Every finding on record at Overton County Health and Rehab Center

Based on facility policy review, medical record review, and interview, the facility failed to document advance directives education and resident advance directive decisions in the medical record for 7 residents (Residents #3, #20, #24, #43, #56, #66, and #81) of 7 residents reviewed for advanced directives. The findings include: Review of the facility's policy titled, Advance Directives, revised 9/2022, revealed .The resident has the right to formulate an advanced directive .The facility defines the following .Advance care planning .Advance Directive .Living Will .Durable power of attorney for Healthcare .Prior to or upon admission of a resident, the social services director or designee inquires .about the existence of any written advanced directives .the resident or representative is provided with written information .information about whether or not the resident has executed an advanced directive is displayed prominently in the medical record . Medical record review revealed Resident #3 was admitted to the facility on [DATE] with diagnoses including Schizoaffective Disorder, Mood Disorder, Psychotic Disorder with Hallucinations, Anxiety Disorder, Unspecified Dementia with Behavioral Disturbance, Chronic Kidney Disease, Convulsions, Spinal Stenosis, and Parkinson's Disease without Dyskinesia. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #3 scored a 3 on the Brief Interview for Mental Status (BIMS) assessment which indicated severe cognitive impairment. Review of an admission Agreement dated 8/2/2010, revealed no written documentation of advance directive education for Resident #3 was discussed or provided to the resident's representative. Review of the medical record revealed no documentation for Resident #3's decisions regarding advanced directives to include advanced care planning, living will, and power of attorney. Review of the medical record revealed Resident #20 was admitted to the facility on [DATE] with diagnoses including Obstructive and Reflux Uropathy, Chronic Atrial Fibrillation, and Unsteadiness of Feet. Review of an admission MDS assessment dated [DATE], revealed Resident #20 scored a 13 on the BIMS assessment which indicated the resident was cognitively intact. Review of an admission Agreement signed 2/28/2025, revealed no writen documentation of advanced directive education for Resident #20 was discussed or provided to the resident or resident's representative. Review of the medical record revealed no documentation for Resident #20's decisions regarding advanced directives to include advanced care planning, living will, and power of attorney. Review of the medical record revealed Resident #24 was admitted to the facility on [DATE] with diagnoses including Parkinson's Disease, Dementia, Depression, Psychotic Disorder, and Pain. Review of a quarterly MDS assessment dated [DATE], revealed Resident #24 scored a 12 on the BIMS assessment which indicated moderate cognitive impairment. Review of an admission Agreement signed 4/6/2024, revealed no written documentation of advance directive education for Resident #24 was discussed or provided to the resident or resident's representative. Review of the medical record revealed no documentation for Resident #24's decisions regarding advanced directives to include advanced care planning, living will, and power of attorney. Review of the medical record revealed Resident #43 was admitted to the facility on [DATE] with diagnoses including Stroke, Depression, Hypertension, and Difficulty Swallowing. Review of a quarterly MDS assessment dated [DATE], revealed Resident #43 scored an 11 on the BIMS assessment which indicated moderate cognitive impairment. Review of an admission Agreement signed 8/23/2024, revealed no written documentation of advance directive education for Resident #43 was discussed or provided to the resident or resident's representative. Review of the medical record revealed no documentation for Resident #43's decisions regarding advanced directives to include advanced care planning, living will, and power of attorney. Review of the medical record revealed Resident #56 was admitted to the facility on [DATE] with diagnoses including Parkinson's Disease, Type 2 Diabetes, Anxiety, and Depression. Review of a quarterly MDS assessment dated [DATE], revealed Resident #56 scored a 14 on the BIMS assessment which indicated the resident was cognitively intact. Review of an admission Agreement signed 2/16/2023, revealed no written documentation of advance directive education for Resident #56 was discussed or provided to the resident or resident's representative. Review of the medical record revealed no documentation for Resident #56's decisions regarding advanced directives to include advanced care planning, living will, and power of attorney. Review of the medical record revealed resident #66 was admitted to the facility on [DATE], with readmission on [DATE], with diagnoses which included Malignant Neoplasm of Prostate, Secondary Malignant Neoplasm of Right Lung, Attention to Cystostomy, Gastrostomy, and Adult Failure to Thrive. Review of an end of Prospective Payment System stay MDS assessment dated [DATE], revealed Resident #66 scored an 8 on the BIMS assessment which indicated moderate cognitive impairment. Review of an admission Agreement signed 10/5/2023, revealed no written documentation of advance directive education for Resident #66 was discussed or provided to the resident's representative. Review of the medical record revealed no documentation for Resident #66's decisions regarding advanced directives to include advanced care planning, living will, and power of attorney. Review of the medical record revealed Resident #81 was admitted to the facility on [DATE] with diagnosis including Fracture of Lower End of Left Humerus, Generalized Anxiety Disorder, and Acute Kidney Disorder. Review of an admission MDS assessment dated [DATE], revealed Resident #81 scored a 15 on the BIMS assessment which indicated the resident was cognitively intact. Review of an admission Agreement signed 4/14/2025, revealed no written documentation of advanced directive education for Resident #81 was discussed or provided to the resident or resident's representative. Review of the medical record revealed no documentation for Resident #81's decisions regarding advanced directives to include advanced care planning, living will, and power of attorney. During a record review and interview on 5/14/2025 at 9:00 AM, the Social Services Director (SSD) reviewed the signed admission Agreements and medical records for Residents #3, #20, #24, #43, #56, #66, and #81. The SSD stated there was no documentation in the medical records to indicate the residents had received and understood the advance directive education provided or information regarding the residents advance directive decisions. During further interview the SSD confirmed the facility failed to document advance directives education and resident advance directive decisions in the medical record for Residents #3, #20, #24, #43, #56, #66, and #81.

Based on facility policy review, medical record review, observation, and interview, the facility failed to secure resident identifiable information during medication administration for 3 residents (Residents #16, #52, and #23) of 4 residents observed for medication administration. The findings include: Review of the facility's policy titled, Electronic Medical Records, revised 3/2014, revealed .Electronic records are an acceptable form of medical record management .Only authorized persons who have been issued a password and user ID [identification] code will be permitted to access .The facility will make reasonable efforts to limit the use or disclosure of protected health information .Our electronic medical records system has safeguards to prevent unauthorized access of electronic protected health information . Review of the medical record revealed Resident #16 was admitted to the facility on [DATE] with diagnoses including Tourette's Disorder, Type 2 Diabetes, Mood Disorder, and Seizures. Review of an annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #16 scored a 10 on the Brief Interview for Mental Status (BIMS) assessment which indicated moderate cognitive impairment. Review of the medical record revealed Resident #52 was admitted to the facility on [DATE] with diagnoses including Parkinson's Disease, Depression, Adjustment Disorder, and Pain. Review of an annual MDS assessment dated [DATE], revealed Resident #52 scored a 13 on the BIMS assessment which indicated the resident was cognitively intact. Review of the medical record revealed Resident #23 was admitted to the facility on [DATE] with diagnoses including Adjustment Disorder, Schizophrenia, Anxiety, Bipolar Disorder, and Pain. Review of an end of Prospective Payment System stay MDS assessment dated [DATE], revealed Resident #23 scored a 5 on the BIMS assessment which indicated severe cognitive impairment. During an observation on 5/13/2025 at 10:01 AM, Licensed Practical Nurse (LPN) A pushed a medication cart to Resident #16 and Resident #52's room. The medication cart contained a laptop used for accessing electronic health care records and a narcotic record book which contained residents' narcotic prescription information. LPN A opened the Electronic Medication Record Administration tab on the laptop. LPN A left the medication cart and entered Resident #16's room to perform hand hygiene. LPN A left the medication cart with Resident #16's medical record information visible on the laptop screen. During further observation LPN A returned to the cart, opened the narcotic record book, prepared Resident #16's medications, partially closed the laptop screen, did not close the narcotic record book, and entered Resident #16's room for medication administration. The resident's medical record was visible on the laptop screen and the resident's narcotic prescription information was visible. During an observation on 5/13/2025 at 10:05 AM, LPN A returned to the medication cart. LPN A re-opened the laptop, prepared medications for Resident #52, closed the narcotic record book, partially closed the laptop screen, left the medication cart, and entered Resident #52's room for medication administration. Further observation revealed Resident #52's medical record was visible on the laptop screen. During an observation on 5/13/2025 at 10:07 AM, LPN A returned to the medication cart and pushed the medication cart to Resident #23's room. LPN A prepared Resident #23's medications, partially closed the laptop screen, left the medication cart, and entered Resident #23's room for medication administration. During an interview on 5/13/2025 at 10:10 AM, LPN A stated he was unaware he left Resident #16's medical record visible when he performed hand hygiene, and stated he was unaware he left Resident #16's narcotic prescription information visible during Resident #16's medication administration. LPN A also stated he was unaware he should have completely closed the laptop screen to prevent visibility and access to Residents #16, #52, and #23's health information. During further interview LPN A stated he was not aware and did not know how to use the electronic medical record system safeguards intended to protect residents' health information. During an interview on 5/13/2025 at 2:10 PM, the Director of Nursing (DON) stated it was her expectation for nurses to use the electronic medical record system safeguards, and expected nurses to secure resident medical record information. During further interview the DON confirmed the facility failed to secure residents medical information during medication administration for Residents #16, #52, and #23. During an interview on 5/13/2025 at 2:18 PM, the Administrator confirmed the facility failed to secure resident medical information during medication administration for Residents #16, #52, and #23.

Based on review of the Resident Assessment Instrument (RAI) Manual 3.0, medical record review, and interview the facility failed to accurately assess the discharge status for 1 resident (Resident #83) of 3 residents reviewed. The findings include: Review of the RAI Manual dated 10/2024, revealed .The RAI process has multiple regulatory requirements .the assessment accurately reflects the resident's status .A2105: Discharge Status .This item documents the location to which the resident is being discharged at the time of discharge. Knowing the setting to which the individual was discharged helps to inform discharge planning . Review of the medical record revealed Resident #83 was admitted to the facility on [DATE] with diagnoses including Orthopedic Aftercare, Hypertension, Atrial Fibrillation, and Presence of Right Artificial Knee. Review of the Care Plan Report dated 1/27/2025 for Resident #83 revealed, .Focus .Potential for discharge to lower level of care .Goal .Resident/Responsible party/POA (Power of Attorney) will be aware of community resources prior to discharge . Review of the Discharge Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #83 scored a 14 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Further review revealed Resident #83's discharge status was coded as being discharged to .04. Short-Term General Hospital . Review of a Social Services progress note for Resident #83 dated 2/13/2025 at 11:10 AM revealed, .SW (Social Worker) spoke with [Named Home Health], and they have resident's referral and plan on admitting her to home health services in the morning . Review of a Discharge Summary note for Resident #83, dated 2/13/2025 at 5:05 PM, revealed, .Resident discharging home with daughter at this time . Review of the facility Transfer/Discharge report dated 2/13/2025 revealed Resident #83 was, .Discharging home with family and [Named Home Health] assisting with care . During an interview on 5/14/2025, at 10:28 AM, the Administrator confirmed Resident #83 was discharged home on 2/13/2025 and the MDS discharge asssessment was inaccurate. During an interview on 5/14/2025, at 10:40 AM, the MDS/Licensed Practical Nurse (LPN) stated Resident #83 was discharged home with home health on 2/13/2025. The MDS/LPN confirmed the resident's discharge MDS assessment dated [DATE] coded the resident as discharged to the hospital and was inaccurate.

Based on review of facility policy, medical record review, observation, and interview, the facility failed to ensure bedpans were store in a sanitary manner for 2 residents (#1, #4) of 9 residents reviewed for sanitary storage of bedpans. The findings include: Review of facility policy Bedpan/Urinal, Offering/Removal revised 2/2018, revealed .Clean the bedpan or urinal. Wipe dry with a clean paper towel. Discard paper towel into designated container. Store the bedpan or urinal per facility policy . Review of facility policy Bedpan/Urinal Storage Revised 2/2018, revealed .Store bedpan in plastic bag under resident's sink . Medical record review revealed Resident #1 was admitted to the facility on 7/3/18 and readmitted on [DATE] with [DIAGNOSES REDACTED]. Observation on 6/26/19 at 11:10 AM, in Resident #1's bathroom, revealed the resident's bedpan had dried brown debris on the outside and inside of the bedpan and was stored uncovered on top of the trash can. Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation on 6/26/19 at 11:20 AM, in Resident #4's bathroom, revealed the resident's bed pan had dried dark brown debris on the inside of the bed pan and was stored uncovered on the resident's commode. Interview with Licensed Practical Nurse (LPN) #2 on 6/26/19 at 11:20 AM, on the 300 hall, confirmed Resident #1 and Resident #4's bed pans had not been properly cleaned and were stored improperly. Interview with the Director of Nursing on 6/26/19 at 11:45 AM, on the 200 hall, confirmed the facility failed to proper clean and store the resident's bed pans and the facility failed to follow facility policy.

Based on review of the facility policy, medical record review, and interview, the facility failed to ensure a stop date was in place for as needed [MEDICAL CONDITION] MEDICATION ORDERS FOR [REDACTED]. The findings include: Review of the facility policy Antipsychotic Medication Use, last revised 12/2016, revealed .The need to continue PRN (as needed) orders for [MEDICAL CONDITION] medications beyond 14 days requires that the practitioner document the rationale for the extended order. The duration of the PRN order will be indicated in the order . Medical record review revealed Resident #41 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Physician's Order dated 11/12/18 revealed .[MEDICATION NAME] (antianxiety medication) 5 MG (milligrams) tablet take one tablet by mouth every 6 hours as needed for anxiety . Continued review revealed no stop date for the [MEDICATION NAME] ordered on [DATE]. Medical record review of the Medication Administration Record [REDACTED].Order date 11/12/18 . Continued review of the MAR indicated [REDACTED]. Interview with the Director of Nursing (DON) on 11/28/18 at 1:13 PM, in the conference room, confirmed a stop date was not in place on the Physician's Order for the [MEDICATION NAME] on 11/12/18 and confirmed the resident received 2 doses of the [MEDICATION NAME] after the 14 days specified in the facility policy.

Based on facility policy review, medical record review, review of a facility investigation, and interview, the facility failed to ensure the safety for 1 resident (#59) of 5 residents reviewed for accidents of 23 residents sampled. The findings include: Review of the Facility Policy Fall Risk Reduction and Management revised 2/2013, revealed .It is the policy of the facility to ensure a safe environment with the least restrictive measures while promoting the highest possible level of independence and quality of life . Medical record review revealed Resident #59 was admitted to the facility on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. Medical record review of the 30 Day Minimum Data Set ((MDS) dated [DATE] revealed Resident #59 scored a 3 (cognitively impaired) on the Brief Interview for Mental Status (BIMS). Continued review revealed the resident required extensive assistance of 1 or 2 staff members for activities of daily living and had 1 fall since admission. Review of a facility fall investigation dated 10/9/18 revealed .was called to hallway from another resident's room and observed resident sitting on right hip with back against geri chair (recliner) .no apparent injury . Continued review revealed .Immediate post-incident action .Educated staff to ensure geri chair is securely reclined in locked position . Further review revealed .Resident's legs had been reclined but resident was able to push the foot rest down and attempt to get up. Staff to ensure when geri chair is in reclined position that the lock is engaged securely for safety . Interview with Registered Nurse #1 on 11/27/18 at 10:09 AM, in the conference room, confirmed the level holder (locking device) on Resident #59's geri chair was not locked at the time of the fall.

Based on facility policy review, medical record review, and interview the facility failed to monitor potential adverse effects of [MEDICAL CONDITION] drug use for 1 resident (#103) of 5 residents reviewed for [MEDICAL CONDITION] drug use. The findings included: Review of facility policy, Behavior Assessment and Monitoring, revised date of 11/03/12 .The nursing staff and the physician will monitor for side effects and complications related to psychoactive medications . Medical record review revealed Resident #103 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Medication Administration Record (MAR) dated December 2016 revealed the resident receved the following [MEDICAL CONDITION] medications: Duloxetine (antidepressant), [MEDICATION NAME] (antidepressant), [MEDICATION NAME] (antipsychotic), and [MEDICATION NAME] (antianxiety). Review of the care plan revealed Problem onset: dated 08/29/2016 At risk for developing adverse effects to [MEDICAL CONDITION] meds . Approaches . Evaluate effectiveness and adverse effects of meds for possible decrease/elimination of [MEDICAL CONDITION] meds . Observe resident for adverse effects . Medical record review revealed no documentation of monitoring for adverse effects with the use of [MEDICAL CONDITION] medications since admission. Interview with Licenced Practical Nurse #1 on 12/07/16 at 7:58 AM in the hallway near the dayroom/dining room in the Dogwood Cottage revealed the monitoring of adverse effects of [MEDICAL CONDITION] medications was to be documented on the MAR per shift. Interview with the Director of Nursing (DON) on 12/07/2016 at 8:08 AM in the DON's office revealed the nursing staff was to document the monitoring for side effects/adverse reactions of [MEDICAL CONDITION] medications on the MAR. Continued interview confirmed the facility had failed to monitor for side effects/adverse reaction of [MEDICAL CONDITION] medications as per the resident's care plan.

Based on facility policy review, medical record review, and interview, the facility failed to assess pressure ulcers accurately and measure ulcers in a consistent manner for 1 (Resident #4) of 6 residents reviewed. The findings included: Review of facility policy entitled Skin/Wound Management Protocols in the section on Unstageable Pressure Ulcer or Full Thickness Wounds with Eschar or Slough revealed unstageable is defined as .full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed . Topical wound management includes selecting a product that will promote moist wound healing properties. Dressing choice should be determined by wound characteristics such as size, depth, amount of drainage. If the wound does not progress within 2-4 weeks contact a physician for further evaluation For wound with dead space (craters) gently fill with dressing product but do not pack tightly as this will impede healing. Monitor patient for signs and symptoms of infection. Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #4 scored 4/15 on the Brief Interview for Mental Status indicating she was severely impaired cognitively. Continued review of the MDS revealed Resident #4 was totally dependent on 2 staff for transfers and bathing; was totally dependent on 1 person for eating; required extensive assistance of 2 people for dressing and grooming; had a Foley catheter in place; and was frequently incontinent of bowel. Medical record review of the Nursing Admission assessment dated [DATE] revealed Resident #4 had an excoriated area to the right anterior thigh, skin tear to left posterior shoulder, and a skin tear to the right inner thigh. Continued review revealed .Multiple pressure areas noted to buttocks et coccyx area . Medical record review of wound care notes revealed Resident #4 was admitted with a skin tear to the right upper shoulder measuring 1.5 centimeters (cm) x (by) 1.0 cm with the edges not well approximated. Continued review revealed Resident #4 was also admitted with a skin tear to the right breast measuring 1.5 cm x 3.0 cm with its edges not well approximated. Further review revealed Resident #4 was also admitted with a ruptured blister to the right inner thigh measuring 2.5 cm x 1.5 cm with scant serous drainage. Continued review revealed Resident #4 was admitted with a sacral pressure ulcer which was unstageable due to slough but measured 6.0 cm x 9.0 cm x 4.0 cm. Continued review revealed the wound bed was 75% eschar and 25% slough with macerated borders of the wound and a moderate amount of serosanguinous drainage. Medical record review of wound care notes dated 12/30/15 revealed the sacral wound measured 8.5 cm x 10 cm x 3.8 cm with 75% eschar and 25% slough. Continued review revealed the wound bed was covered with [MEDICATION NAME] cream and the wound was packed with gauze. Medical record review of wound care notes dated 1/10/16 revealed the sacral wound was still unstageable and measured 11.0 cm x 7.0 cm x 3.5 cm with 25% [MEDICATION NAME] and 75% slough. Medical record review of wound care notes dated 1/20/16 revealed the sacral wound was still unstageable and measured 10.0 cm x 9.0 cm x 3.0 cm. Continued review revealed the wound bed was 100% slough with purulent drainage and macerated wound edges. Medical record review of wound care notes dated 1/27/16 revealed the sacral wound was still unstageable due to slough/eschar and measured 10.0 cm x 13.0 cm x 2.0 cm. Continued review revealed the wound bed was 100% slough and there was a small amount of serous drainage. Further review revealed there was undermining at 12,1 and the wound had a slight mal odor. Medical record review of a communication with the resident's personal physician revealed .unstageable wound to sacrum showing decline. Modest amount of purulent drainage noted. Applied [MEDICATION NAME] per (named wound care physician) orders. She continues to follow up with him next appt (appointment) is Feb. 15th. Any new orders? . Continued review revealed the physician wrote OK on the communication. Further review revealed no notification of the wound care physician concerning the decline of the sacral pressure ulcer. Review of the Nursing Admission Assessment from the hospital dated 1/27/16 revealed Resident #4 had a Stage IV pressure ulcer to the coccyx which measured 10 cm x 6 cm x 3.5 cm with undermining with yellow slough in the middle and necrotic tissue around the edge and bloody drainage. Continued review revealed a Stage II pressure ulcer on the right buttock measuring 5 cm x 3.8 cm with yellow wound bed. Further review revealed a stage II pressure ulcer to the right buttock measuring 2 cm x 1.8 cm. Continued review revealed 4 stage II pressure ulcers around the rectum. Review of the admission History and Physical revealed under the skin assessment .revealed a large stage IV decubitus ulcer measuring 6 or 8 cm across located in the decubitus area. There is some purulence in them, some surrounding redness and some shallow stage II ulcerations, 2 of which I saw just to the right of the larger decubitus ulcer . Medical record review of a physician's note dated 2/13/16 revealed Resident #4 was transferred to the hospital for a .large gaping coccygeal wound. Since discharge a culture has been obtained of her coccygeal wounds had has grown out E-Coli with ESBL characteristics (organisms normally in feces with antibiotic resistant tendency). She has a large decubitus ulcer that is at least a Grade 4 is noted on the coccygeal area that measures 6-8 cm. Continue wound care as is being done now. If it does not improve we may want to revisit another wound care evaluation . Interview with the Director of Nursing (DON) on 8/16/16 at 2:20 PM in the Administrator's office revealed the Wound Care Nurse who treated the sacral ulcer of Resident #4 was no longer employed by the facility. Continued interview revealed the new Wound Care Nurse had only been in the position for 2 1/2 months. In further interview the DON confirmed the sacral ulcer was the only ulcer documented as being treated from admission on 12/22/15 through 1/27/16. Continued interview revealed without a picture it was difficult to read the wound reports since it was not clear in which direction the Wound Care Nurse was measuring due to inconsistent changes in measurements.

