] ([MEDICATION(S)]) 40 mg, Losartan 50 mg, [MEDICATION(S)] 100 mg, Tylenol-[MEDICATION(S)] #3, [MEDICATION(S)] 100 mg, and [MEDICATION(S)] 30 mg. MA A went to Resident #4's room where she was awake and sitting up at the bedside. MA A took Resident #4's blood pressure which was 186/94 and her heart rate was 76. MA A told Resident #4 that her blood pressure was high and said to make sure she took all her medication. MA A administered the medication and exited the room. Interview on 3/3/22 at 1:30 p.m. with MA A, he said he did not notify the nurse that he did not administer Resident #4's medications this morning because he had not seen the nurse until now. He said he tried to go back and administer the medications to Resident #4 earlier, but the resident was asleep at times and walking around without clothes other times. He said Resident #4 did not normally wake up until around lunch time. He said at 6:10 a.m. Resident #4's blood pressure was 118/60 and her heart rate was 99. He said he would let the oncoming shift know to hold the next scheduled pills (scheduled for 3:00 p.m.) because he would not want the resident to overdose. He said he was not sure what could happen to Resident #4 if the medications were not given this morning because the resident was good and did not have any behaviors on the morning shift. He said this was the first time he had seen her blood pressure that high. He said he was not provided much training on how to address residents who were sleeping but said that he would try to administer the medication again. Interview on 3/3/22 at 1:45 p.m. with LVN A, he said he took Resident #4's blood pressure approximately 10 minutes ago and it was 191/89. He said MA A did not inform him that he did not administer Resident #4's medications this morning. He said if a resident was sleeping the medication aide should try to wake them up to administer the medication. If they did not wake up the medication aide should notify the nurse. He said the nurse would notify the MD and could possibly hold the medication. He said if blood pressure medications were not given it could cause the resident to have an acute issue such as a hypertensive crisis (a severe increase in blood pressure that can lead to a stroke). Record review of Resident #4's Amend Administration document dated 3/3/22 revealed: [MEDICATION(S)] 100 mg (scheduled for 7:00 a.m.) was signed as administered on 3/3/22 at 1:49 p.m. by MA A. Record review of Resident #4's Amend Administration document dated 3/3/22 revealed: [MEDICATION(S)] 100 mg (scheduled for 7:00 a.m.) was signed as administered on 3/3/22 at 1:49 p.m. by MA A. Record review of Resident #4's Amend Administration document dated 3/3/22 revealed: [MEDICATION(S)] 40 mg (scheduled for 7:00 a.m.) was signed as administered on 3/3/22 at 1:49 p.m. by MA A. Record review of Resident #4's Amend Administration document dated 3/3/22 revealed: Losartan 50 mg (scheduled for 7:00 a.m.) was signed as administered on 3/3/22 at 1:49 p.m. by MA A. Record review of Resident #4's Amend Administration document dated 3/3/22 revealed: [MEDICATION(S)] 500 mg (scheduled for 7:00 a.m.) was signed as administered on 3/3/22 at 1:49 p.m. by MA A. Record review of Resident #4's Amend Administration document dated 3/3/22 revealed: Tylenol-[MEDICATION(S)] #3 (scheduled for 7:00 a.m.) was signed as administered on 3/3/22 at 1:49 p.m. by MA A. Interview on 3/3/22 at 1:52 p.m. with the DON, she said if the medication aide was not able to give the morning medication because the resident was asleep, he should report it to the nurse and try to administer the medication again within the allotted time frame. She said the time frame was an hour before and an hour after the scheduled time. She said it was important to notify the nurse if the medication was not given because the nurse would contact and consult with the MD. She said if the medication was not given in the appropriate timeframe the resident's blood pressure could rise. She said Resident #4's blood pressure was normally in the 130s/70s range. Record review of Resident #4's Clinical Notes Report dated 3/3/22 at 2:36 p.m. written by LVN A read in part, at 1330 (1:30 p.m.) this nurse was notified by CMA that 0700 (7:00 a.m.) meds were administered at 1300 (1:00 p.m.) and that BP was 186/90. This nurse assessed patient. BP 191/89. HR 83. No s/s of acute distress noted. Patient denied headache, vision changes, and chest pain. NP notified of incident, new order to monitor BP every 30 minutes for 2 hours. If systolic does not drop below 170 in 2 hours to call back . Record review of Resident #4's Accident/Incident Report dated 3/3/22 at 2:49 p.m. written by LVN A read in part, .(Resident #4) . Nature of accident/incident: medication error . Account of Occurrence: notified by CMA that 0800 medications were administered at 1300 (1:00 p.m.) due to patient sleeping and would not wake up . Record review of the facility's undated Medication Administration policy read in part, .2. The 6 Rights of Medication Administration . e. Right Time: Confirm med-pass time window (1 hr before to 1 hr after administration time on MAR .). 3. Oral Administration: h. You must document on MAR and administration notes why dose was not given . ii. Report consistent refusals to charge nurses for order review by MD .

