Every finding on record at Palms at Sebring Nursing and Rehabilitation the

Based on observations, record review and interviews, the facility failed to provide antiretroviral medication for an immunocompromised resident for one resident (# 1) out of three residents sampled.Findings included: On 1/28/2026 at 9:45 AM., an observation was made revealing Resident #1 lying in bed. He was observed alert with no signs of distress. Resident #1 stated he had issues in the past with his insurance which caused him delays in getting his medication, for which he missed some doses.Review of Resident #1 admission Record showed he was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include but not limited to an immunocompromised Disease, Type 2 Diabetes Mellitus Hyperglycemia, major depressive disorder, recurrent, unspecified. Review of Resident #1's Medication Administration Record [MAR] dated October 2025 revealed Biktarvy Oral Tablet 50-200-25 Milligram [MG], (Bictegravir Emtricitabine-Tenofovir Alafenamide Fumarate) Give one tablet by mouth one time a day for start date 10/18/25. The documentation revealed number 9 was marked on the 19th and the 20th. The MAR revealed 9 meant other/see progress notes.Progress notes for the month of October 2025 were requested but not provided by the facility. Review of Resident #1's MAR dated November 2025 revealed Biktarvy Oral Tablet 50-200-25 Milligram [MG], (Bictegravir Emtricitabine-Tenofovir Alafenamide Fumarate) Give one tablet by mouth one time a day. The documentation revealed the medication was not administered 6 times during this month on 11/18, 11/20, 11/23,11/24, 11/25 and 11/26, 2025. The documentation in the MAR revealed number 9 was marked, which meant other/see progress notes.Review of Order Administration progress notes for Biktarvy Oral Tablet 50-200-25- Milligram [MG], revealed the medication was not administered with the following notes:On 11/18/2025 medication is not available - [Nurse] notified the patient. He said it was already ordered. Just waiting for it to arrive.On 11/20/2025 awaiting resident to bring in.On 11/21/2025 awaiting resident to bring from home.On 11/23/2025 med not available., Spoke with resident re: Biktarvy medication. Reason he has been out is d/t (due to) insurance changes. He needs to call [Name of Pharmacy] to have medication refilled.On 11/24/2025 awaiting resident to bring med from home, MD (Medical Doctor) aware.On 11/25/2025 pending delivery, per resident it will arrive in the morning.On 1/28/2026 at 1:45 PM. an interview was conducted with Staff A. License Practical Nurse [LPN]. Staff A said she was familiar with Resident #1. She was his nurse when he was on the first floor. Staff A said Resident #1 was out of his medication for a while. She stated the facility doesn't provide that type of antiretroviral medication due to the cost. She stated she would let Resident #1 know whenever his medication was low so he could reach out to his family to bring his medication to the facility. She stated he went for two days in a row without receiving his Biktarvy medication. She said she reached out to Resident #1 's doctor about the medication. Staff A said the physician told her to put the medication on hold at that time. Staff A stated the Biktarvy medication and Cancer medications are not provided by the facility due to the cost.On 1/28/2026 at 2:22 PM., an interview was conducted with Staff B, License Practical Nurse [LPN]. Staff B stated Resident #1 was not given Biktarvy medication because it was not available most of the time and it was not a medication provided by the facility. Staff B stated when she reached out to Resident #1's family to bring his medication, she was told Resident #1 was out of his medication due to issues with his insurance. Staff B stated the facility does not pay for Resident #1 Biktarvy medication due to the cost. On 1/28/26 at 3:16 PM. an interview was conducted with Staff C, Registered Nurse, [RN]. Staff C said Resident #1 was responsible for providing the facility with his antiretroviral medication. Staff C stated Resident #1 could not receive his medication, It was not a medication the facility provided due to the cost.On 1/28/2026 at 1:30 PM., an interview was conducted with the interim Director of Nursing (DON). The DON said upon admission to the facility, they explained to Resident #1 that he was responsible for the Biktarvy medication because it was too expensive for the facility to provide. The DON did not confirm if any resources or assistance were provided to enable Resident #1 to obtain the medication.On 01/28/2026 at 3:30 PM., an interview was conducted with the Nursing Home Administrator, [NHA]. The NHA stated when a resident is first admitted to their facility, the pharmacy sends an email alert if there is a high-cost medication for approval. The email is sent to the NHA, the DON, the Assistant DON and the Unit Managers. The NHA said they review the medication to see if there is an alternative medication and then reach out to the physician to see if they can change the medication to a more cost-efficient medication. She stated then they follow the physician order. The NHA stated she was made aware of Resident #1's Biktarvy medication. The NHA stated she does not approve medication because she is not clinical. She stated the DON at the time made the decision not to approve Resident #1's medication. The NHA stated if she would have known Resident #1 had issues getting his medication, she would have made sure the facility covered the cost. On 1/28/2026 to 4:33 PM an interview was conducted with Resident #1's physician. The physician said he had followed Resident #1 for over a year. The physician said Resident #1 was immunocompromised, but it is controlled. The physician stated he was notified about the situation with his medication and his weight loss. He said Resident #1 had issues getting his family to bring his Biktarvy medication to the facility. The physician said he was informed Resident #1 did not receive his medication for a week and a couple of days. He stated he told the facility that they had to make sure Resident #1 got his medication. The physician stated, that is a medication Resident #1 cannot go without, he has to take it every day.The facility administration said they did not have a policy about their process for providing antiretroviral medications.

Based on interviews and record review, the facility did not ensure grievances were documented and/or resolved for the Resident Council for five months in 2025 (June, July, August, September and October 2025) out of five months reviewed.Findings included: A review of resident council minutes revealed there were multiple discussions related to residents wanting more ice water and snacks to be offered from June 2025-October 2025. An interview was conducted on 10/13/25 at 4:25 p.m. with Resident #2. The resident said she goes to the resident council meeting, and they had discussed needing water refills and wanting snacks several times, but nothing changed. Resident #2 said she occasionally had heard staff refilling water in the hall, but they didn't come to her side of the hall. Review of Resident #2's Brief Interview for Mental Status (BIMS), conducted 5/29/25, revealed a score of 15, indicating she was cognitively intact. An interview was conducted on 10/13/25 at 4:30 p.m. with Resident #3. The resident said she attended resident council meetings. She said they still did not get more water refills and snacks even though it had been requested multiple times. Resident #3 said she had to get up occasionally at night to go find water because she didn't get her water refilled. Review of Resident #3's Minimum Data Set (MDS), Section C, Cognitive pattern, revealed a BIMS score of 13, indicating she was cognitively intact. Review of Resident Council Meetings showed:6/11/15 11:00 a.m. 20 residents attending.New Business included: Wanting extra snacks and ice water to be offered during the day.7/9/25 11:00 a.m. 22 residents attending.Old Business included: Wanting extra snacks and ice water to be offered throughout the day.8/13/25 11:00 a.m. 25 residents attending.Old Business included: Wanting extra snacks and hydration to be offered throughout the day.10/8/25 11:00 a.m. 19 residents attending.New Business included: Requested that additional snacks and hydration be offered throughout the day. A review of grievance log from June 2025 through October 2025 revealed there were no documented grievances from the resident council related to residents wanting more ice water and snacks or any other resident council concerns. An interview was conducted on 10/13/25 at 3:45 p.m. with the facilities Activities Director. She said they had resident council meeting once a month and she took minutes for the meetings. The activities director said about the concerns that are discussed; if it is one person that had a concern, she would put it in as a grievance, but if it was a group concern it was not entered as a grievance. She said group concerns were talked about in the Interdisciplinary Team (IDT) meeting and addressed. The activities director said for example there was a group concern related to staff customer service, so it was discussed at the IDT meeting and education was done even though a grievance wasn't filed. The Activities Director recalled hydration and snacks being discussed at resident council. She said when it first came up, she told IDT members staff need to pass extra hydration and snacks. She agreed the concern was not being tracked or followed up on. The activities director said if the resident council concern was entered as a grievance, it would be tracked. An interview was conducted on 10/13/25 at 4:58 p.m. with the Nursing Home Administrator (NHA). The NHA said for grievances, anyone can fill them out either by paper or by scanning the barcode on their phone. She said grievances are turned into social services and logged. The grievance was then given to the appropriate person to follow up. She said social services tracks the logs ensuring paper and electronic grievances are followed-up on. The NHA said she remembered discussing resident's hydration concerns in the management meetings. She said she knew education was a part of what they did. She said she thought the hydration and snack concern was being tracked. The NHA was not aware resident council concerns were not being entered as grievances. Review of a facility policy titled Complaint/Grievance, effective date 9/7/23, showed:Policy: - The Center will support each resident's right to voice a complaint/grievance without fear of discrimination or reprisal. The center will make prompt efforts to resolve the complaint/grievance and inform the resident of progress towards resolution. Grievances will be reviewed by the Quality Assurance Performance Improvement Committee. Grievances discovered to meet the definition of Abuse, Neglect, Exploitation or Misappropriation will be handled per the facility's Abuse Policy. The resident should have reasonable expectations of care and services and the center should address those expectations in a timely, reasonable, and consistent manner. The Center will inform residents of the right to file a grievance orally and in writing, the right to file grievances anonymously, the contact information of the Grievance Officer, a reasonable time frame for completing the review of the grievance, the right to obtain a written decision regarding the grievance, and contact information of independent entities with whom grievances may be file (State agency, Ombudsman, Quality Improvement Organizations) The Executive Director will designate a Grievance Officer at the facility.Procedure:1. An employee receiving a complaint/grievance from a resident, family member and/or visitor will initiate a Complaint/Grievance Form. Complaint/Grievance forms will be available 24 hours per days 7 days a week in an unsecured common area. Accommodations will be made to ensure residents have the opportunity regardless of their physical abilities or limitations.2. Original grievance forms are then submitted to the Grievance Officer /designee for further action.3. The Grievance Officer /designee shall act on the grievance and begin follow-up of the concern or submit it to the appropriate department director for follow-up.4. The grievance follow-up should be completed in a reasonable time frame; this should not exceed 14 days.5. The findings of the grievance shall be recorded on the Complaint/Grievance Form.6. The results will be forwarded to the Executive Director for review and filing.7. The Grievance Official will log complaints/grievances on a Monthly Grievance Log.

Based on observation, record review, and interviews, the facility failed to ensure three residents (#41, #167, and #168) out of three residents reviewed for beneficiary notifications were provided with the correct notification prior to changes of skilled services and related changes. Findings included: Review of the Beneficiary Notice-Residents discharged within the Last Six Months form, completed by the facility, revealed 20 residents. Three randomly selected residents were chosen for review. Resident #41 was selected and identified as remained in facility, Resident #167 was selected and identified as remained in facility, and Resident #168 was selected and identified as discharged Home. Review of Resident #41's Skilled Nursing Facility Beneficiary Notification Review form, completed by the facility, showed the following information: - Skilled Services Start Date: 1/5/24. - Last Day of Services Covered: 11/15/24. - Voluntary Discharge from Services. - Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) was provided and signed by Resident #41 on 11/15/24. - Notice of Medicare Non-coverage (NOMNC) was not provided. - Additional information: Resident #41 and Daughter requested to be discharged back to [Name of Assisted Living Facility] Assisted Living. Review of Resident #167's Skilled Nursing Facility Beneficiary Notification Review form, completed by the facility, showed the following information: - Skilled Services Start Date: 11/13/24. - Last Day of Services Covered: 12/8/24. - Voluntary Discharge from Services. - SNF ABN was provided and signed by Resident #167 on 11/15/24. - NOMNC was not provided. Review of Resident #168's Skilled Nursing Facility Beneficiary Notification Review form, completed by the facility, showed the following information: - Skilled Services Start Date: 1/10/25. - Last Day of Services Covered: 2/3/25. - Voluntary Discharge from Services. - SNF ABN was provided and signed by Resident #168 on 2/3/25. - NOMNC was not provided. - Additional Information: Resident expressed his wish to be discharged as soon as he arrived at [Name of Facility]. Resident requested to be discharged . During an interview on 2/25/25 at 3:04 p.m., the Social Services Director (SSD) said the facility quit giving NOMNC forms as of 10/31/24. The SSD also stated he received an email from the Administrator on 10/31/24 advising the use of the new SNF ABN form effective 10/31/24 and to provide all residents with changes in skilled services using this form. The SSD stated, I was told it was just one page now. The SSD stated prior to the direction of the Administrator in October 2024, he used to provide residents that were being discharged from the facility the required NOMNC. An observation on 2/25/25 at 3:06 p.m. revealed an email dated 10/31/24 from the Administrator to the SSD titled new SNF ABN with the form attached to the email. On 2/25/25 at 3:08 p.m., the SSD stated the SNF ABN form was the only notification given to residents when services were terminated or exhausted since 10/31/24. The SSD also stated he used to give the NOMNC form to those residents who were being discharged from the facility but had not since 10/31/24 per the Administrators instruction. The SSD stated there was a mistake on the Beneficiary Notice-Residents discharged within the Last Six Months form as all three residents reviewed were discharged from the facility and did not remain in the facility as identified on the form. The SSD stated since all three residents were all discharged from the facility, a NOMNC form should have been provided to all three residents instead of the SNF ABN. The SSD stated those residents who were identified as remaining in the facility were discharged to the adjoining Assisted Living Facility (ALF) that shared a lobby with the Long-Term Care (LTC) Facility. The SSD stated he assisted residents from both the LTC Facility and ALF and had to remember to treat the LTC and ALF as separate entities.

Based on record review and interview, the facility failed to ensure the comprehensive Minimum Data Set (MDS) assessments were accurately coded for four residents (#80, #91, #56, and #39) out of 22 sampled residents. Findings included: 1. Review of the Admission Record showed Resident #80 was admitted to the facility on [DATE] with diagnoses that included but not limited to epilepsy unspecified, unspecified dementia without behavioral disturbance, anxiety disorder unspecified, major depression recurrent, moderate, and seizures. Review of a physician order for Resident #80 dated 11/21/24 showed Memantine HCI [hydrochloride] Oral Tablet 10 [milligrams] MG. Give one tablet by mouth two times a day for Alzheimer/Dementia. Review of a Psychiatry Subsequent Note dated 11/19/24 showed Resident #80 presented with major depression recurrent, moderate, unspecified dementia without behavioral disturbance, primary insomnia and other specified persistent mood disorders. The plan of action was to continue Memantine because in general, it helps Dementia related cognitive decline and maintaining of daily living. Review of the Modification (02) of Admission /Medicare - 5 Day Minimum Data Set (MDS) dated [DATE] showed Section I - Active Diagnoses (Check all that apply), the diagnosis of Non-Alzheimer's Dementia was not marked. During an interview on 2/24/25 at 10:00 a.m., Staff E MDS, Registered Nurse (RN) stated the diagnosis of Dementia for Resident #80 was not marked because it was overlooked. 2. Review of the Admission Record showed Resident #91 was admitted to the facility on [DATE] with diagnoses that included but not limited to bipolar disorder unspecified, major depressive disorder, recurrent, moderate, generalized anxiety disorder, bipolar disorder, current episode, mixed moderate and brief psychotic disorder. Review of Resident #91's physician orders showed the following: - A physician order dated 2/11/25 showed, Olanzapine Oral Tablet 5 MG (Olanzapine) - Give 1 tablet by mouth in the evening related to brief psychotic disorder. - A physician order dated 2/11/25 showed, Alprazolam Oral Tablet 2 MG (Alprazolam) *Controlled Drug*--Give 1 tablet by mouth in the morning related to generalized anxiety disorder. - A physician order dated 12/5/24 showed, Paroxetine HCl Oral Tablet 20 MG (Paroxetine HCl)- Give 2 tablet by mouth in the morning related to major depressive disorder, recurrent, moderate. Review of the Quarterly MDS dated [DATE] showed Section N - Medications (Check all that apply) the antipsychotic and antianxiety medication boxes were not marked. During an interview on 2/24/25 at 10:00 a.m., Staff E MDS, RN stated the antipsychotic and antianxiety medications were not selected on the Quarterly MDS because they were overlooked. 46234 3. Review of Admission Records showed Resident #56 was admitted on [DATE] with diagnoses including morbid obesity and diabetes mellitus with diabetic neuropathy. Review of Resident 56's care plan showed a focus area of ADL self-care performance deficit with interventions including TRANSFER: The resident requires partial/moderate assistance by staff to move between surfaces, dated 8/13/24. Review of Resident #56's 2/7/25 Quarterly MDS, Section GG, Functional Abilities, showed for chair/bed-to-chair transfer the resident is partial/moderate assistance. An interview was conducted on 2/24/25 at 2:52 p.m. with the Director of Rehab (DOR). He said Resident #56 needed a mechanical list with maximum assistance to get out of bed and has always needed that. 4. Review of Admission Records showed Resident #39 was admitted on [DATE] with diagnoses including protein-calorie malnutrition. Review of Resident #39's 1/14/25 Quarterly MDS, Section B, Hearing, Speech, and Vision indicated the resident had adequate vision. Section C, Cognitive Patterns showed a Brief Interview for Mental Status (BIMS) score of 13, indicating she was cognitively intact. An interview was conducted on 2/22/25 3:08 p.m. with Resident #39. She said she had no idea what she was eating each meal because she could only see shadows and staff do not tell her what she had and where it was. She said she just pokes her finger around it to try and figure out what she had. Resident #39 said it would be nice to know what she is eating each meal. Review of an eye doctor note, dated 10/11/24, showed Resident #39 had highly impaired vision and cataracts in both eyes Review of Resident #39's care plan did not reveal any focus area or interventions related to vision loss. 48223 During an interview on 2/25/25 at 5:48 p.m., the Director of Nursing (DON) stated the expectation is the facility mark the MDS assessments accurately.

Based on record review and interview, the facility failed to ensure the Level I Preadmission Screening and Resident Review (PASRR) were accurately completed for nine residents (#44, #55, #91, #94, #33, #39, #56, #6, and #5) out of 22 sampled residents. Findings included: 1. Review of the Admission Record showed Resident #44 was admitted to the facility on [DATE] with diagnoses that included but not limited to major depressive disorder, recurrent, moderate and muscular dystrophy. Review of a psych note dated 2/6/25 showed Resident #44 presented with major depressive disorder, recurrent, moderate, other specified anxiety disorders, primary insomnia, and muscular dystrophy. Review of the Level I PASRR, dated 1/9/25, showed in Section I, Part A. MI (Mental Illness) or suspected MI (Mental Illness) the diagnosis of Depressive Disorder was not marked. Section I, Part B Intellectual Disability (ID) or suspected ID (check all that apply) Muscular Dystrophy was not marked under Related Condition. 2. Review of the Admission Record showed Resident #55 was admitted to the facility on [DATE] with diagnoses that included but not limited to bipolar disorder unspecified, epilepsy unspecified, other seizures, major depressive disorder recurrent, mild, and bipolar disorder, current episode mixed, mild. Review of a psych note dated 12/9/24 revealed under New evaluation, Resident #55 presented with major depressive disorder, recurrent, moderate and bipolar disorder, current episode, mixed and mild. Review of the Level I PASRR, dated 11/8/24, showed in Section I , Part A. MI (Mental Illness) or suspected MI (Mental Illness), the diagnosis of Depressive Disorder was not marked. Section I, Part B. Intellectual Disability (ID) or suspected ID (check all that apply) Epilepsy was not marked under Related Condition. 3. Review of the Admission Record showed Resident #91 was admitted to the facility on [DATE] with diagnoses that included but not limited to bipolar disorder unspecified, major depressive disorder, recurrent, moderate, generalized anxiety disorder, bipolar disorder, current episode, mixed moderate, and brief psychotic disorder. Review of a psych note dated 12/5/24 showed Resident #91 present with major depressive disorder, generalized anxiety disorder, primary insomnia, bipolar disorder, current episode mixed, moderate, and a brief psychotic disorder. Review of the Level I PASRR, dated 9/24/24, showed in Section I, Part A. MI (Mental Illness) or suspected (Mental Illness) MI (check all that apply), the diagnoses of Anxiety Disorder, Bipolar Disorder, and Depressive Disorder were not marked. 4. Review of the Admission Record showed Resident #94 was admitted to the facility on [DATE] with diagnoses that included but not limited to depression unspecified and schizophrenia unspecified. Review of a psych note dated 2/18/25 showed Resident #94 presented with major depressive disorder, recurrent, mild, other specified persistent mood disorders, and disorganized schizophrenia. Review of the Level I PASRR, dated 12/3/24, showed in Section I, Part A. MI (Mental Illness) or suspected (Mental Illness) MI (check all that apply), the diagnosis of Bipolar Disorder and Schizophrenia were not marked. 48441 5. A review of Resident #33's Admission Record showed an original admitted [DATE] with a readmitted [DATE]. Resident #33's Admission Record showed the following diagnoses: major depressive disorder recurrent, moderate and conversion disorder with seizures or convulsions. A review of Resident #33's February 2025 physician orders showed the following orders: - Divalproex Sodium oral capsule delayed release sprinkle 125 milligrams (mg), give two capsules by mouth in the evening for mood disorder, ordered 2/13/25. - Divalproex Sodium oral capsule delayed release sprinkle 125 milligrams, give two capsules by mouth in the morning for mood disorder, ordered 2/13/25. - Levetiracetam oral tablet 500 mg, give one tablet by mouth in the evening related to conversion disorder with seizures or convulsions, ordered 11/4/24. - Levetiracetam oral tablet 500 mg, give one tablet by mouth in the morning related to conversion disorder with seizures or convulsions, ordered 11/4/24. - Escitalopram oxalate oral tablet 10 mg, give one tablet by mouth in the morning for depression, ordered 11/4/24. - A review of Resident #33's Level I PASRR dated 9/13/24 showed under Section I, Part A. Mental Illness or suspected Mental Illness (check all that apply, conversion disorder with seizures or convulsions was not marked. 46234 6. Review of Admission Records showed Resident #39 was admitted on [DATE] and readmitted on [DATE] with diagnoses including depression, added during her stay on 6/20/23, major depressive disorder, added during her stay on 2/27/24, and generalized anxiety disorder, added during her stay on 2/27/24. Review of Resident #39's PASRR Level I screen, dated 12/22/21, only indicated depressive disorder as a diagnosis. Anxiety was not indicated on the PASRR Level I screen. The facility was unable to provide an updated PASRR Level I screen. 7. Review of Admission Records showed Resident #56's was admitted on [DATE] with diagnoses including schizoaffective disorder, post-traumatic stress disorder (PTSD), schizoaffective disorder bipolar type, major depressive disorder, other specified persistent mood disorders, depression, anxiety disorder, and psychotic disorder with delusions due to known physiological condition. Review of Resident #56's PASRR Level I screen, dated 8/27/24, only indicated depressive disorder, and psychotic disorder as diagnoses. Schizoaffective disorder, bipolar disorder, PTSD, mood disorder, and anxiety disorder was not indicated on the Level I screen. The facility was unable to provide an updated PASRR Level I screen. 48223 8. Review of Resident #6's Admission Record revealed an admitted [DATE] with diagnoses of senile degeneration of brain and delusional disorders. Review of Resident #6's psych note dated 11/7/24 showed a diagnosis of anxiety disorder. Review of Resident #6's Level I PASRR, dated 10/4/19, showed in Section I, Part A. MI or suspected MI, Anxiety and Delusional Disorder was not marked. 9. Review of Resident #5's Admission Record revealed an admitted [DATE] with diagnoses of brief psychotic disorder, insomnia, moderate major depressive disorder, persistent mood disorder, and anxiety disorder. Review of Resident #5's psych note dated 11/7/24 showed the resident had been a harm to himself or others in the past. Review of Resident #5's Level I PASRR, dated 9/24/24, showed in Section I, Part A. MI or suspected MI, anxiety, persistent mood disorder, and psychotic disorder were not marked; Section II: #4. Is marked no for has the individual exhibited actions or behaviors that may make them a danger to themselves or others. During an interview on 2/25/25 at 10:10 a.m., the Director of Nursing (DON) stated she was responsible for reviewing and ensuring all PASRRs for residents were accurate when a resident was first admitted to the facility. The DON stated she tried to review all PASRRs and make sure the diagnoses were accurate on the PASARR. The DON also stated should a resident get diagnosed with a new diagnosis, the PASRR should be evaluated and updated to reflect the new diagnosis. The DON reviewed the PASRRs for Residents #5, #33, #39, #44, #55, #56, #91, and #94 and confirmed the Level I PASRRs were not correct for these residents. Review of the facility's policy PASRR Completion Policy showed: Policy Statement: The Center will a make sure that all admissions have the appropriate Patient Assessment ad Resident Review (PASRR) completed. Practice Guidelines: 1. Center Administrator will designate either the Admissions Director or Social Worker to make sure that the PASRR and/or Level of Care (LOC) is done on all potential residents. If the referral indicates anything which night constitute an SMI [Severe Mental Illness] or ID [Intellectual Disability], the PASRR must be completed prior to admission. If the resident is deemed hospital except that must be clearly documented in the transfer documents to admission from the acute care facility. 2. Administrator will also designate a backup in case the designated person is not available. 3. Administrator is accountable for monitoring the process of completing the necessary paperwork for the admission. 4. Business Office Manager (BOM) must have copies of the LOC ad or PASRR in the Business Office resident file.