Based on facility policy review, medical record review, and interview, the facility failed to follow their policy to obtain urine cultures for residents with cloudy urine for 1 (Resident #4) of 6 residents reviewed. The findings included: Review of policy entitled Culture tests and confirmed by the DON on 8/16/16 at 3:30 PM as being the policy the facility currently follows, revealed .Urine cultures may be obtained by the Charge Nurse if a resident develops cloudy urine or other signs of urinary tract infection. An order from the physician must be obtained before the specimen is sent to the laboratory . Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #4 scored 4/15 on the Brief Interview for Mental Status indicating she was severely impaired cognitively. Continued review of the MDS revealed Resident #4 was totally dependent on 2 staff for transfers and bathing; was totally dependent on 1 person for eating; required extensive assistance of 2 people for dressing and grooming; had a Foley catheter in place; and was frequently incontinent of bowel. Medical record review of a communication with the physician dated 12/29/15 revealed .Family noted dark colored urine which they verbalized was indicative of a UTI (urinary tract infection). May we obtain UA (urinalysis) to verify? . Continued review revealed the physician responded on 1/2/16 to obtain one by an in and out catheterization. Further review revealed a note from the physician's office dated 1/4/16 stating .do not obtain UA D/T (due to) ABT (antibiotics) in use . Medical record review of nursing notes dated 1/13/16 revealed Resident #4 had a Foley catheter which was draining cloudy urine with sediment. Continued review of notes dated 1/15/16 revealed the Foley catheter was draining cloudy yellow urine with moderate amount of sediment. Further review of nursing notes dated 1/19/16 revealed the Foley was draining cloudy yellow urine with sediment. Continued review of nursing notes dated 1/23/16 revealed Foley catheter was patent draining cloudy yellow urine. Further review of nursing notes dated 1/24/16 revealed the Foley was draining light yellow urine. Review of physician communications revealed no documentation the physician was notified of the cloudy urine with sediment. Further review revealed no nursing orders for a urinalysis as per policy. Continued review of the History and Physical from the hospital revealed one of the admitting [DIAGNOSES REDACTED]. Interview with the DON on 8/16/16 at 2:20 PM in the Administrator's office, revealed Resident #4 was receiving [MEDICATION NAME] 250 milligrams four times daily for [MEDICAL CONDITION] infection from admission and it was discontinued on 1/22/16. In continued interview the DON confirmed a urine culture should have been sent 3 days after completion of the antibiotics which was facility policy and would have been 1/25/16 but a culture was not sent. In further interview the DON confirmed the policy on Culture Tests was the one currently in use in the facility and there was a statement the charge Nurse could order a urinalysis if a resident had cloudy urine and no culture was ordered.

Based on observation, review of the portion control spread sheet, and interview, the facility dietary department failed to serve the chicken casserole according to the specified portion for 20 of 32 trays observed. The findings included: Observation on 12/14/15 at 11:32 AM in the dietary department, of the resident mid-day meal service in progress, revealed the regular and mechanical soft texture diets were served a 4 ounce portion of chicken casserole and the pureed texture diets were served 1 #16 scoop (provided 2 - 2 1/4 ounce portion) of chicken casserole. Review of the portion control spread sheet, posted on the trayline during the meal service, revealed the regular and mechanical soft texture diets were to receive a 9 ounce portion and the pureed texture diets were to receive 2 #8 scoops ( #8 scoop provides 4 - 5 ounces per serving) of the chicken casserole. Interview with the Dietary Manager on 12/14/15, in the dietary department at the trayline during the meal service at 11:55 AM and on the Wing 3 dining room at Noon, confirmed the chicken casserole was not served as specified on the portion control spread sheet for regular and mechanical soft at 9 ounces, and the pureed diets at 8 - 10 ounces.

Based on medical record review and interview the facility failed to accurately complete a Minimum Data Set (MDS) for 1 (Resident #113) of 33 residents reviewed. The findings included: Medical record review revealed Resident #113 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Physician order [REDACTED]. Medical record review of the Medication Administration Record [REDACTED]. Medical record review of a Quarterly MDS dated [DATE] documented under section N0410 Medication Received, 0 doses of antipsychotic drugs had been received by the resident in the past 7 day look back period (7 days prior to 9/25/15). Interview with Registered Nurse #1 on 12/16/15 at 10:45 AM, in the MDS office confirmed the facility had failed to accurately complete the 9/25/15 Quarterly MDS for Resident #113 by failure to accurately assess the administration of the antipsychotic medication Quetiapine.

Based on family interview, facility record review, medical record review, and interview, the facility failed to prevent a significant medication error for one resident (#107) of twenty-nine residents reviewed. The findings included: Resident #107 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Interview with the resident's family, on October 27, 2014, at 1:30 p.m., in the conference room revealed "They overdosed...with [MEDICATION NAME]." Review of a facility investigation dated September 8, 2014, at 3:40 a.m., revealed "Employee...administered 1 milliliter (ml) /20 milligrams (mg) [MEDICATION NAME] (liquid [MEDICATION NAME] pain medication) instead of 0.1 ml/2mg [MEDICATION NAME] notified shift sup (supervisor)...MD (physician) was notified with res (resident) sent to...(hospital) and admitted for observation...husband notified." Medical record review of the hospital Discharge Summary dated September 9, 2014, revealed "...(Resident) was admitted to the ICU (Intensive Care Unit) for observation after receiving an overdose of [MEDICATION NAME] at the nursing home. Doing well without any mental status changes or any other problems. Vital signs remain stable. This morning...going to be returned to the nursing home in good condition." Medical record review of a Physician's Progress Note dated September 14, 2014, revealed "...had recent episode where...was actually placed in the hospital for an inadvertant overdose of some [MEDICATION NAME] done well since without any other changes or difficulties...we have made some alterations in medications... " Interview with the Director of Nursing (DON), on October 29, 2014, at 10:00 a.m., in the DON's office confirmed the facility had failed to prevent a significant medication error when [MEDICATION NAME] 20 mg was administered instead of the ordered [MEDICATION NAME] 2 mg.

Based on observation, medical record review, and interview, the facility failed to apply a safety device correctly resulting in the inappropriate use of a restraint for one resident (#21) of thirty-five residents observed for the use of restraints. The findings included: Resident #21 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Observation of the resident on October 27, 2014, at 2:10 p.m., in the hallway of Wing 2, revealed the resident was seated in a shower chair and was being pushed down the hall by Certified Nursing Assistant (CNA #1) and #2. Continued observation revealed the resident had a self-release seat belt which was fastened around the resident's waist. Further observation of the resident revealed the resident's arms were at the resident's side and the seatbelt was also wrapped around the resident's arms securing the resident's arms to the resident's side. Continued observation revealed the resident was not able to self-release the restraint due to the resident's arms secured to the resident's side by the seatbelt. Medical record review of the most recent quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident was assessed as not having a restraint in use. Medical record review of a Pre-Restraining Evaluation dated August 14, 2014, revealed, "...Restraints not indicated..." Review of facility policy, Restraint Management, (not dated) revealed, "...Restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully. Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience, or for the prevention of falls...Practices that inappropriately utilize equipment to prevent resident mobility are considered restraints and are not permitted..." Interview with Certified Nurse Assistant (CNA) on October 27, 2014, at 2:11 p.m., in the Wing 2 Shower room, confirmed the CNA had applied the seat belt on the shower chair to the resident. Continued interview with CNA #1 confirmed the seat belt was wrapped around the resident's waist and had also been wrapped around the resident's arms preventing the resident from moving the resident's arms. Further interview with CNA #1 confirmed the resident was unable to move the resident's arms and CNA #1 stated "...it was an accident..." Interview with Licensed Practical Nurse (LPN) #1 on October 27, 2014, at 2:17 p.m., at the Wing 2 Nurse Station, confirmed seat belts are to be used as a safety device when a resident is transported to the shower room. Continued interview confirmed the seat belt was not to be applied in a manner to restrict a resident's arms. Further interview with LPN #1 confirmed the seat belt was applied incorrectly and was an improper use of a restraint.

Based on observation and interview, the facility failed to dispose of refuse properly. The findings included: Observation and interview on September 17, 2013, at 8:25 a.m., with the Dietary Manager and Dietary Technician present during the observation, confirmed the following: The facility had an exterior dumpster with three of three upper doors open. Continued observation revealed boxes and bagged refuse exposed in two of three open doors of the dumpster. Further observation revealed a facility housekeeper swinging two of two filled plastic refuse bags over the housekeeper's head in order to get the bagged refuse into the dumpster. Further observation revealed the housekeeper take a mop handle and push the bagged refuse and boxes away from two of three door openings. Further observation revealed two dietary staff members lifting numerous card board boxes over their heads into the dumpster. Further observation revealed the exterior rear door was unsecured. Interview with the Dietary Manager at that time confirmed the facility staff were able to walk into the dumpster to dispose of refuse from the unsecured rear door, and confirmed the facility failed to dispose of garbage and refuse properly.

Based on observation and interview, the facility dietary department failed to maintain and process dietary equipment in a sanitary manner. The findings included: Observation and interview on September 17, 2013, at 7:50 a.m., with the Dietary Manager present during the observation, confirmed the following: 1.) The can opener slot had an accumulation of blackened debris. 2.) The interior lid and extension arm of the tilt skillet had a very heavy accumulation of blackened debris. 3.) Two of two walk-in refrigerator condenser fan grates and ceiling areas had blackened debris present. 4.) The dietary staff member working the dirty side of the dish machine pushed dish racks containing dirty pans into the dish machine. Further observation revealed the dirty dish racks came into direct contact with the clean dishes inside the machine in four observed cycles of the operation.

Based on medical record review, and interview, the facility failed to follow physician's orders for one resident (#25) of thirty-one residents reviewed. The findings included: Resident #25 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a physician's order dated June 18, 2013, revealed "...D/C (Discontinue) Glucerna (Diabetic Nutritional Supplement) TID (Three Times a Day) d/to (Due To) wt (Weight) increase..." Interview with the Dietetic Technician on September 17, 2013, at 3:40 p.m., in the Wing I nurses' station revealed "...is receiving a can of Glucerna at HS (at night) for bedtime snack..." Interview with the Dietetic Technician and Registered Nurse #1 on September 17, 2013, at 4:00 p.m., at the Wing 1 nurses'station, confirmed the resident had received the Glucerna without a physician's order.

Based on Minimum Data Set review, and interview, the facility failed to complete the comprehensive assessment for one resident (#151) of thirty-one residents reviewed. The findings included: Resident #151 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) information, and interview with the MDS Coordinator, on September 18, 2013, at 10:18 a.m., in the MDS office, revealed the facility process was to complete the admission comprehensive assessment with the 5 (five) day MDS. Further interview confirmed the Admission/5 day MDS had not been completed or submitted.

Based on observation, and interview, the facility failed to maintain a safe and sanitary shower stall for one out of two showers in Wing III. The findings included: Observation on September 16, 2013, at 9:30 a.m., in the Wing III shower room, revealed cracked and loose tile proximate to the drain. Further observation revealed black debris on the shower walls and on the shower floor seams. Interview with the Licensed Practical Nurse (LPN) #2, on September 16, 2013, at 9:40 a.m., in the Wing III shower room, confirmed the cracked and loose tile in the shower drain. Further interview with the LPN #2 confirmed the black debris on the shower walls and on the shower floor seams. Interview with Maintenance worker #1, on September 17, 2013, at 2:00 p.m., in the Wing III shower room confirmed the broken tile and the black debris around the seams of the shower stall.

Based on observation, medical record review, facility policy review, and interview, the facility failed to notify the physician of a skin condition for one resident (#151) of thirty-one residents reviewed. The findings included: Resident #151 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the facility form, Visual Observation, dated September 7, 2013, revealed "Resident has a sore on...head L (left) side of forehead..." Further review revealed a written notation of "Cream applied. Nurse Aware." Medical record review of the physician progress notes [REDACTED]. Medical record review of the Skilled Daily Nurses Note dated September 7 through 17, 2013, revealed the "skin color normal" and the rest of the skin condition section was not completed other than "slight" pallor on September 15, 2013. Further review revealed no documentation of physician notification regarding the skin condition discovered on September 7, 2013. Medical record review of the Nurse's Note dated September 17, 2013, at 4:25 p.m., revealed "...0.75 cm (centimeters) x 0.5 cm rough area to forehead. Bed of area red et tanned edges. No drainage. No [MEDICAL CONDITION] or redness to surrounding integument...MD (physician) notified..." Review of the facility document titled Weekly Skin Integrity Review dated September 7 and 14, 2013, revealed no documentation of the "...sore on...head L side of forehead..." identified on the September 7, 2013, Visual Observation form. Review of the facility policy titled Wound and Skin Management Protocols (undated), revealed "...Purpose: An easy reference is provided for the attending physician and nursing staff when a resident experiences a skin condition or wound...Standard: The attending physician prescribes skin and wound care treatment as indicated...Process: I Documentation...When skin conditions or wounds appear in a resident, the nurse should: a) Refer to wound care protocols to assist the attending physician in the determination of appropriate treatment regimen...c) The weekly Pressure Sore Tool should be completed weekly to provide information on the current condition of a wound...e) Nursing notes should include pertinent observations regarding the resident's skin or changes in condition..." Observation on September 16, 2013, at 2:41 p.m., and September 17, 2013, at 9:00 a.m., 12:00 p.m., and at 4:14 p.m., with Licensed Practical Nurse (LPN) #1 present, revealed the resident had a scabbed area on the left side of the forehead. Interview with LPN #1 on September 17, 2013, at 4:13 p.m., with the resident present, by the Wing 4 nursing station, confirmed the resident had a sore area on the left side of the forehead. Further interview confirmed the Nurse's Notes and the Skilled Daily Nurses Note from September 7 to 17, 2013, did not address the skin condition. Interview on September 18, 2013, at 8:50 a.m., at the Wing 4 nursing station, with LPN #2 (Wound Nurse), revealed the nurses would report any skin concerns to the wound nurse for further assessment. Interview on September 18, 2013, at 9:35 a.m., at the Wing 4 nursing station, with the Director of Nursing, revealed the Certified Nurse Aides were to complete a Visual Observation form when bathing the resident. Further interview confirmed the Visual Observation form dated September 7, 2013, addressed a "...sore on...head L side of forehead..." Further interview confirmed there was no documentation the physician had been notified on September 7, 2013, regarding the skin condition.