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections and follow accepted national standards. The facility failed to ensure CNA C provided proper hand hygiene and infection control procedure while providing incontinent care for Resident #13. This deficient practice could affect residents and place them at risk for infection and/or reinfection. Finding included: Resident # 13 Record review of Resident #13's face sheet revealed a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #13's Annual MDS dated on 08/02/2021, revealed a BIMS of 6 which indicated severely impaired cognition. It also revealed the resident was incontinent of bowel and required total assist with ADL with 2 person assistance with bed mobility, and 1 for transfer, dressing and personal hygiene. Record review of Resident #13's care plan dated 7/24/2020 revealed Resident #13 was always incontinent of bowel movements. Intervention: check for incontinence; clean and dry skin if wet or soiled. Document when resident is incontinent. It also revealed resident had decreased ADL function and required staff assistance with all Activities of Daily Living on a daily basis. Observation on 03/03/2022 at 8:50 a.m., with Resident #13's incontinent care provided by CNA C and CNA D, revealed resident's incontinent brief was clean and not soiled. CNA C and CNA D walked into the resident room and washed their hands in the resident's restroom and donned their gloves. CNA C provided incontinent care to Resident #13 and changed her gloves without performing hand hygiene in between glove changes. Interview on 03/03/2022 at 9:30 a.m., with CNA C; she said she makes incontinent care rounds every two hours. She said both she and CNA D work on a different hallway but it was set up by the DON for her and CNA D to do peri-care with Resident #13 on this day and she had never worked with him before. She said she had skill check-off on incontinent care, hand hygiene and infection control in-service but she was not aware that she needed to use hand sanitizer in between glove changes. She stated that she would be sure to have it with her from now on and would use it with each glove change, and wash her hands before and after beginning any resident care. She said the charge nurse monitors the aides to make sure they are providing care to the residents. Interview on 03/03/2020 at 3:11 p.m., with DON; she said the aides should have sanitized their hands between glove changes to prevent the transferring of germs from their hands from removing the soiled gloves onto the clean gloves and then to the resident. She said the aide should do this every time incontinent care is provided to any resident. She stated the CNAs were trained on infection control at hire and yearly, as well as monitored and in-serviced frequently on hand hygiene. She stated she would follow up with CNA C to make sure she reviewed the correct steps to follow for hand hygiene during incontinent care. She stated that CNA C was probably very nervous. She would make sure that the entire staff was in-serviced on infection control and hand hygiene. Record review of facility policy and procedure titled Handwashing, dated August 2012, reads, in part, Hand washing is the single most important means if preventing the spread of infection .After patient contact .Wash hands with soap and running water .May use Hand sanitizing gel in place of soap and water . Record review of facility policy and procedure titled Perineal Care Protocol dated February 2022, reads, in part, Assemble equipment and supplies on bedside. Use a towel to set up a clean field, box of gloves (will need at least 4 pair of gloves), wipes, barrier cream, hand sanitizer, new brief, plastic bags (2), and second towel to go under patient's buttocks .wash hands; apply gloves Remove gloves, sanitize hands and apply new gloves .Wash/sanitize hands. Apply clean gloves .Apply barrier cream to perineal and buttock area, dispose of gloves, sanitize hands and apply clean gloves .If needed clean soiled areas first by wiping off fecal material with wipes. Wash hands and apply gloves .Wash and sanitize hands .Apply clean gloves Apply barrier cream to perineal and buttock area, dispose of gloves, sanitize hands and apply clean gloves .Wash hands.

Based on record review and interview, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 1 (CR #1) of 9 residents reviewed for quality of care. LVN A failed to immediately seek emergency intervention when CR #1, who was a full code, experienced a serious change in condition. She was found by EMS unconscious and had to be intubated, the transported to the hospital and admitted to the ICU with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] These failures placed all residents who experienced a change of condition and placed them at risk of not receiving emergency care and possible death. Findings include: Record review of CR #1's clinical record revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. She was diagnosed with [CONDITION(S)], diabetes, high blood pressure, dementia, [CONDITION(S)] following a cerebral infarction, chronic pulmonary [CONDITION(S)], depression, anxiety, and unspecified convulsions. Further review of the record revealed CR #1 was full code. Record review of CR #1's MDS assessment, dated [DATE] revealed her vision was severely impaired, she had a BIMS score of 2 (severe cognitive impairment), she required extensive assistance from staff with bed mobility, transfers, locomotion (wheelchair), dressing, toileting, personal hygiene, limited assistance with eating, and total assistance with bathing, she was always incontinent of bowel and bladder, and she occasionally experienced pain. Record review of CR #1's care plan, last updated, [DATE] revealed the resident was a full code, she was cognitively impaired (dementia), she had impaired vision, she was always incontinent of bowel and bladder, she had combative behaviors, and she was on hospice due to a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of CR #1's clinical progress notes for [DATE] revealed the following: On [DATE], at 7:47 p.m., LVN A wrote, Resident appears less responsive, unable to verbalize needs, incoherent, crying out, in and out of consciousness, appears to be asleep snoring with eyes wide open, upon observation resident has abdominal distention, cries out when nurse touches stomach, pupils not dilating and not reacting to light, Temp 100.6 at 6:30 p.m. and 100.9 at 7:20 p.m. Respirations are fast and 44, blood pressure ,d+[DATE], pulse 61 unable to obtain oxygen level, wheezing noted, called hospice, they stated they would be out to see her with the next few hours. Notified responsible party. Will continue to monitor. On [DATE], at 8:36 p.m., LVN A wrote, Responsible party called and stated he wants resident to go to hospital. This nurse stated hospice was less than 5 minutes away and he demanded we call 911 and send her anyway and wished to revoke hospice. Notified DON and called 911 per family request. EMS arrived at 8:20 p.m., transferred resident to stretcher, face sheet, discharge form and medication list given to EMS. Responsible party called again while EMS was leaving and was notified that EMS had picked her up and that they were taking her to a local hospital. Record review of CR #1's SBAR, dated [DATE], revealed it was completed by LVN A and it read in part: Situation Abdominal distention, temp., respirations, and non dilating pupils Background Vital Signs Blood Pressure ,d+[DATE], Apical heart rate 62, Temperature 100.9, pulse 61, Respiratory 44 Resident Evaluation 1. Mental Status - Decreased level of consciousness, in an out of consciousness 4. Abnormal lung sounds, Labored or rapid breathing 6. Abdominal /GI Evaluation - Abdominal pain, Abdominal tenderness, Distended abdomen, Decreased appetite/fluid intake 9. Pain Evaluation - Does the patient have pain?