Based on observations, interviews, and record review, the facility did not ensure the development and implementation of the comprehensive care plan for five residents (#104, #4, #56, #39, and #6) out of twenty-two residents sampled. Findings included: 1. A review of Resident #104's Admission Record showed an admitted [DATE] with a diagnosis of tobacco use. A review of Resident #104's care plans did not show a care plan for tobacco use. 46234 2. Review of Admission Records showed Resident #4 was admitted on [DATE] with diagnoses including morbid obesity, idiopathic gout, and age-related osteoporosis. Review of Resident #4's care plan showed a focus area of ADL (Activities of Daily Living) self-care performance deficit with interventions including TRANSFER: The resident requires partial/moderate assistance by staff to move between surfaces, dated 7/24/24. An interview was conducted on 2/24/25 at 2:21 p.m. with Staff J, Certified Nursing Assistant (CNA). She stated Resident #4 has always needed a mechanical lift and was definitely not a partial assist. An interview was conducted on 2/24/25 at 2:52 p.m. with the Director of Rehabilitation (DOR). He stated Resident #4 needed a mechanical lift with maximum assistance to get up. 3. Review of Admission Records showed Resident #56 was admitted on [DATE] with diagnoses including morbid obesity and diabetes mellitus with diabetic neuropathy. Review of Resident 56's care plan showed a focus area of ADL self-care performance deficit with interventions including TRANSFER: The resident requires partial/moderate assistance by staff to move between surfaces, dated 8/13/24. An interview was conducted on 2/24/25 at 2:52 p.m. with the DOR. He said Resident #56 needed a mechanical list with maximum assistance to get out of bed and has always needed that. 4. Review of Admission Records showed Resident #39 was admitted on [DATE] with diagnoses including protein-calorie malnutrition. Review of Resident #39's 1/14/25 Quarterly MDS, Section C, Cognitive Patterns showed a Brief Interview for Mental Status (BIMS) score of 13, indicating she was cognitively intact. An interview was conducted on 2/22/25 3:08 p.m. with Resident #39. She said she had no idea what she was eating each meal because she could only see shadows and staff do not tell her what she had on her meal tray and where it was. She said she just pokes her finger around it to try and figure out what she had. Resident #39 said it would be nice to know what she is eating each meal. Review of an eye doctor note, dated 10/11/24, showed Resident #39 had highly impaired vision and cataracts in both eyes Review of Resident #39's care plan did not reveal any focus area or interventions related to vision loss. 48223 5. Review of Resident #6's Admission Record revealed readmitted on [DATE] with diagnoses of senile degeneration of brain, delusional disorders, hypertension, and other co-morbidities. Review of Resident #6's Hospice Comprehensive Assessment and Plan of Care Update Report dated 1/22/25 showed a start of service date of 10/27/24 and the Hospice interdisciplinary group discussed the resident's hospice care and Resident #6 remains eligible for hospice services. Review of Resident #6's current care plan showed no focus, goal, or interventions for Hospice Care. During an interview on 2/25/25 at 3:00 PM, Staff E MDS Registered Nurse (RN) stated Residents #104, #4, #56, #39, and #6 should have a comprehensive care plan for the services provided to them and a care plan should be developed or an explanation in the record to as why it is not. During an interview on 2/25/25 at 5:48 p.m., the Director of Nursing (DON) stated the expectation is to have a care plan developed and implemented based on the care the resident requires. Review of the facility's policy and procedures titled Care Plans, Comprehensive Person-Centered, not dated, showed: Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation: 1. The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. 2. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS assessment (Admission, Annual or Significant Change in Status), and no more than 21 days after admission. 3. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 4. Each resident's comprehensive person-centered care plan is consistent with the resident's rights to participate in the development and implementation of his or her plan of care, including the right to: a. participate in the planning process; b. identify individuals or roles to be included; c. request meetings; d. request revisions to the plan of care; e. participate in establishing the expected goals and outcomes of care; f. participate in determining the type, amount, frequency and duration of care; g. receive the services and/or items included in the plan of care; and h. see the care plan and sign it after significant changes are made. 5. The resident is informed of his or her right to participate in his or her treatment and provided advance notice of care planning conferences. 6. If the participation of the resident and his/her resident representative in developing the resident's care plan is determined to not be practicable, an explanation is documented in the resident's medical record. The explanation should include what steps were taken to include the resident or representative in the process. 7. The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including: 1. services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment; 2. any specialized services to be provided as a result of PASARR recommendations; and 3. which professional services are responsible for each element of care; c. includes the resident's stated goals upon admission and desired outcomes; d. builds on the resident's strengths; and e. reflects currently recognized standards of practice for problem areas and conditions. 8. Services provided for or arranged by the facility and outlined in the comprehensive care plan are: a. provided by qualified persons; b. culturally competent; and c. trauma informed. 9. Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. 10. When possible, interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers. 11. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. 12. The interdisciplinary team reviews and updates the care plan: a. when there has been a significant change in the resident's condition; b. when the desired outcome is not met; c. when the resident has been readmitted to the facility from a hospital stay; and d. at least quarterly, in conjunction with the required quarterly MDS assessment. 13. The resident has the right to refuse to participate in the development of his/her care plan and medical and nursing treatments. Such refusals are documented in the resident's clinical record in accordance with established policies.

Based on interviews and record reviews the facility did not ensure care plans were revised for five residents (#13, #10, #6, #65, and #89) out of twenty-two sampled residents. Findings included: 1. Review of Admission Records showed Resident #13 was admitted on [DATE] with diagnoses including dementia, chronic cough, and dysphagia. Review of the Dining Assistance list provided by the Director of Nursing (DON) had Resident #13 listed as cue and assist, prefers bowls. Review of Resident #13's care plan showed a focus area of ADL (Activities of Daily Living) self-care performance deficit with interventions including, Eating: The resident is a feeder, at times feeds self, adaptive device of sippy cup and sided dishes. 2. Review of Admission Records showed Resident #10 was admitted on [DATE] with diagnoses including dementia and gastro-esophageal reflux disease. Review of the Dining Assistance list provided by the DON had Resident #10 listed as cue and assist. Review of Resident #10's care plan showed a focus area of ADL self-care performance deficit with interventions including EATING: The resident is able to eat with set up assistance. An additional focus area was risk for malnutrition and altered mental status with interventions included assist with set up at meals, dated 7/12/24, and monitor/document/report PRN (as needed) any signs/symptoms of dysphagia: pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat, appears concern during meals, dated 8/18/24. An interview was conducted on 2/25/25 at 10:10 a.m. with a hospice aide. She said Resident #10 needs assistance with eating and someone should be with her to cue her. 48223 3. Review of Resident #6's Admission Record revealed an admitted [DATE] with diagnoses of senile degeneration of brain, delusional disorders, and hypertension. Review of Resident #6's progress notes dated 12/22/24 showed Resident #6 had a small open area to left side of the coccyx. The physician was contacted and order given for treatment, which was still active as of 2/24/25. Review of Resident #6's current care plan showed no evidence of skin impairment. During an interview on 2/25/25 at 3:00 p.m., Staff E, RN/MDS confirmed Resident #6 had a treatment order for impaired skin and there should be a care plan for this, but there is not one. 4. Review of Resident #65's Admission Record revealed an admitted [DATE] with diagnoses of mood disorder due to known physiological condition, moderate major depressive disorder, and delusional disorder. Review of Resident #65's progress notes dated 1/29/25 showed Resident #65 was fighting with staff, yelling at them, calling them names. Review of Resident #65's progress notes dated 2/2/25 showed Resident #65 was standing in the hallway and main dining, yelling and cursing at other residents and staff. Review of Resident #65's current care plan showed the following: Focus dated 8/16/24: Resident #65 is verbally aggressive related to mood disorder and delusions. Resident #65 confabulates, manipulates, and blames staff and residents consistently for verbal abuse and neglect, follows staff around and torments them. Goal dated 1/21/25: Resident #65 will verbalize understanding of need to control verbally abusive behavior through the review date. Resident #65 will demonstrate effective coping skills through the review date. Interventions dated 8/23/24: 2 Certified Nursing Assistants (CNA) at all times while providing care. Administer medications as ordered. Monitor/document for side effects and effectiveness. Analyze of key times, places, circumstances, triggers, and what de-escalates behavior and document. Assess and anticipate resident's needs: food, thirst, toileting needs, comfort level, body positioning, pain etc. Assess resident's understanding of the situation. Allow time for the resident to express self and feelings toward the situation. Monitor behaviors. Document observed behavior and attempted interventions. Provide positive feedback for good behavior. Emphasize the positive aspects of compliance. Psychiatric/Psychogeriatric consult as indicated. When the resident becomes agitated: intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later. During an interview on 2/25/25 at 3:00 p.m., Staff E, RN/MDS confirmed Resident #65's care plan for behaviors has not been revised with alternate interventions since 8/23/24. 5. Review of Resident #89's Admission Record revealed an admitted [DATE] with diagnoses of cerebral infarction due to thrombosis of bilateral cerebellar arteries (stroke), chronic obstructive pulmonary disease (COPD), brief psychotic disorder, moderate major depressive disorder, and anxiety. During an interview on 2/24/25 at 3:30 p.m., Staff X, RN stated Resident #89 had a history of picking at his skin. Review of Resident #89's current care plan showed a Focus area dated 2/5/25, Resident #89 has a psychosocial well-being problem, hallucination, resident reaching for items not there, no other changes were made to the care plan. During an interview on 2/25/25 at 3:00 p.m., Staff E, RN/MDS confirmed Resident #89's care plan for behaviors was not revised with alternate interventions, nor implemented for behaviors. During an interview on 2/25/25 at 5:48 p.m., the Director of Nursing (DON) stated the expectation is for the facility to update the care plans when an incident/behavior/condition of a resident has changed. This permits the staff to try something different. Review of the facility's policy and procedure titled Care Plan, Comprehensive Person-Centered, not dated, revealed the following: Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation: l. The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. 2. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS assessment (Admission, Annual or Significant Change in Status), and no more than 21 days after admission. 3. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 4. Each resident's comprehensive person-centered care plan is consistent with the resident's rights to participate in the development and implementation of his or her plan of care, including the right to: a. participate in the planning process; b. identify individuals or roles to be included; c. request meetings; d. request revisions to the plan of care; e. participate in establishing the expected goals and outcomes of care; f. participate in determining the type, amount, frequency and duration of care; g. receive the services and/or items included in the plan of care; and h. see the care plan and sign it after significant changes are made. 5. The resident is informed of his or her right to participate in his or her treatment and provided advance notice of care planning conferences. 6. If the participation of the resident and his/her resident representative in developing the resident's care plan is determined to not be practicable, an explanation is documented in the resident's medical record. The explanation should include what steps were taken to include the resident or representative in the process. 7. The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including: 1. services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment; 2. any specialized services to be provided as a result of PASARR recommendations; and 3. which professional services are responsible for each element of care; c. includes the resident's stated goals upon admission and desired outcomes; d. builds on the resident's strengths; and e. reflects currently recognized standards of practice for problem areas and conditions. 8. Services provided for or arranged by the facility and outlined in the comprehensive care plan are: a. provided by qualified persons; b. culturally competent; and c. trauma informed. 9. Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. 10. When possible, interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers. 11. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. 12. The interdisciplinary team reviews and updates the care plan: a. when there has been a significant change in the resident's condition; b. when the desired outcome is not met; c. when the resident has been readmitted to the facility from a hospital stay; and d. at least quarterly, in conjunction with the required quarterly MDS assessment. 13. The resident has the right to refuse to participate in the development of his/her care plan and medical and nursing treatments. Such refusals are documented in the resident's clinical record in accordance with established policies.