Based on medical record review, review of facility policies, observation, and interview, the facility failed to follow facility policies and provide medically-related social services for four (#1, #27, #16, #17) residents of thirty-two residents reviewed. The facility's failure to ensure policies were followed and medically-related social services were provided for a resident in crisis beginning on February 25, 2012, resulted in the resident obtaining a dinner knife, and attempting to stab (resident #1's) self in the chest. Resident #1's attempted suicide on [DATE], required a transfer to the hospital emergency room and admission to a mental health unit for treatment. The facility's failure placed resident #1 in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). The Administrator and Director of Nursing were informed of the Immediate Jeopardy in the Conference Room on [DATE], at 11:30 a.m. F250 resulted in Substandard Quality of Care. The findings included: Resident #1 was admitted to the facility from the local hospital on February 10, 2012, with [DIAGNOSES REDACTED]. Medical record review of the hospital Discharge Summary dated February 10, 2012, revealed, (the resident was) "...significantly disabled...due to a cerebrovascular accident in...2009 which has left (resident) [DIAGNOSES REDACTED] and very poorly coordinated..." and had a history of [REDACTED]. Medical record review of the admission orders [REDACTED]. Medical record review of the Nursing Admission assessment dated [DATE], at 1:00 p.m., revealed the resident's cognition as oriented to person, place, time, and was alert. The resident was able to recall three named objects after five minutes, and was able to understand communication. Medical record review of a Nurse's Note dated February 15, 2012, at 9:45 a.m., revealed the resident was beginning to exhibit confusion, "...thinks...is going home today...states (spouse) is getting out of the hospital...going home with (spouse)...will monitor." Medical record review of the Social Service Progress Notes revealed no documentation the Social Worker (SW) assessed the resident's confusion and/or provided interventions to determine the cause of the resident's confusion on February 15, 2012, at 9:45 a.m. Medical record review of a Social Service Progress Note dated February 24, 2012, at 1:35 p.m., revealed, "Family told SW (Social Worker) resident called the POA (Power-of-Attorney)...and (resident's spouse) late last night at 10:40 p.m. and made a delusional statement. (Resident) said...would send (resident's sibling) over to (resident's spouse's) home to run off a (spouse's visitor) according to...POA...also stated resident had a hx (history) of making statement(s) wanting to take pills to end (resident's) life...stated (resident) has made these statements to family ,[DATE] (one-to-two) yrs (years). SW talked to the DON (Director of Nursing) and (contracted Mental Health Service) referral being sent for counseling and Dr. (Physician #1) notified for medication and instruction. SW spoke to the resident...stated...was concerned about spouse but not thinking of hurting (resident's) self @ (at) this time. (Resident) thinks...spouse has...(someone else)...Spouse just (recently) got out of hospital with heart by-pass (heart surgery). SW asked (resident) if (resident) had thoughts of how (resident) would hurt (resident's) self. Resident stated, 'I would use a knife because my family took my guns from me.' SW spoke to DON and nurse on unit. Resident to eat in dining room with plastic spoon and plastic knife for safety measure since (resident) made statement. (Physician #1) has ordered medications to address depression and anxiety. SW sent (contracted Mental Health Service) referral signed by (Physician #1) for counseling. SW will continue to monitor and will assist with any needs. Continued review of the SW notes revealed no supportive counseling due to the resident's concerns of the spouse having someone else, history of suicidal ideations, or the plan to use a knife to hurt the resident's self. Continued review revealed no documentation of the SW providing any medically-related social services during the remainder of the resident's admission at the nursing home. Medical record review of a (contracted Mental Health Service) physician's orders [REDACTED]. 1. Sad; 2. Agitation; 3. Delusions. Continued review of the referral revealed no documentation of urgency or crisis intervention ordered for this resident. Medical record review of an "Admit Note" dated February 25, 2012, (no time), documented by the Physician #1, revealed the resident was unable to care for (resident's) self, "particularly with (resident's) declining health." The note revealed the resident "has some delusional thought patterns about (resident's spouse) running off with somebody." The Physician's impression revealed the following: 1. CVA with left-sided hemiparesis; 2. CAD (Coronary Artery Disease) S/P (status [REDACTED]. 3. Type II diabetes mellitus currently on insulin therapy; 4. Chronic atrial fibrillation; 5. [DIAGNOSES REDACTED]. The Physician's plan revealed "Continue as per orders at this time." Continued review of the note revealed no documentation of the resident being at risk of suicide, and/or collaboration with the SW. Medical record review of a Nurse's Note dated February 25, 2012, at 9:59 p.m., revealed the resident was on the phone talking to the resident's spouse, "...(the resident)...talking and getting emotional et (and) crying continuing to state 'I'll just end it now.' (Resident) quickly changes tone et says sorry to (spouse)...This nurse (Licensed Practical Nurse (LPN) #1) spoke with...spouse et assured will keep close watch on Res (resident). Administered PRN Lunesta to help Res sleep. Res calm et polite to staff at this moment. Will cont (continue) to monitor..." Continued review revealed no documentation of the type of monitoring to be done or the frequency. Medical record review of the Social Service Progress Notes revealed no documentation the SW assessed the resident's suicidal ideations and/or provided interventions to address the suicidal ideations. Medical record review of a Nurse's Note dated [DATE], at 7:45 p.m., revealed, "This nurse (LPN #2) was coming down the hall and saw resident had a butter knife...trying to stab self in the chest. (LPN #2) got knife away from resident...asked (resident) what (resident) was doing. Resident stated, 'I just wanted to end this'..." Continued review revealed a Certified Nursing Assistant (CNA) was assigned to stay with the resident. LPN #2 notified the Physician on-call; orders were received to send to the (Hospital) emergency room (ER) for an evaluation. The resident's POA was also notified. Continued review revealed the Emergency Medical Service (EMS) arrived at 8:00 p.m., and the resident was transferred from the nursing home at 8:15 p.m. Medical record review of a Patient Transfer Form dated [DATE], (no time), revealed the resident tried to "stab self in the chest with a butter knife" as the reason for transfer (to the hospital from the nursing home). Medical record review of the Social Service Progress Notes revealed no documentation of the resident's attempted suicide on [DATE], until [DATE]; which was two days after the resident was admitted to the hospital's inpatient mental health services program for treatment of [REDACTED]. Medical record review of an inpatient Psychiatric Consultation report dated [DATE], revealed, "...sent over in the middle of the night (on [DATE]) from the nursing home after making a suicide gesture...was found sitting in a chair in the hallway with butter knife trying to stab...self in the chest...they (nursing home staff) were able to get the knife away...(resident) stated that (resident) was trying to end (resident's) life...sent to (hospital) for evaluation..." The resident was admitted to the hospital's inpatient mental health services program for treatment of [REDACTED]. Review of facility policy, Social Services, revised [DATE] revealed, "Our facility provides medically-related social services to assure that each resident can attain or maintain his/her highest practicable physical, mental, or psychosocial well-being...1. The Social Services Staff is...responsible for: a. Consultation with other departments regarding...planning...and priority setting of social services...Consultation to allied professional health personnel regarding provisions for the...emotional needs of the resident...2. Medically-related social services is provided to maintain or improve each resident's ability to control everyday...mental and psychosocial needs (e.g...coping abilities...)...3. Factors that have a potentially negative effect on psychosocial functioning include:...c. Problems in coping with grief...e. Presence of progressive, chronic disabling condition...g. Behavioral problems (i.e., confusion, anxiety...depressed mood...)...4. The social services department is responsible for:...b. Identifying individual...emotional needs; c. Assisting in providing corrective action for the resident's needs by developing and maintaining individualized social care plans; d. Maintaining regular processes and follow-up notes indicating the resident's response to the plan...i. making supportive visits to the residents and performing needed services...l. participating in interdisciplinary staff conferences, providing social services information to ensure treatment of [REDACTED]. Review of facility policy, Referrals, Social Services, revised [DATE], revealed, "...1. Social services shall coordinate resident referrals...3. Social services will collaborate with nursing staff or other pertinent disciplines to arrange for services that have been ordered by the physician...4. Social services will...ensure adequate follow-up with appropriate documentation from referral source..." Interview with LPN #2 on [DATE], at 12:50 p.m., in the Conference Room, confirmed on [DATE], shortly after supper (dinner), LPN #2 was walking out from another resident's room, to the hallway, and observed resident #1 with a knife trying to stab (resident's) self in the chest with the knife. During this interview, while describing the attempt, LPN #2 demonstrated how the resident attempted to stab self in the chest, by hitting (LPN #2's) self in the chest repeatedly with a fisted right hand, and made a forceful thumping sound with each strike of the fist to the chest. "(Resident) was using a metal knife...like the ones that come on the residents' trays for meals. I think (resident) got it off of another resident's tray...I grabbed the knife...I asked 'what are you doing?'...(resident) said, 'I just want to end it...kill myself '...finally got the knife from (resident)...(resident) had a tee-shirt and sweat shirt on...I pulled them up to make sure...saw no wounds or lacerations...I directed a nearby CNA to stay with (resident)...called Physician, got an order to send to the ER for evaluation, and called the family..." LPN #2 confirmed to know of previous suicidal ideations with the resident, and confirmed, "I do not know what suicide precautions are...I have never been told...I had no idea...(resident) was not placed 1:1 until after the suicide attempt...we (staff) were just told to watch (resident) closer and give plastic silverware because of previous suicidal ideations..." LPN #2 confirmed, "Watch closer meant to keep in common areas...a hallway or at nurse's station..." LPN #2 confirmed there were times when other residents were being cared for and resident #1 was not being observed by any staff. Interview with CNA #2 on [DATE], at 8:45 p.m., in the conference room confirmed CNA #2 worked on [DATE], on the 2:00 p.m.-10:00 p.m. shift; and was assigned to the dining room for supper. "...After supper, I transported (resident #1) to the nurse's station straight across the hall from the dining room on Wing 4, and then proceeded down the hall to pick up trays...As I came out from room number 85 (near the end of the hall), I looked up and heard (LPN #2) say, 'I need some help down here.' I ran to assist (LPN #2)...Resident #1 had a metal knife in (resident's) right hand...was repeatedly stabbing (resident's) chest with the knife and yelling, 'I'm going to kill myself...I'm going to kill myself.' (LPN #2) was struggling with (resident) to get the knife, as (resident) was going at it...stabbing at (resident's) chest...By the time I reached (LPN #2) and the resident, (LPN #2) had removed the knife from the resident...I realized (resident #1) had gotten the knife from another resident seated at (resident #1's) table during supper and I said, 'Oh, no! (Resident #1) got the knife off of (random resident's) tray'....I looked at (resident's) chest immediately...it had multiple red, dime-size areas but, no lacerations or stab wounds. (LPN #2) assigned me to stay 1:1 with (resident #1)...I stayed at (resident's) bedside until EMS (Emergency Medical Services), arrived. (Resident) previously made multiple statements...wanted to kill (resident's) self, and wanted to die." CNA #2 confirmed these statements were made prior to [DATE], but, could not recall the dates, or date of onset. "I tried to encourage (resident) everyday...I just never dreamed (resident) would try to kill (resident's) self." Interview with the SW on [DATE], at 2:45 p.m., in the Conference Room, confirmed, on February 24, 2012, staff (unable to recall who) reported the resident had voiced suicidal ideations. "After I had been told (resident) had voiced suicidal ideations, I talked with (resident's) POA...the resident had a history of [REDACTED].; the DON was there. I talked with the Administrator and DON; and reported the resident had suicidal ideations, had a plan, and showed signs and symptoms of suicide attempt. I feared the resident would attempt to take or end (resident's) life. Continued interview with the SW confirmed plastic silverware was the only precaution implemented. When the surveyor asked if mental health services were provided, the SW confirmed, "An order was written for (contracted Mental Health Service) to evaluate but I don't know if it was done or not." When the surveyor asked if supportive counseling had been done by the SW, the SW confirmed, "No; I was waiting on (contracted Mental Health Service) to provide counseling." When the surveyor asked the SW who is responsible for arranging and tracking Psychiatric referrals, the SW replied, "I am." Telephone conference interview on [DATE], at approximately 3:30 p.m., with the (contracted Mental Health Service's) Compliance Officer and Director of Business Development confirmed the physician's orders [REDACTED]. Continued interview confirmed the referral did not indicate a crisis situation (urgent, stat (immediately), or suicidal). "A clinician went to the facility to evaluate the resident on [DATE]; the resident was in the hospital and no treatment was provided." A second interview with the SW, in the presence of the Administrator, on [DATE], at 6:50 p.m., in the conference room confirmed on February 24, 2012, the resident's POA informed the SW of the resident's history of wanting to take pills to end the resident's life. The SW was told on February 24, 2012, by staff (names unrecalled) the resident had asked questions regarding ending life and/or end of life, including "how to cut-off (resident's) air supply (SW placed hand around SW's throat and described an action of choking self); if insurance would pay if (resident) died ." The SW assessed the resident after the reports on February 24, 2012, and determined the resident had a plan to kill (resident's) self with a knife. The SW reported the assessment and suicidal concerns to the Administrator and DON, on February 24, 2012. The SW confirmed, "...The resident needed to be sent out to (local mental health service) for a psychiatric evaluation...I instructed the unit nurse to call the Physician and get orders for (contracted Mental Health Service) consult and medications for depression and anxiety. Continued interview with the SW confirmed no Mental Health Service consult occurred as ordered on February 24, 2012. Interview with Physician #1 on [DATE], at 6:00 p.m., in the conference room confirmed the facility did not make the Physician aware of the resident's depressed state, or any suicidal ideations, or any plan as documented by the SW on February 24, 2012. "If the facility had reported the resident to be significantly depressed to the point of suicidal ideations and/or intent with a plan, I would have ordered to send the resident out to the ER for an evaluation immediately...I was not aware the resident was required to use plastic silverware to prevent self-harm." A second interview with CNA #2 on [DATE], at 10:15 p.m., in the conference room confirmed "...I was never told or educated on what to do when a resident threatened to harm themselves or wished to die. Nobody ever told me why (resident #1) had plastic silverware. I never asked and I never really thought about why...I'm doing the best I can...I had no idea what to look for...I've not had psych (psychiatric) training...I was never told what to do for (resident #1's) psychiatric or suicidal care." Interview with the SW on [DATE], at 4:30 p.m., in the conference room confirmed, "...The resident voiced...wanted to die...how would kill...self, with a knife. (Resident) was depressed and suicidal...all of my bells and whistles...going off. The SW confirmed, "I strongly felt (resident) needed to go out for an eval." Continued interview confirmed, the SW failed to ensure the following for the resident (#1) in crisis: failed to follow Social Services policies; failed to in-service facility staff on related Social Services policies; failed to follow-up on any orders for new medications or medication changes for the resident's depression and/or anxiety; failed to provide medically-related social services and supportive counseling; failed to revise the resident's individual care plan regarding risk of suicide; and failed to provide facility education on the resident's required plan of care regarding risk of suicide. "Most of the facility staff is unaware of what suicide preventions and precautions are. Oh, I know very well what they are and I knew this (attempted suicide) was about to happen." Interview with the Administrator on [DATE], at 7:35 p.m., in the conference room confirmed the SW failed to follow Social Services policies; and failed to ensure medically-related Social Services were provided to the resident (#1) in crisis. The facility's failure to ensure policies were followed and medically-related social services were provided for a resident (#1) in crisis beginning on February 24, 2012, resulted in the resident obtaining a dinner knife, and attempts to stab (resident #1's) self in the chest. Resident #27 was admitted to the facility [DATE], with [DIAGNOSES REDACTED]. Medical record review of a Quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident scored zero on the Brief Interview for Mental Status (BIMS), indicating severely impaired cognition; and exhibited feeling or appearing down, depressed, or hopeless nearly every day. Medical record review of the Physician's Recapitulation Orders dated [DATE], revealed "...Alprazolam (Xanax-for anxiety). Take 1 (one) tablet By MOUTH 3 (three) times daily AT 5:00 AM (a.m.); AT 1:00 PM (p.m.); AT 9:00 PM; Start Date: [DATE] ([DATE])...DX: INCREASED ANXIETY/ (and; or) CRYING." (Prior to the routine order dated [DATE], the Alprazolam was ordered as needed). Medical record review of the Nurse's Notes, revealed: [DATE], at 12:10 a.m. "...Resident crying, turning on light (call light). Xanax given..." [DATE], at 10:30 p.m. "...Res (resident) given Xanax d/t (due to) anxiety up, crying..." [DATE], at 2:15 p.m. "...crying...Xanax...po (by mouth)..." [DATE], at 10:00 a.m. "...Res @ times has increased anxiety...Xanax...administered...cries easily..." [DATE], at 2:00 p.m. "...Res with increased anxiety crying uncontrollably...Xanax...for agitation..." [DATE], at 3:00 p.m. "Res lying in bed rocking back & forth crying. (Spouse) unable to redirect. This nurse admin (administered)...Xanax...Res less anxious when told medication would help (resident) to calm down..." [DATE], at 2:15 p.m. "Res crying & agitated says, 'Help me, Help me.' Xanax...admin..." [DATE], at 12:07 p.m. "Res crying cont (continuously)...Xanax give (given)..." [DATE], at 11:20 p.m. "..repeatedly turning on call light...Xanax...d/t increased anxiety..." [DATE], at 10:32 a.m. "...Res in bed crying cont asking for 'help & nurse' over & over again..." [DATE], (no time). "...Res cries a lot..." [DATE], at 9:40 a.m. "...episodes of crying with Xanax...administered..." [DATE], at 8:00 a.m. "Res in bed crying on & off..." [DATE], at 8:40 a.m. "...Res has episodes of crying at (and) stating 'Nurse, Nurse help me' repeatedly..." [DATE], (no time). "...res verbal of wants and needs..." [DATE], at 9:00 a.m. "Continues to cry @ times..." Medical record review of the Nurse's Monthly Summary dated [DATE]; [DATE]; [DATE]; [DATE]; and [DATE]; revealed the consistent presence of mood symptoms, which included "Little interest or pleasure in doing things...Feeling or appearing down, depressed, or hopeless...Feeling tired or having little energy..Indicates that s/he (she or he) feels bad about self, is a failure, or has let family down..." Medical record review of the Physician's Progress notes revealed: [DATE], (no time). "Pt (patient) is crying today..." [DATE], (no time). "...is crying...continues to have crying spells." Medical record review of the Social Service Progress Notes, dated [DATE], at 5:10 p.m., revealed "Annual Note:...Resident cries often according to...(spouse)..." Continued review revealed no documentation the SW provided supportive counseling or emotional support for depression and multiple episodes of anxiety and crying. Continued review revealed no documentation the SW collaborated with the Physician or any other facility staff to provide in-house or outside Mental Health Services. Observation of the resident and interview, on [DATE], at 6:30 p.m., in the resident's room confirmed the resident was lying in bed, with the television on. During the beginning of the interview the resident began to cry. The surveyor asked the resident what was wrong and the resident answered, "I want to go home." The surveyor validated the resident missed being at home. The resident confirmed the validation, and continued to cry. Tears rolled from the resident's eyes, and down both sides of the face. The surveyor commented regarding the spouse's daily visits, and the resident confirmed, "Yes, but, (spouse) is only here a few hours during the day." Surveyor asked the resident what the resident enjoyed most when the spouse visited, and the resident confirmed, "Watching TV (television)." By this time during the interview, the resident's crying decreased, and then stopped. As the interview ended and the surveyor turned to leave the room, the resident began to cry again. Interview with the SW on [DATE], at 4:30 p.m., in the conference room confirmed the SW failed to follow Social Services policies; and failed to provide medically-related social services and supportive counseling for resident #27. Resident #16 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a Quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident scored zero on the Brief Interview for Mental Status (BIMS), indicating severely impaired cognition. Medical record review of a (contracted) Psychology Progress Note dated [DATE], revealed, during the treatment session, the resident exhibited sadness, hopeless, and was fearful. The resident's depression was ongoing with intermittent periods of anxiety but the cognitive status waivered. The resident was discharged from therapy services due to poor cognition; and "...informed social service...of plan..." Behavioral suggestions for staff: "...consider soothing patient with a security object...when the patient is fearful or agitated...redirecting to calming...such as quiet music or comfort objects when...exhibits general agitation..." Medical record review of the Nurses Notes and Daily Skilled Nurses Notes revealed: [DATE], at 1:00 a.m. "...was given...Ativan...anxiety and restlessness..." [DATE], (night shift). "...Anxious..." [DATE], at 2:15 a.m. "...Ativan was administered d/t anxiety and restlessness..." [DATE], at 6:20 a.m. "Resident was very anxiouse (anxious) at 4:30 AM...Ativan..administered..." [DATE], and 31, 2012, (night shift); [DATE], and 23, 2012, (day shift). "...Anxious..." [DATE], and 3, 2012, (day shift). "...Anxious..." [DATE], at 9:30 AM. "...Res states 'I want out of here'...depressed..." [DATE] and 14, 2012, (night shift). "...Anxious..." [DATE] and 12, 2012, (day shift). "...Anxious..." Medical record review of the Social Service Progress Notes, dated [DATE], through [DATE], revealed no documentation the SW provided support or interventions to meet the psychosocial needs of the resident. Interview with the SW on [DATE], at 4:30 p.m., in the conference room confirmed the SW failed to follow Social Services policies; and failed to provide medically-related social services and supportive counseling for resident #16. Resident #17 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a Quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident scored fifteen on the Brief Interview for Mental Status (BIMS), indicating the resident's cognition was intact. Medical record review of a (contracted) Psychology Progress Note dated [DATE], revealed the resident's [DIAGNOSES REDACTED]. slowly with brief gaps of silence verbalized feelings of sadness and worry...Pt continues with s/s (signs and symptoms) of depression that are negatively impacting...health status including lack of motivation, tearfulness, and general agitation toward issues (resident) cannot change...Based on current status, progress and need, counseling will continue for approximately ,[DATE] (nine to eleven) weeks...Planned Session Frequency: ,[DATE]/mo (two-to-three sessions per month)...Behavioral Suggestions to Staff:...consider providing positive support and understanding..." This session was the last session provided by the contracted Mental Health Service provider, and/or any Mental Health Service provider. Medical record review of a Nurse's Note dated [DATE], at 3:00 p.m., revealed "...res not happy about going home next week. Staff reported that Res stated to them...was going to do everything...can do to make sure...won't have to leave...staff stated while working with (resident), Res attempted to throw (resident's) self backwards, so (resident) would fall but they were able to keep (resident) upright. Res was also trying to kick prosthetic leg off et was putting all...weight...on...staff..." Medical record review of the Social Service Progress Notes revealed no documentation the SW provided assessment and/or interventions to address the resident's inability to cope with loss of function due to the amputation of the right leg; difficulty with prosthetic adjustment; the need for physical and emotional support; and difficulty with the planned discharge to home with the daughter. Continued review of the progress notes revealed the resident was discharged home (with daughter) on [DATE]. Interview with the SW on [DATE], at 4:30 p.m., in the conference room confirmed the SW failed to follow Social Services policies; and failed to provide medically-related social services and supportive counseling for resident #17. Interview with the Administrator on [DATE], at 7:35 p.m., in the conference room confirmed the SW failed to follow Social Services policies; and failed to provide medically-related social services and supportive counseling for residents #27, #16, and #17. In summary, the facility failed to provide medically-related social services to resident #1 after being made aware the resident had a history and current threat of suicide. The initial threat was reported to the DON on February 24, 2012, by the POA; and then to the Administrator and DON on February 24, 2012, by the SW. Physician orders [REDACTED]. The SW stated and documented Physician #1 made changes in the resident's medications for depression and anxiety; the Physician was unaware of the resident's crisis and no changes were made in medications to address the depression or anxiety. Due to the facility's failure to follow Social Services policies, failure to provide medically-related social services and implement interventions, the resident (#1) in crisis obtained a dinner knife from another resident's meal tray during supper and attempted suicide by repeatedly stabbing (resident #1's) self in the chest on [DATE]. Continued review revealed the facility failed to follow Social Services policies, and failed to provide medically-related social