- Yes, Is the pain new?- New, Description/location of pain: abdomen, Does the resident show non-verbal signs of pain (for residents with dementia): Yes (describe) grimacing when nurse touches her stomach 10. Neurological Evaluation - Abnormal speech, Decreased level of consciousness, Describe symptoms and signs: unable to verbalize needs, incoherent, in and out of consciousness Advance Care Planning Information (the resident has orders for the following advance directives): Full code Appearance Summarize your observation and evaluation: Resident appears less responsive, unable to verbalize needs, incoherent, crying out, in and out of consciousness, appears to be asleep snoring with eyes wide open, upon observation resident has abdominal distention, cries out when nurse touches stomach, pupils not dilating and not reacting to light, Temp 100.6 at 6:30 p.m. and 100.9 at 7:20 p.m. Respirations are fast and 44, blood pressure ,d+[DATE], pulse 61 unable to obtain oxygen level, wheezing noted. Review and Notify Primary Care Clinician Notified: Hospice, [DATE], 7:05 p.m. Recommendations of primary clinician: Hospice nurse stated to give 1 ml [MEDICATION(S)] and she will be out too see resident with in the next hour. Interventions Transfer to the hospital, Call 911 Nursing Notes - Notified responsible party, he stated he wanted her to go to hospital and cancel hospice. Name of Family/Health Care Agent Notified: Responsible party, [DATE], 7:45 p.m. Record review of CR #1's hospice communication note written by Hospice Nurse B on [DATE], read in part, 7:06 p.m. Received phone call from facility nurse who states that patient eyes are wide open and dilated. Patient is not making and sense and nurse states that this is somewhat normal for her. Instructed nurse to administer [MEDICATION(S)], which she states she has already done. She states that she gave .5 sublingual. Instructed her to repeat dose now and that this nurse would make visit. While on way to facility, phone call received from social worker. She states that family responsible party would like patient sent to hospital. This nurse reached out to responsible party. Explained symptoms patient was having and requested permission to assess patient and call him back prior to sending to hospital. He states he is agreeable to this plan. Received phone call from responsible party at 8:02 p.m. (this nurse was very close to facility within 5 minutes of arrival at this time). Responsible party states that he does not want this RN to assess patient, he has instructed nursing facility to call 911 and send patient to hospital. He states that he will sign revocation paperwork with social worker in the morning. This nurse then called facility nurse. She states that she is initiating ambulance transfer of patient to facility. Notified DON (hospice DON) of patient transfer. Doctor also notified. Record review of CR #1's hospital records revealed the following: Upon arrival to the emergency roiagnom on [DATE], at 9:13 p.m., her appearance was described as debilitated, frail, pale, and toxic appearing. CR #1 was admitted to the ICU on [DATE] and died on [DATE]. Diagnosis, Assessment and Plan: [AGE] year-old white female . EMS found her unresponsive, tachypneic (fast breathing), and [CONDITION(S)] (fast heart rate) .On arrival here she was on a NRB mask with sats in the 80's (86%). She was intubated on arrival here. She was noted to be febrile (fever) to 103.3 with [CONDITION(S)]. A CT was performed looking for a source. This revealed small bowel dilation consistent with possible distal PSBO. Acute Kidney Injury - Likely from [CONDITION(S)] [CONDITION(S)] - resolved Septic Shock - Fever, lactic acidosis, [CONDITION(S)] required pressors. Acute Respiratory Failure - Respiratory acidosiss, intubated on vent support, management per critical care NSTEMI (Non - ST - elevation [CONDITION(S)] infarction) - Troponin trended up to 11.9 SBO (small bowel obstruction) versus Ileus (a painful obstruction of the ileum or other part of the intestine) [CONDITION(S)] In an interview with the facility's Administrator and DON on [DATE], at 10:15 a.m., the Administrator said she was hired in [DATE] and she recalled an investigation was conducted regarding CR #1 in [DATE]. The DON said CR #1 was deteriorating and when the hospice nurse was on her way, two family members were arguing until the responsible party finally said to send the resident out and they wanted to revoke hospice. The DON said LVN A, who was PRN, was on duty that night and one of the family members eventually said the nurse did not send CR #1 to the hospital right away. The DON said if a family member wanted to revoke hospice, they would call the hospice agency but if the family member told facility staff they wanted to revoke hospice, that staff would send the resident out to the hospital and contact hospice and do the paperwork later. Neither the Administrator or the DON could recall at that time if CR #1 was full code while at the facility. In an interview with the Administrator on [DATE], at 11:02 a.m., she said although the resident was full code, the responsible party told LVN A to keep CR #1 at the facility because he was on his way. In a telephone interview with a local hospice administrator on [DATE], at 12:00 p.m., she said she was very familiar with CR #1 because she had been on hospice with them for a long time before she was admitted to the facility. She said even though a resident is on hospice, they do not have to sign a DNR. She said in the event of an emergency, the expectation was to call 911 for a full code resident first and then call hospice next. The representative said a hospice nurse visited the resident on [DATE] because CR #1 had diarrhea, nausea, and vomiting. She said if the resident had a DNR, hospice would have been involved but since she did not, the facility would have initiated CPR, called 