Based on observations, interviews, and record review, the facility failed to provide care treatment and care in accordance with professional standards of practice related to 1.) did not ensure three residents (#13, #10, and #39) were assisted with eating, 2.) did not ensure two residents (#4 and #56) were assessed for transfers and provided wheelchairs, 3.) did not ensure notification of change in condition was completed appropriately for one resident (#29), 4.) did not ensure one resident (#309) was assessed appropriately for pain, and 5.) did not ensure wound care was provided for two residents (#71 and #89) out of twenty-two sampled residents. Findings included: 1. An observation was conducted on 2/22/25 at 12:52 p.m. of Resident #13 lying in bed with the head of the bed elevated and his tray table in front of him. The resident's lunch was on the tray table and he was feeding himself. His food was placed in bowls and he had a regular cup with no lid. The resident had food spilled down the front of his shirt. Resident #13's tray card showed he should have a cup with lid. The resident was observed struggling to hold the regular cup between his hands to drink from it. Both of the resident's hands were contracted. Review of Admission Records showed Resident #13 was admitted on [DATE] with diagnoses including dementia, chronic cough, and dysphagia. Review of Resident #13's 12/2/24 Quarterly Minimum Data Set (MDS) assessment, Section C - Cognitive Patterns, revealed the resident is rarely/never understood. Review of Resident #13's orders showed an order for a regular diet, pureed texture, nectar consistency, uses sippy cup, dated 8/17/24. Review of the Dining Assistance list provided by the Director of Nursing (DON) had Resident #13 listed as cue and assist, prefers bowls. Review of Resident #13's care plan showed a Focus area of ADL (activities of daily living) self-care performance deficit with interventions including Eating: The resident is a feeder, at times feeds self, adaptive device of sippy cup and sided dishes. A second observation was conducted on 2/23/25 at 12:39 p.m. of Resident #13 lying in his bed with the head of the bed elevated and his tray table with lunch was in front of him. The resident had a regular cup with no lid and bowls. The resident was eating independently with no staff in sight. He continued to pick up and drop the bowls on his bed. He had food down his shirt and on his face. An interview was conducted on 2/23/25 at 1:12 p.m. with the Director of Rehabilitation (DOR). He said Resident #13 had contractures in both hands and needed a sippy cup and assistance with eating. An interview was conducted on 2/23/25 at 1:33 p.m. with Staff C, Licensed Practical Nurse (LPN). She said Resident #13 fed himself pretty well, but she did not know he needed a sippy cup. She said she checked on him during lunch on 2/22/25 and confirmed he was served a regular cup with no lid. She said she did not know where to get information related to which residents need assistance with eating. An interview was conducted on 2/23/25 at 1:37 p.m. with Staff O, Certified Nursing Assistant (CNA). She said the DON has a list of residents that need queuing or assisting with eating. Staff O, CNA also said she knew Resident #13 had thickened liquids but did not know he needed a sippy cup. An interview was conducted on 2/23/25 at 2:32 p.m. with Staff R, LPN/ MDS. She looked at the nurses' station and said the list of residents who need assistance or special equipment is not in the book it should be in. She said the other problem is the kitchen only has a few sippy cups, not enough for what is needed. An interview was conducted on 2/25/25 at 1:22 p.m. with Staff Q, LPN. She confirmed Resident #13 should not be in his room by himself with his meal tray. An observation as conducted on 2/23/25 at 9:27 a.m. of Resident #10 sitting in bed with her breakfast tray in front of her. She was having a difficult time eating and was very slowly moving the utensil from her plate to her mouth. Review of Admission Records showed Resident #10 was admitted on [DATE] with diagnoses including dementia and gastro-esophageal reflux disease. Review of the Dining Assistance list provided by the DON had Resident #10 listed as cue and assist. Review of Resident #10's care plan showed a Focus area of ADL self-care performance deficit with interventions including EATING: The resident is able to eat with set up assistance. An additional Focus area was risk for malnutrition and altered mental status with interventions included assist with set up at meals, dated 7/12/24, and monitor/document/report PRN (as needed) any signs/symptoms of dysphagia: pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat, appears concern during meals, dated 8/18/24. An interview was conducted on 2/25/25 at 10:10 a.m. with Resident #10's hospice aide. She said Resident #10 needs assistance with eating, and someone should be with her to cue her. She said if the resident is in the dining room eating, she did ok but if she was in her room she needed a staff member to be with her cueing her and keeping her awake. The hospice aide said she came in multiple times and Resident #10 had her breakfast tray in front of her. She said when she came in the day prior, on 2/24/25, the resident was in bed with her tray in front of her and the resident was bent over asleep with food all over. An interview was conducted on 2/25/25 at 1:10 p.m. with Staff Q, LPN. She said Resident #10 needs cueing and assisting with meals and the resident should not be in her room with her tray by herself. An observation as conducted on 2/25/25 at 1:31 p.m. of Resident #10. She was lying in bed with the head of the bed elevated. Her lunch tray was in front of her, and she was attempting to eat. The resident said someone should help her and she couldn't do those with a spoon, referring to her carrots. The resident said no one helped her eat her lunch. An observation and interview was conducted on 2/25/25 at 1:37 p.m. with Staff C, LPN. Staff C, LPN was observed entering Resident #10's room. She said the resident should not be in her room eating on her own. Staff C, LPN said it had been over an hour since the lunch trays were passed to residents. Staff C, LPN asked Resident #10 is she was still hungry and the resident replied yes I could be if the carrots were lined up right and I could eat them. Staff C, LPN was observed assisting the resident with completing her lunch. An interview was conducted on 2/25/25 at 2:00 p.m. with Staff P, CNA. She said she was assigned to Resident #10 and she had gone in and checked on the resident. Staff P, CNA said Resident #10 is set up only for her meals according to her care plan. Staff P, CNA also said it is frustrating because different documents will say different things. An interview was conducted on 2/22/25 3:08 p.m. with Resident #39. She said she had no idea what she was eating for each meal because she could only see shadows and staff did not tell her what she had and where it was. She said she just pokes her finger around it to try and figure out what she had and it would be nice to know what she is eating each meal. Review of Admission Records showed Resident #39 was admitted on [DATE] with diagnoses including protein-calorie malnutrition, abnormal weight loss, and need for assistance with personal care. Review of Resident #39's 1/14/25 Quarterly MDS assessment, Section C - Cognitive Patterns showed a Brief Interview for Mental Status (BIMS) score of 13 indicating she was cognitively intact. Review of an eye doctor note dated 10/11/24 showed Resident #39 had highly impaired vision and cataracts in both eyes. Review of Resident #39's care plan did not reveal any Focus area or interventions related to vision loss. An interview was conducted on 2/25/25 at 10:12 a.m. with Staff P, CNA. She said Resident #39 had vision issues and can only see shadows, but staff don't have to help her with meals. An interview was conducted on 2/25/25 at 10:40 a.m. with Staff C, LPN. Staff C, LPN said Resident #39 had glasses and her vision is adequate. When told Resident #39 could only see shadows, Staff C, LPN said she had no idea and would have thought it would have been on the resident's care plan with interventions to help her. 2. An interview was conducted on 2/22/25 at 1:27 p.m. with Resident #4. The resident was observed lying in bed with the head of the bed elevated. Resident #4 said she was not able to get out of bed because she did not have a wheelchair and the mechanical lift hurt when they got her up. The resident said she would like to be able to get up. Review of Admission Records showed Resident #4 was admitted on [DATE] with diagnoses including morbid obesity, idiopathic gout, and age-related osteoporosis. Review of Resident #4's MDS assessment dated [DATE], Section C - Cognitive Patterns, showed a BIMS score of 14, indicating the resident was cognitively intact. Review of Resident #4's care plan showed a focus area of ADL self-care performance deficit with interventions including TRANSFER: The resident requires partial/moderate assistance by staff to move between surfaces, dated 7/24/24. An interview was conducted on 2/24/25 at 2:21 p.m. with Staff J, CNA. She stated Resident #4 would need a mechanical lift and was not a partial assist. Staff J, CNA also said Resident #4 doesn't get up, not that I am aware of. An interview was conducted on 2/24/25 at 2:52 p.m. with the DOR. He stated Resident #4 needed a mechanical lift with maximum assistance to get up and he agreed it would be a problem if a staff member attempted to get the resident up with a partial/moderate assist. The DOR said they had no record of Resident #4 being screened by therapy. The DOR also said residents are typically rescreened at their quarterly and annual review. An interview was conducted on 2/22/25 at 10:40 a.m. with Resident #56. The resident said she lays in bed all day and doesn't get up. She said she had a wheelchair and then it got taken for someone else. She also said the facility had been working on getting her a new wheelchair for a year. Review of Admission Records showed Resident #56 was admitted on [DATE] with diagnoses including morbid obesity and diabetes mellitus with diabetic neuropathy. Review of Resident #56's Quarterly MDS assessment dated [DATE], Section C - Cognitive Patterns showed a BIMS score of 13, indicating she was cognitively intact. Review of the MDS assessment also there was no therapy screen completed during the quarterly review. Review of Resident 56's care plan showed a focus area of ADL self-care performance deficit with interventions including TRANSFER: The resident requires partial/moderate assistance by staff to move between surfaces, dated 8/13/24. An interview was conducted on 2/24/25 at 2:52 p.m. with the DOR. He said Resident #56 needed a mechanical list with maximum assistance to get out of bed and has always needed that. The DOR also said Resident #56 had her own wheelchair but someone is borrowing it because she doesn't ever get up. The DOR provided a therapy screen request, dated 11/4/24, showing Resident does not get out of bed. No changes observed. The responses on 11/7/24 from occupational therapy was no change in function and from physical therapy was no change in LOF [level of function] at this time. The DOR said a therapy screen is conducted at the residents quarterly and annual review and he did not know the resident had a quarterly MDS review on 2/8/25. An interview was conducted on 2/24/25 at 2:21 p.m. Staff J, CNA. She said Resident #56 is not a partial/moderate assist. She said the resident can move her arms around and help but cannot do very much. Staff J, CNA said she had never seen Resident #56 out of bed and confirmed Resident #56 did not have a wheelchair. An interview was conducted on 2/24/25 at 3:11 p.m. with Staff L, CNA. She said for the last 5 months or more when she would ask Resident #56 if she wanted to get up she would say no because they took my chair. She said if the resident wanted to get out of bed staff would have found her a chair. A follow-up interview was conducted on 2/24/25 at 3:29 p.m. with Resident #56. She said staff did not ask her if she wanted to get up but it wouldn't have mattered because she hasn't had a wheelchair in a year. 3. An interview was conducted on 2/23/25 at 7:30 p.m. with a family member of Resident #29. The family member said there was an incident of alleged abuse that occurred on 1/24/25 and she was not notified until the next day, over 14 hours after the incident occurred. An interview was conducted on 2/25/25 at 2:19 p.m. with Resident #29's primary care Nurse Practitioner (NP). The NP said she was not notified of the incident with Resident #29 until the next day. She said she would have expected to have been called right away. The NP said Resident #29 was sent out to the hospital the day after the event when the provider was notified. Review of Admission Records showed Resident #29 was admitted on [DATE] with diagnoses including Alzheimer's disease. An interview was conducted on 2/25/25 at 4:32 p.m. with Staff AA, Registered Nurse (RN). She said she was assigned to care for Resident #29 on 1/24/25 when the incident of alleged abuse occurred. She said she notified the DON immediately. She also said she did not call the resident's provider or emergency contact because the DON said she was coming to the facility and would take care of notifying the appropriate parties when she arrived. An interview was conducted on 2/25/25 at 5:24 p.m. with the DON. She said she was called immediately on 1/24/25 regarding the incident with Resident #29 and she went to the facility. The DON said she did not call the family until the next day and the NP was not called. She said, honestly I don't know why I didn't call that minute. The DON said she wanted to get more details about what happened. The DON also said she was overwhelmed the night of the incident and she should have called the resident's primary care NP and the family. 48441 4. On 2/22/25 at 11:24 a.m., an observation and interview were conducted with Resident #309 in his room with his family member at his bedside. The resident had his right arm wrapped in several neutral colored pressure wrappings from his shoulder down to his wrist. A large black brace with a metal joint over the elbow was observed over the pressure wraps from the shoulder to the wrist and a large bulky padding was attached to the black brace under the elbow for support. Under Resident #309's pressure wrappings was a tube extended out from his wrist connected to a portable wound vacuum device, secured under the black brace. The resident and his family member stated he had a fall and he sustained an open comminuted fracture to his right arm and elbow. Resident #309 stated he was having a great deal of pain from the weight of the brace on his shoulder and back pain from a previous back surgery. Resident #309 also stated the facility was slow to address his pain. The resident stated most of the pain was from his back where he had a previous back surgery but his right shoulder ached from the weight of the brace on his arm. The resident also stated he could only sleep in small increments in the bed and would often have to get up and sit in the chair to try and relieve his back and shoulder pain. Resident #309 stated one night a male nurse came in, dropped off medication on his bedside table, and walked away. The resident stated he was not asked why he was out of bed, how he was doing, or if he needed anything. The resident stated a day shift nurse asked him about his night one day and he told her how hard it was to sleep due to his right shoulder and chronic back pain. The resident stated the nurse practitioner came in with the day nurse and a mutual decision was made to have acetaminophen prescribed at nighttime. Resident #309 stated the same night shift nurse came into his room, dropped off medication in a cup, and left before the resident could ask what the medication was. The resident stated he was not given the opportunity to ask for pain medication. Resident #309 stated he had the same day shift nurse the following day and she was able to rectify the situation. Resident #309 stated moving forward he has been given Tylenol every evening and can remove his brace while in bed. Resident #309 stated this has made a big difference for him in a positive way, but he could not understand how something so simple took so long to rectify. Review of Resident #309's Admission Record showed an admitted [DATE] with diagnoses of displaced comminuted fracture of shaft of ulna, right arm subsequent encounter for closed fracture with routine healing, unspecified open wound of right upper arm subsequent encounter, and unspecified arthritis unspecified site. A review of Resident #309's February 2025 physician orders showed an order for acetaminophen extra strength tablet 500 milligram, give two tablets by mouth at bedtime for pain, ordered 2/21/25. Resident #309's physician orders did not reveal an order related to pain monitoring. A review of Resident #309's care plan showed a Focus area of Pain initiated 2/18/25 related to arthritis and fracture of the right ulna. The Goal for Resident #309's Focus area for pain revealed the resident will verbalize adequate relief of pain or ability to cope with incompletely relieved pain through the review date. Interventions include but are not limited to: - Administer analgesia as per orders. Give 1/2 hour before treatments or care - Anticipate the resident's need for pain relief and respond immediately to any complaint of pain. - Monitor/record/report to nurse any signs or symptoms of non-verbal pain. - Observe and report changes in usual routine, sleep patterns, decrease in functional abilities, decrease in ROM (range of motion), withdrawal or resistance to care. A review of Resident #309's initial Pain Evaluation dated 2/18/25 revealed the following under Pain Indicators: 3. Staff Evaluation for Pain. Check all that apply: a. Non-verbal sounds (e.g., crying, whining, gasping, moaning, or groaning). 4. Frequency with which Resident complains or shows evidence of pain or possible pain: a. indicators of pain 1 to 2 days. On 2/24/25 at 12:00 p.m., an interview was conducted with Staff U, LPN , Staff C, LPN, and Staff V, RN. All three nursing staff members stated they will ask their residents if they are having any discomfort/pain, especially any new admissions and during their morning rounds if there is any indication the resident was having any discomfort or pain. On 2/24/25 at 12:08 p.m., an interview was conducted with Staff V, RN. Staff V, RN stated the first day she had Resident #309 she asked him how he slept and he stated he did not have a good night's sleep. Staff V, RN also stated the resident had a large bulky post-operative dressing and brace to his right arm. Staff V, RN stated she reviewed his medical records and noted no pain medication was ordered for the resident so she notified the primary physician's nurse practitioner, who was in the facility. She and the nurse practitioner went into the resident's room together and the resident agreed to acetaminophen but preferred to have the medication administered at nighttime. Staff V, RN assumed the medication was ordered by the nurse practitioner until she followed up the next day with Resident #309, who stated he did not have a good night again and confirmed he did not receive acetaminophen. Staff V, RN stated when she reviewed Resident #309's medical record, she noticed the acetaminophen was not ordered and obtained an order for the acetaminophen to be administered at nighttime. On 2/25/25 at 3:21 p.m., an interview was conducted with Staff W, RN/weekend supervisor. Staff W, RN stated she will ask her residents if they are having any pain during her morning rounds and in the medical records, any nurse can add to a resident order to check for pain every shift and added there are batch orders for pain to be considered as well. On 2/25/25 at 5:58 p.m., an interview was conducted with the (DON. The DON stated all residents' pain should be addressed when they are first admitted . Residents with a fracture should be addressed on a day-to-day basis. If the resident stated no pain upon admission, an ongoing assessment should be made of the potential for unforeseen future pain or non-verbal cues for pain, such as facial grimacing. The nursing staff can place a batch order for pain in the resident's medical record to assess for pain every shift. A review of the facility's policy and procedures titled Admission Assessment and Follow Up: Role of the Nurse, revised in September 2012, showed the following: Purpose: The purpose of this procedure is to gather information about the resident's physical, emotional, cognitive, and psychosocial condition upon admission for the purposes of managing the resident, initiating the care plan, and completing required assessment instruments, including the MDS. . Steps in the Procedure 7. Conduct an assessment (history and physical), including: a. A summary of the individual's recent medical history, including hospitalization s, acute illnesses, and overall status prior to admission. b. Relevant medical, social and family history. c. A list of active medical diagnosis and patient problems (such as recurrent falling or impaired mobility), especially those most related to reasons for admission to the facility and those that are affecting function, behavior, cognition, nutrition, hydration, quality of life, likelihood of functional recovery, and ability to participate in activities and to socialize. d. Current medications and treatments. . 9. Conduct supplemental assessments following facility forms and protocols including: a. Activity level b. Pain assessment c. Fall risk assessment d. Neurological assessment e. Skin assessment f. Functional assessment ability to perform ADL's (Activities of Daily Living), and g. Behavioral assessment A review of the facility's policy and procedures titled Pain Assessment and Management, last revised in October 2022, showed the following: Purpose: The purposes of this procedure are to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain. General Guidelines: 1. The pain management program is based on a facility wide commitment to appropriate assessment and treatment of pain, based on professional standards of practice, the comprehensive care plan, and the residents choices related to pain management. . 3. Pain management is a multidisciplinary care process that includes the following: a. Assessing the potential for pain b. Recognizing the presence of pain c. Identifying the characteristics of pain d. Addressing the underlying causes of the pain e. Developing and implementing approaches to pain management f. Identifying and using specific strategies for different levels and sources of pain g. Monitoring for the effectiveness of interventions and h. Modifying approaches as necessary . Steps in the Procedure: . 4. Ask the resident if he or she is experiencing pain. Be aware that the resident may avoid the term pain and use other descriptions such as throbbing, aching, hurting, cramping, numbness or tingling. Assessing Pain: 1. Assess the resident at admission and during ongoing assessments to help identify the resident who is experiencing pain or for whom pain may be anticipated during specific procedures, care, or treatment. 2. Monitor the resident for the presence of pain and the need for further assessment when there is a change of condition. 3. Assess the resident whenever there is a suspicion of new pain or worsening of existing pain. 4. Assess pain using a consistent approach and a standardized pain assessment instrument appropriate to the resident's cognitive level. 5. During the pain assessment gather the following information as indicated from the resident or legal representative): a. History of pain and its treatment, including pharmacological and non-pharmacological interventions . b. Characteristics of pain: 1. Location of pain 2. Intensity of pain (as measured on a standardized pain scale); 3. Characteristics of pain (aching, burning, crushing, numbness, burning, etcetera); 4. Pattern of pain (constant or intermittent); and 5. Frequency, timing and duration of pain Identifying the Causes of Pain: 1. Residents may experience pain from several different causes simultaneously 2. in addition, common procedures such as moving the resident, physical therapies, or wound care can cause the resident pain. 3. Review the residents clinical record to identify conditions or situations that may predispose the resident to pain, including: A. Musculoskeletal conditions. a. degenerative joint disease b. rheumatoid arthritis c. osteoporosis d. fractures, and e. amputation B. Skin/ wound conditions: a. Pressure, venous or arterial ulcers; and b. surgical incision(s) Defining Goals and Appropriate Interventions: 1. The pain management interventions are consistent with the resident's goals for treatment which are defined and documented in the care plan. Pain management interventions reflect the source, type and severity of pain. 2. Pain management interventions shall we address the underlying causes of the resident's pain. 3. For those situations where the cause of the resident's pain has not been or cannot be determined, current standards of practice for managing pain are followed to help determine appropriate options. Monitoring and Modifying Approaches: 1. Monitor the resident's pain and consequences of pain at least each shift for your acute pain or significant changes in levels of chronic pain and at least weekly and stable chronic pain. 2. Monitor the resident by performing a basic assessment with enough detail, and as needed, with standardized assessment tools (for example approved pain scales, etcetera) and relevant criteria for measuring pain management (for example target signs and symptoms.) 3. Monitor the following factor to determine if the resident's pain is being adequately controlled: a. The resident's response to interventions and level of comfort over time; b. The status of the underlying causes of pain, if identified previously; and c. The presence of adverse consequences to treatment Documentation: 1. Document the resident's reported level of pain with adequate detail (for example enough information to gauge the status of pain) and the effectiveness of interventions for pain as necessary and in accordance with the pain management program. 2. Upon completion of the pain assessment, the person conducting the assessment shall record the information obtained from the assessment in the resident's medical record. 48223 5. Review of Resident #89's Admission Record revealed an admitted [DATE]. During an observation and interview on 2/22/25 at 3:09 p.m., Resident #89's Responsible Party (RP) stated Resident #89 scraped forearm during an incident last week. Resident #89's right forearm was observed with a bandage from the wrist to the elbow. The bandage was not dated. During an observation and interview on 2/23/25 at 1:14 p.m., Resident #89's RP stated a dressing was on the wound yesterday, not sure why there is not one today. The RP raised Resident #89's right sleeve of the sweatshirt and the right forearm was observed with no bandage. The skin impairment had a bright red middle and black scab surrounding the edges. During an observation on 2/24/25 at 10:05 a.m., Resident #89's right forearm was observed without a bandage. The right forearm had an impairment with bright red middle and black scab area surrounding. Four additional open skin areas were noted above the elbow, uncovered. During an interview on 2/24/25 at 11:18 a.m., Staff X, RN stated Resident #89 hurt their arm during an incident at the end of last week and the resident has orders for treatment to the areas. Review of Resident #89's February 2025 order summary showed an order dated 2/20/25 treatment as follows: right antecubital. Cleanse with wound cleanser then apply silicone cream and dry dressing every day for skin tear. Right elbow. cleanse area with wound cleanser then apply silicone cream and dry dressing every day shift for skin tear. Treatment as follows: right elbow. cleanse area with wound cleanser then apply silicone cream and dry dressing every day shift for skin tear. Review of Resident #71's Admission Record revealed an admitted [DATE] with diagnoses of multiple sclerosis, stage 4 pressure ulcer, and need for assistance with personal care. During an interview on 2/22/25 at 12:47 p.m., Resident #71 stated the facility does not complete the wound care as ordered by the physician and the facility misses dressing changes. Review of Resident #71's February 2025 order summary showed a physician order dated 1/11/25: Cleanse wound with wound cleanser then apply Mupirocin ointment to wound base then Santyl and cover with calcium alginate, secure with border gauze, twice daily. The order was discontinued on 2/5/25. Review of Resident #71's electronic Treatment Administration Record for January and February 2025 revealed the dressings were not completed on 1/16/25 p.m. shift; 1/21/25 p.m. shift; 1/24/25 a.m. shift; 1/27/25 p.m. shift; 1/28/25 p.m. shift; and 1/31/25 a.m. shift. A total of 6 dressing changes were not completed. During an interview on 2/23/25 at 12:33 p.m., Staff Z, Licensed Practical Nurse (LPN) stated she ran out of time on occasions to complete dressing changes for Resident #71. During an interview on 2/25/25 at 5:48 p.m., the DON stated the expectation is the facility follow the physician orders and dressings should be dated. Review of the facility's policy and procedure titled Wound Care, not dated, revealed the following: Purpose: The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Preparation: 1. Verify that there is a physician's order for this procedure. 2. Review the resident's care plan to assess for any special needs of the resident. a. For example, the resident may have PRN (as needed) orders for pain medication to be administered prior to would care . Steps in the Procedure: . 11. Place one (1) gauze to cover all broken skin. Wash tissue around the wound that is usually covered by the dressing, tape or gauze with antiseptic or soap and water. 13. Dress wound. Pick up sponge with paper and apply directly to area. [NAME] tape with initials, time, date and apply to dressing. Be certain all clean items are on clean field. Documentation: The following information should be recorded in the resident's medical record: 1. The type of wound care given. 2. The date and time the wound care was given. 3. The position in which the resident was placed. 4. The name and title of the individual performing the wound care. 5. Any change in the resident's condition. 6. All assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound. 7. How the resident tolerated the procedure. 8. Any problems or complaints made by the resident related to the procedure. 9. If the resident refused the treatment and the reason(s) why. 10. The signature and title of the person recording the data. Reporting: 1. Notify the supervisor if the resident refuses the wound care. 2. Report other information in accordance with facility policy and professional standards of practice. [TRUNCATED]

Based on observations, interviews, and record review, the facility did not ensure food preferences were honored for four residents (#309, #28, #39, and #71) out of twenty-two residents sampled. Findings included: 1. On 2/22/2025 at 11:24 a.m., an observation and interview were conducted with Resident #309 in his room with his family at his bedside. Resident #309 stated he requested hot tea in the morning since his arrival and so far, tea has not been offered to him. Resident #309 stated the facility continued to offer coffee when the resident dislikes coffee. He stated each time they ask him he would request hot tea instead, but no one would bring him a hot tea. The resident denied meeting any representatives from the kitchen regarding his food preferences. The resident stated, at this point, I've given up on getting a hot cup of tea in the morning. On 2/24/2025 at 9:30 a.m., an interview was conducted with the Food Service Director (FSD). The FSD stated her team will conduct a food preference interview with every new admission. On the food preference sheet, options are provided for food preferences and likes and dislikes for foods such as fruits, vegetables, and meats. The FSD stated the usual timeframe to complete the food preferences sheet is within three days but stated it may take a day or two more depending on the number of new admissions. The FSD also stated the food preference sheet responses are placed in the resident's medical record and dated. The kitchen will have a list of the resident's food preference sheet and the original paper will be placed in a binder in her office. Long-term residents will have a reevaluation done every three months prompted by the medical record for review. The FSD stated she did not see a Food Preference Sheet completed for Resident #309 and hot tea is an option for beverages preferences, but stated any staff member could have honored his wishes. 2. On 2/23/2025 at 12:30 p.m., an observation and interview were conducted with Resident #28 in his room. Resident #28 was sitting in his wheelchair with his lunch tray on his bedside table. On the lunch tray there was the remainder of a baked potato skin, a chicken breast, three asparagus stalks, a full cup of a light creamy soup and small remnants of a yellow cake in a cup. Resident #28 stated he could only eat the baked potato and dessert because he could not chew the chicken or the asparagus. Resident #28 also stated he only has three teeth in his mouth so sometimes he can't eat what is served to him because he cannot chew the food. The resident stated at home he would eat food that is softer or ground up and if his chicken was ground up, he could eat it today. On 2/23/2025 at 12:40 p.m., an interview was conducted with Staff U, Licensed Practical Nurse (LPN), who was assigned to Resident #28. Staff U, LPN was unaware of Resident #28's lack of dentation and difficulty in chewing his food. 46234 3. An interview was conducted on 2/22/25 at 3:08 p.m. with Resident #39. She said she would love to have yogurt, fruit, and/or muffins sometimes. She said she asked but never gets them. Review of the Admission Record showed Resident #39 was admitted on [DATE] with diagnoses including protein-calorie malnutrition. Review of Resident #39's 1/14/25 Quarterly Minimum Data Set (MDS) assessment, Section C - Cognitive Patterns showed a Brief Interview for Mental Status (BIMS) score of 13, indicating she was cognitively intact. Review of Resident #39's Food Preferences, dated 10/12/24, showed the resident preferred hot tea, oatmeal, bacon, fruit, and yogurt for breakfast options. A follow-up interview was conducted on 2/24/25 at 11:47 a.m. with Resident #39. The resident said she does not get the hot tea she requested for breakfast except occasionally one Certified Nursing Assistant (CNA) will go downstairs and find her some. She reiterated the fact she never gets fruit and yogurt. 48223 4. During an interview and observation on 2/22/25 at 12:47 p.m., Resident #71 stated they did not receive condiments on the meal tray. No ketchup, mustard, salt, pepper, and crackers if they have soup. Resident #71 stated not being on a restrictive diet, so they don't understand why they cannot provide the items. No condiments were observed on the resident's meal tray. An observation was made on 2/23/25 at 12:25 p.m. of Resident #71's lunch tray and no condiments were on the meal tray. During an interview on 2/23/25 at 12:45 p.m., Staff L, CNA stated condiments don't come on the trays and if a resident requests something we get the item for them. During an interview on 2/24/25 at 10:15 a.m., the FSD stated condiments are supposed to be on the trays and extras are available in the dining room if anyone requests them. Review of the facility's policy and procedure titled Resident Food Preferences, not dated, revealed: Policy Statement: Individual food preferences will be assessed upon admission and communicated to the interdisciplinary team. Modifications to diet will only be ordered with the resident's or representative's consent. Policy Interpretation and Implementation 1. Upon the resident's admission the Dietitian or nursing staff will identify a resident's food preferences. 2. When possible, staff will interview the resident directly to determine current food preferences based on history and life patterns related to food and mealtimes. 3. Nursing staff will document the resident's food and eating preferences in the care plan. 4. The Dietitian and nursing staff, assisted by the Physician, will identify any nutritional issues and dietary recommendations that might be in conflict with the resident's food preferences. 5. The Dietitian will discuss with the resident or representative the rationale of any prescribed therapeutic diet. The Physician and Dietitian will communicate the risks and benefits of specialized therapeutic vs. liberalized diets. 6. The resident has the right not to comply with therapeutic diets. 7. The Food Services Department will offer a variety of foods at each scheduled meal, as well as access to nourishing snacks throughout the day and night. 8. The facility's Quality Assessment and Performance Improvement (QAPI) Committee will periodically review issues related to food preferences and meals to try to identify more widespread concerns about meal offerings, food preparation, etc.