Based on medical record review, review of facility policies, and interview, the facility failed to follow facility policies to provide the necessary services, and prevent neglect for one (#1) resident of thirty-two residents reviewed. The facility's failure to follow policies, provide Mental Health Services, and prevent neglect resulted in one resident (#1) attempting suicide by stabbing (resident's self) in the chest with a table knife, of thirty-two residents reviewed. The facility's failure to ensure policies were followed and interventions were implemented for a resident in crisis resulted in the resident obtaining a dinner knife, and attempting to stab (resident #1's) self in the chest. Resident #1's attempted suicide on [DATE], required a transfer to the hospital emergency room and admission to a mental health unit for treatment. The facility's failure placed resident #1 in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). The Administrator and Director of Nursing were informed of the Immediate Jeopardy in the Conference Room on [DATE], at 11:30 a.m. F224 resulted in Substandard Quality of Care. The findings included: Resident #1 was admitted to the facility from the local hospital on February 10, 2012, with [DIAGNOSES REDACTED]. Medical record review of the hospital Discharge Summary dated February 10, 2012, revealed, (the resident was) "...significantly disabled...due to a [MEDICAL CONDITION] in...2009 which has left (resident) [DIAGNOSES REDACTED] and very poorly coordinated..." and had a history of [REDACTED]. Medical record review of the Nursing Admission assessment dated [DATE], at 1:00 p.m., revealed the resident's cognition as oriented to person, place, time, and was alert. The resident was able to recall three named objects after five minutes, and was able to understand communication. The resident required assistance with all physical functioning: two people were required for bed mobility, transfers, toileting and bathing; one person was required for walking/locomotion, dressing, eating and personal hygiene. Eating required the supervised assistance of one person. Medical record review of a Nurse's Note dated February 15, 2012, at 9:45 a.m., revealed the resident was beginning to exhibit confusion, "...thinks...is going home today...states (spouse) is getting out of the hospital...going home with (spouse)...will monitor." Medical record review of the Social Service Progress Notes revealed no documentation the Social Worker (SW) assessed the resident's confusion and/or provided interventions to determine the cause of the resident's confusion on February 15, 2012, at 9:45 a.m. Medical record review of a Social Service Progress Note dated February 24, 2012, at 1:35 p.m., revealed, "Family told SW (Social Worker) resident called the POA (Power-of-Attorney)...and (resident's spouse) late last night at 10:40 p.m. and made a delusional statement. (Resident) said...would send (resident's sibling) over to (resident's spouse's) home to run off a (spouse's visitor) according to...POA...also stated resident had a hx (history) of making statement(s) wanting to take pills to end (resident's) life...stated (resident) has made these statements to family ,[DATE] (one-to-two) yrs (years). SW talked to the DON (Director of Nursing) and (contracted Mental Health Services) referral being sent for counseling and Dr. (Physician) notified for medication and instruction. SW spoke to the resident...stated...was concerned about spouse but not thinking of hurting (resident's) self @ (at) this time. (Resident) thinks...spouse has...(someone else)...Spouse just (recently) got out of hospital with heart by-pass (heart surgery). SW asked (resident) if (resident) had thoughts of how (resident) would hurt (resident's) self. Resident stated, 'I would use a knife because my family took my guns from me.' SW spoke to DON and nurse on unit. Resident to eat in dining room with plastic spoon and plastic knife for safety measure since (resident) made statement. (Physician) has ordered medications to address depression and anxiety. SW sent (contracted Mental Health Services) referral signed by (Physician) for counseling. SW will continue to monitor and will assist with any needs." Continued review of the SW notes revealed no further monitoring or assistance during the remainder of the resident's admission at the nursing home. Medical record review of a Physician's Telephone Order dated February 24, 2012, revealed: 1515 (3:15 p.m.) "...(contracted Mental Health Services) to eval (evaluate) and treat as indicated..." Medical record review of a (contracted Mental Health Services) physician's orders [REDACTED]. 1. Sad; 2. Agitation; 3. [MEDICAL CONDITION]. Continued review of the referral revealed no documentation of urgency or crisis intervention ordered for this resident. Medical record review of an "Admit Note" dated February 25, 2012, (no time), documented by the Physician, revealed the resident was unable to care for (resident's) self, "particularly with (resident's) declining health." The note revealed the resident "has some delusional thought patterns about (resident's spouse) running off with somebody." The Physician's impression revealed the following: 1. [MEDICAL CONDITION] left-sided [MEDICAL CONDITION]; 2. CAD ([MEDICAL CONDITION]) S/P (status [REDACTED]. 3. Type II diabetes mellitus currently on insulin therapy; 4. Chronic [MEDICAL CONDITION]; 5. [MEDICAL CONDITION]. The Physician's plan revealed "Continue as per orders at this time." Continued review of the note revealed no documentation of the resident being at risk of suicide. Medical record review of a Nurse's Note dated February 25, 2012, at 9:59 p.m., revealed the resident was on the phone talking to the resident's spouse, "...(the resident)...talking and getting emotional et (and) crying continuing to state 'I'll just end it now.' (Resident) quickly changes tone et says sorry to (spouse)...This nurse (Licensed Practical Nurse (LPN) #1) spoke with...spouse et assured will keep close watch on Res (resident). Administered PRN [MEDICATION NAME] to help Res sleep. Res calm et polite to staff at this moment. Will cont (continue) to monitor..." Medical record review revealed no other interventions for the resident's threat of suicide. Medical record review of a Nurse's Note dated [DATE], at 7:45 p.m., revealed, "This nurse (LPN #2) was coming down the hall and saw resident had a butter knife...trying to stab self in the chest. LPN #2 got knife away from resident...asked (resident) what (resident) was doing. Resident stated, 'I just wanted to end this'..." Continued review revealed a Certified Nursing Assistant (CNA) was assigned to stay with the resident. LPN #2 notified the Physician on-call; orders were received to send to the (Hospital) emergency room (ER) for an evaluation. The resident's POA was also notified. Continued review revealed the Emergency Medical Service (EMS) arrived at 8:00 p.m., and the resident was transferred from the nursing home at 8:15 p.m. Medical record review of a Patient Transfer Form dated [DATE], (no time), revealed the resident tried to "stab self in the chest with a butter knife" as the reason for transfer (to the hospital from the nursing home). Medical record review of an inpatient Psychiatric Consultation report dated [DATE], revealed, "...sent over in the middle of the night (on [DATE]) from the nursing home after making a suicide gesture...was found sitting in a chair in the hallway with butter knife trying to stab...self in the chest...they (nursing home staff) were able to get the knife away...(resident) stated that (resident) was trying to end (resident's) life...sent to (hospital) for evaluation..." The resident was admitted to the hospital's inpatient mental health services program for treatment of [REDACTED]. Review of facility policy, Suicide Assessment and Intervention Practice, (no date) revealed, "Purpose: To maintain safety of individual residents while receiving services in this facility...Standard: Residents who display characteristics of suicidal ideation will be evaluated for risk of self harm and intent to inflict self harm (does the resident have a plan?)...If intent is implied, then monitor for safety (keep resident within eyesight at all times) and notify MD (Physician) and resident's family...Process: 1. Remove means of harming self or other from resident. 2. Assess resident for actual harm to self/others and follow up as indicated. 3. Resident will be kept within eyesight of staff at all times...until family arrives or resident is sent out of facility..." Review of facility policy, Suicide Prevention, (no date) revealed, "...Identifying Potential for Suicide Attempt...a) Identify resident at high risk...place on suicide precautions...b) Designate staff to closely observe at all times..." Continued review revealed no policy for suicide precautions. Interview with the Administrator and DON on [DATE], at approximately 11:25 a.m., in the Conference Room, confirmed the resident did attempt suicide. The Administrator confirmed, "I felt like the suicide threats were threats only. I did not believe (resident) would attempt suicide, or could attempt suicide...(resident) obtained a regular stainless steel dinner knife and tried to stab (resident's) self in the chest. I knew the resident from before, from a previous admission...I just did not believe (resident) would attempt suicide. I can't recall the specific date of the initial threat but, yes, the SW reported the threat to me and the DON. That's when we implemented the plastic silverware. We (Administrator and DON) didn't put the resident on one-on-one (1:1) observations (one staff person providing constant observation of one resident, and within reach of that resident) because we felt the threat wasn't real." The DON confirmed the Administrator's statements were correct, and "I have told multiple people, staff and the resident's sibling, the (resident) is in a safe place and nothing could happen. We (DON and Administrator) didn't implement 1:1 because we felt (resident) was safe and the threat was not real." Interview with LPN #1 on [DATE], at 12:17 p.m., in the Conference Room, confirmed, the entry in the nurse's note on February 25, 2012, at 9:59 p.m., was documented by LPN #1. LPN #1 confirmed on the evening of February 25, 2012, the resident called the spouse and was emotional; which ranged from crying and remorse, to anger, then back to crying and remorse. LPN #1 confirmed (resident) said, "I'll just end it now;" and LPN #1 told the spouse (resident) would be watched closer. LPN #1 confirmed the resident did have periods of no observation, such as when the staff were providing care to other residents, and/or when staff were in the bathroom, or away from the particular area where the resident was positioned (nurse's station, hallway, and so on). "There are just too many variables here for a resident to be safe if they are suicidal...While (resident) had mood swings and was emotional, I just didn't think (resident) would do something like that (attempt suicide)..." Interview with LPN #2 on [DATE], at 12:50 p.m., in the Conference Room, confirmed on [DATE], shortly after supper (dinner), LPN #2 was walking out from another resident's room, to the hallway, and observed resident #1 with a knife trying to stab (resident's) self in the chest with the knife. During this interview, while describing the attempt, LPN #2 demonstrated how the resident attempted to stab self in the chest, by hitting (LPN #2's) self in the chest repeatedly with a fisted right hand, and made a forceful thumping sound with each strike of the fist to the chest. "(Resident) was using a metal knife...like the ones that come on the residents' trays for meals. I think (resident) got it off of another resident's tray...I grabbed the knife...I asked 'what are you doing?'...(resident) said, 'I just want to end it...kill myself '...finally got the knife from (resident)...(resident) had a tee-shirt and sweat shirt on...I pulled them up to make sure...saw no wounds or lacerations...I directed a nearby CNA to stay with (resident)...called Physician, got an order to send to the ER for evaluation, and called the family..." LPN #2 confirmed to know of previous [MEDICAL CONDITION] with the resident, and confirmed, "I do not know what suicide precautions are...I have never been told...I had no idea...(resident) was not placed 1:1 until after the suicide attempt...we (staff) were just told to watch (resident) closer and give plastic silverware because of previous [MEDICAL CONDITION]" LPN #2 confirmed, "Watch closer meant to keep in common areas...a hallway or at nurse's station..." LPN #2 confirmed there were times when other residents were being cared for and resident #1 was not being observed by any staff. Interview with CNA #2 on [DATE], at 8:45 p.m., in the conference room confirmed CNA #2 worked on [DATE], on the 2:00 p.m.-10:00 p.m. shift; and was assigned to the dining room for supper. "During dining room assignment, you assist, feed, and observe for choking and swallowing difficulties...you watch everybody (residents). During supper on [DATE], there were seven residents with three tables in use in the dining room. Six residents were seated at two of the tables, with three per table; and one resident required to be fed, at the third table. I sat at the table with the one resident that had to be fed. There were two other CNAs (no longer employed at the facility), which had passed trays and were feeding residents on the hall...(LPN #2) was at the desk (Wing 4 nurse's station) charting. My focus was on the resident I was feeding (not resident #1). I was unable to continuously watch any one resident...(Resident #1) was seated at a table with two other residents. After supper, I transported (resident #1) to the nurse's station straight across the hall from the dining room on Wing 4, and then proceeded down the hall to pick up trays. The other two CNAs were in different rooms picking up trays, and (LPN #2) may have been on the hall somewhere answering a call light...As I came out from room [ROOM NUMBER] (near the end of the hall), I looked up and heard (LPN #2) say, 'I need some help down here.' I ran to assist (LPN #2)...Resident #1 had a metal knife in (resident's) right hand...was repeatedly stabbing (resident's) chest with the knife and yelling, 'I'm going to kill myself...I'm going to kill myself.' (LPN #2) was struggling with (resident) to get the knife, as (resident) was going at it...stabbing at (resident's) chest...By the time I reached (LPN #2) and the resident, (LPN #2) had removed the knife from the resident. (LPN #2) asked me, 'Where did (resident) get this knife?' I said, 'I don't know.' I thought about it, and I realized (resident #1) had gotten the knife from another resident seated at (resident #1's) table during supper and I said, 'Oh, no! (Resident #1) got the knife off of (random resident's) tray'....I looked at (resident's) chest immediately...it had multiple red, dime-size areas but, no lacerations or stab wounds. (LPN #2) assigned me to stay 1:1 with (resident #1)...I stayed at (resident's) bedside until EMS (Emergency Medical Services), arrived. (Resident) previously made multiple statements...wanted to kill (resident's) self, and wanted to die." CNA #2 confirmed these statements were made prior to [DATE], but, could not recall the dates, or date of onset. "I tried to encourage (resident) everyday...I just never dreamed (resident) would try to kill (resident's) self." Interview with the SW on [DATE], at 2:45 p.m., in the Conference Room, confirmed, on February 24, 2012, staff (unable to recall who) reported the resident had voiced [MEDICAL CONDITION]. "After I had been told (resident) had voiced [MEDICAL CONDITION], I talked with (resident's) POA...the resident had a history of [REDACTED].; the DON was there. I talked with the Administrator and DON; and reported the resident had [MEDICAL CONDITION], had a plan, and showed signs and symptoms of suicide attempt. I feared the resident would attempt to take or end (resident's) life. I informed them (Administrator and DON) the resident needed (local mental health service) evaluation now. The DON stated, "This is a safe place...(resident) was irrational, and when irrational, will not attempt suicide..." The SW confirmed the Administrator and DON stated, "You don't understand; it is a safe place here, and the resident attempting or committing suicide is not going to happen here." Continued interview with the SW confirmed plastic silverware was the only precaution implemented. When the surveyor asked if mental health services were provided, the SW confirmed, "An order was written for (contracted Mental Health Services) to evaluate but I don't know if it was done or not." When the surveyor asked if supportive counseling had been done by the SW, the SW confirmed, "No; I was waiting on (contracted Mental Health Services) to provide counseling." When the surveyor asked the SW who is responsible for arranging and tracking Psychiatric referrals, the SW replied, "I am." Telephone interview on [DATE], at approximately 3:30 p.m., with the (contracted Mental Health Service Provider's) Compliance Officer and Director of Business Development confirmed the physician's orders [REDACTED]. Continued interview confirmed the referral did not indicate a crisis situation (urgent, stat (immediately), or suicidal). "A clinician went to the facility to evaluate the resident on [DATE]; the resident was in the hospital and no treatment was provided." A second interview with the SW, in the presence of the Administrator, on [DATE], at 6:50 p.m., in the conference room confirmed on February 24, 2012, the resident's POA informed the SW of the resident's history of wanting to take pills to end the resident's life. The SW was told on February 24, 2012, by staff (names unrecalled) the resident had asked questions regarding ending life and/or end of life, including "how to cut-off (resident's) air supply (SW placed hand around SW's throat and described an action of choking self); if insurance would pay if (resident) died ." The SW assessed the resident after the reports on February 24, 2012, and determined the resident had a plan to kill (resident's) self with a knife. The SW reported the assessment and suicidal concerns to the Administrator and DON, on February 24, 2012. The SW confirmed, "...The resident needed to be sent out to (local mental health service) for a psychiatric evaluation...I instructed the unit nurse to call the Physician and get orders for (contracted Mental Health Services) consult and medications for depression and anxiety. Dietary was notified to provide plastic silverware." The Administrator revealed to be unaware of the (resident's) threat to cut-off (resident's) air supply; the SW revealed, "I thought I told the Administrator." The Administrator confirmed, "The DON and I felt the (resident) to be in a safe environment and did not feel the resident needed to be sent out...we (Administrator and DON) felt the resident was not a threat of harm to (resident's) self...felt the resident was unable to attempt suicide. Both the SW and Administrator confirmed to be unaware of the resident's [MEDICAL CONDITION] voiced to the spouse on a phone call documented in the nurse's notes on February 25, 2012, at 9:59 p.m. Continued interview confirmed no psychiatric consult occurred as ordered on February 24, 2012. Interview with CNA #1 on [DATE], at 5:25 p.m., in the conference room confirmed to recall the resident talked about ending (resident's) life one night (unable to recall date). "I told (resident) not to talk like that...still had family and not to talk like that." CNA #1 confirmed to report the resident's threat to a nurse but could not recall when or who the nurse was. Interview with Physician on [DATE], at 6:00 p.m., in the conference room confirmed the facility did not make the Physician aware of the resident's depressed state, or any [MEDICAL CONDITION], or any plan as documented by the SW on February 24, 2012, or on February 25, 2012. "If the facility had reported the resident to be significantly depressed to the point of [MEDICAL CONDITION] and/or intent with a plan, I would have ordered to send the resident out to the ER for an evaluation immediately. No medications were ordered on February 24, 2012 for depression or anxiety, or at any other time during the resident's admission at the nursing home. The [MEDICATION NAME] was a previous medication...was taking prior to admission (to the nursing home). I was not aware the resident was required to use plastic silverware to prevent self-harm." A second interview with the DON on [DATE], at 1:00 p.m., in the conference room confirmed, the initial threat of suicide was reported to the DON by the POA on February 24, 2012, prior to meeting with the Administrator and SW about resident #1. "The POA and I were at the Wing 4 Nurse's Station; and we discussed the resident's anxiety and threats of suicidal ideation due to having to be admitted (to the nursing home) on February 10, 2012. During this conversation, staff was present at the desk...I think it was a nurse, CNA, and possibly the SW...can't recall which nurse and CNA...I reassured the staff and the POA the resident was in a safe place and nothing could happen. The SW proceeded to assess the resident, and then met with me and the Administrator...SW reported to us (DON and Administrator) the resident had a history of [REDACTED]. reported to us (DON and Administrator) the resident needed to be sent out for a psych (Mental Health Service) eval..." Continued interview confirmed the resident was not placed on 1:1 observation, and to "watch closer" did not mean the resident would be under constant supervision. The DON confirmed the Physician was not immediately notified of the SW's assessment or the concerns of suicide. Interview with the SW on [DATE], at 4:30 p.m., in the conference room confirmed, "...The resident voiced...wanted to die...how would kill...self, with a knife. (Resident) was depressed and suicidal...all of my bells and [MEDICATION NAME] off. The SW confirmed, "I strongly felt (resident) needed to go out for an eval." Continued interview confirmed, the SW failed to ensure the following for the resident (#1) in crisis: failed to follow Social Services policies; failed to in-service facility staff on related Social Services policies; failed to provide medically-related social services and supportive counseling; failed to revise the resident's individual care plan regarding risk of suicide; and failed to provide facility education on the resident's required plan of care regarding risk of suicide. "Most of the facility staff is unaware of what suicide preventions and precautions are. Oh, I know very well what they are and I knew this (attempted suicide) was about to happen." Interview with the Administrator on [DATE], at 7:35 p.m., in the conference room confirmed the facility's neglect to follow policies, provide Mental Health Services, and lack of interventions, allowed the resident to obtain a dinner knife, and then carried out an attempted suicide (by stabbing self repeatedly in the chest) on [DATE]. In summary, the facility neglected resident #1 after being made aware the resident had a history and current threat of suicide. The initial threat was reported to the DON on February 24, 2012, by the POA; and then to the Administrator and DON on February 24, 2012, by the SW. Physician orders [REDACTED]. Due to the facility's neglect of the resident in crisis, the failure to follow facility policies and implement interventions, the resident obtained a dinner knife from another resident's meal tray during supper and attempted suicide by repeatedly stabbing (resident's) self in the chest on [DATE]. The Immediate Jeopardy was effective from February 25, 2012, through [DATE], and was removed on [DATE]. An Acceptable Allegation of Compliance, which removed the immediacy of the jeopardy, was received and corrective actions were validated by the surveyor through review of documents, staff interviews, and observations conducted onsite on [DATE]. The surveyor verified the allegation of compliance by: 1. Reviewing the facility's in-service records to ensure all staff were educated regarding changes to and implementation of the facility's following policies: a. Change in Resident's Condition and Status; b. Suicide Threats; c. Care of a Suicidal Resident; e. Behavioral Management; f. Care Planning and Using the Care Plan. 2. Conducting interviews with facility staff, to include fifteen of thirty-one nurses, three of nine environmental services, one of three maintenance, two of four activities, one of two social services, twenty-nine of fifty-two CNA's, ten of twenty-three dietary, seven of seventeen laundry and housekeeping, on staff to determine the level of comprehension gained through in-service education conducted regarding changes to and implementation of the facility's policies, "Change in Resident's Condition and Status; Suicide Threats; Care of a Suicidal Resident; Behavioral Management; Care Planning and Using the Care Plan;" to ensure staff recognize and respond to the following: a. A resident making suicide threats or statements are immediately placed 1:1 for constant observation; staff will remain with the resident at all times until (1) the Physician orders [REDACTED]. b. Warning signs of suicide; c. Statements and behaviors that may be a warning sign of suicide; d. Using probes for more information; d. Risk factors for suicide; e. Protective factors for suicide; f. Restricting access to lethal means and removal of any harmful objects. g. Residents at risk of suicide are communicated to all staff via the current Care Plan; Nursing 24-Hour Report; noted on the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] h. Residents at risk of suicide are discussed weekly in the department head meetings. i. A newly identified resident at risk of suicide will result in a suicide watch, and an emergency department head meeting will be called for immediate discussion. 3. Reviewing the facility's in-service records with the Social Worker ensuring responsibilities were reviewed and clarified, to include the following: a. A Suicidal Rating Scale has been added to the Social Services Assessment, to be completed on new admissions, quarterly, and with a significant change in condition; b. Social Services is responsible for ensuring the referral source sees the resident and responding/appropriate notes are in the medical record; c. Supportive Counseling; d. Bachelor of Social Work (BSW) Scope of Practice; e. Responsibilities of Social Services; f. Federal Regulations. 4. Review of the facility's contract with the Licensed Master of Social Work (LMSW) to ensure services are contracted to occur on a monthly basis beginning on [DATE], to provide visits, ensure oversight of the current SW, and compliance with State and Federal Regulations, facility's policies, and Standards of Practice. 5. Reviewing of Suicide Risk Assessments on all residents in the facility. No residents were identified to have suicide risks. 6. Reviewing the new contract with a different Mental Health Services provider, who will be providing weekly services to the facility's residents, as identified and indicated. 7. Reviewing assessments and supportive counseling provided by a contracted BSW with Long Term Care experience. The assessments and supportive counseling was provided to all residents receiving services from a previous contracted Mental Health Services; and new admissions from the past two months were assessed and supportive counseling was provided. 8. An emergency Quality Assurance/Performance Improvement Committee Meeting was held on [DATE], with the Medical Director, DON, Administrator, Consultant, Infection Control Nurse, and two other facility staff to include the Safety Leader. Non-compliance continues at a "D" level for monitoring corrective actions. The facility is required to submit a plan of correction. CO #