911, then called hospice later. In a telephone interview with RN B on [DATE], at 12:52 p.m., she said she did not really know CR #1 but she was the on-call nurse that night. After reading CR #1's symptoms listed on LVN A's progress note, RN B said whether or not to send the resident out depended on what the family wanted. She said it also depended on what the facility's protocol was. RN B said she tried to triage the call and if it was serious, she asked the facility staff if they called the family to see what they wanted. She first received a call from the facility at 7:06 p.m. Then, the social worker called and said the family member wanted the resident sent to the facility. RN B called the family member and said she was minutes away and he agreed to let her assess before sending the resident out. She then got a call back from the family member saying he told the facility to send CR #1 out. In an interview with the ADON on [DATE], at 1:12 p.m., she said CR #1 was alert and oriented more of the time than not and she probably could walk but was unstable. She said CR #1 could voice her needs and wants but had declined some towards the end. The ADON recalled CR #1 was on hospice but was full code. After hearing the list of CR #1's symptoms from [DATE], the ADON said she would have sent the resident out at that point. She said depending on the severity of her condition, she would call 911, then call the family, then call hospice. She said that would be the expectation for all staff and as a nurse, she should know the status (hospice and DNR) of all residents on her hall. She said she would still check the residents' chart in the event of an emergency. In a telephone interview with LVN A on [DATE], at 1:50 p.m., she said she was PRN and only picked up shifts once or twice per month. She recalled CR #1 was on hospice but she could not recall if she was full code. She said on the night CR #1 went out, she called hospice and the nurse said she would be there. The responsible party called and said he wanted the resident to go out. After hearing CR #1's symptoms from [DATE], LVN A said she would think the symptoms indicated a stroke or heart attack. She said she probably would call 911 for a full code resident with those symptoms. She said a big percentage of hospice residents were DNR and she only knew of one hospice resident who was full code. LVN A said most hospice residents had orders to not go to the hospital. She said if a resident was on hospice but was full code, she would notify hospice in the event of an emergency because they would make the decision to send a resident out. She then said if a full code hospice resident's heart stopped, she would do CPR and send out. In an interview with the DON on [DATE], at 10:30 a.m., she said CR #1's symptoms would have possibly indicated [CONDITION(S)]. She said for a full code resident, she would have called 911, then hospice and family. She said all nurses would be in-serviced on change of condition for full code residents and hospice residents. In a telephone interview with CR #1's family member on [DATE], at 11:30 a.m., he said on [DATE] in the evening, he received a call from another family member who said the resident had a 100.3 fever and respirations of 32 but was conscious. He told the other family member to have the facility send CR #1 out to the hospital. The family member said he told the staff to send the resident out but they told him they would not send her out until hospice arrived at the facility. He told the family member since he was the responsible party, he could make that decision. The family member called the facility himself and spoke to the nurse. He said he told the nurse they wanted CR #1 to be sent to the hospital and the nurse told him they had to wait for hospice. The family member said he told the nurse they had POA and they had the right to say send the resident out. He said the nurse again told him they had to wait for hospice but ten minutes later, someone called the other family member and said the nurse was wrong in what she did and they were sending CR #1 out. He could not recall the name of the person who called. He said 30 minutes later, the other family member called and said CR #1 was at the hospital with a fever of 103 and was unconscious and septic. CR #1 died on [DATE]. In a telephone interview with another family member of CR #1, on [DATE], at 1:50 p.m., he said on the evening of [DATE], he received a call from a nurse at the facility saying CR #1 had a fever. He said he told the nurse immediately to send the resident to the hospital. He said the nurse told him he could not make that decision because the resident was on hospice. He said he called the social worker (hospice social worker) and she said the facility nurse had to send the resident out if the family wanted her send out. He said he then called the hospice nurse. A different nurse called him and asked if he wanted CR #1 to be sent out and he said yes. The nurse told him the resident would be sent out. The family member said it took him 45 minutes to get to the hospital and CR #1 arrived at the hospital 20 minutes after him. He said CR #1 was unresponsive and had a fever of 103. He said when CR #1 was admitted to the facility, she was initially able to communicate and she said she wanted to be full code. Record review of facility document, Advance Directives, dated [DATE], revealed it read in part 1. An Acknowledgement Receipt for Advance Directives/Medical Treatment Decisions must be completed for each Patient upon admission and upon any change in the status of the Patient's Advance Directives. 2. The Advance Directives Decision Tree Protocol must be used for each Patient at any time a question arises with respect to whether a Patient has Advance Directives, should have Advance Directives, or has requested to have Advance Directives .6. A Patient's Advance Directive choice must be care planned and updated as warranted with any changes in the Advance Directives . Record review of, Patient Care Management System 18, dated [DATE], revealed it read in part, Interact 1. The Stop and Watch Early Warning Tool must be initiated upon the first signs of a Patient presenting with a change in condition and the nurse notified immediately. 2. A Care Path must be used as a guide when a Patient presents with a change in condition. 3. A Situation, Background, Assessment and Request (SBAR) Communication Form and Progress Note must be completed upon a Patient's change in condition and prior to contacting the attending physician. The SBAR Communication Form can replace a nurse's note . Record review of, Resident rights, dated [DATE], revealed it read in part, .(4) The facility must treat the decision of a resident representative as the decision of the resident to the extent required by the court or delegated by the resident, in accordance with applicable law .