Based on observations and interviews, the facility did not ensure dignity was maintained for residents in one out of two dining rooms related to residents at a single table not being served meals at the same time. Findings included: An observation was conducted on 2/23/25 during lunch in the second-floor dining room. At 12:20 p.m., the first tray cart arrived in the dining room. There were 14 residents in the dining room for lunch: - At a table with two residents, the first resident was served their tray at 12:25 p.m. and the second resident was not served until 12:44 p.m. - At a table with three residents, the first two residents were served their trays at 12:34 p.m. and the third resident was not served until 12:45 p.m. - At a table with two residents, the first resident was served their tray at 12:42 p.m. After a couple of minutes, the resident was overheard asking her table mate if she minded if she went ahead and began eating. The second resident was not served until 12:46 p.m. - At 12:46 p.m., 5 of the 14 residents in the dining room were not served. - At 12:48 p.m., two residents were overheard asking where their food was, and the Certified Nursing Assistant (CNA) said they were on another tray cart coming up soon. 48223 An observation was conducted on 2/22/25 at 12:08 p.m. in the dining room of the second floor during meal service: - Staff were observed removing trays from the meal cart, looking around the dining room for the resident whose tray they were holding, and determining if the resident was in the dining room. If the resident was not in the dining room, the staff member proceeded to exit the dining room with the tray. - At a table with two residents, the first resident was served their tray at 12:19 p.m. and the second resident was not served until 12:34 p.m. - At a table of two residents, the first resident was served their tray at 12:19 p.m. and the other resident was not served until 12:26 p.m. - At a table with three residents, two residents were served their trays at 12:20 p.m. The third resident was not served until 12:44 p.m. Meanwhile, the other two residents completed the meal and one exited the dining room. An interview was conducted on 2/23/25 at 12:45 p.m. with Staff L, CNA and Staff N, CNA. Staff L, CNA said the trays arrive in the meal carts by room number and there are three meal carts total. Staff take the tray to the room from the dining room, then come back to the dining room and finish the tray pass. Staff N, CNA said this makes it hard to serve everyone at the table at the same time as one person's tray might arrive on the first cart and the other resident's tray doesn't arrive until the third cart. An interview was conducted on 2/24/25 at 10:15 a.m. with the Food Service Director (FSD). The FSD confirmed the meal carts arrive to the units with resident trays in room number order. The FSD said she was not aware numerous residents dine in the dining room, I was told only about five residents eat in the dining room. The FSD stated, absolutely not should a resident have to watch someone else eat while they wait for their meal. An interview was conducted on 2/25/25 at 5:48 p.m. with the Director of Nursing (DON). The DON stated the expectation is residents are served at the same time. Review of the facility's policy and procedure titled Dignity, not dated, showed: Policy Statement: Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Policy Interpretation and Implementation: 1. Residents are treated with dignity and respect at all times. 2. The facility culture supports dignity and respect for residents by honoring resident goals, choices, preferences, values and beliefs. This begins with the initial admission and continues throughout the resident's facility stay. 3. Individual needs and preferences of the resident and identified through the assessment process. 4. Residents may exercise their rights without interference, coercion, discrimination, or reprisal from any person or entity associated with this facility. 5. When assisting with care, residents are supported and exercising their rights .

Based on interviews and record review, the facility failed to honor resident rights to formulate advance directives for two residents (#259 and #94) of 22 residents sampled for advance directives. Findings included: 1. During an interview on 2/26/25 at 9:36 a.m., the court appointed guardian for Resident #259 stated contacting the facility on multiple occasions to inform and ascertain information related to Resident #259, including the resident being intellectually disabled since birth and not able to make decisions. The guardian also stated the hospital had the paperwork from the court and the paperwork was sent with Resident #259 upon admission to the facility. The guardian stated they verbally told the nurses and sent the court documents of the guardianship to the facility. The facility not only had him sign to papers of disenrollment of healthcare coverage, but the facility also had Resident #259 sign vaccination consents and discharge paperwork, all being a violation of the court order. Review of Resident #259's Admission Record revealed an admitted [DATE] with a diagnosis of genetic related intellectual disability. Review of Resident 259's, Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form dated 12/16/24 revealed under section C - Decision Making Capacity (Patient), the resident required a surrogate. Section D - Emergency Contact revealed the name and phone number of Resident #259's guardian. Review of Resident 259's Preadmission Screening and Resident Review (PASRR) dated 12/16/24 revealed the resident was receiving services for a Mental Illness (MI) and has a current diagnosis of an Intellectual Disability. Review of Resident #259's Clinical Admission nursing note dated 12/17/24 at 1:07 a.m. revealed Resident #259 is only oriented to person and place. Review of Resident #259's Social Service note dated 12/17/24 at 10:24 a.m. revealed, Resident was observed to be alert, disoriented but able to follow instruction. Review of Resident #259's Brief Interview for Mental Status dated 12/17/24 at 12:04 p.m. revealed a score of 9 out of 15, indicating moderate cognitive impairment. Review of Resident #259's Guardianship paperwork, signed and sealed by a Circuit Judge in Highlands County, Florida, dated 7/6/16, revealed Resident #259 lacks capacity to take care of person, property, and estate. The document was uploaded to the facility electronic medical record on 12/24/24. Review of Resident #259's nursing notes dated 12/26/24 at 6:31 p.m. revealed a note created by the Director of Nursing (DON), spoke to resident POA [power of attorney] . Review of Resident #259's Discharge Summary dated 1/2/25 at 11:42 a.m. revealed: Pt [patient] discharged back to group home with group home staff. D/c [discharge] paperwork gone over and all signed by resident and copies made for pt/group home staff. Meds sent home with pt (given to staff). Pt A&O [alert and oriented] and denies and [sic] pain, discomfort or SOB [shortness of breath]. Review of Resident #259's discharge paperwork dated 1/2/25 revealed, Resident #259's signature. Review of Resident #259's vaccination consent form dated 12/17/24 revealed Resident #259's signature and vaccination received on 12/19/24. Review of Resident #259's Disenrollment Request form dated 12/27/24 revealed Resident #259's signature to disenroll from Medicare Advantage and enroll in Medicare. During an interview on 2/24/25 at 4:29 p.m., the Business Office Manager (BOM) stated the facility did not have paperwork stating the resident was not competent and the family brought in the documents after the resident was already asked to disenroll. The BOM stated when learning of the error, they immediately emailed the case manager liaison of the facility, with that particular Medicare Advantage program. The BOM confirmed not notifying the Medicare official website. During an interview on 2/25/25 at 12:56 p.m., the Nursing Home Administrator (NHA) stated the facility should have honored Resident #259's guardianship paperwork that was uploaded to the system on 12/24/24. 41015 2. During an attempted interview on 2/22/25 at 3:00 p.m., Resident #9 was sitting at the edge of his bed playing with paper. Resident #94 did not acknowledge the State Agency (SA) Surveyor and began to have a conversation with himself. Review of the Admission Record showed Resident #94 was admitted to the facility on [DATE] with diagnoses including but not limited to adult failure to thrive and schizophrenia. The Contacts section of the Admission Record showed Resident #94 was his own responsible party. Review of the Medical Certifications for Medicaid Long-Term Care Services and Patient Transfer Form (Form 3008) dated 12/5/24 showed section C - Decision Making Capacity, Resident #94 required a surrogate. Review of the care plan showed Focus: [Resident #94] is dependent on staff for meeting emotional, intellectual, physical, and social needs r/t [related to] Cognitive deficits. Goals: The resident will maintain involvement in cognitive stimulation, social activities as desired through review date. Interventions: - All staff to converse with resident while providing care. - Assist with arranging community activities. Arrange transportation. - Encourage ongoing family involvement. Invite the resident's family to attend special events, activities, meals. - Ensure that the activities the resident is attending are: Compatible with physical and mental capabilities; Compatible with known interests and preferences; Adapted as needed (such as large print, holders if resident lacks hand strength, task segmentation), Compatible with individual needs and abilities; and Age appropriate. - Establish and record the resident's prior level of activity involvement and interests by talking with the resident, caregivers, and family on admission and as necessary. - Introduce the resident to residents with similar background, interests and encourage/facilitate interaction. Review of the Modification (02) Admission/Medicare - 5 Day Minimum Data Set (MDS) dated [DATE], Section C - Cognitive Patterns, revealed Resident #94 had a Brief Interview for Mental Status (BIMS) score of 99 indicating the resident was unable to complete interview. Section C0100 showed no BIMS was conducted resident is rarely/never understood. During an interview on 2/22/25 at 3:04 p.m., Staff A Certified Nursing Assistant (CNA) stated Resident #94 was usually in his own world and the resident does smile at times, but was not coherent very often or for too long. During an interview on 2/22/25 at 3:10 p.m., Staff B Registered Nurse (RN) stated to find out if a resident has capacity to make their decisions, staff would look on the a residents profile page to see if that resident was their own responsible party. Staff B, RN stated Resident # 94 had a POA as he was very confused. Staff B, RN reviewed Resident #94's profile page and stated Resident #94 did not have a POA, but he was very confused. Staff B, RN stated the profile page showed Resident #94 was his own responsible party, but stated he was not. Staff B, RN stated Resident #94 had an emergency contact, so she would call the emergency contact for medical decisions. Staff B, RN stated there was a discrepancy between the Form 3008 and Resident #94's profile page. During an interview on 2/23/25 at 12:27 p.m., Staff C Licensed Practical Nurse (LPN) stated to find residents' emergency contact information, look in the electronic medical record for emergency contact under the profile on the administration record. Staff C, LPN stated the profile page would tell who information can be given to and who to contact for the resident. Staff C LPN stated the admitting nurse would be responsible for entering emergency contact information from the Form 3008 to the profile page for new admissions. During an interview on 2/23/25 at 4:45 p.m., the Social Service Director (SSD) stated the process for advanced directives started with Admissions Department as the Admission Department would receive the Form 3008 and enter the information from the 3008 form to create a resident's profile page. The SSD stated to find out if a resident had capacity or not staff could find the information in the electronic medical record on the profile page. The SSD stated Resident #94 should never have been placed as his own responsible party on the profile page because the 3008 form showed he needed a surrogate. The SSD also stated the discrepancy was a mistake and someone should have caught the discrepancy and followed up on it. The SSD stated according to Resident # 94's medical record, he did not have a Power of Attorney (POA), Health Care Surrogate (HCS), or an assigned Guardian at this time and stated the record did not show where a physician declared Resident #94 with capacity either. The SSD stated the original discharge plan was for Resident #94 to go back and live with family. However, it was determined the family would not be able to provide the care for Resident #94 he would need so Resident #94 would now be staying at the facility in long term care. The SSD stated that someone in the facility should have caught that Resident #94 was not his own responsible party. During an interview on 2/24/25 at 10:15 a.m., the Assistant Administrator (AA), formerly the Admissions Director, stated the admitting nurse would be responsible for taking the information off a new resident's Form 3008, reviewing the hospital record, and inputting the information into the resident's electronic medical record. The AA stated the admitting nurse should have reviewed Resident #94's 3008 form and saw the resident required a surrogate. The AA also stated even if the information on the 3008 form was wrong then it should have been fixed. The AD stated even with Resident #94's mental health decline, she was not sure why the 3008 form showed a needing surrogate was not caught. The AA/AD said, I am not disagreeing with you there was a discrepancy between the advance directive information on Resident #94's 3008 form and what was transcribed onto Resident #94 profile page. During an interview on 2/24/25 at 10:30 a.m., Staff D CNA and Concierge stated Resident # 94 was seen talking to himself more and was showing more and more incoherent behaviors lately. During an interview on 2/25/25 at 10:58 a.m., the Director of Nursing (DON) stated the admitting nurse puts in all the information in the chart from the 3008 form, which is considered the facility's starting orders. The DON also stated the process for advanced directives are for the admitting nurse to put the information in the medical record and then the social service department would also review the chart and the 3008 form to ensure all advanced directives are in place. The DON stated if a resident needs a surrogate, it would be the Social Service Department that would act on that and contact the court system to initiate a court appointed guardian. The DON also stated she knew nothing about that process. Review of the facility's policy and procedure titled Resident Rights, not dated, showed: Policy Statement: Employees shall treat all residents with kindness, respect, and dignity. Policy Interpretation and Implementation: 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence; b. be treated with respect, kindness, and dignity; . k. appoint a legal representative of his or her choice, in accordance with state law; . t. privacy and confidentiality; . Review of the facility's policy and procedure titled Advance Directives, not dated, showed: Policy Statement: The resident has the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment. Advance directives are honored in accordance with state law and facility policy. Policy Interpretation and Implementation: Definitions: 1. The facility defines the following in accordance with current OBRA (Omnibus Budget Reconciliation Act) definitions and guidelines: . b. Advance Directive - a written instruction, such as living will or durable power of attorney for health care, recognized by state law (whether statutory or as recognized by the courts of the state), relating to the provisions of health care when the individual is incapacitated (per S489.100). c. Healthcare decision-making capacity - refers to possessing the ability (as defined by State law) to make decisions regarding health care and related treatment choice. Determining Existence of Advance Directive: 1. Prior to or upon admission of a resident, the social services director or designee inquires of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives. 5. If the resident is incapacitate and unable to receive information about his or her right to formulate an advance directive, the information may be provided to the resident legal representative. Decision-Making Capacity: 1. Upon admission the interdisciplinary team assesses the resident's decision-making capacity and identifies the primary decision-maker if the resident is determined not to have decision-making capacity. 2. The interdisciplinary team conducts ongoing review of the resident's decision-making capacity and invokes the resident representative or health care agent if the resident is determined not to have decision-making capacity. [NAME] are documented in the care plan and medical record.

Based on observation and interview, the facility did not ensure privacy of residents' personal health information on one unit (East) out of two units in the facility. Findings included: An observation was conducted on 2/22/25 at 10:28 a.m. of a medication cart outside of room [ROOM NUMBER]. The computer screen was unlocked with a resident's medical record displayed. The nurse was in a resident room and people were observed moving through the halls. An observation was conducted on 2/22/25 at 10:44 a.m. of a lab book sitting on the top counter at the nurses' station with a resident's face sheet sticking out of the book. The book was visible to anyone walking past the nurses' station. At the time, four residents were sitting at the nurses' station and no staff were present. An observation was conducted on 2/22/25 at 12:10 p.m. of a second-floor medication cart sitting in a resident hall with the computer screen unlocked and a resident's medical record displayed on the screen. No staff were present and residents were moving through the hall to the dining room for lunch. An observation was conducted on 2/23/25 at 12:50 p.m. of a second-floor medication cart sitting at the nurses' station with the computer screen unlocked and a resident's medical record displayed. The screen was partially covered with a sheet of paper. However, information could be seen and it was logged in to the nurses' account. An observation was conducted on 2/24/25 at 3:20 p.m. of a second-floor medication cart with the computer screen unlocked and a resident's medical record displayed. The nurse walked away from the cart, leaving the screen unlocked, and went to another medication cart. Residents were in the hall near the cart. An interview was conducted on 2/25/25 at 10:12 a.m. with Staff Q, Certified Nursing Assistant (CNA). She said staff are educated to make sure computer screens are locked and papers are turned over so no one can see resident information. An interview was conducted on 2/25/25 at 10:30 a.m. with Staff L, CNA. She said computers should be logged off when staff are not using them. She also said they try not to put papers on the top counter of the nurses' station, papers should be placed on the lower counter behind the nurses' station. An interview was conducted on 2/25/25 at 10:54 a.m. with Staff R, Licensed Practical Nurse (LPN). She said the computer screens on the medication cart should be locked when the nurse is not at the cart and all papers should be turned over. An interview was conducted on 2/25/25 at 5:54 p.m. with the Director of Nursing (DON). She said absolutely staff should be locking computer screens when they are not using them. The DON said papers with resident information should not be on the top counters at the nurses' station. She confirmed computer screens should not just be covered with a piece of paper; they should be locked. Review of a facility policy titled Resident Rights, revised December 2021, showed: Policy Statement Employees shall treat all residents with kindness, respect, and dignity. Policy Interpretation and Implementation 2. The unauthorized release, access, or disclosure of resident information is prohibited. All release, access, or disclosure of resident information must be in accordance with current laws governing privacy of information issues. All inquiries concerning the release of resident information should be directed to the HIPAA (Health Insurance Portability and Accountability Act) compliance officer. Photographic Evidence Obtained