Based on medical record review, review of facility policies, and interview, the facility failed to follow facility policies to immediately notify the Physician of one (#1) resident voicing [MEDICAL CONDITION] of thirty-two residents reviewed. The facility's failure to ensure policies were followed and immediately notify the Physician for a resident in crisis beginning on February 25, 2012, resulted in the resident obtaining a dinner knife, and attempting to stab (resident #1's) self in the chest. Resident #1's attempted suicide on [DATE], required a transfer to the hospital emergency room and admission to a mental health unit for treatment. The facility's failure placed resident #1 in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). The Administrator and Director of Nursing were informed of the Immediate Jeopardy in the Conference Room on [DATE], at 11:30 a.m. The findings included: Resident #1 was admitted to the facility from the local hospital on February 10, 2012, with [DIAGNOSES REDACTED]. Medical record review of the hospital Discharge Summary dated February 10, 2012, revealed, (the resident was) "...significantly disabled...due to a [MEDICAL CONDITION] in...2009 which has left (resident) [DIAGNOSES REDACTED] and very poorly coordinated..." and had a history of [REDACTED]. Medical record review of the admission orders [REDACTED]. Medical record review of the Nursing Admission assessment dated [DATE], at 1:00 p.m., revealed the resident's cognition as oriented to person, place, time, and was alert. The resident was able to recall three named objects after five minutes, and was able to understand communication. Medical record review of a Nurse's Note dated February 15, 2012, at 9:45 a.m., revealed the resident was beginning to exhibit confusion, "...thinks...is going home today...states (spouse) is getting out of the hospital...going home with (spouse)...will monitor." Medical record review of a Social Service Progress Note dated February 24, 2012, at 1:35 p.m., revealed, "Family told SW (Social Worker) resident called the POA (Power-of-Attorney)...and (resident's spouse) late last night at 10:40 p.m. and made a delusional statement. (Resident) said...would send (resident's sibling) over to (resident's spouse's) home to run off a (spouse's visitor) according to...POA...also stated resident had a hx (history) of making statement(s) wanting to take pills to end (resident's) life...stated (resident) has made these statements to family ,[DATE] (one-to-two) yrs (years). SW talked to the DON (Director of Nursing) and (contracted Mental Health Service) referral being sent for counseling and Dr. (Physician) notified for medication and instruction. SW spoke to the resident...stated...was concerned about spouse but not thinking of hurting (resident's) self @ (at) this time. (Resident) thinks...spouse has...(someone else)...Spouse just (recently) got out of hospital with heart by-pass (heart surgery). SW asked (resident) if (resident) had thoughts of how (resident) would hurt (resident's) self. Resident stated, 'I would use a knife because my family took my guns from me.' SW spoke to DON and nurse on unit. Resident to eat in dining room with plastic spoon and plastic knife for safety measure since (resident) made statement. (Physician) has ordered medications to address depression and anxiety. SW sent (contracted Mental Health Service) referral signed by (Physician) for counseling. SW will continue to monitor and will assist with any needs." Interview with the SW on [DATE], at 2:45 p.m., in the Conference Room, confirmed, on February 24, 2012, staff (unable to recall who) reported the resident had voiced [MEDICAL CONDITION]. "After I had been told (resident) had voiced [MEDICAL CONDITION], I talked with (resident's) POA...the resident had a history of [REDACTED].; the DON was there. I talked with the Administrator and DON; and reported the resident had [MEDICAL CONDITION], had a plan, and showed signs and symptoms of suicide attempt. I feared the resident would attempt to take or end (resident's) life. I informed them (Administrator and DON) the resident needed (local mental health service) evaluation now. The DON stated, "This is a safe place...(resident) was irrational, and when irrational, will not attempt suicide..." The SW confirmed the Administrator and DON stated, "You don't understand; it is a safe place here, and the resident attempting or committing suicide is not going to happen here." Continued interview with the SW confirmed plastic silverware was the only precaution implemented. When the surveyor asked if mental health services were provided, the SW confirmed, "An order was written for (contracted Mental Health Service) to evaluate but I don't know if it was done or not." When the surveyor asked if supportive counseling had been done by the SW, the SW confirmed, "No; I was waiting on (contracted Mental Health Service) to provide counseling." A second interview with the SW, in the presence of the Administrator, on [DATE], at 6:50 p.m., in the conference room confirmed on February 24, 2012, the resident's POA informed the SW of the resident's history of wanting to take pills to end the resident's life. The SW was told on February 24, 2012, by staff (names unrecalled) the resident had asked questions regarding ending life and/or end of life, including "how to cut-off (resident's) air supply (SW placed hand around SW's throat and described an action of choking self); if insurance would pay if (resident) died ." The SW assessed the resident after the reports on February 24, 2012, and determined the resident had a plan to kill (resident's) self with a knife. The SW reported the assessment and suicidal concerns to the Administrator and DON, on February 24, 2012. The SW confirmed, "...The resident needed to be sent out to (local Mental Health Service provider) for an evaluation...I instructed the unit nurse to call the Physician and get orders for (contracted Mental Health Service) consult and medications for depression and anxiety. Dietary was notified to provide plastic silverware." The Administrator revealed to be unaware of the (resident's) threat to cut-off (resident's) air supply; the SW revealed, "I thought I told the Administrator." The Administrator confirmed, "The DON and I felt the (resident) to be in a safe environment and did not feel the resident needed to be sent out...we (Administrator and DON) felt the resident was not a threat of harm to (resident's) self...felt the resident was unable to attempt suicide. Both the SW and Administrator confirmed to be unaware of the resident's [MEDICAL CONDITION] voiced to the spouse on a phone call documented in the nurse's notes on February 25, 2012, at 9:59 p.m. Continued interview confirmed no Mental Health Service consult occurred as ordered on February 24, 2012, and the Physician was not immediately notified by the SW of the assessment and concerns of suicide. Medical record review of a Physician's Telephone Order dated February 24, 2012, revealed: 1515 (3:15 p.m.) "...(contracted Mental Health Service) to eval (evaluate) and treat as indicated..." Medical record review of a (contracted Mental Health Service) physician's orders [REDACTED]. 1. Sad; 2. Agitation; 3. [MEDICAL CONDITION]. Continued review of the referral revealed no documentation of urgency (suicidal ideation) or crisis intervention ordered for this resident. Continued review revealed no documentation of a Mental Health Service evaluation or treatment. Medical record review of an "Admit Note" dated February 25, 2012, (no time), documented by the Physician, revealed the resident was unable to care for (resident's) self, "particularly with (resident's) declining health." The note revealed the resident "has some delusional thought patterns about (resident's spouse) running off with somebody." The Physician's impression revealed the following: 1. [MEDICAL CONDITION] left-sided [MEDICAL CONDITION]; 2. CAD ([MEDICAL CONDITION]) S/P (status [REDACTED]. 3. Type II diabetes mellitus currently on insulin therapy; 4. Chronic [MEDICAL CONDITION]; 5. [MEDICAL CONDITION]. The Physician's plan revealed "Continue as per orders at this time." Continued review of the note revealed no documentation of the resident being at risk of suicide. Medical record review of a Nurse's Note dated February 25, 2012, at 9:59 p.m., revealed the resident was on the phone talking to the resident's spouse, "...(the resident)...talking and getting emotional et (and) crying continuing to state 'I'll just end it now.' (Resident) quickly changes tone et says sorry to (spouse)...This nurse (Licensed Practical Nurse (LPN) #1) spoke with...spouse et assured will keep close watch on Res (resident). Administered PRN [MEDICATION NAME] to help Res sleep. Res calm et polite to staff at this moment. Will cont (continue) to monitor..." Continued review revealed no documentation the physician was notified of the resident's suicidal ideation. Medical record review of a Nurse's Note dated [DATE], at 7:45 p.m., revealed, "This nurse (LPN #2) was coming down the hall and saw resident had a butter knife...trying to stab self in the chest. LPN #2 got knife away from resident...asked (resident) what (resident) was doing. Resident stated, 'I just wanted to end this'..." LPN #2 notified the Physician on-call; orders were received to send to the (Hospital) emergency room (ER) for an evaluation. Continued review revealed the Emergency Medical Service (EMS) arrived at 8:00 p.m., and the resident was transferred from the nursing home at 8:15 p.m. Medical record review of a Patient Transfer Form dated [DATE], (no time), revealed the resident tried to "stab self in the chest with a butter knife" as the reason for transfer (to the hospital from the nursing home). Medical record review of an inpatient Mental Health Service Consultation report dated [DATE], revealed, "...sent over in the middle of the night (on [DATE]) from the nursing home after making a suicide gesture...was found sitting in a chair in the hallway with butter knife trying to stab...self in the chest...they (nursing home staff) were able to get the knife away...(resident) stated that (resident) was trying to end (resident's) life...sent to (hospital) for evaluation..." The resident was admitted to the hospital's inpatient mental health services program for treatment of [REDACTED]. Review of facility policy, Change in Medical Condition of Residents, (no date) revealed, "...Purpose: To keep the physician...informed of the resident's medical condition...Standard: Notification of the physician...occur...according to federal regulations, when there is a change in the resident's condition. Change in condition is identified as:...A change in the resident's physical, mental or psychosocial status (i.e., deterioration in health, mental or psychosocial status in either life-threatening conditions or clinical complications)...need to alter a treatment (i.e...commence a new form of treatment)..." Interview with LPN #1 on [DATE], at 12:17 p.m., in the Conference Room, confirmed, the entry in the nurse's note on February 25, 2012, at 9:59 p.m., was documented by LPN #1. LPN #1 confirmed on the evening of February 25, 2012, the resident called the spouse and was emotional; which ranged from crying and remorse, to anger, then back to crying and remorse. LPN #1 confirmed (resident) said, "I'll just end it now." LPN #1 confirmed, "There are just too many variables here for a resident to be safe if they are suicidal...While (resident) had mood swings and was emotional, I just didn't think (resident) would do something like that (attempt suicide)...and confirmed (LPN #1) failed to immediately or ever notify the Physician of the resident's mood swings, emotional status, and [MEDICAL CONDITION]. Interview with LPN #2 on [DATE], at 12:50 p.m., in the Conference Room, confirmed, on [DATE], shortly after supper (dinner), LPN #2 was walking out from another resident's room, to the hallway, and observed resident #1 with a knife trying to stab (resident's) self in the chest with the knife. During this interview, while describing the attempt, LPN #2 demonstrated how the resident attempted to stab self in the chest, by hitting (LPN #2's) self in the chest repeatedly with a fisted right hand, and made a forceful thumping sound with each strike of the fist to the chest. "(Resident) was using a metal knife...like the ones that come on the residents' trays for meals. I think (resident) got it off of another resident's tray...I grabbed the knife...I asked 'what are you doing?'...(resident) said, 'I just want to end it...kill myself '...finally got the knife from (resident)...(resident) had a tee-shirt and sweat shirt on...I pulled them up to make sure...saw no wounds or lacerations...I directed a nearby CNA (Certified Nursing Assistant) to stay with (resident)...called Physician, got an order to send to the ER for evaluation, and called the family..." LPN #2 confirmed to know of previous [MEDICAL CONDITION] with the resident, and confirmed, "I do not know what suicide precautions are...I have never been told...I had no idea...(resident) was not placed 1:1 (one staff person providing constant observation of one resident, and within reach of that resident) until after the suicide attempt...we (staff) were just told to watch (resident) closer and give plastic silverware because of previous [MEDICAL CONDITION]" Interview with Physician on [DATE], at 6:00 p.m., in the conference room confirmed the facility did not make the Physician aware of the resident's [MEDICAL CONDITION], or any plan to commit suicide as documented by the SW on February 24, 2012, or on February 25, 2012. "If the facility had reported the resident to be significantly depressed to the point of [MEDICAL CONDITION] and/or intent with a plan, I would have ordered to send the resident out to the ER for an evaluation immediately." A second interview with the DON on [DATE], at 1:00 p.m., in the conference room confirmed the Physician was not immediately notified of the concerns of suicide. Interview with the Administrator on [DATE], at 7:35 p.m., in the conference room confirmed the resident was in a mental health crisis, as identified and reported on February 24, 2012. Continued interview confirmed the resident obtained a knife from another resident's tray, which the Administrator confirmed to be a stainless steel dinner knife. Continued interview with the Administrator confirmed the facility failed to follow its policy, Change in Medical Condition of Residents, and immediately notify the Physician of the concerns of suicide. In summary, the facility failed to immediately notify the Physician when resident #1 had a change in condition; and after being made aware the resident had a history and current threat of suicide. The initial threat was reported to the DON on February 24, 2012, by the POA; and then to the Administrator and DON on February 24, 2012, by the SW. Physician orders [REDACTED]. Due to the facility's failure to follow facility policies and notify the Physician of the resident in crisis, the resident remained in the facility, obtained a dinner knife from another resident's meal tray during supper and attempted suicide by repeatedly stabbing (resident's) self in the chest on [DATE]. The Immediate Jeopardy was effective from February 25, 2012, through [DATE], and was removed [DATE]. An Acceptable Allegation of Compliance, which removed the immediacy of the jeopardy, was received and corrective actions were validated by the surveyor through review of documents, staff interviews, and observations conducted onsite on [DATE]. The surveyor verified the allegation of compliance by: 1. Reviewing the facility's in-services records to ensure all staff was educated regarding changes to and implementation of the facility's following policies: a. Change in Resident's Condition and Status; b. Suicide Threats; c. Care of a Suicidal Resident; e. Behavioral Management; f. Care Planning and Using the Care Plan. 2. Conducting interviews with facility staff, to include fifteen of thirty-one nurses, three of nine environmental services, one of three maintenance, two of four activities, one of two social services, twenty-nine of fifty-two CNA's, ten of twenty-three dietary, seven of seventeen laundry and housekeeping, on staff to determine the level of comprehension gained through in-service education conducted regarding changes to and implementation of the facility's policies, "Change in Resident's Condition and Status; Suicide Threats; Care of a Suicidal Resident; Behavioral Management; Care Planning and Using the Care Plan;" to ensure staff recognize and respond to the following: a. A resident making suicide threats or statements are immediately placed 1:1 for constant observation; staff will remain with the resident at all times until (1) the Physician orders [REDACTED]. b. Warning signs of suicide; c. Statements and behaviors that may be a warning sign of suicide; d. Using probes for more information; d. Risk factors for suicide; e. Protective factors for suicide; f. Restricting access to lethal means and removal of any harmful objects. g. Residents at risk of suicide are communicated to all staff via the current Care Plan; Nursing 24-Hour Report; noted on the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] h. Residents at risk of suicide are discussed weekly in the department head meetings. i. A newly identified resident at risk of suicide will result in a suicide watch, and an emergency department head meeting will be called for immediate discussion. 3. Reviewing the facility's in-service records with the Social Worker ensuring responsibilities were reviewed and clarified, to include the following: a. A Suicidal Rating Scale has been added to the Social Services Assessment, to be completed on new admissions, quarterly, and with a significant change in condition; b. Social Services is responsible for ensuring the referral source sees the resident and responding/appropriate notes are in the medical record; c. Supportive Counseling; d. Bachelor of Social Work (BSW) Scope of Practice; e. Responsibilities of Social Services; f. Federal Regulations. 4. Review of the facility's contract with the Licensed Master of Social Work (LMSW) to ensure services are contracted to occur on a monthly basis beginning on [DATE], to provide visits ensure oversight of the current SW and compliance with State and Federal Regulations, facility's policies, and Standards of Practice. 5. Reviewing of Suicide Risk Assessments on all residents in the facility. No residents were identified to have suicide risks. 6. Reviewing the new contract with a different Mental Health Services provider, who will be providing weekly services to the facility's residents, as identified and indicated. 7. Reviewing assessments and supportive counseling provided by a contracted BSW with Long Term Care experience. The assessments and supportive counseling was provided to all residents receiving services from a previous contracted Mental Health Services; and new admissions from the past two months were assessed and supportive counseling was provided. 8. An emergency Quality Assurance/Performance Improvement Committee Meeting was held on [DATE], with the Medical Director, DON, Administrator, Consultant, Infection Control Nurse, and two other facility staff to include the Safety Leader. Non-compliance continues at a "D" level for monitoring corrective actions. The facility is required to submit a plan of correction. CO #

Based on medical record review, review of facility policies, and interview, the facility failed to follow facility policies and failed to revise the care plan with interventions to protect and prevent suicide attempts for one (#1) resident of thirty-two residents reviewed. The facility's failure to follow policies, and revise the care plan resulted in one resident (#1) attempting suicide by stabbing (resident's self) in the chest with a table knife, of thirty-two residents reviewed. The facility's failure to ensure policies were followed and revise the care plan with interventions to prevent suicide attempts resulted in the resident obtaining a dinner knife, and attempting to stab (resident #1's) self in the chest. Resident #1's attempted suicide on March 3, 2012, required a transfer to the hospital emergency room and admission to a mental health unit for treatment. The facility's failure placed resident #1 in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). The Administrator and Director of Nursing were informed of the Immediate Jeopardy in the Conference Room on November 29, 2012, at 11:30 a.m. The findings included: Resident #1 was admitted to the facility from the local hospital on February 10, 2012, with [DIAGNOSES REDACTED]. Medical record review of the hospital Discharge Summary dated February 10, 2012, revealed, (the resident was) "...significantly disabled...due to a [MEDICAL CONDITION] in...2009 which has left (resident) [DIAGNOSES REDACTED] and very poorly coordinated..." and had a history of [REDACTED]. Medical record review of a Social Service Progress Note dated February 24, 2012, at 1:35 p.m., revealed, "Family told SW (Social Worker) resident called the POA (Power-of-Attorney)...and (resident's spouse) late last night at 10:40 p.m. and made a delusional statement. (Resident) said...would send (resident's sibling) over to (resident's spouse's) home to run off a (spouse's visitor) according to...POA...also stated resident had a hx (history) of making statement(s) wanting to take pills to end (resident's) life...stated (resident) has made these statements to family 1-2 (one-to-two) yrs (years). SW talked to the DON (Director of Nursing) and (contracted Mental Health Service) referral being sent for counseling and Dr. (Physician) notified for medication and instruction. SW spoke to the resident...stated...was concerned about spouse but not thinking of hurting (resident's) self @ (at) this time. (Resident) thinks...spouse has...(someone else)...Spouse just (recently) got out of hospital with heart by-pass (heart surgery). SW asked (resident) if (resident) had thoughts of how (resident) would hurt (resident's) self. Resident stated, 'I would use a knife because my family took my guns from me.' SW spoke to DON and nurse on unit. Resident to eat in dining room with plastic spoon and plastic knife for safety measure since (resident) made statement. (Physician) has ordered medications to address depression and anxiety. SW sent (contracted Mental Health Service) referral signed by (Physician) for counseling. SW will continue to monitor and will assist with any needs." Medical record review of an electronically printed Care Plan, revealed a handwritten entry: (Problem) "2-24-12, (February 24, 2012) Risk for harm to self AEB (as evidenced by) HX (history) of statements of wanting to end life." (Goal) "No Harm to resident per self thru 5-13-12, (May 13, 2012)" (Approaches) "Meds (medications) as ordered per MD (Medical Doctor); Psychiatric Services/Counseling (Mental Health Services and/or Counseling); Plastic utensils at meals for safety; Social Worker to monitor and assist c (with) needs. (emotional); Observe for possible adverse reactions to meds." Medical record review of a Nurse's Note dated February 25, 2012, at 9:59 p.m., revealed the resident was on the phone talking to the resident's spouse, "...(the resident)...talking and getting emotional et (and) crying continuing to state 'I'll just end it now.' (Resident) quickly changes tone et says sorry to (spouse)...This nurse (Licensed Practical Nurse (LPN) #1) spoke with...spouse et assured will keep close watch on Res (resident). Administered PRN [MEDICATION NAME] to help Res sleep. Res calm et polite to staff at this moment. Will cont (continue) to monitor..." Continued review revealed no documentation of the type of monitoring to be done or the frequency, or revision to the care plan. Medical record review of the Care Plan revealed no documentation the Care Plan was revised with interventions (approaches) to protect and prevent suicide attempts by the resident. Medical record review of a Nurse's Note dated March 3, 2012, at 7:45 p.m., revealed, "This nurse (LPN #2) was coming down the hall and saw resident had a butter knife...trying to stab self in the chest. (LPN #2) got knife away from resident...asked (resident) what (resident) was doing. Resident stated, 'I just wanted to end this'..." Continued review revealed a Certified Nursing Assistant (CNA) was assigned to stay with the resident. LPN #2 notified the Physician on-call; orders were received to send to the (Hospital) emergency room (ER) for an evaluation. The resident's POA was also notified. Continued review revealed the Emergency Medical Service (EMS) arrived at 8:00 p.m., and the resident was transferred from the nursing home at 8:15 p.m. Medical record review of a Patient Transfer Form dated March 3, 2012, (no time), revealed the resident tried to "stab self in the chest with a butter knife" as the reason for transfer (to the hospital from the nursing home). Medical record review of an inpatient Psychiatric Consultation report dated March 4, 2012, revealed, "...sent over in the middle of the night (on March 3, 2012) from the nursing home after making a suicide gesture...was found sitting in a chair in the hallway with butter knife trying to stab...self in the chest...they (nursing home staff) were able to get the knife away...(resident) stated that (resident) was trying to end (resident's) life...sent to (hospital) for evaluation..." The resident was admitted to the hospital's inpatient mental health services program for treatment of [REDACTED]. Review of facility policy, Social Services, revised August 2006 revealed "...The care plan shall be used in developing the resident's daily care... 4. The social services department is responsible for:...b. Identifying individual...emotional needs; c...providing for the resident's needs by developing and maintaining individualized social care plans..." Review of facility policy, Care Plans-Comprehensive, revised April 2010 revealed "...2...care plans are revised as information about the resident and the resident's change...3. Each resident's...care plan is designed to: a. Incorporate identified problem areas; b. Incorporate risk factors associated with identified problems...Revisions: The Care Planning/Interdisciplinary Team is responsible for the periodic review and updating of the care plans: a. When there has been a significant change in the resident's condition..." Telephone interview with Registered Nurse (RN) #1 on November 27, 2012, at approximately 10:50 a.m., revealed when the surveyor initiated the investigation on November 5, 2012, and requested the resident's record from medical records, RN #2 realized the surveyor would be reviewing the resident's care plan. On November 5, 2012, (unable to recall time), RN #2, realized the resident care plan had not been revised, called RN #1, and asked how to write a suicide precaution care plan. RN #1 revealed the care plan was not revised on February 24, 2012, as documented but, was falsely revised on November 5, 2012. Interview with RN #2 on November 27, 2012, at 11:21 a.m., in the conference room confirmed, the surveyor had requested the chart when the complaint investigation was first initiated on November 5, 2012. "...I looked at the chart before giving it to the surveyor and realized the care plan had not been updated (revised) for suicide precautions from when the resident threatened suicide on February 24, 2012...I documented the care plan update on November 5, 2012, to reflect a February 24, 2012, date, to prevent the surveyor from finding it had not been updated..." Interview with LPN #2 on November 26, 2012, at 12:50 p.m., in the conference room, confirmed on March 3, 2012, shortly after supper (dinner), LPN #2 was walking out from another resident's room, to the hallway, and observed resident #1 with a knife trying to stab (resident's) self in the chest with the knife. During this interview, while describing the attempt, LPN #2 demonstrated how the resident attempted to stab self in the chest, by hitting (LPN #2's) self in the chest repeatedly with a fisted right hand, and made a forceful thumping sound with each strike of the fist to the chest. "(Resident) was using a metal knife...like the ones that come on the residents' trays for meals. I think (resident) got it off of another resident's tray...I grabbed the knife...I asked 'what are you doing?'...(resident) said, 'I just want to end it...kill myself '...finally got the knife from (resident)...(resident) had a tee-shirt and sweat shirt on...I pulled them up to make sure...saw no wounds or lacerations...I directed a nearby CNA to stay with (resident)...called Physician, got an order to send to the ER for evaluation, and called the family..." LPN #2 confirmed to know of previous [MEDICAL CONDITION] with the resident, and confirmed, "I do not know what suicide precautions are...I have never been told...I had no idea...(resident) was not placed 1:1 until after the suicide attempt...we (staff) were just told to watch (resident) closer and give plastic silverware because of previous [MEDICAL CONDITION]" Interview with CNA #2 on November 27, 2012, at 8:45 p.m., in the conference room confirmed CNA #2 worked on March 3, 2012, on the 2:00 p.m.-10:00 p.m. shift; and was assigned to the dining room for supper. "...After supper, I transported (resident #1) to the nurse's station straight across the hall from the dining room on Wing 4, and then proceeded down the hall to pick up trays...As I came out from room [ROOM NUMBER] (near the end of the hall), I looked up and heard (LPN #2) say, 'I need some help down here.' I ran to assist (LPN #2)...Resident #1 had a metal knife in (resident's) right hand...was repeatedly stabbing (resident's) chest with the knife and yelling, 'I'm going to kill myself...I'm going to kill myself.' (LPN #2) was struggling with (resident) to get the knife, as (resident) was going at it...stabbing at (resident's) chest...By the time I reached (LPN #2) and the resident, (LPN #2) had removed the knife from the resident...I realized (resident #1) had gotten the knife from another resident seated at (resident #1's) table during supper and I said, 'Oh, no! (Resident #1) got the knife off of (random resident's) tray'....I looked at (resident's) chest immediately...it had multiple red, dime-size areas but, no lacerations or stab wounds...I stayed at (resident's) bedside until EMS (Emergency Medical Services), arrived. (Resident) previously made multiple statements...wanted to kill (resident's) self, and wanted to die." CNA #2 confirmed these statements were made prior to March 3, 2012, but, could not recall the dates, or date of onset. "I tried to encourage (resident) everyday...I just never dreamed (resident) would try to kill (resident's) self..." Interviews were conducted in the conference room, on November 27, 2012, with LPN #1, at 3:10 p.m.; LPN #2, at 3:20 p.m.; CNA #3, at 3:50 p.m.; LPN #4, 4:05 p.m.; LPN #3, at 4:30 p.m.; CNA #4, at 4:40 p.m.; CNA #7, at 4:50 p.m.; CNA #5, at 5:00 p.m.. The interviews confirmed no education was provided on the resident's care plan to protect and prevent suicide attempts. A second interview with CNA #2 on November 27, 2012, at 10:15 p.m., in the conference room confirmed "...I was never told or educated on what to do when a resident threatened to harm themselves or wished to die. Nobody ever told me why (resident #1) had plastic silverware. I never asked and I never really thought about why...I'm doing the best I can...I had no idea what to look for...I've not had psych (psychiatric) training...I was never told what to do for (resident #1's) psychiatric or suicidal care." Interview with the SW on November 28, 2012, at 4:30 p.m., in the conference room confirmed, "...The resident voiced...wanted to die...how would kill...self, with a knife. (Resident) was depressed and suicidal...all of my bells and [MEDICATION NAME] off. The SW confirmed, "I strongly felt (resident) needed to go out for an eval." Continued interview confirmed, the SW failed to ensure the following for the resident (#1) in crisis: failed to follow Social Services policies; failed to revise the resident's individual care plan to protect and prevent suicide attempts; and failed to provide facility education on the resident's individual care plan to protect and prevent suicide attempts. "Most of the facility staff is unaware of what suicide preventions and precautions are. Oh, I know very well what they are and I knew this (attempted suicide) was about to happen." Interview with the Administrator on November 28, 2012, at 7:35 p.m., in the conference room confirmed the facility failed to follow Social Services and Care Plan policies, failed to revise the resident's individual care plan to protect and prevent suicide attempts; and failed to provide facility education on the resident's individual care plan to protect and prevent suicide attempts. In summary, the facility failed to ensure the care plan was revised for resident #1, after being made aware the resident had a history and current threat of suicide. The initial threat was reported to the DON on February 24, 2012, by the POA; and then to the Administrator and DON on February 24, 2012, by the SW. The care plan was not revised until November 5, 2012, approximately months after the resident voiced suicide ideations (on February 24, 2012), and eight months after the resident was discharged due to a suicide attempt (on March 3, 2012). The Immediate Jeopardy was effective from February 25, 2012, through November 29, 2012, and was removed on November 30, 2012. An Acceptable Allegation of Compliance, which removed the immediacy of the jeopardy, was received and corrective actions were validated by the surveyor through review of documents, staff interviews, and observations conducted onsite on November 30, 2012. The surveyor verified the allegation of compliance by: 1. Reviewing the corrective action implemented for the SW and RN #2. 2. Reviewing the facility's in-service records to ensure all staff were educated regarding changes to and implementation of the facility's following policies: a. Change in Resident's Condition and Status; b. Suicide Threats; c. Care of a Suicidal Resident; e. Behavioral Management; f. Care Planning and Using the Care Plan. 3. Conducting interviews with facility departments, to include fifteen of thirty-one nurses, three of nine environmental services, one of three maintenance, two of four activities, one of two social services, twenty-nine of fifty-two CNA's, ten of twenty-three dietary, seven of seventeen laundry and housekeeping, on staff to determine the level of comprehension gained through in-service education conducted regarding changes to and implementation of the facility's policies, "Change in Resident's Condition and Status; Suicide Threats; Care of a Suicidal Resident; Behavioral Management; Care Planning and Using the Care Plan;" to ensure staff recognize and respond to the following: a. A resident making suicide threats or statements are immediately placed 1:1 for constant observation; staff will remain with the resident at all times until (1) the Physician orders [REDACTED]. b. Warning signs of suicide; c. Statements and behaviors that may be a warning sign of suicide; d. Using probes for more information; d. Risk factors for suicide; e. Protective factors for suicide; f. Restricting access to lethal means and removal of any harmful objects. g. Residents at risk of suicide are communicated to all staff via the current Care Plan; Nursing 24-Hour Report; noted on the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] h. Residents at risk of suicide are discussed weekly in the department head meetings. i. A newly identified resident at risk of suicide will result in a suicide watch, and an emergency department head meeting will be called for immediate discussion. 4. Reviewing the facility's in-service records with the Social Worker ensuring responsibilities were reviewed and clarified, to include the following: a. A Suicidal Rating Scale has been added to the Social Services Assessment, to be completed on new admissions, quarterly, and with a significant change in condition; b. Social Services is responsible for ensuring the referral source sees the resident and responding/appropriate notes are in the medical record; c. Supportive Counseling; d. Bachelor of Social Work (BSW) Scope of Practice; e. Responsibilities of Social Services; f. Federal Regulations. 5. Review of the facility's contract with the Licensed Master of Social Work (LMSW) to ensure services are contracted to occur on a monthly basis beginning on November 30, 2012, to provide visits, ensure oversight of the current SW, and compliance with State and Federal Regulations, facility's policies, and Standards of Practice. 6. Reviewing of Suicide Risk Assessments on all residents in the facility. No residents were identified to have suicide risks. 7. Reviewing the new contract with a different Mental Health Service provider, who will be providing weekly services to the facility's residents, as identified and indicated. 8. Reviewing assessments and supportive counseling provided by a contracted BSW with Long Term Care experience. The assessments and supportive counseling was provided to all residents receiving services from a previous contracted Mental Health Service provider; and new admissions from the past two months were assessed and supportive counseling was provided. 9. An emergency Quality Assurance/Performance Improvement Committee Meeting was held on November 30, 2012, with the Medical Director, DON, Administrator, Consultant, Infection Control Nurse, and two other facility staff to include the Safety Leader. Non-compliance continues at a "D" level for monitoring corrective actions. The facility is required to submit a plan of correction. CO #