Based on observation, interview and record review, the facility failed to establish an infection prevention and control program that included hand hygiene procedures to be followed by staff involved in direct resident contact for two of two residents (Resident #1) and Resident #2), and two of CNA's (CNA A and CNA B) reviewed for infection control. - CNA A failed to provide appropriate incontinent care -CNA A and CNA B failed to perform appropriate hand washing techniques during incontinent care These failures could affect all residents for incontinent cares at risk for infections. Findings include: Resident #1 Record review of Resident #1's face sheet on 9/2/20 at 2:30pm revealed he was [AGE] years old and admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #1's significant change MDS assessment on 9/2/20 at 3:30 pm, dated 3/26/2020 revealed he had a BIMS score of 9 of 15 which indicated that he was moderately cognitively impaired. He required extensive assistance from two people for bed mobility. He required extensive assistance from at least one staff member for transfers, dressing, eating, toilet use and personal hygeine. He was also coded as being always incontinent of bowel and bladder. Record review of Resident #1's care plan on 9/2/20 at 3:35pm, and dated as Effective: 1/6/2020-Present revealed the facility had approaches in place to address Resident #1's incontinence and prevent skin breakdown. Some of the interventions read as follows: Check for incontinence; change if wet/soiled. Clean skin with mild soap and water. Apply moisture barrier. STATUS: Active (Current). He also had the following entry listed under the heading Problems. Urinary Continence: Resident #1 is always incontinent. STATUS: Active (Current). Resident #2 Record review of Resident #2's face sheet on 9/2/20 at 2:40 pm, revealed he was an [AGE] year old male who admitted to the facility on [DATE]. His daignoses included dehydration, dementia, type II diabtes mellitus, [MEDICAL CONDITION], hypertension, [MEDICAL CONDITION], anorexia, pressure ulcer of the right heel, [MEDICAL CONDITION], and functional intestinal disorder. Record review of Resident #2's annual MDS assessment on 9/2/2020 at 3:40 pm and dated 7/17/2020 revealed he had a BIMS score of 2 of 15 indicating he was severely cognitively impaired. He required extensive assistance of at least 1 person for bed mobility, transfers, dressing, toilet use and personal hygeine. He was also coded as being frequently incontinent of urine and always incontinent of bowels. Record review of Resident #2's care plan on 9/2/20 at 3:38 pm, and dated as Effective: 07/27/2020-Present, revealed the facility had approaches in place to address Resident #2's incontinence and maintain maximum control of bladder. The number of incontinent episodes will be reduced over the next 90 days. STATUS: Active (Current).Some of the interventions read as follows: Check for incontinence; change i wet/soiled. clean skin with mild soap and water. Apply moisture barrier. STATUS: Active (Current). Evaluate incontinence pattern to determine voiding schedule. Record output per shift. STATUS: Active (Current). Observation on 9/2/20 at 1:05 pm revealed CNA A had a prepared and clean overbed table with supplies for Resident #1's incontinent care already set up upon entry to the room. CNA A washed her hands and closed the privacy curtain and the door to the room. CNA A, then put on her gloves without sanitizing or re-washing her hands. CNA A removed Resident #1's soiled brief by rolling and folding down the front flap to his brief and tucking it under his testicles. CNA A removed and discarded her gloves and then washed her hands for less than 20 seconds. CNA A returned to the bedside, changing her gloves with difficulty. CNA A used one wipe to dab and blot around the head of Resident #1's penis. She did not retract the foreskin and said, this is hard and it does not pull back. when asked if she was commenting on the fact that she could not retract the foreskin on Resident #1's penis, she replied, Yes. When asked what she does in that instance, she said they know already. When asked if this would be something she would report to the charge nurse, she said they know already and that Resident #1's foreskin had always been like that. CNA A then folded the same wipe and wiped in between the creases and folds of Resident #1's left and right thighs. CNA A then removed and discarded her gloves and reapplied gloves without sanitizing her hands and rolled Resident #1 to his left side. CNA B assisted by helping to hold Resident #1 on his side, while CNA A began to apply a barrier cream to Resident #1's buttock without first clealing the resident. CNA A was about to roll Resident #1 to his right side and had completely removed the soiled brief and discarded it. When asked why CNA A had not cleaned Resident #1's bottom before applying barrier cream, she replied, Oh, I forgot. CNA A then used one wipe to clean Resident #1's entire buttocks and rectum. Observation on 9/2/20 at 1:40 pm of CNA B assisting Resident #2 with incontinent care. CNA B was observed not washing her hands as she entered Resident #2's room and she put on gloves. Resident #2's privacy curtain was pulled very close to the table which had been set up with the new clean brief and wipes. The privacy curtain was observed touching the new clean brief and wipes. Resident #2 was observed being addressed as 'baby' and by his surname by CNA B during incontinent care. After cleaning Resident #2's genital area in the front, Resident #2 was rolled to one side to remove the soiled brief. After removing Resident #2's soiled brief, CNA B did not perform hand hygiene or change her gloves. Resident #2 was rolled onto his back and CNA B dropped one of the clean gloves onto Resident #2's bed. CNA B picked up the clean glove from the resident's bed and applied the glove to her hand. Interview on 9/2/20 at 2:45 p.m, the Administrator said the CNA's had been trained and all should have had competencies on incontinent care. She said that the staff also complete monthly CBT's. The Administrator said that they were planning in completing a skills fair and that the skills fair are ususally completed prior to annual survey. She said that they had recently hired a staffing educator. Requested skills checklists and or competencies for CNA A and B and Administrator was uanble to provide prior to exit. Record review on 9/2/20 at 3:00pm of facility in-service dated 3/26/20 and titled. Infection Control read in part, .3. Wash hands: c. Before and after peri care + diaper ^ . (^ symbol means change). Further record review revealed no observations of either CNA A or CNA B's signatures

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 5 residents (Resident #1) reviewed for comprehensive care plans in that: -Resident #1 had no plan of care for having a PICC (Peripherally Inserted Central Cather) line or Midline. This failure affected 1 resident and placed her at risk of not having her healthcare needs met, which could cause an avoidable deterioration in her health status. Findings include: Record review of Resident #1's face sheet revealed she was an [AGE] year-old female who was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #1's quarterly MDS assessment dated as completed on 10/15/19 revealed she had a BIMS score of 12 out of 15 indicating moderate cognitive impairment. She required extensive assistance with bed mobility, limited assistance during transfer, dressing, toilet use, and personal hygiene. Record review of Residents #1's (MONTH) 2019 Physician order [REDACTED]. Record review of Residents #1's (MONTH) 2019 Treatments revealed PICC/mideline was inserted on 10/29/19. Record review of Resident #1's current electronic Comprehensive Care Plans revealed there was no care plan for PICC/Midline use, care, and possible complications. During an interview and observation on 10/31/19 at 10:30 am Resident#1 said she did not remember when she was admitted to the facility. She was lying in bed, noted to have dressing on her left, upper arm with IV tubing and a blue port on its tip. During an interview on 10/31/19 at 1:50 pm, LVN A said she was assigned to take care of Resident #1. She said Resident #1 had a PICC line inserted on 10/29/19 for her antibiotic therapy. During an interview on 10/29/19 at 1:59 pm the MDS Nurse said she was responsible for making care plans for Resident #1. She said Resident #1 did not have a care plan for PICC line right now, but Resident #1 was on her list to add the item to the care plan. During an interview on 10/29/19 at 2:03 pm the ADON/Unit Manger said a PICC line should be care planned. During an interview and record review on 10/29/19 at 2:10 pm the MDS Nurse said they did have the PICC line care plan for Resident #1. She presented a care plan for Resident #1's antibiotic use. Record review of the care plan presented by the MDS Nurse revealed it did not address Resident #1's PICC line use and care. Record review of the facility's policy and procedure titled Comprehensive Assessments and the Care Delivery Process revised (MONTH) (YEAR) revealed in part, .Policy Statement . Comprehensive assessments will be conducted to assist in developing person-centered care plans. Comprehensive assessments, care planning and the care delivery process involve collecting and analyzing information, choosing and initiating interventions, and then monitoring results and adjusting interventions.