Based on observations, interviews, and record review, the facility failed to ensure the prevention of the development of pressure wounds for one resident (#28) out of eight residents sampled. Findings included: On 2/22/2025 at 10:15 a.m., an observation and interview were conducted with Resident #28 and his family member in his room. Resident #28 was in bed and stated he was in a car accident and broke both his legs. Resident #28's family member stated the resident has several new open wounds on his right leg and bottom since he has been in the facility. An observation was made when Resident #28 lifted his right leg to reveal a dressing on the lateral lower area. The dressing had dried light to dark brown drainage and was dated 2/20. Resident #28's family member stated the wounds to his legs were from the brace he was wearing after his accident, but added he no longer wears the brace while he is in bed. An observation was made of two soft boots on the resident's wheelchair seat. The family member stated sometimes the staff will place the soft boots on the resident when he is in bed. On 2/22/2025 at 11:30 a.m., an observation was made of a nursing staff with a wound treatment cart in front of Resident #28's room. On 2/23/2025 at 12:30 p.m., an observation and interview were conducted with Resident #28 in his room. Resident #28 was sitting in his wheelchair with bilateral braces to his lower extremities. Resident #28 had his lunch tray on his bedside table. Resident #28 stated he would like to get back to bed because he had been up since 7:00 in the morning. An observation was made of a seat cushion shaped in a donut on the resident's chair in his room. Resident #28 stated he was not sure why it was there and could not recall if the cushion is supposed to be used while sitting in his wheelchair. On 2/25/2025 at 2:10 p.m., an observation was conducted in Resident #28's room. Resident #28 was in his bed and two soft boots were observed on top of the resident's wheelchair. A review of Resident #28's Admission Record showed an admitted [DATE] with diagnoses of displaced bicondylar fracture of the left tibia subsequent encounter for closed fracture with routine healing, displaced bicondylar fracture of the right tibia subsequent encounter for closed fracture with routine healing, wedge compression fracture of second lumbar vertebra subsequent encounter for fracture with routine healing, unspecified protein-calorie malnutrition, and need for assistance with personal care A review of Resident #28's February 2025 physician orders showed the following: - House supplement two times a day related to unspecified protein-calorie malnutrition ordered 2/19/2025 - Immobilizer to BLE (bilateral lower extremities) when out of bed only every shift ordered 2/15/2025 - Prevalon boot to right and left heel as tolerated when in the bed with lateral lift for foot drop/AFO (ankle foot orthosis) every shift for DTI (deep tissue injury)/Foot drop, ordered 1/21/2025. - Treatment as follows: right outer lower extremity. Cleanse with wound cleanser and then apply xeroform every day shift every Monday, Thursday, and Saturday for skin tear, ordered 2/20/2025 discontinued 2/23/2025. - Treatment as follows: right lower calf cleanse with wound cleanser then pat dry and apply Santyl alginate calcium and dry dressing every day shift for wound care ordered 2/24/2025. - Treatment as follows: right upper calf cleansed with wound cleanser then apply Santyl alginate calcium and dry dressing as every day shift for wound care order 2/24/2025. - Treatment as follows: skin prep to both heels every shift for right heel DTI (deep tissue injury), left red/soft ordered 1/19/2025. - Treatment as follows: zinc oxide to right buttock as needed every day shift for wound care order 2/17/2025. - Wound consult for active wounds right lower extremity ordered 1/19/2025 On 2/25/25 at 1:51 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated nurses should remove a brace or sling for skin assessments. The DON also stated Resident #28 should be on an air mattress, if he's not already, he will be on one. The DON stated anyone can put a work order for an air mattress. The DON was made aware of the dressing dated 2/20 on 2/22/2025's observation for Resident #28 and stated the dressing change should have been addressed daily. On 2/25/2025 at 2:15 p.m., an interview was conducted with Staff W, (Registered Nurse) RN. Staff W, RN stated she is the wound nurse during the weekends and will make wound rounds with the wound physician every Monday and Thursday during wound rounds. Staff W, RN also stated she provided wound care for Resident #28 on 2/22/2025 and agreed the wound dressing was dated 2/20. Staff W, RN stated the resident initially arrived with bilateral lower leg braces, which made it a challenge for potential development of pressure wounds, but stated the resident has an order to now remove the resident's immobilizers while in bed. Staff W, RN stated nurses should be removing the immobilizers to do skin checks and during bathing. Staff W. RN agreed Resident #28 has two areas to his legs from the immobilizer and a pressure area on his sacrum. Staff W, RN stated the resident was not on an air mattress but he should be. Staff W, RN stated Resident #28 may refuse to wear the Prevalon boots ordered but his heels are good. A review of Resident #28 Treatment Administration Record for the month of February 2025 showed Resident #28 as compliant and wearing his bilateral boots with no refusals documented. A review of Resident #28's weekly skin check dated 1/19/2025 showed in Section B - Skin Impairment items (a) bruise and (c)skin tear as checked items. In Section D - New Skin Impairment Interventions items (c) wound care consult and (d) treatment order were checked. A review of Resident #28's Initial Wound Evaluation and Management Summary dated 1/20/2025 showed a focused wound exam (Site 1) to the right calf partial thickness as a trauma injury with wound size (L [length] x W [width] x D [depth]) = 6 x 6.3 10.2 cm [centimeters] with a total surface area of 37.80 cm2 [square centimeters]. A follow up Wound Evaluation and Management Summary dated 1/27/2025 showed the trauma wound to right calf as resolved. A record review of Resident #28's Wound Evaluation and Management Summary dated 2/10/2025 showed a new wound to right buttocks (Site 2) partial thickness with wound size (L x W x D) =1 x 1 x 0.1 cm with a total surface area of 1.00 cm2. Under section Musculoskeletal System, chair with pressure reduction cushion and feet with pressure relieving boot were documented by the wound therapy physician. A record review of Resident #28's Wound Evaluation and Management Summary dated 2/20/2025 showed a new wound to the right calf (Site 3). Site 2 right buttock partial thickness showed the following measurements 1.5 x 2 x 0.1 cm with a total surface area of 3.00 cm2 and wound progress noted as not at goal. Site 3 was described as unstageable (due to necrosis) of the right calf full thickness and measured 2 x 1 x 0.3 cm with a total surface area of 2.00 cm2. Site 3 underwent a surgical excisional debridement procedure by the wound care physician with post procedural orders for wound care treatment. A record review of Resident #28's Weekly Pressure Wound Note dated 2/24/2025 showed the right buttocks pressure measured at 1 x 1 x 0.1 cm Stage II, right lower calf pressure wound measured 2.5. x 1 x 0.3 cm unstageable and right upper calf pressure wound measured at 3.5 x 1 unstageable. All three wounds were documented by the wound care physician as in-house acquired. A review of the facility's policy and procedures titled Pressure Ulcers/Skin Breakdown-Clinical Protocol showed the following: Assessment and Recognition 1. The nursing staff and practitioners will assess and document an individual's significant risk factors for developing pressure ulcers, for example, mobility, recent weight loss, and a history of pressure ulcers. 2. In addition, the nurse should describe and document report the following: a. Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue. b. Pain assessment. c. Resident's mobility status d. Current treatments include support surfaces; and e. All active diagnosis 3. The staff and practitioner will examine the skin of newly admitted residents for evidence of existing pressure ulcers or other skin conditions. 4. The physician will assist the staff to identify the type (for example, arterial or stasis ulcer and characteristics presence of necrotic tissue, status of wound bed, etcetera) of an ulcer. 5. The physician will identify and define any complications related to pressure ulcers. Cause Identification 1. The physician will help identify factors contributing or predisposing residents to skin breakdown; (for example, medical comorbidities such as diabetes or congestive heart failure, overall medical instability, cancer or sepsis causing a catabolic state, and macerated or friable skin. 2. The physician will clarify the status of relevant medical issues; for example, whether there is a soft tissue infection or just wound colonization, whether the wound has necrotic tissue, and the impact of comorbid conditions on healing and existing wound period. Treatment /Management 1. The physician will order pertinent wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings (occlusive, absorptive, etcetera), and application of topical agents 2. The physician will help identify medical interventions related to wound management; For example, treating a soft tissue infection surrounding an ulcer, removing necrotic tissue, addressing comorbid medical conditions, managing pain related to the wound or to wound treatment, etcetera. a. The poor nutritional status is associated with increased risk of pressure ulcer development, no specific nutritional interventions clearly prevent or heal pressure ulcers. b. Beyond trying to maintain a stable weight and providing approximately 1.2 to 1.5 grams per kilogram protein daily, there are no routine pressure ultra specific nutritional measures for those with or at risk for developing the pressure ulcer c. Any nutritional supplementation should be based on realistic appraisal of an individual's current nutritional status and minimizing any medications and conditions that may be affecting appetite and weight. 3. The physician will help staff characterize the likelihood of wound healing, based on a review of pertinent factors, For example: a. healing or prevention likely: the resident's underlying physical condition, prognosis, personal goals and wishes, care instructions, and ability to cooperate with the treatment plan make wound healing and subsequent wound prevention realistic. b. Healing or prevention possible: healing may be delayed or may occur only partially; Wounds may occur despite appropriate preventative efforts. c. Healing or prevention unlikely: the resident is likely to decline or die because of his or her overall medical instability; Wounds reflect the individual's overall medical instability; An existing wound is unlikely to improve significantly; Additional wounds are likely to occur despite preventative efforts. 4. As needed, the physician will help identify medical and ethical issues influencing wound healing, For example, the impact of end stage heart disease or because the resident or family declines artificial nutrition and hydration. a. Advance directives may limit the scope, intensity, duration, and selection of various wound related or adjunctive treatments such as a choice to forego artificial nutrition and hydration. Monitoring 1. During resident visits, the physician will evaluate and document the progress of wound healing, especially for those with complicated, extensive, or poorly- healing wounds. 2. The physician will guide the care as appropriate, especially when wounds are not healing as anticipated or new wounds develop despite existing interventions. a. Healing may be delayed or may not occur, or additional ulcers may occur because of other factors which cannot be modified. b. Current approaches should be reviewed for whether they remain pertinent to the resident /patient's medical conditions, are affected by factors influencing wound development or healing, and the impact of specific treatment choices made by the resident /patient or a substitute decision maker.

Based on observations, interviews, and record reviews, the facility did not ensure the environment was free of possible accident hazards related to smoking materials for one resident (#104) of one resident sampled for smoking and related to razors and scissors in two resident rooms (room [ROOM NUMBER] and room [ROOM NUMBER]) of thirty-one resident rooms observed. Findings included: 1. On 2/22/2025 at 12:20 p.m., an observation was made of Resident #104 in his room during the initial tour of the facility. In Resident #104's room there were two packs of cigarettes and three cigarette lighters in view. Resident #104 stated he was in the facility for therapy in hopes to discharge home. On 2/23/2025 at 9:25 a.m., an observation was made of Staff T, Certified Nursing Assistant (CNA) in Resident #104's room, cleaning. Resident #104 was not present in the room. The smoking materials observed the day before in Resident #104's room were no longer present. On 2/23/2025 at 12:49 p.m., an observation and interview were conducted with Resident #104 in the designated smoking area. The staff assigned to the smoking area was not aware Resident #104 had his own smoking paraphernalia. Resident #104 stated he was unaware he could not hold onto his smoking paraphernalia. The staff member explained to Resident #104 he had signed a smoking agreement with the facility and Resident #104 stated he did not receive a smoking agreement. The staff member pulled a sign from the doorway to the smoking patio and presented it to the resident. The staff member told the resident the signage was the contract presented to him. The staff member presented the resident with his smoking agreement he signed on admission. The resident apologized and stated he did not remember signing the smoking policy agreement. On 2/23/2025 at 1:26 p.m., an interview was conducted with Staff T, CNA, who stated she did not observe smoking material in the resident's room when she was cleaning up earlier today. Staff T, CNA stated smoking material should be held in a box in the nurses' station. On 2/23/2025 at 1:35 p.m., an interview was conducted with Staff S, Licensed Practical nurse (LPN). Staff S, LPN stated she did notice smoking paraphernalia in Resident 104's room this morning, but by the time she got back to his room the smoking material was gone. Staff S, LPN could not state who took his smoking paraphernalia out, but stated she thought upper management was making a sweep of all residents' rooms this morning. A review of Resident #104's Admission Record showed an admitted [DATE] with a diagnosis of tobacco use. A review of Resident #104 medical record did not show a smoking evaluation completed by staff for safe smoking. A review of Resident #104's care plan did not show a care plan related to smoking. On 2/24/2025 at 3:20 p.m., an interview was conducted with Staff C, LPN and Staff U, LPN. Both confirmed when a resident arrives new to the facility there is a section in the initial assessment to ask the resident if they smoke. If the resident answers yes, they would have the resident read the smoking policy and have the resident sign the acknowledgment. A review of Resident 104's Minimal Data Set (MDS) assessment dated [DATE], in Section I - Active Diagnoses showed tobacco use. Section C - Cognitive Patterns showed a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident was cognitively intact. A review of current physician orders for Resident #104 showed an order, dated 1/29/2025, for Nicotine patch 24-hour 14 milligram/24 hour to apply one patch transdermally in the morning for nicotine abuse. On 2/24/2025 at 2:39 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated Resident #104 told the facility he was not a smoker, but acknowledged he signed his smoking policy agreement in January. The DON also stated normally a Smoker Evaluation is done upon admission and quarterly and there is a smoker binder on the first-floor nurses' station of which all smokers are listed along with their evaluation and care plan. The DON stated the book is updated weekly by herself or the Assistant Director of Nursing and all smoking paraphernalia is held in a box for the residents on the first-floor nurses' station. The DON stated she will be calling families too to review the smoking policy. A record review of the facility's policy and procedures titled Smoking Policy - Residents, last revised in August 2022, in showed the following: Policy Statement: This facility has established and maintained safe resident smoking practices. The Policy Interpretation and Implementation: 1. Prior to, and upon admission, residents are informed of the facility smoking policy, including designated smoking areas, and the extent to which the facility can accommodate for smoking and non-smoking preferences. . 6. Resident smoking status is evaluated upon admission. If a smoker, the evaluation includes: a. Current level of tobacco consumption b. Method of tobacco consumption (traditional cigarettes, electronic cigarettes, pipe, etcetera) c. Desire to quit smoking, and d. Ability to smoke safely with or without supervision per a completed safe smoking evaluation. 7. The staff consults with the attending physician and the director of nursing services to determine if safety restrictions need to be placed on a resident's smoking privileges based on the safe smoking evaluation. 8. A resident's ability to smoke safely is reevaluated quarterly, upon a significant change (physical or cognitive) and as determined by the staff. 9. Any smoking related privileges, restrictions, and concerns (for example, need for close monitoring) are noted in the care plan, and all personnel caring for the resident shall be alerted to these issues. 11. Any resident with smoking privileges requiring monitoring shall have the direct supervision of a staff member, family member, visitor or volunteer worker at all times while smoking. . 14. Residents without independent smoking privileges may not have or keep any smoking items, including cigarettes, tobacco, etcetera except under direct supervision. 41015 2. An observation on 2/22/2025 at 11:52 a.m. revealed a pair of silver colored metal scissors and a razor stored in the bathroom of room [ROOM NUMBER]. An observation on 2/22/2025 at 11:56 a.m. revealed a razor stored in the bathroom of room [ROOM NUMBER]. During an interview on 2/25/2025 at 9:30 a.m., Staff F CNA stated newly admitted residents who were male received a razor in their welcome hygiene basket and male residents could have razors, but female residents were only given razors as needed. During an interview on 2/25/2025 at 9:35 a.m., Staff G CNA stated all razors are stored in the locked supply room and when a resident needs a razor, a razor would be provided to the resident to use. Once the resident is done with the razor it would be taken and disposed of in a sharp's container. During an interview on 2/25/2025 at 9:40 a.m., Staff B Registered Nurse (RN) stated residents are not allowed to have any kind of razors or scissors in their rooms and all razors and scissors should be locked up and residents should have supervision when using. During an interview on 2/25/2025 at 9:45 a.m., Staff H, Activity Director stated there should be no sharps, including razors or scissors of any kind, stored in residents' rooms. During an interview on 2/25/2025 at 9:51 a.m., Staff I CNA stated the staff provided razors when the resident needed it with supervision. The razors in the facility are disposable and one time use, so staff would throw away the razor in the sharps container on the nurse cart. During an interview on 2/25/2025 at 10:13 a.m., the Director of Nursing stated no residents should have razors or scissors in residents' rooms. During an interview on 2/25/2025 at 12:17 p.m., the Administrator stated there was no policy or procedure regarding residents not being allowed to have razors or scissors in their room and stated, we just educate and the staff just know. Photographic Evidence Obtained.

Based on observations, interviews, and record review, the facility did not ensure post-dialysis communication was implemented and documented in the medical records for one resident (#33) of one resident sampled for dialysis. Findings included: A review of Resident #33's Admission Record showed an original admitted [DATE], with a readmitted [DATE], and a diagnosis of end stage renal disease (ESRD). A review of Resident #33's February 2025 physician orders showed an order dated 2/5/2025 for dialysis weekly on: Monday/Wednesday/Friday at [dialysis center]. A review of Resident #33's dialysis communication records from 1/25/2025 to 2/21/2025 did not show a section for post-dialysis assessment or vital signs upon return to the facility. Upon further record review, no orders to address the resident's central line access for dialysis and/or documentation for post-dialysis assessment or vital signs were revealed. On 2/24/2025 at 12:00 p.m., an interview was conducted with Staff U, Licensed Practical Nurse (LPN) , Staff C, LPN and Staff V, Registered Nurse (RN). All three nursing staff members stated a resident on dialysis should have an order for dialysis and from there a drop-down option is available to assess the hemodialysis site, whether an AV (arteriovenous) fistula or a central catheter used, specifically for dialysis. Staff C, RN stated she checks when a resident returns from dialysis by assessing their port/fistula and vital signs. Staff C, RN also stated nursing staff should assess the dialysis site for any complications such as bleeding. Staff C, RN stated she does not think there is an area on the communication sheet from the dialysis center where she can document this information. Staff U, LPN stated there is an option to assess post-dialysis documentation in the medical record, but stated she does not think the facility utilizes this option. Staff U, LPN demonstrated the drop-down option to her other two nursing staff. At this point, the Director of Nursing (DON) arrived to continue with the interview and stated she was unaware of the option to document in the medical record post-assessment after dialysis. The DON acknowledged the current dialysis communication sheet does not have a section for the nurse to document the resident's assessment post-dialysis. A review of the facility's policy and procedures titled Care of the AV-Fistula-Graft, undated, showed the following: 1. Look for signs of infection: Redness, swelling, pain, warmth to site, drainage, or elevated temperature. Pay special attention to the most recent cannulation sites (where you were stuck last). . 11. Check cannulation (puncture) site carefully for bleeding after dialysis. If bleeding starts again, place pressure over the area for 5-10 minutes. If unable to stop bleeding, call the dialysis center and go to the nearest emergency facility.

Based on interview and record review, the facility did not ensure pharmacy recommendations were completed for two residents (#57 and #5) out of five reviewed for unnecessary medications. Findings included: Review of Admission Records showed Resident #57 was admitted on [DATE] with diagnoses including atherosclerotic heart disease. Review of Resident #57's February 2025 physician orders showed an order for Peridex mouth/throat solution 0.12%. Give 15 ml (milliliters) by mouth every 12 hours for gum/teeth pain, dated 11/20/24 and a second order for Peridex mouth/throat solution 0.12%. Give 15 ml by mouth every 12 hours as needed for mouth pain for 2 weeks, dated 2/9/25 to 2/23/25. A review of a Consultant Pharmacist Medication Regimen Review dated 12/16/24 revealed: Peridex 0.12% (Chlorhexidine Gluconate) should not be swallowed. Please add to the order: Swish 15ml for 15-20 seconds, the expectorate- do not swallow A review of a Consultant Pharmacist Medication Regimen Review dated 2/16/25 revealed: Perdix should not be swallowed. Please add to the order. use 15ml to swish for 20-30 sec[onds], then expectorate- do not swallow. Review of orders showed neither of the recommendations were completed. The recommendations were not signed by the physician. An interview was conducted on 2/25/25 2:35 p.m. with the Consultant Pharmacist. He said he does monthly reviews of resident medication and the recommendations go to the Director of Nursing (DON). He said in the past they had issues getting the pharmacy recommendations completed at the facility. He also said if it isn't critical he will give it one month and if the facility doesn't complete the recommendation he will make another recommendation for the same thing. 48223 Review of Resident #5's Admission Record revealed an admitted [DATE] with diagnoses of brief psychotic disorder, insomnia, moderate major depressive disorder, persistent mood disorder, and anxiety disorder. Review of Resident #5's Consultant Pharmacist Medication Regimen Review dated 12/16/24 showed: Diclofenac [brand name] gel, please add dosage amount to complete this order. Suggest dosing: 1. For upper extremities: Apply 2 grams q [every] 6 hours-not to exceed 8 grams/day to any single joint. 2. For lower extremities: Apply 4 grams q 6 hours- not to exceed 16 grams/day to any single joint. Review of Resident #5's February 2025 physician orders showed: Diclofenac gel, apply to affected areas topically every 6 hours as needed for pain, dated 8/24/24. The recommended dosing was not documented in the order. Review of Resident #5's Consultant Pharmacist Medication Regimen Review dated 1/16/25 showed: 1. Midodrine 10 mg PRN [as needed] frequency, Midodrine is usually given three times daily. Please review Midodrine 10 mg every 1 hour PRN order and consider changing to 10 mg three times daily PRN for SBP<110 [systolic blood pressure]. 2. Calcitonin Nasal solution for COPD [chronic obstructive pulmonary disease] Calcitonin Nasal Solution should only be used in one nostril each day. Suggest clarifying directions to read: one spray in one nostril one time daily, alternate nostrils each day. AIso, please update the diagnoses list and the reason for using the Calcitonin Nasal Spray. [Calcitonin is typically used for osteoporosis]. 3. Mupirocin Ointment 2%; Please check on a stop date for both Mupirocin topical antibiotic orders. Review of Resident #5's February 2025 physician order revealed an order for Midodrine 10 mg, give 1 tablet by mouth every 1 hours as needed for Hypotension related to Other hypotension, administer for systolic b/p (blood pressure) greater 110/60, dated 7/16/24. The recommendation was not addressed. Review of Resident #5's February 2025 physician orders revealed an order for Calcitonin Nasal solution, 1 spray in both nostrils one time a day r/t [related to] Chronic obstructive pulmonary disease w/[with] (acute) exacerbation alternate nostrils daily, dated 10/2/23. The pharmacist recommendations were not addressed. During an interview on 2/25/25 at 5:48 p.m. the DON stated they receive the pharmacy recommendations and tries to complete them, but stated she, must have missed those, I got behind. I try to get them completed within the week. The DON confirmed the recommendations for Resident #5 and #57 should have been completed timely and were not. A policy and procedure for Pharmacy Recommendations was requested on 2/23/25. On 2/25/25 at 6:00 p.m., the DON stated the facility does not have a policy for Pharmacy Recommendations.