Based on medical record review, review of facility policies, observation, and interview, the facility failed to follow facility policies, and failed to provide Mental Health Services for five (#1, #27, #17, #18, #31) residents of thirty-two residents reviewed. The facility's failure to ensure policies were followed and Mental Health Services were provided for a resident in crisis beginning on February 24, 2012, resulted in the resident obtaining a dinner knife, and attempting to stab (resident #1's) self in the chest. Resident #1's attempted suicide on [DATE], required a transfer to the hospital emergency room and admission to a mental health unit for treatment. The facility's failure placed resident #1 in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). The facility failed to ensure policies were followed and Mental Health Services were provided for residents #27, #17, #18, and #31, who experienced mental and/or psychosocial difficulties. The Administrator and Director of Nursing were informed of the Immediate Jeopardy in the Conference Room on [DATE], at 11:30 a.m. F319 resulted in Substandard Quality of Care. The findings included: Resident #1 was admitted to the facility from the local hospital on February 10, 2012, with [DIAGNOSES REDACTED]. Medical record review of the hospital Discharge Summary dated February 10, 2012, revealed, (the resident was) "...significantly disabled...due to a [MEDICAL CONDITION] in...2009 which has left (resident) [DIAGNOSES REDACTED] and very poorly coordinated..." and had a history of [REDACTED]. Medical record review of the admission orders [REDACTED]. Medical record review of the Nursing Admission assessment dated [DATE], at 1:00 p.m., revealed the resident's cognition as oriented to person, place, time, and was alert. The resident was able to recall three named objects after five minutes, and was able to understand communication. Medical record review of a Nurse's Note dated February 15, 2012, at 9:45 a.m., revealed the resident was beginning to exhibit confusion, "...thinks...is going home today...states (spouse) is getting out of the hospital...going home with (spouse)...will monitor." Medical record review of a Social Service Progress Note dated February 24, 2012, at 1:35 p.m., revealed, "Family told SW (Social Worker) resident called the POA (Power-of-Attorney)...and (resident's spouse) late last night at 10:40 p.m. and made a delusional statement. (Resident) said...would send (resident's sibling) over to (resident's spouse's) home to run off a (spouse's visitor) according to...POA...also stated resident had a hx (history) of making statement(s) wanting to take pills to end (resident's) life...stated (resident) has made these statements to family ,[DATE] (one-to-two) yrs (years). SW talked to the DON (Director of Nursing) and (contracted Mental Health Service) referral being sent for counseling and Dr. (Physician) notified for medication and instruction. SW spoke to the resident...stated...was concerned about spouse but not thinking of hurting (resident's) self @ (at) this time. (Resident) thinks...spouse has...(someone else)...Spouse just (recently) got out of hospital with heart by-pass (heart surgery). SW asked (resident) if (resident) had thoughts of how (resident) would hurt (resident's) self. Resident stated, 'I would use a knife because my family took my guns from me.' SW spoke to DON and nurse on unit. Resident to eat in dining room with plastic spoon and plastic knife for safety measure since (resident) made statement. (Physician) has ordered medications to address depression and anxiety. SW sent (contracted Mental Health Service) referral signed by (Physician) for counseling. SW will continue to monitor and will assist with any needs. Continued review of the SW notes revealed no supportive counseling due to the resident's concerns of the spouse having someone else, history of [MEDICAL CONDITION], or the plan to use a knife to hurt the resident's self. Medical record review of a (contracted Mental Health Service) physician's orders [REDACTED]. 1. Sad; 2. Agitation; 3. [MEDICAL CONDITION]. Continued review of the referral revealed no documentation of urgency or crisis intervention ordered for this resident. Continued review revealed no documentation of a Mental Health Service evaluation or treatment. Continued review revealed no documentation of the SW providing any support or collaboration with the physician to get orders for additional referral(s) to evaluate and treat the resident's mental and psychosocial needs during the remainder of the resident's admission at the nursing home. Medical record review of an "Admit Note" dated February 25, 2012, (no time), documented by the Physician, revealed the resident was unable to care for (resident's) self, "particularly with (resident's) declining health." The note revealed the resident "has some delusional thought patterns about (resident's spouse) running off with somebody." The Physician's plan revealed "Continue as per orders at this time." Medical record review of a Nurse's Note dated February 25, 2012, at 9:59 p.m., revealed the resident was on the phone talking to the resident's spouse, "...(the resident)...talking and getting emotional et (and) crying continuing to state 'I'll just end it now.' (Resident) quickly changes tone et says sorry to (spouse)...This nurse (Licensed Practical Nurse (LPN) #1) spoke with...spouse et assured will keep close watch on Res (resident). Administered PRN [MEDICATION NAME] to help Res sleep. Res calm et polite to staff at this moment. Will cont (continue) to monitor..." Medical record review of the Social Service Progress Notes revealed no documentation the SW assessed and/or provided interventions to address the [MEDICAL CONDITION]. Medical record review of a Nurse's Note dated [DATE], at 7:45 p.m., revealed, "This nurse (LPN #2) was coming down the hall and saw resident had a butter knife...trying to stab self in the chest. (LPN #2) got knife away from resident...asked (resident) what (resident) was doing. Resident stated, 'I just wanted to end this'..." Continued review revealed a Certified Nursing Assistant (CNA) was assigned to stay with the resident. LPN #2 notified the Physician on-call; orders were received to send to the (Hospital) emergency room (ER) for an evaluation. The resident's POA was also notified. Continued review revealed the Emergency Medical Service (EMS) arrived at 8:00 p.m., and the resident was transferred from the nursing home at 8:15 p.m. Medical record review of a Patient Transfer Form dated [DATE], (no time), revealed the resident tried to "stab self in the chest with a butter knife" as the reason for transfer (to the hospital from the nursing home). Medical record review of the Social Service Progress Notes revealed no documentation of the resident's attempted suicide on [DATE], until [DATE]; which was two days after the resident was admitted to the hospital's inpatient Mental Health Services program for treatment of [REDACTED]. Medical record review of an inpatient Psychiatric Consultation report dated [DATE], revealed, "...sent over in the middle of the night (on [DATE]) from the nursing home after making a suicide gesture...was found sitting in a chair in the hallway with butter knife trying to stab...self in the chest...they (nursing home staff) were able to get the knife away...(resident) stated that (resident) was trying to end (resident's) life...sent to (hospital) for evaluation..." The resident was admitted to the hospital's inpatient Mental Health Services program for treatment of [REDACTED]. Review of facility policy, Referrals, Social Services, revised [DATE], revealed, "...1. Social services shall coordinate resident referrals...3. Social services will collaborate with nursing staff or other pertinent disciplines to arrange for services that have been ordered by the physician...4. Social services will...ensure adequate follow-up with appropriate documentation from referral source...5. Social service...will maintain a listing of referral agencies that...provide assistance or therapy to residents with special problems and/or needs...." Interview with LPN #2 on [DATE], at 12:50 p.m., in the Conference Room, confirmed on [DATE], shortly after supper (dinner), LPN #2 was walking out from another resident's room, to the hallway, and observed resident #1 with a knife trying to stab (resident's) self in the chest with the knife. During this interview, while describing the attempt, LPN #2 demonstrated how the resident attempted to stab self in the chest, by hitting (LPN #2's) self in the chest repeatedly with a fisted right hand, and made a forceful thumping sound with each strike of the fist to the chest. "(Resident) was using a metal knife...like the ones that come on the residents' trays for meals. I think (resident) got it off of another resident's tray...I grabbed the knife...I asked 'what are you doing?'...(resident) said, 'I just want to end it...kill myself '...finally got the knife from (resident)...(resident) had a tee-shirt and sweat shirt on...I pulled them up to make sure...saw no wounds or lacerations...called Physician, got an order to send to the ER for evaluation, and called the family..." LPN #2 confirmed to know of previous [MEDICAL CONDITION] with the resident. Interview with CNA #2 on [DATE], at 8:45 p.m., in the conference room confirmed CNA #2 worked on [DATE], on the 2:00 p.m.-10:00 p.m. shift; and was assigned to the dining room for supper. "...After supper, I transported (resident #1) to the nurse's station straight across the hall from the dining room on Wing 4, and then proceeded down the hall to pick up trays...As I came out from room [ROOM NUMBER] (near the end of the hall), I looked up and heard (LPN #2) say, 'I need some help down here.' I ran to assist (LPN #2)...Resident #1 had a metal knife in (resident's) right hand...was repeatedly stabbing (resident's) chest with the knife and yelling, 'I'm going to kill myself...I'm going to kill myself.' (LPN #2) was struggling with (resident) to get the knife, as (resident) was going at it...stabbing at (resident's) chest...By the time I reached (LPN #2) and the resident, (LPN #2) had removed the knife from the resident...I realized (resident #1) had gotten the knife from another resident seated at (resident #1's) table during supper and I said, 'Oh, no! (Resident #1) got the knife off of (random resident's) tray'....I looked at (resident's) chest immediately...it had multiple red, dime-size areas but, no lacerations or stab wounds. (LPN #2) assigned me to stay 1:1 with (resident #1)...I stayed at (resident's) bedside until EMS (Emergency Medical Services), arrived. (Resident) previously made multiple statements...wanted to kill (resident's) self, and wanted to die." Interview with the SW on [DATE], at 2:45 p.m., in the Conference Room, confirmed, on February 24, 2012, staff (unable to recall who) reported the resident had voiced [MEDICAL CONDITION]. "After I had been told (resident) had voiced [MEDICAL CONDITION], I talked with (resident's) POA...the resident had a history of [REDACTED].; the DON was there. I talked with the Administrator and DON; and reported the resident had [MEDICAL CONDITION], had a plan, and showed signs and symptoms of suicide attempt. I feared the resident would attempt to take or end (resident's) life. Continued interview with the SW confirmed plastic silverware was the only precaution implemented. When the surveyor asked if Mental Health Services were provided, the SW confirmed, "An order was written for (contracted mental health) to evaluate but, I don't know if it was done or not." When the surveyor asked if supportive counseling had been done by the SW, the SW confirmed, "No; I was waiting on (contracted Mental Health Service) to provide counseling." When the surveyor asked the SW who is responsible for arranging and tracking psychiatric referrals, the SW replied, "I am." Telephone interview on [DATE], at approximately 3:30 p.m., with the (contracted Mental Health Service provider's) Compliance Officer and Director of Business Development confirmed the physician's orders [REDACTED]. Continued interview confirmed the referral did not indicate a crisis situation (urgent, stat (immediately), or suicidal). "A clinician went to the facility to evaluate the resident on [DATE]; the resident was in the hospital and no treatment was provided." A second interview with the SW, in the presence of the Administrator, on [DATE], at 6:50 p.m., in the conference room confirmed on February 24, 2012, the resident's POA informed the SW of the resident's history of wanting to take pills to end the resident's life. The SW was told on February 24, 2012, by staff (names unrecalled) the resident had asked questions regarding ending life and/or end of life, including "how to cut-off (resident's) air supply (SW placed hand around SW's throat and described an action of choking self); if insurance would pay if (resident) died ." The SW assessed the resident after the reports on February 24, 2012, and determined the resident had a plan to kill (resident's) self with a knife. The SW reported the assessment and suicidal concerns to the Administrator and DON, on February 24, 2012. The SW confirmed, "...The resident needed to be sent out to (local Mental Health Service provider) for a Mental Health Service evaluation...I instructed the unit nurse to call the Physician and get orders for (contracted Mental Health Service) consult and medications for depression and anxiety. Continued interview with the SW confirmed no psychiatric consult occurred as ordered on February 24, 2012. Interview with Physician on [DATE], at 6:00 p.m., in the conference room confirmed the facility did not make the Physician aware of the resident's depressed state, or any [MEDICAL CONDITION], or any plan as documented by the SW on February 24, 2012, or on February 25, 2012. "If the facility had reported the resident to be significantly depressed to the point of [MEDICAL CONDITION] and/or intent with a plan, I would have ordered to send the resident out to the ER for an evaluation immediately. No medications were ordered on February 24, 2012 for depression or anxiety, or at any other time during the resident's admission at the nursing home. The [MEDICATION NAME] was a previous medication...was taking prior to admission (to the nursing home). I was not aware the resident was required to use plastic silverware to prevent self-harm." Continued interview confirmed the orders for Ambien, [MEDICATION NAME], and [MEDICATION NAME], were to treat [MEDICAL CONDITION]. Interview with the SW on [DATE], at 4:30 p.m., in the conference room confirmed, "...The resident voiced...wanted to die...how would kill...self, with a knife. (Resident) was depressed and suicidal...all of my bells and [MEDICATION NAME] off. The SW confirmed, "I strongly felt (resident) needed to go out for an eval." Continued interview confirmed, the SW failed to ensure the policy, Referrals, Social Services, was followed and failed to ensure the psychiatric referral for evaluation and treatment was obtained for the resident (#1) in crisis. Interview with the Administrator on [DATE], at 7:35 p.m., in the conference room confirmed the resident was in a mental health crisis, as identified and reported on February 24, 2012. Continued interview confirmed the resident obtained a knife from another resident's tray, which the Administrator confirmed to be a stainless steel dinner knife. Continued interview with the Administrator confirmed the SW failed to ensure the policy, Referrals, Social Services, was followed, and failed to ensure the Mental Health Services referral for evaluation and treatment was obtained for the resident (#1) in crisis. The facility's failure to ensure the policy, Referrals, Social Services, was followed, and failure to provide services and treatment for [REDACTED].#1's) self in the chest. Resident #27 was admitted to the facility [DATE], with [DIAGNOSES REDACTED]. Medical record review of a Quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident scored zero on the Brief Interview for Mental Status (BIMS), indicating severely impaired cognition; and exhibited feeling or appearing down, depressed, or hopeless nearly every day. Medical record review of the Physician's Recapitulation Orders dated [DATE], revealed "[MEDICATION NAME] ([MEDICATION NAME]-for anxiety). Take 1 (one) tablet By MOUTH 3 (three) times daily AT 5:00 AM (a.m.); AT 1:00 PM (p.m.); AT 9:00 PM; Start Date: [DATE] ([DATE])...DX: INCREASED ANXIETY/ (and; or) CRYING." (Prior to the routine order dated [DATE], the [MEDICATION NAME] was ordered as needed). Medical record review of the Nurse's Notes, revealed: [DATE], at 12:10 a.m. "...Resident crying, turning on light (call light). [MEDICATION NAME] given..." [DATE], at 10:30 p.m. "...Res (resident) given [MEDICATION NAME] d/t (due to) anxiety up, crying..." [DATE], at 2:15 p.m. "[MEDICATION NAME] (by mouth)..." [DATE], at 10:00 a.m. "...Res @ times has increased [MEDICATION NAME] easily..." [DATE], at 2:00 p.m. "...Res with increased anxiety crying [MEDICATION NAME] agitation..." [DATE], at 3:00 p.m. "Res lying in bed rocking back & forth crying. (Spouse) unable to redirect. This nurse admin (administered)[MEDICATION NAME] less anxious when told medication would help (resident) to calm down..." [DATE], at 2:15 p.m. "Res crying & agitated says, 'Help me, Help me.' [MEDICATION NAME]" [DATE], at 12:07 p.m. "Res crying cont (continuously)[MEDICATION NAME] give (given)..." [DATE], at 11:20 p.m. "..repeatedly turning on call [MEDICATION NAME]/t increased anxiety..." [DATE], at 10:32 a.m. "...Res in bed crying cont asking for 'help & nurse' over & over again..." [DATE], (no time). "...Res cries a lot..." [DATE], at 9:40 a.m. "...episodes of crying with [MEDICATION NAME]" [DATE], at 8:00 a.m. "Res in bed crying on & off..." [DATE], at 8:40 a.m. "...Res has episodes of crying at (and) stating 'Nurse, Nurse help me' repeatedly..." [DATE], (no time). "...res verbal of wants and needs..." [DATE], at 9:00 a.m. "Continues to cry @ times..." Medical record review of the Nurse's Monthly Summary dated [DATE]; [DATE]; [DATE]; [DATE]; and [DATE]; revealed the consistent presence of mood symptoms, which included "Little interest or pleasure in doing things...Feeling or appearing down, depressed, or hopeless...Feeling tired or having little energy..Indicates that s/he (she or he) feels bad about self, is a failure, or has let family down..." Medical record review of the Physician's Progress notes revealed: [DATE], (no time). "Pt (patient) is crying today..." [DATE], (no time). "...is crying...continues to have crying spells." Medical record review of the Social Service Progress Notes, dated [DATE], at 5:10 p.m., revealed "Annual Note:...Resident cries often according to...(spouse)..." Continued review revealed no documentation the SW provided supportive counseling or emotional support for depression and multiple episodes of anxiety and crying. Continued review revealed no documentation the SW collaborated with the Physician or any other facility staff to provide in-house or outside Mental Health Services. Medical record review of a Care Plan dated February 10, 2012, revealed "...Resident has ineffective individual coping related to anxiety, depression...Also has frequent episodes of crying...Approaches:...Consider...Mental Health Services consult and treatment if mood persists..." Medical record review revealed no documentation of mental or psychosocial services and/or treatment were provided. Observation of the resident and interview, on [DATE], at 6:30 p.m., in the resident's room confirmed the resident was lying in bed, with the television on. During the beginning of the interview the resident began to cry. The surveyor asked the resident what was wrong and the resident answered, "I want to go home." The surveyor validated the resident missed being at home. The resident confirmed the validation, and continued to cry. Tears rolled from the resident's eyes, and down both sides of the face. The surveyor commented regarding the spouse's daily visits, and the resident confirmed, "Yes, but, (spouse) is only here a few hours during the day." Surveyor asked the resident what the resident enjoyed most when the spouse visited, and the resident confirmed, "Watching TV (television)." By this time during the interview, the resident's crying decreased, and then stopped. As the interview ended and the surveyor turned to leave the room, the resident began to cry again. Resident #17 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a Quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident scored fifteen on the Brief Interview for Mental Status (BIMS), indicating the resident's cognition was intact. Medical record review of a (contracted) Psychology Progress Note dated [DATE], revealed the resident's [DIAGNOSES REDACTED]. slowly with brief gaps of silence verbalized feelings of sadness and worry...Pt continues with s/s (signs and symptoms) of depression that are negatively impacting...health status including lack of motivation, tearfulness, and general agitation toward issues (resident) cannot change...Based on current status, progress and need, counseling will continue for approximately ,[DATE] (nine to eleven) weeks...Planned Session Frequency: ,[DATE]/mo (two-to-three sessions per month)...Behavioral Suggestions to Staff:...consider providing positive support and understanding..." This session was the last session provided by the contracted Mental Health Service provider, and/or any Mental Health Service provider. Medical record review of a Nurse's Note dated [DATE], at 3:00 p.m., revealed "...res not happy about going home next week. Staff reported that Res stated to them...was going to do everything...can do to make sure...won't have to leave...staff stated while working with (resident), Res attempted to throw (resident's) self backwards, so (resident) would fall but they were able to keep (resident) upright. Res was also trying to kick prosthetic leg off et was putting all...weight...on...staff..." Medical record review of the Social Service Progress Notes revealed no documentation the SW provided assessment and/or interventions to address the resident's inability to cope with loss of function due to the amputation of the right leg; difficulty with prosthetic adjustment; the need for physical and emotional support; and difficulty with the planned discharge to home with the daughter. Continued review of the progress notes revealed the resident was discharged home (with daughter) on [DATE]. Resident #18 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a Quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident scored nine on the Brief Interview for Mental Status (BIMS), indicating the resident's cognition was intact. Medical record review of a (contracted) Psychology Progress Note dated [DATE], revealed the resident's [DIAGNOSES REDACTED]. continue approximately ,[DATE] (five to six) weeks...Planned Session Frequency: ,[DATE]/mo (one to two sessions per month). This session was the last session provided by the contracted Mental Health Service provider, and/or any Mental Health Service provider. Resident #31 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a Quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident scored fourteen on the Brief Interview for Mental Status (BIMS), indicating the resident's cognition was intact. Medical record review of a (contracted) Psychology Progress Note dated [DATE], revealed the resident's [DIAGNOSES REDACTED]. Participating in therapy sessions though has not yet reached maximum potential...continues with negative thinking and other s/s of depression that negatively impact...psychosocial functioning. Termination completed with this pt and...is receptive to be followed by alternate clinician...Based on current status, progress and need, counseling will continue approximately ,[DATE] weeks...Planned Session Frequency: ,[DATE]/mo. Medical record review of the Nurse's Monthly Summary dated [DATE] and [DATE], revealed the consistent presence of mood and behavior symptoms which included "...Mood: Little interest or pleasure in doing things...Behavior: Verbal behavioral symptoms toward others..." Continued review on [DATE], revealed an increase of the number of mood symptoms but, behavior symptoms remained the same as the two prior months, which included "...Mood: Little interest or please in doing things; overeating; being short-tempered, easily annoyed...Behavior: Verbal behavioral symptoms toward others..." Continued review on [DATE], revealed the mood symptoms remained unchanged but, behavioral symptoms increased, which included "...Mood: Little interest or please in doing things; overeating; being short-tempered, easily annoyed...Behavior: Verbal behavioral symptoms toward others ; rejects care..." Medical record review revealed no documentation of mental or psychosocial services provided after [DATE], psychiatric treatment session. Telephone interview on [DATE], at approximately 3:30 p.m., with the (contracted Mental Health Service provider's) Compliance Officer and Director of Business Development confirmed the Mental Health Service provider services were no longer available to the facility due to inability to secure a clinician for the facility (location); the last two dates of service were [DATE], and [DATE]. Interview with the SW on [DATE], at 4:30 p.m., in the conference room confirmed the SW failed to follow the policy, Referrals, Social Services, and failed to provide Mental Health Services for residents #27, #17, #18, and #31. Interview with the Administrator on [DATE], at 7:35 p.m., in the conference room confirmed "We have not had Mental Health Services provider since [DATE]...We've had a big problem with getting (psychiatric) (mental health services) in here...I'll just go ahead and tell you, and be honest about it...we've not had anybody..." Continued interview with the Administrator confirmed resident #1 was in a mental health crisis, as identified and reported on February 24, 2012. Continued interview confirmed the resident obtained a knife from another resident's tray, which the Administrator confirmed to be a stainless steel dinner knife. Continued interview with the Administrator confirmed the facility's failure to follow policies, failure to notify the Physician, failure to provide medically-related Social Services, failure to revise the care plan, failure to provide Mental Health Services, and failure to provide the necessary care and services to maintain the highest practicable mental and psychosocial well-being allowed the resident to obtain a dinner knife, and then carried out an attempted suicide (by stabbing self repeatedly in the chest) on [DATE]. Continued interview confirmed the facility failed to follow policies and failed to provide Mental Health Services for residents #27, #17, #18, and #31. Interview with the Administrator on [DATE], at 11:15 p.m., in the Administrator's Office confirmed "We now have a contract with a new (Mental Health Services provider)...I signed the new contract signed today." The Immediate Jeopardy was effective from February 25, 2012, through [DATE], and was removed on [DATE]. An Acceptable Allegation of Compliance, which removed the immediacy of the jeopardy, was received and corrective actions were validated by the surveyor through review of documents, staff interviews, and observations conducted onsite on [DATE]. The surveyor verified the allegation of compliance by: 1. Reviewing the corrective action implemented for the SW. 2. Reviewing the facility's in-service records to ensure all staff were educated regarding changes to and implementation of the facility's following policies: a. Change in Resident's Condition and Status; b. Suicide Threats; c. Care of a Suicidal Resident; e. Behavioral Management; f. Care Planning and Using the Care Plan. 3. Conducting interviews with facility departments, to include fifteen of thirty-one nurses, three of nine environmental services, one of three maintenance, two of four activities, one of two social services, twenty-nine of fifty-two CNA's, ten of twenty-three dietary, seven of sevent