Based on observation, interview, and record review, the facility failed to maintain medical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 4 residents (Resident #1) reviewed for clinical records in that: -LVN A failed to document blood sugar checks for Resident #1 at the time taken and did not identify the late entries as late entries. -The facility was unable to provide documentation for Resident #1 to show insulin administration date and time. -The facility failed to clarify errors in Physician's orders and on the MAR for Resident #1's sliding scale insulin dose for a blood sugar of 501 or greater. The Order and MAR indicated [REDACTED]. These failures affected 1 resident and placed him at risk of having incomplete and inaccurate medical records resulting in treatment decisions being made based on inaccurate and incomplete medical records. Findings include: Record review of Resident #1's clinical record revealed he was [AGE] years old. He was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #1's Quarterly MDS (Minimum Data Set) assessment dated as complete on 7/02/19 revealed Resident #1 was assessed as scoring a 9 out of 15 on his BIMS (Brief Interview for Mental Status) indicating his cognition was moderately impaired. He required limited assistance with bed mobility, transfers, dressing, locomotion, toilet use, and personal hygiene. He required supervision when eating. He was assessed as having received Insulin Injections for the last 7 days or since admission/entry or re-entry in the facility. Record review of Resident #1's Care Plan dated 5/01/19 read in part, .Resident #1 is a diabetic and is at risk for Hyper/[DIAGNOSES REDACTED]; Goal-Diabetic status will remain stable as evidenced by b/s (blood sugar) staying within the normal limits over the next 90 days; Interventions-Give meds(medications) per order, monitor labs(laboratory). Record review of the physician's order sheet for (MONTH) 2019 dated 7/21/19 for Resident #1 read in part, Humalog U-100 Insulin 100 unit/ml subcutaneous solution (0-12 units) vial (ML) (millimeter) Subcutaneous, three times daily starting 7/21/19, scheduled at 6:30 a.m., 11:30 a.m., and 4:30 p.m. .Notes: Check blood sugar and follow sliding scale: 200-250=6 units, 251-300=8 units,301-350=10 units, 351-400=12 units, 401-450=14 units, 451=500=16 units, 501 or greater = 180 (sic) units and Re-check Blood Sugar in 15 Minutes. If blood sugar still 501 or greater, CALL MD (Medical Doctor). RP (Responsible Party) AWARE, Instructions: Therapeutic range . Record review of Resident #1's (MONTH) 2019 MAR indicated [REDACTED].sliding scale: .501 or greater = 180 units and Re-check Blood Sugar in 15 minutes. Observation and interview on 8/06/19 at 11:03 am revealed Resident #1 was in bed watching TV (Television). He was covered with a blanket from the chest down. He said he knew his blood sugar was being checked but did not know whether it was late or not because it was several times during the day that the staff checked his blood sugar. Record review of Resident #1's Patient Vital Sign Report, printed on 8/06/19 at 2:46 p.m. revealed the following blood sugar testing results: -7/22/19 8:36 a.m. b/s (blood sugar)256; -7/30/19 8:42 a.m. b/s 147 -7/31/19 8:59 a.m. b/s 200; -8/01/19 8:00 a.m. b/s 130; -8/03/19 10:16 a.m. b/s 170; -8/04/19 8:59 a.m. b/s 70; -8/05/19 8:39 a.m. b/s 46; -8/06/19 8:41 a.m. b/s 89. During an interview with LVN (Licensed Vocational Nurse) A on 8/06/19 at 2:30 pm she said, she was doing the blood sugar check for Resident #1 at 6:30 am but documenting it late. When asked if she documented late for all eight of the days, she did not answer. She said that whenever she checked the blood sugar she also administered insulin when it was applicable based on the sliding scale ordered by the physician. When asked to show to the surveyor the actual units and time she administered from (MONTH) 21, 2019 to (MONTH) 6, 2019 she said she did not know how, then LVN A called on the Unit Manager. LVN A said on her computer screen, she could see insulin administration date and time. She attempted to pull up the information on the laptop the facility provided to the surveyor but was unsuccessful due to a weak and intermittent wifi signal. During an interview with the Unit Manager on 8/06/19 at 2:35 pm she said the actual time of Insulin administration would not show in the MAR (Medication Administration Record). She printed the Patient Vital Sign Report that showed the actual time the blood sugar level was checked, and insulin administered for Resident #1. She also said, the facility had the policy that medication should be administered within one hour before or one hour after the prescribed time. The Unit Manager was asked to provide evidence of the insulin administration on 8/6/19. The Unit Manager said on her computer, she could see the insulin administration date and time. Record review the documents provided by the Unit Manager on 8/6/19 at 2:46 p.m. revealed it did not capture insulin administration. During interview and record review with the DON (Director of Nursing) on 8/06/19 at 3:01 pm, when shown Resident #1's Patient Vital Sign report, she reviewed the document and said, It should not be like that. She said the staff had a window of one hour before and one hour after from the prescribed time in administering medications to the residents. Furthermore, she said that morning was the busiest time for the staff but documenting late was not good. Record review of the facility policy and procedure titled Documentation of Medication Administration on MAR/TAR (Treatment Administration Record) dated (MONTH) 2010 read in part, . Purpose-To ensure proper documentation of medication administration and treatments in the medical record. 1. Medications must be administered within the required time, within one hour (60 minutes before or after) the time on the MAR/TAR.