Based on observations and interviews, the facility did not ensure medications were stored properly on two out of two units in the facility related to unlocked medication carts, unsecured medication, and medication in resident rooms. Findings included: An observation was conducted on 2/22/25 at 10:23 a.m. of a medication cart at the second-floor nurses' station. There were two bottles of medication sitting on top of the cart, one was a stool softener and the other a multivitamin. Both bottles contained medication. No staff were in sight of the medication cart and three residents were sitting within 10 to 15 feet of the cart. An observation was conducted on 2/22/25 at 10:47 a.m. of an unlocked medication cart at the first floor nurses' station. No staff were near the cart. An observation was conducted on 2/22/25 at 11:51 a.m. of an unlocked medication cart on the second floor. No staff were in sight of the medication cart and a resident was sitting approximately 5 feet away from the cart. A nurse walked back up to the cart, grabbed something, and walked away with the cart without locking it. An observation was conducted on 2/22/25 4:11 p.m. of a box of over the counter (OTC) medication sitting in an open bedside drawer in room [ROOM NUMBER]. An interview was conducted on 2/25/25 at 2:35 p.m. with the Consultant Pharmacist. He said he does spot checks on medication carts and medication rooms monthly and he found a medication cart unlocked as well. He said nurses need to keep an eye out for medication in resident rooms that families may have brought in. 48223 An observation was conducted on 2/22/25 at 12:46 p.m. in resident room [ROOM NUMBER] b. A resident was lying in the bed with an over the bed table next to the bed. On the table were two medication cups, one was almost full of an orange colored liquid and the other was one fourth full of a dark liquid. An observation was conducted on 2/23/25 at 9:24 a.m. in resident room [ROOM NUMBER] a. A resident was lying in the bed and next to the bed was the over the bed table. On the table was a medication cup one half full of an orange-colored liquid. The resident stated the nurse leaves the medication with them. On 2/23/25 at 10:02 a.m. in resident room [ROOM NUMBER] b, a resident was observed sitting in a recliner and on the table next to the recliner was a bottle of wound cleanser. An interview was conducted on 2/25/25 at 5:49 p.m. with the Director of Nursing (DON). She said she would expect all medication carts to be locked and medications put up. The DON also said medications should not be left in cups at a resident's bedside and residents should not have over the counter medication in their rooms. Review of the facility's policy and procedure titled Medication Storage and Labeling dated 6/2023 showed: . Medications and biologicals in medication rooms, carts, boxes, and refrigerators were maintained within: - Secured (locked) locations, accessible only to designated staff; - Clean and sanitary conditions; Photographic Evidence Obtained

Based on observations, record review, and interviews, the facility failed to implement protocols from the facility's antibiotic stewardship program for one resident (#3) out of three residents reviewed for antibiotic use. Findings included: An observation and interview on 2/22/25 at 2:32 p.m. showed Resident #3 lying in bed with an Intravenous Therapy (IV) pole at the bedside. The IV pole contained two empty bags of Vancomycin, both dated 2/22/25. Resident #3 stated she was getting IV antibiotics because she recently had a severe Urinary Tract Infection (UTI) that sent her to the hospital. Resident #3 stated she did not know how long she would be on IV antibiotics but stated she was feeling much better. Review of the Admission Record showed Resident #3 was readmitted to the facility on [DATE] with diagnoses that included but not limited to infection and inflammatory reaction due to other urinary tract infection (UTI) unspecified, urinary catheter initial encounter, infection and inflammatory reaction due to indwelling urethral catheter, and bacterial infection. Review of Resident #3's February 2025 physician orders showed: - A physician order dated 2/18/25, Vancomycin [Hydrochloride Salt] HCl in NaCl Intravenous Solution 750-0.9 [milligrams] MG/250 [milliliters] ML- [percent] % (Vancomycin HCl-Sodium Chloride)- Use 750 MG intravenously two times a day related to urinary tract infection unspecified. There was no end date for the order. - A physician order dated 2/18/25, Cefepime HCl Intravenous Solution 2 [grams] GM/100 ML (Cefepime HCl)- Use 2 gram intravenously every 12 hours related to urinary tract infection unspecified. There was no end date to the order. Review of the care plan showed a Focus: The resident is on antibiotic therapy related to infection (UTI). The Goal showed the resident will be free of any discomfort or adverse side effects of antibiotic therapy through the review date. During an interview on 2/25/25 at 10:18 a.m. the Director of Nursing (DON) stated she worked with Staff R, Licensed Practical Nurse (LPN) Minimum Data Set (MDS) and acting Infection Preventionist (IP) on infection control in the facility. The DON also stated she was usually on top of all the clinical aspects of infection control in the facility. The DON reviewed Resident # 3's current physician orders and stated all antibiotics should have an end date so appropriate monitoring of antibiotic duration occurred. The DON stated antibiotic monitoring was part of the facility's antibiotic stewardship program and, in Resident #3's case, no end date was added to the order and stated that was a problem. The DON also stated Resident #3 just returned from the hospital with a severe UTI and no one seemed to know how long she was going to need the IV antibiotics. Review of the facility's policy titled Antibiotic Stewardship, revised in December 2016, showed: Policy Statement: Antibiotics will be prescribed and administered under the guidance of the facility's Antibiotic Stewardship Program. Policy Interpretation and Implementation: . 4. If an antibiotic is indicated, prescribers will provide complete antibiotic orders including the following elements: a. Drug name b. Dose c. Frequency of administration d. Duration of treatment; 1. Start and Stop date, or 2. Number of days of therapy. e. Route of administration f. Indications for use.

Based on observations, interviews, and record review, the facility failed to ensure the protection of a resident's right to remain at the facility by issuing an inaccurate reason on a thirty-day Nursing Home Transfer and Discharge Notice for one resident (#4) out of one resident reviewed for admission, transfer, and discharge. Findings included: On 01/09/2025 at 10:30 a.m., Resident #4 was observed in his room, in bed, working on his laptop. Resident #4 stated the facility was discharging him for non-payment. He stated he did not want to talk about it. On 01/09/2025 at 11:15 a.m., the Nursing Home Administrator (NHA) stated, one resident, Resident #4 had been provided a 30-day discharge notice on 12/05/2024. He stated the reason for the 30-day notice was that the resident was combative. A review of the quarterly Minimum Data Set (MDS), dated [DATE], showed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 15, which meant he was cognitively intact. A review of the medical record showed Resident #4's medical diagnoses included: Cerebral Infarction, unspecified, bed confinement status, and need for assistance with personal care. An interview was conducted on 01/09/2025 at 12:15 p.m. with the Business Office Manager (BOM). The BOM stated Resident #4 did not receive any money at the facility. She stated the resident did not owe any money to the facility. An interview was conducted on 01/09/2025 at 12:25 p.m. with the Social Worker (SW). The SW presented the 30-day notice which had been provided to Resident #4 for review. A review of the notice, dated 12/05/2024 with an effective date of 01/04/2025, revealed the following: -The reason for the notice was check marked, Your bill for services at this facility has not been paid after reasonable and appropriate notice to pay, and Your health has improved sufficiently so that you no longer need the services provided by his facility. -The brief explanation written was, Patient to be discharged to another long-term care facility. -The transfer location was documented to be another nursing facility. -The signature space for the physician to sign the form, reflected the name of a physician with the words telephone order. The SW stated Resident #4 did not want to be transferred to the listed nursing facility, The SW stated the resident wanted to go to a different local nursing facility. The SW stated he did not know what monies Resident #4 owed the facility, what a bill was for, or the amount owed. The SW stated, the other reason for the discharge was that the resident was a little combative with the nurses. The SW stated he had put the name of the physician in the box, and the IDT (Interdisciplinary Team) talked to the physician, but the physician did not sign the form. The SW said, Resident #4 is alert and oriented, we talked to him, he refused to sign the form. An interview was conducted with the NHA on 01/09/2025 at 12:40 p.m. He confirmed the Nursing Home Transfer and Discharge notice was not accurate. He stated the reason Resident #4 was going to be discharged was due to being combative. A review of the comprehensive care plan, review start date 1/2/2025, revealed the following: Focus area: Resident needs discharge planning R/T (related to) : Adjustment to LTC (Long Term Care) placement. Goals: Resident will develop and participate in day-to-day facility routine that includes social out of room activities and daily care preferences. Interventions/Tasks: Resident's discharge plan is to remain in the facility LTC. An interview was conducted on 01/09/2025 at 1:50 a.m. with the Director of Nursing (DON)The DON stated Resident #4 could be combative. She stated, He refuses care a lot of the time. He refuses his medication, he chooses what he wants when he wants it. He is bedbound because he wants to be. She stated, When he refuses care, he will threaten to hit you. She stated she could not say if he actually ever made contact with anyone. The DON stated, He is a very angry man. I do not think they have put anything under behaviors. I was aware he was being given a 30-day notice, but I did not know why. The DON stated Resident #4 was a long-term resident, he required nursing care, and his health had not improved enough for discharge. She stated, He is bedbound and cannot care for himself.

Based on resident record review, staff interview, and policy review, the facility failed to have a complete accurately documented medical record for one (Resident #1) of four residents reviewed. Findings Included: A review of the record for Resident #1 revealed a physician's telephone order dated 5/9/23 to, send to ER [emergency room ] for eval [evaluation] per resident request. A review of Resident # 1's nursing notes revealed the last documented note was dated 5/9/23 at 6:41 p.m. The nursing note, written by Staff A Licensed Practical Nurse ( LPN) revealed, At this time [Resident # 1] has complaints of pain and discomfort but refused all medications. Lung sounds are diminished along with his bowel sounds, trouble swallowing and speaking. He is refusing to eat on a regular basis, will continue to monitor this shift. There was no documentation in the nurses' notes of the transfer to the hospital per resident request, no documentation of the resident's condition upon transfer and no documentation that the family was notified of the transfer. An interview with the Director of Nursing (DON) on 6/6/23 at 1: 38 p.m., revealed she could not locate an SBAR (Situation, Background, Assessment, Recommendation) form that should have been completed when the resident was sent to the hospital. On 6/6/23 at 2:54 p.m., the DON confirmed there was no nursing note or any other documentation related to the transfer to the hospital. She stated that a transfer form was not completed if a patient requested to go to the hospital. She stated, We notify the physician and send them with a face sheet and a medication list and call report to the hospital, we don't do a transfer form. An interview was conducted with Staff A, the LPN who wrote the last documented nursing note on 5/9/23. She stated Resident #1 requested to be sent out to the hospital that evening. She stated he was adamant about it . He was feeling so sick by that point, I think. He wasn't eating or drinking. Staff A stated she called EMS (Emergency Medical Services) for him. Staff A stated she was an orientee at that time and did not recall who she was orienting with . She stated she did not know why there was no nursing note regarding Resident #1 being sent to the hospital. Staff A stated she could not recall if the family was notified that Resident # 1 was transferred to the hospital. At 5: 28 p.m., DON stated there was no policy for medical records documentation. Review of a policy entitled Transfers, Reducing Acute Care revised 11/8/2021, revealed Policy statement: Transfers to acute care hospitals will be minimized in situations where early intervention would make such transfers avoidable and in situations where the resident's directives specifically request that he or she remain in the facility. Policy Interpretation and Implementation 4. Symptoms or problems that may require physician or practitioner intervention will be documented in a format that will facilitate adequate information when communication occurs. For example: d. Situation: Information about the condition , situation or sign; e Background - Information about the resident, medications, vital signs, recent lab results and changes related to the problem (i.e., mental, functional, respiratory changes, etc. ), including advance directive information. f. Assessment or Appearance - What appears to be going on with the resident; and g. Request _ suggestions or requests for the provider ( i.e., labs, x- ray, acute care transfer, etc.). 5. Should it become necessary to make an emergency transfer or discharge to the hospital or other related in-situation, our facility will implement the following procedures: e. Prepare a transfer form to send with the resident (including Bed Hold). F. Notify the representative (sponsor) or other family members. i. Document disposition and actions in the chart.