Based on medical record review, facility policy review and interview, the facility failed to be administered in a manner to ensure processes were in place to train and educate all staff on suicide prevention, failed to prevent neglect by following facility policies for resident change in condition to protect and prevent suicide attempts, failed to notify the physician of verbal statements of and plan for suicide, failed to provide Social Service counseling, failed to revise the care plan with interventions to prevent suicide attempts, failed to provide the necessary care and services to maintain the highest practicable mental and psychosocial well-being, for one resident (#1) in crisis of thirty-two residents reviewed; and failed to provide Mental Health Services for five residents (#1, #27, #17, #18, #31) of thirty-two residents reviewed. The facility's failure to be administered in a manner to attain or maintain the highest practicable physical, mental, and psychosocial well-being of a resident in crisis resulted in the resident obtaining a dinner knife, and attempting to stab (resident #1's) self in the chest. Resident #1's attempted suicide on March 3, 2012, required a transfer to the hospital emergency room and admission to a mental health unit for treatment. The facility's failure placed resident #1 in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). The Administrator and Director of Nursing were informed of the Immediate Jeopardy in the Conference Room on November 29, 2012, at 11:30 a.m. A partial extended survey was conducted on December 4, 2012. The findings included: Interview with the Administrator on November 30, 2012, at 9:00 a.m., in the Administrator's Office confirmed the facility failed to provide in-service training to staff after resident #1 made verbal threats of suicide on February 24, 2012, or after the resident attempted suicide on March 3, 2012; failed to prevent neglect by not following facility policies for resident change in condition to protect and prevent suicide attempts, failed to notify the physician of verbal statements of and plan for suicide, failed to provide Social Service counseling, failed to revise the care plan with interventions to prevent suicide attempts, failed to implement interventions in addition to plastic silverware, failed to provide the necessary care and services to maintain the highest practicable mental and psychosocial well-being, failed to provide Mental Health Services, failed to administer the facility in a manner to attain or maintain the highest practicable physical, mental, and psychosocial well-being, and failed to identify issues, develop and implement plans of corrective action to ensure the effectiveness of facility systems, for one resident (#1) of thirty-two residents reviewed. Continued interview confirmed the facility failed to ensure policies were followed and Mental Health Services were provided for residents #27, #17, #18, and #31, who experienced mental and/or psychosocial difficulties. The facility's failure placed resident #1 at risk for suicide attempts and resulted in Immediate Jeopardy (a situation in which the provider's noncompliance has caused or is likely to cause serious injury, harm, impairment, or death). Refer to F157 J Refer to F224 J Substandard Quality of Care Refer to F250 J Substandard Quality of Care Refer to F280 J Refer to F309 J Substandard Quality of Care Refer to F319 J Substandard Quality of Care The Immediate Jeopardy was effective from February 25, 2012, through November 29, 2012, and was removed on November 30, 2012. An Acceptable Allegation of Compliance, which removed the immediacy of the jeopardy, was received and corrective actions were validated by the surveyor through review of documents, staff interviews, and observations conducted onsite on November 30, 2012. The surveyor verified the allegation of compliance by: 1. Reviewing the facility's in-service records to ensure all staff were educated regarding changes to and implementation of the facility's following policies: a. Change in Resident's Condition and Status; b. Suicide Threats; c. Care of a Suicidal Resident; e. Behavioral Management; f. Care Planning and Using the Care Plan. 2. Conducting interviews with facility staff, to include fifteen of thirty-one nurses, three of nine environmental services, one of three maintenance, two of four activities, one of two social services, twenty-nine of fifty-two CNA's, ten of twenty-three dietary, seven of seventeen laundry and housekeeping, on staff to determine the level of comprehension gained through in-service education conducted regarding changes to and implementation of the facility's policies, "Change in Resident's Condition and Status; Suicide Threats; Care of a Suicidal Resident; Behavioral Management; Care Planning and Using the Care Plan;" to ensure staff recognize and respond to the following: a. A resident making suicide threats or statements are immediately placed 1:1 for constant observation; staff will remain with the resident at all times until (1) the Physician orders [REDACTED]. b. Warning signs of suicide; c. Statements and behaviors that may be a warning sign of suicide; d. Using probes for more information; d. Risk factors for suicide; e. Protective factors for suicide; f. Restricting access to lethal means and removal of any harmful objects. g. Residents at risk of suicide are communicated to all staff via the current Care Plan; Nursing 24-Hour Report; noted on the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] h. Residents at risk of suicide are discussed weekly in the department head meetings. i. A newly identified resident at risk of suicide will result in a suicide watch, and an emergency department head meeting will be called for immediate discussion. 3. Reviewing the facility's in-service records with the Social Worker ensuring responsibilities were reviewed and clarified, to include the following: a. A Suicidal Rating Scale has been added to the Social Services Assessment, to be completed on new admissions, quarterly, and with a significant change in condition; b. Social Services is responsible for ensuring the referral source sees the resident and responding/appropriate notes are in the medical record; c. Supportive Counseling; d. Bachelor of Social Work (BSW) Scope of Practice; e. Responsibilities of Social Services; f. Federal Regulations. 4. Review of the facility's contract with the Licensed Master of Social Work (LMSW) to ensure services are contracted to occur on a monthly basis beginning on November 30, 2012, to provide visits, ensure oversight of the current SW, and compliance with State and Federal Regulations, facility's policies, and Standards of Practice. 5. Reviewing of Suicide Risk Assessments on all residents in the facility. No residents were identified to have suicide risks. 6. Reviewing the new contract with a different Mental Health Services provider, who will be providing weekly services to the facility's residents, as identified and indicated. 7. Reviewing assessments and supportive counseling provided by a contracted BSW with Long Term Care experience. The assessments and supportive counseling was provided to all residents receiving services from a previous contracted Mental Health Services; and new admissions from the past two months were assessed and supportive counseling was provided. 8. An emergency Quality Assurance/Performance Improvement Committee Meeting was held on November 30, 2012, with the Medical Director, DON, Administrator, Consultant, Infection Control Nurse, and two other facility staff to include the Safety Leader. Non-compliance continues at "E" level for monitoring of corrective actions. The facility is required to submit a plan of correction. CO #

Based on medical record review, facility policy review and interview, the facility failed to ensure an effective system was in place to train and educate all staff on suicide prevention, failed to ensure an effective system to prevent neglect by following facility policies for resident change in condition to protect and prevent suicide attempts, failed to ensure an effective system to notify the physician of verbal statements of and plan for suicide, failed to ensure an effective system to provide Social Service counseling, failed to ensure an effective system to revise the care plan with interventions to prevent suicide attempts, and failed to ensure an effective system to provide the necessary care and services to maintain the highest practicable mental and psychosocial well-being, for one resident (#1) in crisis of thirty-two residents reviewed; and failed to ensure an effective system to provide Mental Health Services for five residents (#1, #27, #17, #18, #31) of thirty-two residents reviewed. The facility's failure to ensure effective systems for a resident in crisis resulted in the resident obtaining a dinner knife, and attempted to stab (resident #1's) self in the chest. Resident #1's attempted suicide on March 3, 2012, required a transfer to the hospital emergency room and admission to a mental health unit for treatment. The facility's failure placed resident #1 in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). The Administrator and Director of Nursing were informed of the Immediate Jeopardy in the Conference Room on November 29, 2012, at 11:30 a.m. A partial extended survey was conducted on December 4, 2012. The findings included: Interview with the Administrator on November 30, 2012, at 9:00 a.m., in the Administrator's Office confirmed the facility's Quality Assurance/Performance Improvement Committee had not addressed the facility's failure to prevent neglect by following facility policies for resident change in condition to protect and prevent suicide attempts, failure to notify the physician of verbal statements of and plan for suicide, failure to provide Social Service counseling, failure to revise the care plan with interventions to prevent suicide attempts, failure to provide the necessary care and services to maintain the highest practicable mental and psychosocial well-being, failure to provide Mental Health Services, failure to administer the facility in a manner to identify issues and develop and implement plans of corrective action to ensure the effectiveness of facility systems, for one resident (#1) of thirty-two residents reviewed; and failure to provide Mental Health Services for five residents (#1, #27, #17, #18, #31) of thirty-two residents reviewed. Refer to F157 J Refer to F224 J Substandard Quality of Care Refer to F250 J Substandard Quality of Care Refer to F280 J Refer to F309 J Substandard Quality of Care Refer to F319 J Substandard Quality of Care Refer to F490 J The Immediate Jeopardy was effective from February 25, 2012, through November 29, 2012, and was removed on November 30, 2012. An Acceptable Allegation of Compliance, which removed the immediacy of the jeopardy, was received and corrective actions were validated by the surveyor through review of documents, staff interviews, and observations conducted onsite on November 30, 2012. The surveyor verified the allegation of compliance by: 1. Reviewing the facility's in-service records to ensure all staff were educated regarding changes to and implementation of the facility's following policies: a. Change in Resident's Condition and Status; b. Suicide Threats; c. Care of a Suicidal Resident; e. Behavioral Management; f. Care Planning and Using the Care Plan. 2. Conducting interviews with facility staff, to include fifteen of thirty-one nurses, three of nine environmental services, one of three maintenance, two of four activities, one of two social services, twenty-nine of fifty-two CNA's, ten of twenty-three dietary, seven of seventeen laundry and housekeeping, on staff to determine the level of comprehension gained through in-service education conducted regarding changes to and implementation of the facility's policies, "Change in Resident's Condition and Status; Suicide Threats; Care of a Suicidal Resident; Behavioral Management; Care Planning and Using the Care Plan;" to ensure staff recognize and respond to the following: a. A resident making suicide threats or statements are immediately placed 1:1 for constant observation; staff will remain with the resident at all times until (1) the Physician orders [REDACTED]. b. Warning signs of suicide; c. Statements and behaviors that may be a warning sign of suicide; d. Using probes for more information; d. Risk factors for suicide; e. Protective factors for suicide; f. Restricting access to lethal means and removal of any harmful objects. g. Residents at risk of suicide are communicated to all staff via the current Care Plan; Nursing 24-Hour Report; noted on the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] h. Residents at risk of suicide are discussed weekly in the department head meetings. i. A newly identified resident at risk of suicide will result in a suicide watch, and an emergency department head meeting will be called for immediate discussion. 3. Reviewing the facility's in-service records with the Social Worker ensuring responsibilities were reviewed and clarified, to include the following: a. A Suicidal Rating Scale has been added to the Social Services Assessment, to be completed on new admissions, quarterly, and with a significant change in condition; b. Social Services is responsible for ensuring the referral source sees the resident and responding/appropriate notes are in the medical record; c. Supportive Counseling; d. Bachelor of Social Work (BSW) Scope of Practice; e. Responsibilities of Social Services; f. Federal Regulations. 4. Review of the facility's contract with the Licensed Master of Social Work (LMSW) to ensure services are contracted to occur on a monthly basis beginning on November 30, 2012, to provide visits, ensure oversight of the current SW, and compliance with State and Federal Regulations, facility's policies, and Standards of Practice. 5. Reviewing of Suicide Risk Assessments on all residents in the facility. No residents were identified to have suicide risks. 6. Reviewing the new contract with a different Mental Health Services provider, who will be providing weekly services to the facility's residents, as identified and indicated. 7. Reviewing assessments and supportive counseling provided by a contracted BSW with Long Term Care experience. The assessments and supportive counseling was provided to all residents receiving services from a previous contracted Mental Health Services; and new admissions from the past two months were assessed and supportive counseling was provided. 8. An emergency Quality Assurance/Performance Improvement Committee Meeting was held on November 30, 2012, with the Medical Director, DON, Administrator, Consultant, Infection Control Nurse, and two other facility staff to include the Safety Leader. Non-compliance continues at "E" level for monitoring of corrective actions. The facility is required to submit a plan of correction. CO #