Based on observation, interview and record review the facility failed to ensure 1 of 10 sampled residents (Resident #3) reviewed for neglect was free from neglect in that: CNA A transferred Resident #3 alone resulting in a fracture to the right leg. RN B failed to order an X-ray timely to evaluate Resident #3's right leg swelling. These failures affected 1 resident and placed 10 additional residents that were transferred via mechanical lift at risk for neglect, delayed [DIAGNOSES REDACTED]. Intake: # 1 Findings include: Record review of Resident #3's admission sheet revealed she was an [AGE] year old female who was admitted on [DATE]. Her [DIAGNOSES REDACTED]. Record review of the Care Plan for Resident #3 revealed she had care plans dated 3/5/17-Present in place for: - Bowel and urinary incontinence. - Pressure ulcer risk. - Impairment in cognitive skills. - Risk for falls. - ADL's - Requires Hoyer lift for transfers. Two person assist. - [DIAGNOSES REDACTED]. - [MEDICAL CONDITION] proximal tibia and is at risk for increased pain. Record review of Resident #3's Quarterly Minimum Data Set assessment dated [DATE] revealed her cognition was moderately impaired. She usually understands and was usually understood. She required the total assistance of 2 staff for with transfers. She required extensive assistance with bed mobility, locomotion, dressing, hygiene, and toilet use. She was not steady, only able to stabilize for surface-to-surface transfers. Her range of motion was impaired on both sides of her upper and lower extremities. She was always incontinent of bowel and bladder. She did not report any pain. She had no falls. She received antianxiety, antidepressant, anticoagulant, antibiotics and diuretic medications. Her care areas summary triggered for cognitive loss/dementia, communication, Activities of Daily Living (ADL's), incontinence, falls, nutrition, pressure ulcers, and [MEDICAL CONDITION] drug use. Record review of the Radiology Report for Resident #3 dated 6/21/18 revealed: Conclusion- Oblique [MEDICAL CONDITION] tibia. Record review of the Clinical Notes for Resident #3 revealed: -6/20/18 at 6:41 p.m. Residents right leg is swelling and she complain of pain. Notified NP (Nurse Practitioner) and he ordered X-ray to right leg. - 6/21/18 at 11:53 am X-ray results shows oblique [MEDICAL CONDITION] proximal tibia. - 6/21/18 at 12:28 pm Resident had X-ray of right lower extremity due to intermittent pain and swelling with bruising. X-ray results showed fracture to tibia. Resident had complaints of pain this morning. [MEDICATION NAME] given with effectiveness, denies pain this afternoon. Resident to be sent to local hospital. - 6/21/18 Resident picked up at 13:45 pm by emergency ambulance and transported to local hospital. - 6/22/18 Resident in hospital. - 6/23/18 at 11:13 pm Resident complained of pain in her right leg. Administered pain medication and anxiety medication. Record review of the Medication Administration Record [REDACTED]. Start date 3/6/17. During an observation and interview on 7/5/18 at 9:21 Resident #3 was laying in her bed facing the window. She said she did not remember if she fell . She said she was feeling very sleepy and did not want to continue the interview. Record review of the Provider Investigation Report for Resident #3 revealed: - 6/20/18 at 7:26 pm- Description of Incident - CNA A was transferring the resident from the chair in to the bed. The resident yelled my leg, my leg. CNA A transferred the resident to her bed. RN B assessed the resident, noted swelling, redness and pain to the right leg and obtained an order for [REDACTED].>- 6/21/18 an x-ray revealed generalized osteopenia, oblique [MEDICAL CONDITION] tibia, and oblique [MEDICAL CONDITION] tibia. Resident #3 went to the emergency room . - 6/21/18 Date reported to HHSC. During an interview on 8/1/18 at 9:50 am the Director of Nursing said they reported the incident with Resident #3 as soon as they were informed of her fracture. During an attempted interview on 8/3/18 at 3:00 pm. CNA A was called and a message was left. She did not rturn the call. During an attempted interview on 8/3/18 at 3:05 pm. RN B was called and a message was left. She did not rturn the call. Record review of the hospital records for Resident #3 dated 6/22/18 revealed: - Admission - 6/21/18. - Discharge - 6/22/18 back to nursing home. - Imaging Results 6/21/18: - X-ray ankle 3 views right - Findings: Diffuse osteopenia is present. The distal tibia and distal fibula appears intact. - X-ray Right knee, 3 views - Findings: Diffuse osteopenia is present. There is a spiral fracture present within the proximal tibia. Record review of the statement dated 6/21/18 by RN B revealed: I am the charge nurse working the afternoon shift on 6/20/18 on 400 hall. I was taking care of Resident #3. During my first rounds I noted she was agitated and complained of pain in her right leg. When I assessed her, I noticed her right leg was swelling. I called the physician and got an order to do an x-ray to the right leg, which I did. Resident #3 was given [MEDICATION NAME] for pain with good effect. During my shift, resident did not fall or hit anywhere. Record review of the Accident/Incident Report for Resident #3 completed by LVN C dated 6/21/18 revealed: Person in charge- Account of occurrence: On the evening of 6/20/18 Resident #3 was noted to have redness, swelling and pain in right lower extremity .Resident complained of pain. [MEDICATION NAME] given, effective. Physician was contacted and order for x-ray was given. Record review of the Employee coaching and counseling Record for CNA A dated 6/22/18 revealed: - Date of violation 6/20/18 - Time of violation 2-10 pm - Location - in resident room. - Type of