Based on resident interviews, staff interviews, resident record review and a review of the facility policy titled Suicide Threats, the facility failed to provide timely services necessary to ensure the physical safety and alleviate mental anguish for three of four sampled residents who verbalized [MEDICAL CONDITION] within a six day period. The facility also failed to fully operationalize their policy for "Suicide Threats." This affected Residents # 325, #337 and #145 of those who were referred for psychiatric consults in June 2013. Resident #325 was heard by a staff member to express comments that he wanted to harm himself and "end it" which was reported to Social Services on 6-18-13. A psychiatric evaluation was not completed until 6-24-13, six days following the report of the resident's suicidal ideation to the facility social worker, nor was there evidence of an environmental safety assessment. Resident #337 was documented on 6-21-13 as stating "If I could find a way to commit suicide, I would ". A psychiatric evaluation was not completed until 6-27-13, six days after the resident expressed suicidal thoughts, nor was there evidence of an environmental safety assessment. Resident #145 appeared on a facility Psychiatric Consults tracking log for verbalizing suicidal thoughts. Resident #145 expressed a desire to kill himself on 6-23-13. A psychiatric evaluation was not done for over 24 hours after the resident's documented suicidal ideation, nor was there evidence of an environment safety assessment. The facility demonstrated a lack of awareness, action and commitment to protect residents from the possibility of neglect and failed to implement measures to ensure that resident safety and supervision were met which resulted in the determination of Immediate Jeopardy on 7-1-13. The finding of Immediate Jeopardy was found to be removed on 7-1-2013 at 3:45 p.m. and scope and severity reduced to an E. Findings include: 1.A review of the medical record for Resident #337 showed Nurse's Notes dated 6-21-13 which revealed that at 8:55 p.m. the resident's POA (Power of Attorney) reported to the evening nurse that she was very concerned that the resident had expressed "If I could find a way to commit suicide I would. " The Nurse's Note documented that a call was placed to the resident's PCP (Primary Care Provider) and the nurse was waiting a return call from the physician. The nurse documented: "Resident is very depressed, gave [MEDICATION NAME] (anti-anxiety medication) per order. Will continue to monitor. Call light placed in reach. " There was no documented evidence of any visual observations being performed following the resident's verbalization of [MEDICAL CONDITION]. There was no evidence that the resident's environment was assessed to ensure that there were no objects that could be used for self-harm. The next entry into the resident's chart was dated 6-25-2013 at 1:36 a.m. which stated: "Resident lying in bed, nurse asked resident if any pain. Resident stated no. Speech is very clear, stated I don't need anything." A weekly Nursing Summary dated 6-22-2013 was added to the chart three days after the record review by the survey team on 6-27-13. A review of Resident #337's transfer orders from a local hospice facility dated 6-14-13 revealed that Resident #337 was receiving [MEDICATION NAME] 0.5-1 mg (milligram) every four hours sublingually for dyspnea (difficult breathing) and anxiety. A Physician's progress note dated 6-8-13 from the referring hospice facility revealed the following assessment: "[AGE] year old woman with hospice [DIAGNOSES REDACTED]. Six months or less prognosis should the disease take expected course. Given my current assessment, findings and progression of her terminal condition, I expect a continued decline and demise in a matter of days to weeks. Inpatient level of care, to manage pain. However in light of symptom improvement, social worker to begin disposition planning with possible change in level of care very soon. Anxiety managed with [MEDICATION NAME]. Pain managed with [MEDICATION NAME], Oxyfast (trade name for [MEDICATION NAME]) and [MEDICATION NAME] (a steroid). " A review of Resident #337's Social Service assessment dated [DATE] revealed under the Psychosocial Information & Social Practices/Behaviors section that the resident denied any current issues with Depression, Anxiety. "She is prescribed an anti-anxiety medication. She has a poor appetite. She is an ex-smoker and does not drink." On 6-27-13 at approximately 1:44 p.m. Employee D, a Resident Care Manager (RCM) for the unit where the resident resided, was asked if she was aware that Resident #337 had verbalized [MEDICAL CONDITION]. The employee stated she was not aware. Employee D was shown the Nurse's Note dated 6-21-13 and again stated she had not been previously aware of the incident. Employee D called Employee A, a facility Social Worker, and was informed that a psych (psychiatric) evaluation was completed on Resident #337 on 6-24-13, three days after the resident verbalized suicidal thoughts. An interview on 6-27-13 was conducted at approximately 2:13 p.m. with Employee A. She revealed that on 6-24-13 there was a referral placed in her box for Resident #337 to have a consult for psych services related to suicidal comments on 6-21-13. Employee A was asked if, after learning of the resident's suicidal comments, she spoke with the resident and assessed the resident for depression or increased anxiety. Employee A revealed she had not. The Employee was asked whose responsibility it was to assess the resident for depression. Employee A stated that it was the responsibility of nursing. Employee A was asked had the psych evaluation been done. She stated it was completed on the day it was requested, 6-24-13. Employee A was asked to obtain a copy of the psych evaluation as there was no copy on the resident's chart for review. Employee A called the unit and spoke with Employee D and learned that the evaluation was never completed. Employee D explained that the psychiatric provider noted on the chart that the resident was receiving hospice services and did not complete the evaluation. On further chart review with Employee D, it was determined that hospice services were not initiated on admission as ordered and that Resident #337 was not receiving hospice services at the time that the psychiatric referral was made and deferred. On 6-27-13 at 2:45 p.m. Employee D wrote an order to have a psych evaluation done on Resident #337, six days after the original nurse's note on 6-21-2013 that the resident had expressed a desire to commit suicide. An interview on 6-27-13 at 3:40 p.m. was conducted with Employee B. She was asked if she was the nurse who made the entry on 6-21-13 regarding Resident #337 verbalizing [MEDICAL CONDITION]. She stated that she was. The employee revealed that the resident's POA came up to her after visiting the resident in the sun room that day. She stated the POA came back upset- "looking like she wanted to cry" and said the resident told her, "If I could find a way to commit suicide, I would. " Employee B went on to say that she talked with the resident the next day, but did not make a note in the chart. She stated, "I wanted to see if she mentioned anything. I asked her if she was feeling better about being here. She said she didn't need to be here because she could take care of herself." Employee B was asked if she assessed the resident on the evening of 6-21-13. She stated that she had spoken with the resident but that she did not ask her about "that word." Employee B stated, "She looked like her usual self - she was depressed. I called the doctor and told him what the POA said. Since she didn't say anything to me, I can't really act on it." Employee B was asked about the resident's demeanor and appearance. Employee B stated, "She looked sad, but she looked sad when she came in." Employee B was asked if the resident's MD (medical doctor) gave any new orders that night. She stated that he ordered [MEDICATION NAME]. She was asked to locate the new order in the medical record. After searching the chart for an order, Employee B stated, "I gave her some [MEDICATION NAME] that was ordered when she came in. It was already on the MAR (Medication Administration Record)." Employee B was asked again if she spoke with the MD that evening, as her note referenced that she was waiting a return call from the MD. Employee B stated she did speak with the MD but forgot to write a follow up note. Employee B was asked if she reported what the resident said to the DON (Director of Nursing), Unit Manager, NHA (Nursing Home Administrator) or RM (Risk Manager). She responded, "I know some places you call and report. But it can't be hearsay. It must come from the resident. That's why I talked with her. She was feeling better about not having pain, but she was not happy about being here." She was asked if she questioned the resident about having a plan to commit suicide. She responded, "No! " Employee B was asked if there had been any facility in-service education on how to handle residents who wanted to commit suicide. She stated, "Yes, but I"m not sure if I"ve been to one here. I"ve only been here since November." She was asked if the facility education covered what to do if a resident talks about suicide. She stated, " I'm not sure about here, but have heard in other places that you should notify the DON and put the resident on a watch. But I knew the resident in the community before she came here. I used to work in a grocery store and she was one of my regular customers. She's always been sad." An interview was conducted on 6-27-13 at 4:00 p.m. with Resident #337. The resident was asked if she remembered making the statement "If I could find a way to commit suicide, I would"? She responded, "Who told you that? I might have said that or said I wish I was dead. Every once in a while, I think about it but not all the time." The resident stated, "I'm not happy. I don"t even know why I am here. But I wasn"t trying to kill myself." The resident was asked if she had ever thought about a particular plan or way to commit suicide. She stated, " No. It"s like a thought that slides into my head then out of my head. " On 6-27-13 at 4:20 p.m. in an interview with the Assistant Director of Nursing (ADON), findings and concerns were discussed related to the interview with Employee B. It was verified that the nurse documented the [MEDICAL CONDITION] of the resident but did not arrange for the resident to be assessed or notify the DON or the RM. The ADON was unaware that the psych evaluation had been ordered for Resident #337 and not completed. She was asked if there was a facility policy related to staff response to residents at risk for suicide. The ADON asked if she could obtain the facility policy before continuing the interview. The ADON left to get the policy put did not return. At 5:00 p.m. the ADON was located by a member of the survey team and a copy of the facility policy titled "Suicide Threats" was provided. The facility policy titled "Suicide Threats", 2001 MED-PASS, Inc. (Revised December 2007) with a second Policy Revised date pf 1/17/13 was reviewed. The Policy Statement noted "Resident suicide threats shall be taken seriously and addressed appropriately". Policy Interpretation and Implementation contained seven items as follows: (1) Staff shall report any resident threats of suicide immediately to the Nurse Supervisor/Charge Nurse. (2) The Nurse Supervisor/Charge Nurse shall immediately assess the situation and identify if the resident has a plan or the means to carry out the suicidal ideation. (3) After assessing the resident in more detail, the Nurse Supervisor/Charge Nurse shall notify the resident's Attending Physician and responsible party, and shall seek further direction from the physician. (4) If threat validated, all nursing personnel and other staff involved in caring for the resident shall be informed of the suicide threat and instructed to report changes in the resident's behavior immediately. (5) As indicated, a psychiatric consultation or transfer for emergency psychiatric evaluation may be initiated through social services. (6) If the resident remains in the facility, staff will monitor the resident's mood and behavior and update care plans accordingly, until a physician has determined that a risk of suicide does not appear to be present. (7) Staff shall document details of the situation objectively in the resident's medical record. There was no documented evidence that staff followed the facility policy related to assessment, reporting or monitoring for safety for resident #337, a resident identified to have expressed a desire to end her life. At 5:55 p.m. on 6-27-13 Resident #337' s psych evaluation was completed. The psych note was reviewed by the DON and surveyor. Per the psych evaluation the resident denied [MEDICAL CONDITION] at the time of the assessment. She stated she must have been misunderstood. 2. An interview on 6-28-13 at 11:00 a.m. was conducted with the Social Service Director (SSD). She was asked about the process in the Social Services department for making a referral for psychiatric services. She stated that when Social Services received a written referral or was notified of an issue requiring a psych evaluation, the referral was communicated to the psychiatric consultant. She stated that if it was reported that a resident verbalized suicidal ideation, typically a Social Worker (SW) would talk with the resident and assess for a plan, emotional state, etc. The SW would then communicate with nursing as to the resident's monitoring needs. She stated it was not a written policy for the SW to assess before submitting a referral, but that it was "usually done in order to provide as much information as possible" to the psych consultant. The SSD noted that there was a psychiatric service provider in the building weekly and that they could also be contacted immediately. The SSD was asked about the facility policy regarding who should be contacted when a resident expressed suicidal thoughts. She replied that the staff member should contact the physician, SS, DON, RM and ADON. She noted that the staff member should talk with the individual and make a referral. If [MEDICAL CONDITION] were verbalized, the psychiatric service provider would be contacted and could come in "within hours". The SSD was asked to provide a list of psychiatric referrals related to suicidal thoughts or ideations since the last facility survey of April 2012. A Psychiatric Consults log was provided for March 2013 with one resident identified and a log for June 2013 which contained three resident names, including resident #337. The remaining two residents were identified as Resident #325 and Resident #145. 3. Resident #325 was a [AGE] year old male admitted on [DATE] with [DIAGNOSES REDACTED]. Per a hospital history and physical, dated 4/19/13, the resident complained of dizziness and headaches and was sent by his PCP (Primary Care Physician) to a local hospital for evaluation and subsequently diagnosed with [REDACTED]. After stabilization at the local hospital, the resident was transferred to a local rehabilitation facility for extensive therapy services and then to the long term care facility for skilled services on 4-26-13. On admission, the resident's Physician Order Sheet, dated 4-26-13, included an order for [REDACTED]. A review of the resident's Admission Data Collection assessment, dated 4-26-2013, did not capture the resident's [DIAGNOSES REDACTED]. Section D, Mood and Behavior, item (1) Indications for Depression was listed as None of the Above and item (5) [MEDICAL CONDITION] medication used for depression/anxiety was listed as None. The resident's Nursing Interim Care Plan, completed on admission, did not address the admitting [DIAGNOSES REDACTED]. In addition, there was no evidence of non-pharmacological interventions in place to offer the resident when he exhibited depressive behaviors. A Psychiatric Progress Note, dated 6/24/13, was located in the record. The consult stated that the resident denied distress, depression or suicidality. His psychiatric [DIAGNOSES REDACTED]. On 6-30-13 at approximately 12:00 p.m. Resident #325 was observed sitting up in his wheelchair in the dining room. The resident was appropriately dressed for the time of day. The resident was well groomed and no body odors were noted. The resident was observed interacting with fell ow resident and staff member. A review of the medical record revealed no psychiatric referral information for resident #325. An interview was conducted on 6-28-13 at 11:20 am with Employee A, SW. She was asked who made the referral if a resident needed a psych consult related to suicidal thoughts. She stated it was usually made by nursing on a Social Services "pink slip." She was asked if she ever evaluated a resident after receiving a request from nursing for a resident with suicidal thoughts. Employee A stated, "If the resident was talking about actually doing it, I'll go see them." Employee A was asked who initiated a 6/18/2013 psychiatric referral for Resident #325. Unable to locate the source on the computer, the employee remembered that it was reported to her by a member of the therapy department at a Utilization Review Meeting held on 6/18/13. Employee A stated that one of the therapists reported that the resident was showing increased confusion and talking about "ending it." She produced a paper titled Utilization Review Meeting. Beside the typed name of the resident was a hand written note which stated, "requesting UA (urinalysis) and psych eval, increased confusion. Patient making comments about " chopping arm off " and "ending it." Employee A revealed she made the referral for the resident on 6-18-13 for "increased confusion and suicidal comments." Employee A was asked if she assessed the resident on that date after learning of his suicidal comments. She stated that she did not do an assessment of the resident on that date. She stated, "The way it was presented to me, he didn't have a plan." She also stated that when she made the referral to the psych service, she included her opinion that the situation was not urgent. She explained that was why the psych service did not come out immediately, but waited until the normally scheduled weekly facility visit the following Monday, 6-24-13. On 6-29-13 at approximately 3:30 p.m. an interview was held with Employee H. He revealed he had provided therapy service in the past to Resident #325. He denied ever hearing the resident verbalize suicidal statements. He was asked what he would do if a resident expressed suicidal thoughts in his presence. He stated he would have someone keep an eye on the resident and get the nursing manager, if possible. He would report it to nursing and make sure the resident was not left alone. He stated the therapy department received in-service on suicide prevention from the nursing department "a while back." A review of Resident # 325's medical record revealed there was no evidence of documentation indicating that Employee A had informed the nursing staff of the resident's suicidal thoughts/statements or of the psych referral to have the resident evaluated. There was no evidence that the resident's suicidal comments had been reported to risk management, supervisory or administrative staff or to the resident's physician. There was no evidence that a plan for safety monitoring had been put in place or that the resident's environment was assessed to ensure there were no objects that could be used for self-harm. Further review determined that there were no care plans available for review that addressed the resident's verbalization of harming himself. 4. Resident #145 was also identified on the Psychiatric Consults log for June 2013. The entry for resident #145 revealed that a referral was made on 6/24/13 related to "suicidal comments". The space on the log to document when the office was contacted, however, was blank as was the space for the date the resident was seen. Medical record review showed that Resident #145 was readmitted to the facility on [DATE] with diagnoses, per the facility face sheet, which included [MEDICAL CONDITION], altered mental status, [MEDICAL CONDITION] Stage III, and paralysis agitans. A Nursing Data Collection, dated 5-2-13, noted in section 8, Physical Assessment, that the resident had short term memory problems and was moderately impaired in decision making, with cues and/or supervision required. In section D, Mood and Behavior, item (1) Indications of Depression - None of above was selected. Item (3) Sad Mood - None of above was selected. Item (5) [MEDICAL CONDITION] Medications - None of above was selected. An initial Social Services (SS) assessment on 5/3/13 was completed by Social Worker Employee A. On page 1, a synopsis of assessment noted that the resident was alert, oriented and able to communicate his needs to the staff verbally. It was noted that he had a [DIAGNOSES REDACTED]. On page 3, in the section titled Psychosocial Information and Social Practices/Behaviors, it was documented that the resident denied any issues with depression. An MDS (Minimum Data Set), dated 5/2/13, showed a BIMS (Brief Interview for Mental Status) score of 9 out a possible 15. Section D0200 titled Resident Mood Interview revealed that the resident was coded 0 = No for symptoms of "feeling down, depressed or hopeless" and for "thoughts that you would be better off dead, or of hurting yourself in some way." Further review of the medical record showed a nursing note, dated 6/23/13, which stated: "When changing resident, CNAs (Certified Nursing Assistant) heard the resident talking about wishing he could kill himself. Roommate then confirmed to the CNAs that he says things like that every night. Social Services referral filled out for psych consult." There were no additional nursing notes for 6/23/13 or 6/24/13. The next nursing note on the chart was dated 6/25/13 as part of the Weekly Nursing Summary. There was no documentation in the nursing notes that the resident's physician was notified of the resident's suicidal comments. There was no documentation that risk management or administrative staff was made aware of the situation. There was no documentation related to safety monitoring following the resident's comments or that the resident's environment was assessed to ensure there were no objects that could be used for self-harm. There was no Social Services referral form for a psychiatric consult noted on the medical record. Two attempts were made to contact the nurse who had made the record entry on 6-23-13. On a review of the employee file, she was identified as working for the facility on a "prn" (as needed) basis on the week-end night shift. Both contact attempts were unsuccessful. A call-back number was provided with a request for the nurse to contact the surveyor. At the time of exit on 7-1-13, no return call had been received. Resident #145 was observed at approximately 4:00 p.m. on 6-28-13 sitting in a wheelchair at the nursing station. He appeared appropriately dressed and groomed. An attempt was made to interview the resident who was confused and oriented to person only at that time. He was unable to participate in a meaningful interview about the documented events on 6-23-13. A psychiatric progress note was located on the chart dated 6-24-13. A check at the top of the form indicated that it was a follow-up visit. In the History of Present Illness, it was documented that the resident was last seen on 5-6-13 for depression with hallucinations and [MEDICAL CONDITION]. In the section titled, Mental Status, documentation showed the resident ' s mood to be "OK" from a list which included "happy, depressed, anxious, and labile." There were no references in the narrative related to suicidal thoughts or ideation. An interview was conducted with the Social Worker, Employee A on 7-1-13 at 10:00 a.m. She was asked for a copy of the psychiatric referral that was made for resident #145 as referenced on the Psychiatric Consults log for June 2013. She provided a copy for review. The Social Services referral form for resident #145 showed a section for Psych Consult with boxes checked for Psychiatrist and Psychologist. A section for Reason and Comments followed. In the section marked Reason, it was written "Overheard expressing desire to kill himself". In the Comments section, it was written, "CNAs heard resident talking about wishing he could kill himself, then roommate confirmed that by saying he says things like that every night." It was signed by a facility nurse. A handwritten statement at the bottom of the form noted, "Text to (psychiatric service provider) in building currently." Employee A was asked how the referral information was given to the psychiatric provider. She stated she received the referral for resident #145 when she arrived in her office on 6-24-13. She stated she then spoke with the service provider directly to request the referral as the provider was currently in the building that day on weekly rounds. A follow up call on 7-5-13 at 10:00 am with the Psychiatric consultant revealed that she was already scheduled to see Resident #145 to follow-up on a recent medication change when she received the referral request on 6-24-13. She stated that she always assesses residents for suicidality as part of her visits. 5. An interview was conducted on 6-28-13 at 2:20 p.m. with the NHA (Nursing Home Administrator) and DON. The NHA was asked about his expectations of his staff regarding residents who verbalize [MEDICAL CONDITION]. The NHA stated the following, "If a staff member received a report of resident verbalizing suicidal thoughts, it should be reported to the resident's physician. The charge nurse should be contacted to do an assessment - don't just report it to the next shift. Find out if the resident has a plan and a way to carry it out. Get a psych evaluation. If it's an actual threat, provide 1:1 monitoring or q15min (every 15 minute) checks. If there was no plan confirmed, continue with the psych evaluation and notification of the resident's PCP and family." The NHA noted that the psych service was "pretty quick", usually responding the same day. He stated that Social Service was a part of the referral process. He noted that Nursing initiates the request for a referral to psych. He stated that, on the weekends, nursing would handle the referral directly. 6. The NHA and DON were asked what type of in-service education was provided to the staff related to suicidal prevention. They stated that education on that topic was a part of the new employee orientation as well as the annual evaluation. The NHA stated an electronic program was utilized for staff education. The staff member logged in to complete the required in-service and the staff education coordinator could access the record for compliance. The DON noted that an in-house presentation was done "recently" by an ARNP )Advanced Registered Nurse Practitioner) related to suicidal residents. The NHA returned to clarify that suicide prevention was not a part of the computerized new orientation or annual training for the staff. 7. On 6/28/13 at approximately 2:30 p.m., an unsuccessful attempt was made to contact the PCP for Resident #337. The office reached using the number on the resident's chart informed the surveyor that the doctor no longer worked with that office. She did not have a contact number for him but thought he could be reached through the area hospital. A second contact number provided by the facility was answered by an individual who stated the doctor would be available on Monday from 9 a.m. to 1 p.m. A call back number was provided. 8. On 6-28-13 at approximately 2:35 p.m. a telephone interview was conducted with one of the facility consultants for psych services who provided the assessment for residents #337, #325 and #145. The consultant was asked about her expectations of the facility staff when residents verbalized [MEDICAL CONDITION] or plans to harm themselves. The consultant stated "the nurse should immediately evaluate the resident, call the PCP and contact psych for a consult. If immediate danger was determined, one on one observation should be started". 9. On 6/28/13 at 2:32 p.m. an attempt was made to contact the Medical Director. The office staff stated that the doctor was not on call and would not be in the office until Monday. They would not provide another contact number. The DON and NHA were asked for an alternate number to contact the Medical Director. They provided a name and number of his "designee". 10. On 6-28-13 at approximately 3:00 p.m. a phone interview was conducted with the Medical Director's "designee" physician. He stated that he was in practice with the Medical Director and assisted him with associated responsibilities at the facility. He was asked about his expectations of the facility staff if a resident verbalized [MEDICAL CONDITION]. He stated "the nurse should assess the resident for how serious the resident was. The degree of ideation would determine the level of response. The nursing staff should attempt to determine from the resident if there was a plan or method. Talk with the resident, notify their supervisor and call psych services". He noted the first priority was to keep the resident safe. 11. At approximately 4 p.m. on 6-28-13 a second attempt was made to contact Resident #337' s PCP. A voice message was left with contact information. 12. An interview on 6-29-13 at 11:25 a.m. with the Risk Manager (RM) revealed the RM had been in the position for 6 months but had worked at the facility for 1.5 years. The Risk Manager was asked what her role was when Resident #337 verbalized [MEDICAL CONDITION]. The RM stated she was never told of the event. The RM was asked how staff members were notified of resident behavioral changes. The RM stated they are informed but was unaware of the exact procedure. The RM went on to say she does not attend care plan meetings and she gets information on resident issues generally at morning IDT meetings. She noted that her primary responsibility was to investigate falls and injuries. 13. On 6-30-13 at 1:00 pm a telephone interview was conducted with the physician for Resident #337. The Physician was asked if he recalled being contacted on 6-21-13 regarding his resident's verbalization of [MEDICAL CONDITION]. He stated he could not confirm or deny whether he had received a call on that particular date without checking phone records. He stated if he were told a resident had expressed a desire to commit suicide, he would give orders for safety monitoring and to have a psych evaluation done to determine the seriousness of the intent. He stated he would not just say "Thanks for calling, have a good day." He stated that, based on the individual situation, he would give orders if needed to have the patient evaluated for hospital transfer or Baker Acted. 14. As reported by the American Association for Marriage and Family Therapy in a brochure titled Suicide in the Elderly, older adults make up 12% of the U.S. population, but account for 18% of all suicide deaths. Warning signs include: ? Loss of interest in things or activities usually found enjoyable ? Cutting back social interaction, self care and grooming ? Breaking medical regimens (such as going off diets, prescriptions) ? Experiencing or expecting a significant personal loss (spouse or other) ? Feeling hopeless and/or worthless ? Putting affairs in order, giving things away, or making changes in wills ? Stock-piling medications or obtaining other lethal means ? Other clues are a preoccupation with death or a lack of concern about personal safety ? The most significant indicator is an expression of suicidal intent