Based on medical record review, review of facility policies, and interview, the facility failed to notify the physician of verbal statements of and plan for suicide, failed to prevent neglect by following facility policies for resident change in condition to protect and prevent suicide attempts, failed to provide Social Service counseling, failed to revise the care plan with interventions to prevent suicide attempts, and failed to provide Mental Health Services for one resident (#1), of thirty-two residents reviewed. The facility's failure resulted in one resident (#1) attempting suicide by stabbing (resident's self) in the chest with a table knife, of thirty-two residents reviewed. The facility failed to ensure policies were followed and Mental Health Services were provided for residents #27, #17, #18, and #31, who experienced mental and/or psychosocial difficulties. The facility's failure to ensure policies were followed and interventions were implemented for a resident in crisis resulted in the resident obtaining a dinner knife, and attempted to stab (resident #1's) self in the chest. Resident #1's attempted suicide on [DATE], required a transfer to the hospital emergency room and admission to a mental health unit for treatment. The facility's failure placed resident #1 in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). The Administrator and Director of Nursing were informed of the Immediate Jeopardy in the Conference Room on [DATE], at 11:30 a.m. F309 resulted in Substandard Quality of Care. The findings included: Resident #1 was admitted to the facility from the local hospital on February 10, 2012, with [DIAGNOSES REDACTED]. Medical record review of the hospital Discharge Summary dated February 10, 2012, revealed, (the resident was) "...significantly disabled...due to a [MEDICAL CONDITION] in...2009 which has left (resident) [DIAGNOSES REDACTED] and very poorly coordinated..." and had a history of [REDACTED]. Medical record review of the admission orders [REDACTED]. Medical record review of the Nursing Admission assessment dated [DATE], at 1:00 p.m., revealed the resident's cognition as oriented to person, place, time, and was alert. The resident was able to recall three named objects after five minutes, and was able to understand communication. The resident required assistance with all physical functioning: two people were required for bed mobility, transfers, toileting and bathing; one person was required for walking/locomotion, dressing, eating and personal hygiene. Eating required the supervised assistance of one person. Medical record review of a Nurse's Note dated February 15, 2012, at 9:45 a.m., revealed the resident was beginning to exhibit confusion, "...thinks...is going home today...states (spouse) is getting out of the hospital...going home with (spouse)...will monitor." Medical record review of a Social Service Progress Note dated February 24, 2012, at 1:35 p.m., revealed, "Family told SW (Social Worker) resident called the POA (Power-of-Attorney)...and (resident's spouse) late last night at 10:40 p.m. and made a delusional statement. (Resident) said...would send (resident's sibling) over to (resident's spouse's) home to run off a (spouse's visitor) according to...POA...also stated resident had a hx (history) of making statement(s) wanting to take pills to end (resident's) life...stated (resident) has made these statements to family ,[DATE] (one-to-two) yrs (years). SW talked to the DON (Director of Nursing) and (contracted Mental Health Services) referral being sent for counseling and Dr. (Physician) notified for medication and instruction. SW spoke to the resident...stated...was concerned about spouse but not thinking of hurting (resident's) self @ (at) this time. (Resident) thinks...spouse has...(someone else)...Spouse just (recently) got out of hospital with heart by-pass (heart surgery). SW asked (resident) if (resident) had thoughts of how (resident) would hurt (resident's) self. Resident stated, 'I would use a knife because my family took my guns from me.' SW spoke to DON and nurse on unit. Resident to eat in dining room with plastic spoon and plastic knife for safety measure since (resident) made statement. (Physician) has ordered medications to address depression and anxiety. SW sent (contracted Mental Health Services) referral signed by (Physician) for counseling. SW will continue to monitor and will assist with any needs." Continued review of the SW notes revealed no further monitoring or assistance during the remainder of the resident's admission at the nursing home. Medical record review of a Physician's Telephone Order dated February 24, 2012, revealed: 1515 (3:15 p.m.) "...(contracted Mental Health Services) to eval (evaluate) and treat as indicated..." Continued review revealed no documentation of a mental health evaluation or treatment, or of the SW collaborating with the Physician in regard to the resident's mental health. Medical record review of a (contracted Mental Health Services) physician's orders [REDACTED]. 1. Sad; 2. Agitation; 3. [MEDICAL CONDITION]. Continued review of the referral revealed no documentation of urgency or crisis intervention ordered for this resident. Interview with the SW on [DATE], at 2:45 p.m., in the Conference Room, confirmed, on February 24, 2012, staff (unable to recall who) reported the resident had voiced [MEDICAL CONDITION]. "After I had been told (resident) had voiced [MEDICAL CONDITION], I talked with (resident's) POA...the resident had a history of [REDACTED].; the DON was there. I talked with the Administrator and DON; and reported the resident had [MEDICAL CONDITION], had a plan, and showed signs and symptoms of suicide attempt. I feared the resident would attempt to take or end (resident's) life. I informed them (Administrator and DON) the resident needed (local mental health service) evaluation now. The DON stated, "This is a safe place...(resident) was irrational, and when irrational, will not attempt suicide..." The SW confirmed the Administrator and DON stated, "You don't understand; it is a safe place here, and the resident attempting or committing suicide is not going to happen here." Continued interview with the SW confirmed plastic silverware was the only precaution implemented. When the surveyor asked if mental health services were provided, the SW confirmed, "An order was written for (contracted Mental Health Services) to evaluate but I don't know if it was done or not." When the surveyor asked if supportive counseling had been done by the SW, the SW confirmed, "No; I was waiting on (contracted Mental Health Services) to provide counseling." When the surveyor asked the SW who is responsible for arranging and tracking Psychiatric referrals, the SW replied, "I am." A second interview with the SW, in the presence of the Administrator, on [DATE], at 6:50 p.m., in the conference room confirmed on February 24, 2012, the resident's POA informed the SW of the resident's history of wanting to take pills to end the resident's life. The SW was told on February 24, 2012, by staff (names unrecalled) the resident had asked questions regarding ending life and/or end of life, including "how to cut-off (resident's) air supply (SW placed hand around SW's throat and described an action of choking self); if insurance would pay if (resident) died ." The SW assessed the resident after the reports on February 24, 2012, and determined the resident had a plan to kill (resident's) self with a knife. The SW reported the assessment and suicidal concerns to the Administrator and DON, on February 24, 2012. The SW confirmed, "...The resident needed to be sent out to (local mental health service) for a psychiatric evaluation...I instructed the unit nurse to call the Physician and get orders for (contracted Mental Health Services) consult and medications for depression and anxiety. Dietary was notified to provide plastic silverware." The Administrator revealed to be unaware of the (resident's) threat to cut-off (resident's) air supply; the SW revealed, "I thought I told the Administrator." The Administrator confirmed, "The DON and I felt the (resident) to be in a safe environment and did not feel the resident needed to be sent out...we (Administrator and DON) felt the resident was not a threat of harm to (resident's) self...felt the resident was unable to attempt suicide." Both the SW and Administrator confirmed to be unaware of the resident's [MEDICAL CONDITION] voiced to the spouse on a phone call documented in the nurse's notes on February 25, 2012, at 9:59 p.m. Continued interview confirmed no psychiatric consult occurred as ordered on February 24, 2012. Medical record review of an "Admit Note" dated February 25, 2012, (no time), documented by the Physician, revealed the resident was unable to care for (resident's) self, "particularly with (resident's) declining health." The note revealed the resident "has some delusional thought patterns about (resident's spouse) running off with somebody." The Physician's impression revealed the following: 1. [MEDICAL CONDITION] left-sided [MEDICAL CONDITION]; 2. CAD ([MEDICAL CONDITION]) S/P (status [REDACTED]. 3. Type II diabetes mellitus currently on insulin therapy; 4. Chronic [MEDICAL CONDITION]; 5. [MEDICAL CONDITION]. The Physician's plan revealed "Continue as per orders at this time." Continued review of the note revealed no documentation of the resident being depressed, treatment for [REDACTED]. Medical record review of a Nurse's Note dated February 25, 2012, at 9:59 p.m., revealed the resident was on the phone talking to the resident's spouse, "...(the resident)...talking and getting emotional et (and) crying continuing to state 'I'll just end it now.' (Resident) quickly changes tone et says sorry to (spouse)...This nurse (Licensed Practical Nurse (LPN) #1) spoke with...spouse et assured will keep close watch on Res (resident). Administered PRN [MEDICATION NAME] to help Res sleep. Res calm et polite to staff at this moment. Will cont (continue) to monitor..." Continued review revealed no documentation the physician was notified of the resident's suicidal ideation. Medical record review of a Nurse's Note dated [DATE], at 7:45 p.m., revealed, "This nurse (LPN #2) was coming down the hall and saw resident had a butter knife...trying to stab self in the chest. LPN #2 got knife away from resident...asked (resident) what (resident) was doing. Resident stated, 'I just wanted to end this'..." Continued review revealed a Certified Nursing Assistant (CNA) was assigned to stay with the resident. LPN #2 notified the Physician on-call; orders were received to send to the (Hospital) emergency room (ER) for an evaluation. The resident's POA was also notified. Continued review revealed the Emergency Medical Service (EMS) arrived at 8:00 p.m., and the resident was transferred from the nursing home at 8:15 p.m. Medical record review of a Patient Transfer Form dated [DATE], (no time), revealed the resident tried to "stab self in the chest with a butter knife" as the reason for transfer (to the hospital from the nursing home). Medical record review of an inpatient Psychiatric Consultation report dated [DATE], revealed, "...sent over in the middle of the night (on [DATE]) from the nursing home after making a suicide gesture...was found sitting in a chair in the hallway with butter knife trying to stab...self in the chest...they (nursing home staff) were able to get the knife away...(resident) stated that (resident) was trying to end (resident's) life...sent to (hospital) for evaluation..." The resident was admitted to the hospital's inpatient mental health services program for treatment of [REDACTED]. Review of facility policy, Change in Medical Condition of Residents, (no date) revealed, "...Purpose: To keep the physician...informed of the resident's medical condition...Standard: Notification of the physician...occur...according to federal regulations, when there is a change in the resident's condition. Change in condition is identified as:...A change in the resident's physical, mental or psychosocial status (i.e., deterioration in health, mental or psychosocial status in either life-threatening conditions or clinical complications)...need to alter a treatment (i.e...commence a new form of treatment)..." Review of facility policy, Suicide Assessment and Intervention Practice, (no date) revealed, "Purpose: To maintain safety of individual residents while receiving services in this facility...Standard: Residents who display characteristics of suicidal ideation will be evaluated for risk of self harm and intent to inflict self harm (does the resident have a plan?)...If intent is implied, then monitor for safety (keep resident within eyesight at all times) and notify MD (Physician) and resident's family...Process: 1. Remove means of harming self or other from resident. 2. Assess resident for actual harm to self/others and follow up as indicated. 3. Resident will be kept within eyesight of staff at all times...until family arrives or resident is sent out of facility..." Review of facility policy, Suicide Prevention, (no date) revealed, "...Identifying Potential for Suicide Attempt...a) Identify resident at high risk...place on suicide precautions...b) Designate staff to closely observe at all times..." Continued review revealed no policy for suicide precautions. Review of facility policy, Social Services, revised [DATE] revealed, "Our facility provides medically-related social services to assure that each resident can attain or maintain his/her highest practicable physical, mental, or psychosocial well-being..." Review of facility policy, Care Plans-Comprehensive, revised [DATE] revealed "...2...care plans are revised as information about the resident and the resident's change... Interview with the Administrator and DON on [DATE], at approximately 11:25 a.m., in the Conference Room, confirmed the resident did attempt suicide. The Administrator confirmed, "I felt like the suicide threats were threats only. I did not believe (resident) would attempt suicide, or could attempt suicide...(resident) obtained a regular stainless steel dinner knife and tried to stab (resident's) self in the chest. I just did not believe (resident) would attempt suicide. I can't recall the specific date of the initial threat but, yes, the SW reported the threat to me and the DON. That's when we implemented the plastic silverware. We (Administrator and DON) didn't put the resident on one-on-one (1:1) observations (one staff person providing constant observation of one resident, and within reach of that resident) because we felt the threat wasn't real." The DON confirmed the Administrator's statements were correct, and "I have told multiple people, staff and the resident's sibling, the (resident) is in a safe place and nothing could happen. We (DON and Administrator) didn't implement 1:1 because we felt (resident) was safe and the threat was not real." Interview with LPN #1 on [DATE], at 12:17 p.m., in the Conference Room, confirmed, the entry in the nurse's note on February 25, 2012, at 9:59 p.m., was documented by LPN #1. LPN #1 confirmed on the evening of February 25, 2012, the resident called the spouse and was emotional; which ranged from crying and remorse, to anger, then back to crying and remorse. LPN #1 confirmed (resident) said, "I'll just end it now;" and LPN #1 told the spouse (resident) would be watched closer. LPN #1 confirmed the resident did have periods of no observation, such as when the staff were providing care to other residents, and/or when staff were in the bathroom, or away from the particular area where the resident was positioned (nurse's station, hallway, and so on). "There are just too many variables here for a resident to be safe if they are suicidal...While (resident) had mood swings and was emotional, I just didn't think (resident) would do something like that (attempt suicide)..." Interview with LPN #2 on [DATE], at 12:50 p.m., in the Conference Room, confirmed on [DATE], shortly after supper (dinner), LPN #2 was walking out from another resident's room, to the hallway, and observed resident #1 with a knife trying to stab (resident's) self in the chest with the knife. During this interview, while describing the attempt, LPN #2 demonstrated how the resident attempted to stab self in the chest, by hitting (LPN #2's) self in the chest repeatedly with a fisted right hand, and made a forceful thumping sound with each strike of the fist to the chest. "(Resident) was using a metal knife...like the ones that come on the residents' trays for meals. I think (resident) got it off of another resident's tray...I grabbed the knife...I asked 'what are you doing?'...(resident) said, 'I just want to end it...kill myself '...finally got the knife from (resident)...(resident) had a tee-shirt and sweat shirt on...I pulled them up to make sure...saw no wounds or lacerations...I directed a nearby CNA to stay with (resident)...called Physician, got an order to send to the ER for evaluation, and called the family..." LPN #2 confirmed to know of previous [MEDICAL CONDITION] with the resident, and confirmed, "I do not know what suicide precautions are...I have never been told...I had no idea...(resident) was not placed 1:1 until after the suicide attempt...we (staff) were just told to watch (resident) closer and give plastic silverware because of previous [MEDICAL CONDITION]" LPN #2 confirmed, "Watch closer meant to keep in common areas...a hallway or at nurse's station..." LPN #2 confirmed there were times when other residents were being cared for and resident #1 was not being observed by any staff. Interview with CNA #2 on [DATE], at 8:45 p.m., in the conference room confirmed CNA #2 worked on [DATE], on the 2:00 p.m.-10:00 p.m. shift; and was assigned to the dining room for supper. "During dining room assignment, you assist, feed, and observe for choking and swallowing difficulties...you watch everybody (residents). During supper on [DATE], there were seven residents with three tables in use in the dining room. Six residents were seated at two of the tables, with three per table; and one resident required to be fed, at the third table. I sat at the table with the one resident that had to be fed. There were two other CNAs (no longer employed at the facility), which had passed trays and were feeding residents on the hall...(LPN #2) was at the desk (Wing 4 nurse's station) charting. My focus was on the resident I was feeding (not resident #1). I was unable to continuously watch any one resident...(Resident #1) was seated at a table with two other residents. After supper, I transported (resident #1) to the nurse's station straight across the hall from the dining room on Wing 4, and then proceeded down the hall to pick up trays. The other two CNAs were in different rooms picking up trays, and (LPN #2) may have been on the hall somewhere answering a call light...As I came out from room [ROOM NUMBER] (near the end of the hall), I looked up and heard (LPN #2) say, 'I need some help down here.' I ran to assist (LPN #2)...Resident #1 had a metal knife in (resident's) right hand...was repeatedly stabbing (resident's) chest with the knife and yelling, 'I'm going to kill myself...I'm going to kill myself.' (LPN #2) was struggling with (resident) to get the knife, as (resident) was going at it...stabbing at (resident's) chest...By the time I reached (LPN #2) and the resident, (LPN #2) had removed the knife from the resident. (LPN #2) asked me, 'Where did (resident) get this knife?' I said, 'I don't know.' I thought about it, and I realized (resident #1) had gotten the knife from another resident seated at (resident #1's) table during supper and I said, 'Oh, no! (Resident #1) got the knife off of (random resident's) tray'....I looked at (resident's) chest immediately...it had multiple red, dime-size areas but, no lacerations or stab wounds. (LPN #2) assigned me to stay 1:1 with (resident #1)...I stayed at (resident's) bedside until EMS (Emergency Medical Services), arrived. (Resident) previously made multiple statements...wanted to kill (resident's) self, and wanted to die." CNA #2 confirmed these statements were made prior to [DATE], but, could not recall the dates, or date of onset. "I tried to encourage (resident) everyday...I just never dreamed (resident) would try to kill (resident's) self." Telephone interview with Registered Nurse (RN) #1 on [DATE], at approximately 10:50 a.m., revealed when the surveyor initiated the investigation on [DATE], and requested the resident's record from medical records, RN #2 realized the surveyor would be reviewing the resident's care plan. On [DATE], (unable to recall time), RN #2, realized the resident care plan had not been revised, called RN #1, and asked how to write a suicide precaution care plan. RN #1 revealed the care plan was not revised on February 24, 2012, as documented but was revised on [DATE]. Interview with RN #2 on [DATE], at 11:21 a.m., in the conference room confirmed, the surveyor had requested the chart when the complaint investigation was first initiated on [DATE]. "...I looked at the chart before giving it to the surveyor and realized the care plan had not been updated (revised) for suicide precautions from when the resident threatened suicide on February 24, 2012...I documented the care plan update on [DATE], to reflect a February 24, 2012, date, to prevent the surveyor from finding it had not been updated..." Interviews were conducted in the conference room, on [DATE], with LPN #1, at 3:10 p.m.; LPN #2, at 3:20 p.m.; CNA #3, at 3:50 p.m.; LPN #4, 4:05 p.m.; LPN #3, at 4:30 p.m.; CNA #4, at 4:40 p.m.; CNA #7, at 4:50 p.m.; CNA #5, at 5:00 p.m.. The interviews confirmed no education was provided on the resident's care plan to protect and prevent suicide attempts. Telephone interview on [DATE], at approximately 3:30 p.m., with the (contracted Mental Health Service Provider's) Compliance Officer and Director of Business Development confirmed the physician's orders [REDACTED]. Continued interview confirmed the referral did not indicate a crisis situation (urgent, stat (immediately), or suicidal). "A clinician went to the facility to evaluate the resident on [DATE]; the resident was in the hospital and no treatment was provided." Interview with CNA #1 on [DATE], at 5:25 p.m., in the conference room confirmed to recall the resident talked about ending (resident's) life one night (unable to recall date). "I told (resident) not to talk like that...still had family and not to talk like that." CNA #1 confirmed to report the resident's threat to a nurse but could not recall when or who the nurse was. Interview with Physician on [DATE], at 6:00 p.m., in the conference room confirmed the facility did not make the Physician aware of the resident's depressed state, or any [MEDICAL CONDITION], or any plan as documented by the SW on February 24, 2012, or on February 25, 2012. "If the facility had reported the resident to be significantly depressed to the point of [MEDICAL CONDITION] and/or intent with a plan, I would have ordered to send the resident out to the ER (emergency room ) for an evaluation immediately. No medications were ordered on February 24, 2012, for depression or anxiety, or at any other time during the resident's admission at the nursing home. The [MEDICATION NAME] was a previous medication...was taking prior to admission (to the nursing home). I was not aware the resident was required to use plastic silverware to prevent self-harm." A second interview with CNA #2 on [DATE], at 10:15 p.m., in the conference room confirmed "...I was never told or educated on what to do when a resident threatened to harm themselves or wished to die. Nobody ever told me why (resident #1) had plastic silverware. I never asked and I never really thought about why...I'm doing the best I can...I had no idea what to look for...I've not had psych (psychiatric) training...I was never told what to do for (resident #1's) psychiatric or suicidal care." A second interview with the DON on [DATE], at 1:00 p.m., in the conference room confirmed, on February 24, 2012, prior to meeting with the Administrator and SW about resident #1, the DON talked with the resident's POA while at the Wing 4 Nurse's Station. "The POA and I discussed the resident's anxiety and threats of suicidal ideation due to having to be admitted (to the nursing home) on February 10, 2012. During this conversation, staff was present at the desk...I think it was a nurse, CNA, and possibly the SW...can't recall which nurse and CNA...I reassured the staff and the POA the resident was in a safe place and nothing could happen. The SW proceeded to assess the resident, and then met with me and the Administrator...SW reported to us (DON and Administrator) the resident had a history of [REDACTED]. reported to us (DON and Administrator) the resident needed to be sent out for a psych (psychiatric) eval. Continued interview confirmed the resident was not placed on 1:1 observation, and to "watch closer" did not mean the resident would be under constant supervision. The DON confirmed the facility failed to follow policies and implement interventions to meet the psychiatric needs of the resident. Interview with the SW on [DATE], at 4:30 p.m., in the conference room confirmed, "...The resident voiced...wanted to die...how would kill...self, with a knife. (Resident) was depressed and suicidal...all of my bells and [MEDICATION NAME] off. The SW confirmed, "I strongly felt (resident) needed to go out for an eval." Continued interview confirmed, the SW failed to ensure the following for the resident (#1) in crisis: failed to follow Social Services policies; failed to revise the resident's individual care plan to protect and prevent suicide attempts; and failed to provide facility education on the resident's individual care plan to protect and prevent suicide attempts. "Most of the facility staff is unaware of what suicide preventions and precautions are. Oh, I know very well what they are and I knew this (attempted suicide) was about to happen." Resident #27 was admitted to the facility [DATE], with [DIAGNOSES REDACTED]. Medical record review of a Quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident scored zero on the Brief Interview for Mental Status (BIMS), indicating severely impaired cognition; and exhibited feeling or appearing down, depressed, or hopeless nearly every day. Medical record review of the Physician's Recapitulation Orders dated [DATE], revealed "[MEDICATION NAME] ([MEDICATION NAME]-for anxiety). Take 1 (one) tablet By MOUTH 3 (three) times daily AT 5:00 AM (a.m.); AT 1:00 PM (p.m.); AT 9:00 PM; Start Date: [DATE] ([DATE])...DX: INCREASED ANXIETY/ (and; or) CRYING." (Prior to the routine order dated [DATE], the [MEDICATION NAME] was ordered as needed). Medical record review of the Nurse's Notes, revealed: [DATE], at 12:10 a.m. "...Resident crying, turning on light (call light). [MEDICATION NAME] given..." [DATE], at 10:30 p.m. "...Res (resident) given [MEDICATION NAME] d/t (due to) anxiety up, crying..." [DATE], at 2:15 p.m. "[MEDICATION NAME] (by mouth)..." [DATE], at 10:00 a.m. "...Res @ times has increased [MEDICATION NAME] easily..." [DATE], at 2:00 p.m. "...Res with increased anxiety crying [MEDICATION NAME] agitation..." [DATE], at 3:00 p.m. "Res lying in bed rocking back & forth crying. (Spouse) unable to redirect. This nurse admin (administered)[MEDICATION NAME] less anxious when told medication would help (resident) to calm down..." [DATE], at 2:15 p.m. "Res crying & agitated says, 'Help me, Help me.' [MEDICATION NAME]" [DATE], at 12:07 p.m. "Res crying cont (continuously)[MEDICATION NAME] give (given)..." [DATE], at 11:20 p.m. "..repeatedly turning on call [MEDICATION NAME]/t increased anxiety..." [DATE], at 10:32 a.m. "...Res in bed crying cont asking for 'help & nurse' over & over again..." [DATE], (no time). "...Res cries a lot..." [DATE], at 9:40 a.m. "...episodes of crying with [MEDICATION NAME]" [DATE], at 8:00 a.m. "Res in bed crying on & off..." [DATE], at 8:40 a.m. "...Res has episodes of crying at (and) stating 'Nurse, Nurse help me' repeatedly..." [DATE], (no time). "...res verbal of wants and needs..." [DATE], at 9:00 a.m. "Continues to cry @ times..." Medical record review of the Nurse's Monthly Summary dated [DATE]; [DATE]; [DATE]; [DATE]; and [DATE]; revealed the consistent presence of mood symptoms, which included "Little interest or pleasure in doing things...Feeling or appearing down, depressed, or hopeless...Feeling tired or having little energy..Indicates that s/he (she or he) feels bad about self, is a failure, or has let family down..." Medical record review of the Physician's Progress notes revealed: [DATE], (no time). "Pt (patient) is crying today..." [DATE], (no time). "...is crying...continues to have crying spells." Medical record review of the Social Service Progress Notes, dated [DATE], at 5:10 p.m., revealed "Annual Note:...Resident cries often according to...(spouse)..." Continued review revealed no documentation the SW provided supportive counseling or emotional support for depression and multiple episodes of anxiety and crying. Continued review revealed no documentation the SW collaborated with the Physician or any other facility staff to provide in-house or outside Mental Health Services. Medical record review of a Care Plan dated February 10, 2012, revealed "...Resident has ineffective individual coping related to anxiety, depression...Also has frequent episodes of crying...Approaches:...Consider...Mental Health Services consult and treatment if mood persists..." Medical record review revealed no documentation of mental or psychosocial services and/or treatment were provided. Observation of the resident and interview, on November