violation - substandard work - Supervisor remarks - CNA A failed to properly transfer a resident . Record review of the Employee coaching and counseling Record for RN B dated 6/26/18 revealed: - Date of violation 6/20/18 - Time of violation 2-10 pm - Location - facility - Type of violation - Major infraction, failure to order stat x-ray. - Supervisor remarks - On the evening of 6/20/18 failed to order a stat lab on a resident who the next day revealed she had a [MEDICAL CONDITION] extremity. She ordered the lab for the next day (audio from lab company was reviewed by the director of nursing and the administrator on 6/26/18) RN B failed to act as a prudent nurse. Action to be Taken - Termination. Record review of the facilities Policies and Procedures revealed: - Abuse Protocol dated (MONTH) (YEAR) - 1. The resident has the right to be free from abuse, neglect . 8. Any person observing an incident of Resident abuse must immediately report such incidents to the charge nurse . 9. The charge nurse will immediately notify the abuse prevention coordinator . 10. The abuse prevention coordinator will: a. Immediately (within 2 hours) report to the Department of Aging and disability Services and other appropriate authorities' incidents of resident abuse as required under applicable regulations .Report events that cause reasonable suspicion of serious bodily injury immediately (within 2 hours) after forming the suspicion . - Transfers revised 07/2014: Method, equipment and preparation dated 6/14/2006 - When 2 people are moving a patient, one person should lead and count 1-2-3 so the patient and other assisting personnel participate simultaneously. The Administrator said there were 10 residents transferred via mechanical lift.

Based on observation, interview and record review the facility failed to ensure that a resident who entered the facility without pressure sores did not develop pressure sores unless unavoidable; and a resident with pressure sores received necessary treatment and services to promote healing for one of two residents (Resident #6) reviewed for pressure ulcers. The facility did not develop a care plan for Resident #6 to prevent pressure ulcer development who developed a 3.3 x 1.4 x 0.1 open wound on her left buttock at the facility. This failure affected one resident and placed 86 residents receiving preventative skin care at risk of developing pressure ulcers. Findings include: Resident #6 Record review of Resident #6's admission sheet revealed she was a [AGE] year old admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #6's initial MDS dated [DATE] revealed that she had no skin issues when she was admitted to the facility. Record review of Resident #6's initial MDS dated [DATE] CAA (Care Area Assessment) Summary indicated she needed a care plan for Pressure Ulcer prevention or care. Record review of Comprehensive Plan of Care dated 7/15/15 for Resident #6 revealed no Plan of Care for prevention of Pressure Ulcers. Observation and Interview on 10/13/15 at 10:41 a.m. revealed Resident #6 was sitting up in bed. She was dressed in facility gown, groomed, and said, Want to get off my butt, hurts a lot. CNA J informed the resident that she would tell the nurse she needed pain medication. Interview on 10/13/15 at 2:15 p.m. with Resident #6 revealed resident said she had been up since lunch at noon and wanted to go back to bed because her bottom was hurting her. Observation on 10/13/15 at 2:45 p.m. of Resident #6's incontinent care provided by CNA G and CNA F was conducted. There was no protective dressing on an area of Resident #6's left buttock that had an open sore area. There was no visible residue of an ointment. The open area was the size of a quarter; the skin around the open area was red. When the open area was wiped, it bled. Interview on 10/14/15 at 11:00 a.m., the DON said that the CNAs were supposed to report any skin issues to the charge nurse, apply protective cream if there was any a break in the skin, and refer the issue to the wound care nurse. Interview on 10/14/15 at 2:30 p.m., CNA G said that he informed the charge nurse (unnamed) about the wound on Resident #6's buttocks and was told to apply ointment to the area and to reposition the resident every 2 hours. Record review of Resident #6's Nurse Note dated 8/6/15 revealed, Wound care eval: pt. has red area to buttocks, both right & left side. Skin intact in all areas. Will continue to monitor. Record review of October 2015 Treatments revealed, Wound Treatment - Calcium Aliginate w/Silver One Time Daily Starting 09/01/2015 . Notes: Cleanse wound to Lt Buttocks with Normal Saline or Skin Cleanser. Pat Dry. Apply Calcium Alginate w/Silver to wound bed. Cover with dry dressing. Record review by Wound Care Specialist Evaluation dated 9/3/15 revealed, Chief Complaint: Patient has a wound on their buttock. Dressing: Dry Protective Dressing - Once Daily. Record review of Wound assessment dated [DATE] revealed, the wound to be 3.3 x 1.4 x 0.1, had moderate exudate and the Response to treatment - deteriorated. The wound assessment was signed by LVN C. Record review of the facility's Skin policy and procedures revealed, A Wound Assessment form (see Briggs Form 3169HH) must be completed and updated weekly for any pressure ulcer and non-pressure skin condition, including Arterial Ulcers, Diabetic [MEDICAL CONDITION] Ulcers, [MEDICAL CONDITION] Ulcers, Bruises, Skin Tears and Surgical Wounds. Record review the facility's Continence Management Incontinence Care Protocol included Care plan and Daily Care Guide reflects every 2-hour checks, preventive skin care and turning/repositioning. Record review of the facility's CMS 672 revealed there were 87 residents receiving care to prevent pressure ulcers.