Based on interview and record review, the facility failed to operationalize a facility policy developed to recognize and appropriately address threats of suicide for three of four residents reviewed for suicidal ideation. The three identified residents verbalized suicidal thoughts on 6-18-13 (#325), 6-21-13 (#337) and 6-23-13 (#145), all within a six day period. Resident #325 did not receive a psychological evaluation until six days after it was reported to Social Services that he expressed thoughts of self-harm and a desire to "end it". Resident #337 did not receive a psychological evaluation for six days following her statement that "If I could find a way to commit suicide, I would." Resident #145 did not receive a psychological evaluation for more than 24 hours after he expressed to nursing staff that he wanted to kill himself. Despite a policy statement that resident suicide threats shall be taken seriously and addressed appropriately, the facility did not implement their policy to: (a) report the verbalized threats of residents #325, #337 and #145 immediately to the nurse supervisor, (b) provide immediate assessments necessary to determine the seriousness of each threat, (c) notify the responsible parties and attending physicians for further direction, (e) inform all staff involved in caring for the identified residents of the potential suicide threats, and (f) develop an appropriate plan of care to monitor mood and behavior of each at-risk resident until a physician determined that a risk of suicide did not appear to be present for residents #325, #337 and #145. Failure of the facility to correctly implement the policies for Suicide Threats, demonstrated a lack of awareness, action and commitment to protect residents and to ensure that resident safety and supervision were met resulted in the determination of Immediate Jeopardy on 7-1-13. The finding of Immediate Jeopardy was found to be removed on 7-1-2013 at 3:45 p.m. Findings included: 1. The facility policy titled Suicide Threats, 2001 MED-PASS, Inc. (Revised December 2007) with Policy Revised date 1/17/13 was reviewed. The Policy Statement noted that resident suicide threats shall be taken seriously and addressed appropriately. Policy Interpretation and Implementation contained seven items as follows: (1) Staff shall report any resident threats of suicide immediately to the Nurse Supervisor/Charge Nurse. (2) The Nurse Supervisor/Charge Nurse shall immediately assess the situation and resident has a plan or the means to carry out the suicidal ideation. (3) After assessing the resident in more detail, the Nurse Supervisor/Charge Nurse shall notify the resident ' s Attending Physician and responsible party, and shall seek further direction from the physician. (4) If threat validated, all nursing personnel and other staff involved in caring for the resident shall be informed of the suicide threat and instructed to report changes in the resident ' s behavior immediately. (5)As indicated, a psychiatric consultation or transfer for emergency psychiatric evaluation may be initiated through social services. (6) If the resident remains in the facility, staff will monitor the resident ' s mood and behavior and update care plans accordingly, until a physician has determined that a risk of suicide does not appear to be present. (7) Staff shall document details of the situation objectively in the resident ' s medical record. 2. Resident #337 was admitted from a hospice facility on 6-14-13 with [DIAGNOSES REDACTED]. AHCA (Agency for Health Care Administration) form 3008 dated 6-13-13 stated in section D - Additional Orders - (Local hospice provider) to follow. During a review of the resident's medical record, a Nurse's Note was observed dated 6-21-13 which stated that at 8:55 p.m. the resident ' s POA (Power of Attorney) reported to the evening nurse that she was very concerned that the resident had said to her, " If I could find a way to commit suicide I would. " The Nurse ' s Note documented that a call was placed to the resident ' s PCP (Primary Care Provider) and the nurse was waiting for a return call. The note continued to state: " Resident is very depressed, gave [MEDICATION NAME] (anti-anxiety medication) per order. Will continue to monitor. Call light placed in reach. " 3. There was no additional documentation of an assessment of the resident's mental status following the report of the resident's suicidal comments. There was no documentation that the physician notification was completed or that the nursing supervisor was notified. There was no evidence of an environmental assessment or monitoring of the resident ' s mood and behavior to ensure the resident's safety. The next entry into the resident ' s chart was dated 6-25-2013 at 1:36 a.m. which stated: " Resident lying in bed, nurse asked resident if any pain. Resident stated no. Speech is very clear, stated I don ' t need anything. " 4. A review of Resident #337 ' s Social Service assessment dated [DATE] revealed under the Psychosocial Information & Social Practices/Behaviors section that the resident denied any current issues with Depression, Anxiety. " She is prescribed an anti-anxiety medication. She has a poor appetite. She is an ex-smoker and does not drink. " 5. On 6-27-13 at approximately 1:44 p.m. an interview was conducted with Employee D, a Resident Care Manager (RCM) for the unit where the resident resided. Employee D was asked if she was aware that the resident had expressed suicidal thoughts. Employee D stated she was not aware. She was shown the Nurse ' s Note dated 6-21-13 and again stated that she had no prior knowledge of the documented incident. Employee D called Employee A, a facility Social Worker, and was informed that a psych evaluation was requested for Resident #337 on 6-24-13, three days after the resident verbalized suicidal thoughts. 6. Employee A was interviewed on 6-27-13 at approximately 2:13 p.m. She was asked if she knew that Resident #337 had verbalized [MEDICAL CONDITION]. Employee A stated that she found a referral request in her box on 6-24-13, requesting a psych service consult for Resident #337 related to the resident's suicidal comments. Employee A was asked if she spoke with the resident after learning of the resident ' s suicidal thoughts or if she assessed the resident for depression or increased anxiety. Employee A stated that she had not. The Employee was asked whose responsibility it was to assess the resident for depression. Employee A stated that it was the responsibility of nursing. Employee A was asked whether the psych evaluation had been completed as requested. She stated that it had been done on 6-24-13, the same day that she submitted the request. Employee A was asked to obtain a copy of the psych evaluation as there was no copy on the resident ' s chart for review. Employee A called the unit and spoke with Employee D. Employee A learned at that time that the psychiatric evaluation had not been completed as she previously thought. Employee D explained that when the psychiatric provider noted on the chart that the resident was receiving hospice services, the psychiatric evaluation was deferred to the local hospice to provide psychosocial support. On further chart review with Employee D, it was determined that hospice services were not initiated on admission as ordered. She confirmed that Resident #337 was not receiving hospice services at the time that the psychiatric referral was made and deferred. On 6-27-13 at 2:45 p.m. Employee D wrote an order for [REDACTED]. 7. An interview was conducted on 6-27-13 at 3:40 p.m. with Employee B. She confirmed that she was the nurse who made the nursing note entry on 6-21-13 which documented the suicidal comments of Resident #337. Employee B stated that the resident ' s POA came up to her after visiting the resident in the sun room that day. She stated the POA "came back upset, looking like she wanted to cry and said the resident told her " if I could find a way to commit suicide, I would. " Employee D continued to say she talked with the resident the next day, but did not make a note in the chart. She stated, " I wanted to see if she mentioned anything. I asked her if she was feeling better about being here. She said she didn ' t need to be here because she could take care of herself. " Employee B was asked if she assessed the resident's emotional state on the evening of 6-21-13. She stated that she spoke with the resident but that she did not ask her about " that word. " Employee B stated, " She looked like her usual self - she was depressed. I called the doctor and told him what the POA said. Since she didn ' t say anything to me, I can ' t really act on it. " Employee B was asked to describe the resident ' s demeanor and appearance. Employee B stated " She looked sad, but she looked sad when she came in. " Employee B was asked if the resident ' s MD gave any new orders that night. She stated that he ordered [MEDICATION NAME]. She was asked to show the new order. After searching the chart for an order, Employee B clarified, " I gave her some [MEDICATION NAME] that was ordered when she came in. It was already on the MAR (Medication Administration Record). " Employee B was asked a second time if she spoke with the MD that evening. It was pointed out that her note referenced that she was waiting a return call from the MD. Employee B stated she did speak with the MD on the night of 6-21-13, but forgot to write a follow up note. 8. Employee B was asked if she reported the resident's suicidal comments to the DON (Director of Nursing), RCM (Resident Care Manager, NHA (Nursing Home Administrator) or RM (Risk Manager). She responded, " I know some places you call and report. But it can ' t be hearsay. It must come from the resident. That ' s why I talked with her. She was feeling better about not having pain, but she was not happy about being here. " She was asked if she questioned the resident about having a plan to commit suicide. She responded, " No! " . Employee B was asked had there been any facility in-services dealing with how to handle residents who verbalized wanting to commit suicide. She stated, " Yes, but I ' m not sure if I ' ve been to one here. I ' ve only been here since November. " She was asked if she knew whether the facility education covered what to do when a resident talks about suicide. She stated, " I ' m not sure about here, but have heard in other places that you should notify the DON and put the resident on a watch. But I knew the resident in the community before she came here.I used to work in a grocery store and she was one of my regular customers. She's always been sad. " 9. An interview was conducted on 6-27-13 at 4:00 p.m. with Resident #337. The resident was asked if she remembered making the statement " If I could find a way to commit suicide, I would"? She responded,"Who told you that? (Seemed angry and upset) I might have said that or said I wish I was dead. Every once in a while, I think about it but not all the time. " The resident stated, " I ' m not happy. I don ' t even know why I am here. But I wasn ' t trying to kill myself. " The resident was asked if she had ever thought about a particular plan or way to commit suicide. She stated, " No". It ' s like a thought that slides into my head then out of my head. " 10. On 6-27-13 at 4:20 p.m. in an interview with the Assistant Director of Nursing (ADON), findings and concerns were discussed related to the interview with Employee B. It was verified that the nurse documented the [MEDICAL CONDITION] of the resident but did not arrange for the resident to be assessed or notify the Director of Nursing (DON) or the Risk Manager (RM). The ADON was unaware that the psych evaluation had been ordered on 6-24-13, but not completed for the resident. The ADON was asked about facility policy and procedures when a resident voiced suicidal thoughts. She asked if she could obtain the facility policy before continuing the interview. The ADON left to get the policy put did not return. At 5:00 p.m. the ADON was located by a member of the survey team and the facility policy titled " Suicide Threats " was provided. 11. At 5:55 p.m. on 6-27-13 Resident #337 ' s psych evaluation was completed. The psych note was reviewed by the DON and surveyor. Per the psych evaluation the resident denied [MEDICAL CONDITION]. She stated she must have been misunderstood. 12. An interview on 6-28-13 at 11:00 a.m. was conducted with the Social Service Director (SSD). She stated that if it was reported that a resident verbalized suicidal ideation, typically a Social Worker (SW) would talk with the resident and assess for a plan, emotional state, etc. The SW would then communicate with nursing as to the resident ' s monitoring needs. She stated it was not a written policy for the SW to assess before submitting a referral, but that it was " usually done in order to provide as much information as possible " to the psych consultant. The SSD noted that there was a psychiatric service provider in the building weekly and that they could also be contacted immediately. 13. The SSD was asked about the facility policy regarding who should be contacted when a resident expressed suicidal thoughts. She replied that the staff member should contact the physician, SS, DON (Director of Nursing), RM (Risk Manager) and ADON. She noted that the staff member should talk with the individual and make a referral. If [MEDICAL CONDITION] were verbalized, the psychiatric service provider would be contacted and could come in " within hours " . 14. The SSD was asked to provide a list of psychiatric referrals related to suicidal thoughts or ideations since the last facility survey. A Psychiatric Consults log was provided for March 2013 with one resident identified as having a psychiatric consult for suicidal thoughts. A second log was provided for June 2013 which contained three resident names, including resident #337. The remaining two residents were identified as Resident #325 and Resident #145, both referred for psychiatric consults related to suicidal thoughts. 15. Resident #325 was a [AGE] year old male admitted on [DATE] with [DIAGNOSES REDACTED]. Per a hospital history and physical dated 4/19/13, the resident complained of dizziness and headaches and was sent by his PCP (Primary Care Physician) to a local hospital for evaluation and subsequently diagnosed with [REDACTED]. He was admitted to the long term care facility for skilled services on 4-26-13. 16. On admission, the resident's medications per the POS (Physician order [REDACTED]. Review of Resident #325 ' s Physician ' s progress notes dated 5-1-13, 6-11-13, 6-12-13, 6-13-13 and 6-17-13 revealed the resident was being treated for [REDACTED]. 17. A Psychiatric Progress Note dated 6/24/13 was located in the record. The consult stated that the resident had been seen to assess suicidal thoughts. The note stated that the resident denied distress, depression or suicidality. His psychiatric [DIAGNOSES REDACTED]. 18. On 6-30-13 at approximately 1:25 pm Resident #325 was observed sitting up in his wheelchair in the first floor dining room. The resident was appropriately dressed for the time of day. The resident was well groomed. The resident was observed interacting with a fell ow resident and a staff member. 19. A review of the medical record revealed no psychiatric referral information for resident #325. Employee A (SW) was interviewed on 6-28-13. She was asked who was responsible for requesting a psych referral when a resident expressed suicidal thoughts. She stated it was usually made by nursing on a Social Services " pink slip. " She was asked if she ever evaluated a resident after she received a request related to suicidal thoughts. Employee A stated, "If the resident was talking about actually doing it, I'll go see them." 20. Employee A was asked who initiated the psychiatric referral for Resident #325. Unable to locate the referral source by a computer search of consult requests, Employee A then remembered that the resident's psych request came about following a report by a member of the therapy department at a Utilization Review Meeting held on 6/18/13. Employee A stated that one of the therapists reported that Resident #325 was talking about " ending it. " She produced a paper titled Utilization Review Meeting. Beside the typed name of Resident #325 was a hand written note which stated " requesting UA (urinalysis) and psych eval, increased confusion. Patient making comments about " chopping arm off " and " ending it. " Employee A revealed she made a psych referral for the resident on 6-18-13 for " increased confusion and suicidal comments. " The employee stated she did not assess the resident on 6-18-13 after receiving the report. She stated, " The way it was presented to me, he didn ' t have a plan. " She also stated that when she made the referral to the psych service, she included her opinion that the situation was not urgent. She explained that was why the psych service did not come out immediately, but waited until the normally scheduled weekly facility visit the following Monday, 6-24-13. 21. A review of Resident # 325 ' s record revealed there was no documentation indicating the nursing staff caring for the resident were informed of the resident ' s suicidal thoughts/statements by the Therapy department or by the Social Services department. There was no documentation that a psychiatric consult had been requested by Social Services. There was no documentation that the resident ' s suicidal comments had been reported to risk management, supervisory or administrative staff or to the resident ' s physician. There was no evidence that an environmental assessment had been done to ensure resident safety or that safety monitoring had been discussed or provided. 22. Resident #145 was also identified on the Psychiatric Consults log for June 2013. The entry for resident #145 revealed that a referral was made on 6/24/13 for the reason of " suicidal comments " . Per the facility face sheet, Resident #145 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. 23. An initial Social Services assessment on 5/3/13 was completed by Employee A (SW). On page 1, a synopsis of assessment noted that the resident was alert, oriented and able to communicate his needs to the staff verbally. It was noted that he had a [DIAGNOSES REDACTED]. On page 3 in the section titled Psychosocial Information and Social Practices/Behaviors, it was documented that the resident denied any issues with depression. 24. An MDS (Minimum Data Set) dated 5/2/13 showed a BIMS (Brief Interview for Mental Status) score of 9 out a possible 15. Section D0200 titled Resident Mood Interview showed that the resident was coded 0 = No for symptoms of " feeling down, depressed or hopeless " and for " thoughts that you would be better off dead, or of hurting yourself in some way. " 25. A nursing note dated 6/23/13 was observed on the record which stated: "When changing resident, CNAs (Certified Nursing Assistant) heard the resident talking about wishing he could kill himself. Roommate then confirmed to the CNAs that " he says things like that every night. " Social Services referral filled out for psych consult." There were no additional nursing notes for 6/23/13 or 6/24/13. The next nursing note on the chart was dated 6/25/13 on the Weekly Nursing Summary. The entry under Comments stated: " Resident more quiet and calm. No complaints of pain or discomfort voiced. No signs and symptoms noted. Poor safety awareness. " The section titled Mood/Behavior was checked to show that the resident was restless. The section titled Neuro/Cognitive was checked to show that the resident was alert with confusion and no status changes in the past 30 days. 26. There was no documentation of additional assessment at the time of the resident's suicidal comments. There was no indication that the resident's physician was notified for further orders. There was no documentation that the environment was assessed for safety related to self-harm or that any safety monitoring was conducted following the resident ' s comments about suicide. 27. Two attempts were made to contact the nurse who had documented the resident's comments on 6-23-13. A review of the employee file identified that she worked for the facility on a "prn" (as needed) basis on the week-end night shift. Both phone contact attempts were unsuccessful. A call-back number was provided with a request for the nurse to contact the surveyor. At the time of exit on 7-1-13, no return call had been received. 28. Resident #145 was observed at approximately 4:00 p.m. on 6-28-13 sitting in a wheelchair at the nursing station. He appeared appropriately dressed and groomed. An attempt was made to interview the resident who was confused and oriented to person only at that time. He was unable to participate in a meaningful interview about the documented events on 6-23-13. 29. A psychiatric progress note was located on the chart dated 6/24/13. A check at the top of the form indicated that it was a follow-up visit. In the History of Present Illness, it was documented that the resident was last seen on 5/6/13 for depression with hallucinations and [MEDICAL CONDITION]. In the section titled Mental Status, documentation showed the resident ' s mood to be " OK " from a list which included " happy, depressed, anxious, and labile. " There were no references in the narrative related to suicidal thoughts or ideation. 30. An interview was conducted with Employee A (SW) on 7/1/13 at 10:00 a.m. She was asked for a copy of the psychiatric referral that was made for resident #145 as referenced on the Psychiatric Consults log for June 2013. The Social Services referral form for resident #145 showed a section for Psych Consult with boxes checked for Psychiatrist and Psychologist. A section for Reason and Comments followed. In the section marked Reason, it was written, "Overheard expressing desire to kill himself". In the Comments section, it was written, "CNAs heard resident talking about wishing he could kill himself, then roommate confirmed that by saying " he says things like that every night. " It was signed by a facility nurse. A handwritten statement at the bottom of the form noted " Text to (psychiatric service provider) in building currently. " Employee A was asked how the referral information was given to the psychiatric provider. She stated she found the referral in her office when she arrived on Monday morning, 6-24-13. She stated she then spoke with the psych provider directly to request the referral as the provider was currently in the building on weekly rounds. 31. A follow up call on 7-5-13 at 10:00 am with the Psychiatric consultant revealed that she was already scheduled to see Resident #145 to follow-up on a recent medication change when she received the referral request on 6-24-13. She stated that she always assesses residents for suicidality as part of her visits and had done so for Resident #145 on 6-24-13. 32. An interview was conducted on 6-28-13 at 2:20 p.m. with the NHA (Nursing Home Administrator) and DON. The NHA was asked about his expectations of his staff regarding residents who verbalize [MEDICAL CONDITION]. The NHA stated the following, " If a staff member received a report of resident verbalizing suicidal thoughts, it should be reported to the resident ' s physician. The charge nurse should be contacted to do an assessment - don't just report it to the next shift. Find out if the resident has a plan and a way to carry it out. Get a psych evaluation. If it ' s an actual threat, provide 1:1 monitoring or q15min (every 15 minute) checks. If there was no plan confirmed, continue with the psych evaluation and notification of the resident ' s PCP and family". The NHA noted that the psych service was "pretty quick", usually responding the same day. He stated that Social Service was a part of the referral process. He noted that Nursing initiates the request for a referral to psych. He stated that, on the weekends, nursing would handle the referral directly. 33. The NHA and DON were asked what type of facility in-service was provided to the staff related to suicidal prevention. They stated that education on suicide prevention was a part of the new employee orientation as well as the mandatory annual in-service. The NHA stated an electronic program was utilized for staff education. The staff member logged in to complete the required in-service and the staff education coordinator could access the record for compliance. The NHA returned to clarify that suicide prevention was not a part of the computerized new orientation or annual training for the staff. He noted that there was an education module on suicide prevention that could be added to the facility in-service program. 34 .On 6-28-13 at approximately 2:30 p.m., an unsuccessful attempt was made to contact the PCP for Resident #337. The office reached using the number on the resident's chart informed the surveyor that the doctor no longer worked with that office. She did not have a contact number for him but thought he could be reached through the area hospital. A second contact number provided by the facility was answered by an individual who stated the doctor would be available on Monday from 9 a.m. to 1 p.m. A call back number was provided. 35. On 6-28-13 at 2:32 p.m. an attempt was made to contact the Medical Director, who was also the PCP for residents #325 and #145. The office staff stated that the doctor was not on call and would not be in the office until Monday. They would not provide another contact number. The DON and NHA were asked for an alternate number to contact the Medical Director. They provided a name and number of his " designee " . 36. On 6-28-13 at approximately 2:35 p.m. a telephone interview was conducted with one of the facility consultants for psych services who provided the assessment for residents #337, #325 and #145. The consultant was asked about her expectations of the facility staff when residents verbalized [MEDICAL CONDITION] or plans to harm themselves. The consultant stated the nurse should immediately evaluate the resident, call the PCP and contact psych for a consult. If immediate danger was determined, one on one observation should be started. 37. On 6-28-13 at approximately 3:00 p.m. a phone interview was conducted with the Medical Director ' s " designee " physician. He stated that he was in practice with the Medical Director and assisted him with associated responsibilities at the facility. He was asked about his expectations of the facility staff if a resident verbalized [MEDICAL CONDITION]. He stated the nurse should assess the resident for how serious the resident was. The degree of ideation would determine the level of response. The nursing staff should attempt to determine from the resident if there was a plan or method. Talk with the resident, notify their supervisor and call psych services. He noted the first priority was to keep the resident safe. 38. At approximately 4 p.m. on 6-28-13 a second attempt was made to contact Resident #337 ' s PCP. A voice message was left with contact information. 39. An interview on 6-29-13 at 11:25 a.m. with the Risk Manager (RM) revealed the RM had been in the position for 6 months but had worked at the facility for 1.5 years. The Risk Manager was asked what her role was when Resident #337 verbalized [MEDICAL CONDITION]. The RM stated she was never told of the event. The RM was asked how staff members were notified of resident behavioral changes. The RM stated they are told but was unaware of the exact procedure. The RM went on to say she does not attend care plan meetings and she gets information on resident issues generally at morning IDT meetings. She described her primary role was to investigate falls, accidents and other injuries. 40. On 6-30-13 at 1:00 pm a telephone interview was conducted with the PCP for Resident #337. The Physician was asked if he recalled being contacted on 6-21-13 regarding his resident ' s verbalization of [MEDICAL CONDITION]. He stated he could not confirm or deny whether he had received a call on that particular date without checking phone records. He stated if he were told a resident had expressed a desire to commit suicide, he would give an order for [REDACTED]. He stated he would not just say " Thanks for calling, have a good day. " 41. As reported by the American Association for Marriage and Family Therapy in a brochure titled Suicide in the Elderly, older adults make up 12% of the U.S. population, but account for 18% of all suicide deaths. Warning signs include: ? Loss of interest in things or activities usually found enjoyable ? Cutting back social interaction, self-care and grooming ? Breaking medical regimens (such as going off diets, prescriptions) ? Experiencing or expecting a significant personal loss (spouse or other) ? Feeling hopeless and/or worthless ? Putting affairs in order, giving things away, or making changes in wills ? Stock-piling medications or obtaining other lethal means ? Other clues are a preoccupation with death or a lack of concern about personal safety ? The most significant indicator is an expression of suicidal intent Suicide.org, a non-profit organization for suicide prevention, awareness and support also recognizes elderly suicide as a very serious problem. They state " some individuals believe that depression is a normal part of being elderly, which is completely untrue. Depression is not normal for people of any age. " They encourage close monitoring of any elderly person, especially after any stressful life event. They also note that many elderly hide their depression so it is critical to watch closely for any hint of a suicide warning sign or depression symptom. In addition, the section on suicide warning signs noted that some people who die by suicide do not show any suicide warning signs. Neither of the warning sign lists provided by these two organizations included the need for the elderly person to have a plan before the threat of suicide should be taken seriously. 41. A review was conducted of a PubMed article abstract titled " Death ideas, suicidal thoughts, and plans among nursing home residents " . The article was originally published in the June 2009 issue Journal of Geriatric Psychiatry and Neurology. (PubMed is a free resource for over 22 million citations for biomedical literature that is developed and maintained by the National Center for Biotechnology Information (NCBI), at the U.S. National Library of Medicine (NLM), located at the National Institutes of Health (NIH).) The article stated that " Recent studies have shown that suicides are at least as frequent among Nursing Home (NH) residents as they are among older people in the general population. One hundred seventy-two participants were surveyed with a response rate of 59.7%. Five sample questions were asked to investigate the presence of death- and suicidal thoughts, plans and behaviors in different time periods. Among the NH residents, 30.8% admitted having had death or suicidal thoughts or plans during the month prior to the interview. The oldest-old residents (85+y) more frequently reported death-suicide ideation. This high frequency of death and/or suicidal feelings and thoughts among older NH residents should be carefully considered when planning and implementing health care programs in these facilities. " 42. The facility initiated measures to remove Immediate Jeopardy on 6-28-13. The measures were as follows: The facility policy titled "Suicide Threats" was revised and renamed "Suicide Prevention". The revised policy listed warning signs for suicidal

Based on staff interviews, observation and record review it was determined the facility failed to provide timely, medically-related social services to attain or maintain the highest practicable, mental and psychosocial well-being for 3 (#337, #325 and #145) of 4 affected residents reviewed for documented suicidal ideation. Resident #325 was identified to Social Services on 6-18-13 as having verbalized a desire to harm himself and "end it" . A psychiatric consult requested on 6-18-13 was deferred to 6-24-13 due to determination by the Social Worker that the resident "did not have a plan". Resident #337 verbalized a desire to commit suicide on 6-21-13. A psychiatric referral was not made until 6-24-13, three days after the resident verbalized suicidal intent. Due to a failure of the Social Services department to follow up on the initial referral, it was not discovered until 6-27-13 that the psychiatric evaluation for Resident #337 had not been completed, six days after the resident's initial expression of suicidal thoughts. Resident #145 verbalized a desire to kill himself on 6-23-13. A psychiatric evaluation was not done for more than 24 hours after resident expressed suicidal thoughts. There was no evidence that the facility provided timely assessments for the three at-risk residents who had verbalized thoughts of self-harm and suicide to determine the severity of each resident's mental status or to identify possible services and support to alleviate their emotional distress. There was also no evidence of an environmental safety assessment for the three residents. This practice resulted in findings of Immediate Jeopardy on 7-1-13. Immediate Jeopardy was removed on 7-1-13 at 3:45 p.m. Findings include: 1. Resident #337 was an [AGE] year old medically frail female who was admitted to the facility on [DATE]. Admission [DIAGNOSES REDACTED]. Additional [DIAGNOSES REDACTED]. A contracture of the right hand and arm related to atrophy was also documented which caused her to require assistance with performing ADLs (Activities of Daily Living). A psychiatric assessment note, dated 6-10-13 prior to facility admission, noted the resident's neurological status as confused with long term memory loss. According to a hospital history and physical dated 6-1-13, the resident had a close friend who served as POA (Power of Attorney) and had helped to care for the resident in her home prior to admission. During a record review for Resident #337 on 6-27-2013, it was revealed that the resident had been receiving services from a hospice provider prior to her admission to the facility. Based on an AHCA (Agency for Health Care Administration) form 3008 dated 6-13-2013 provided to the receiving facility, there was a signed physician order [REDACTED]. Further review of the resident's medical record revealed [REDACTED]. find a way to commit suicide I would". There was no other documentation noted in the resident's chart related to an assessment of her mental state at the time of her statement or a referral for psychiatric services. There was no documentation that the resident was monitored for safety or that the resident's environment was assessed to ensure there were no objects that could be used for self-harm. The next nursing note was dated 6-25-13 and made no reference to the resident's expression of suicidal thoughts on 6-21-13. On 6-27-2013 at 1:44 p.m. Employee D, a Resident Care Manager (RCM), was asked if she could provide evidence of care plans being developed by the hospice agency for Resident #337. Employee D called the agency and learned that the local hospice agency had never been informed of the resident's need for services and consequently the medically fragile individual had not received hospice services for thirteen days since admission on 6-14-13. Employee D was also asked if she was aware that Resident #337 had verbalized a desire to commit suicide on 6-21-13. Employee D stated she was not aware of the resident's suicidal thoughts prior to being shown the chart documentation by the surveyor on 6-27-13. An interview was conducted on 6-27-13, at approximately 2:13 p.m., with Employee A, a Social Worker (SW) for the facility. Employee A was asked if she was aware that Resident #337 had verbalized suicidal ideations. Employee A revealed that on the morning of 6-24-13, she found a referral in her box for Resident #337 requesting a consult for Psych services due to the resident's expression of suicidal thoughts. Employee A was asked if she spoke with the resident after learning of the resident's desire to commit suicide and if she assessed the resident for increased depression or anxiety. Employee A revealed she had not. She was asked whose responsibility it was to assess the resident for depression or mood problems. Employee A stated it was the responsibility of nursing. Employee A was asked if the psych (psychiatric) evaluation had been completed for Resident #337. She stated that it was completed on the same day it was requested, which was 6-24-13. Employee A was asked to obtain a copy of the psychiatric evaluation for the surveyor to review as there was no copy in the resident's chart. Employee A called the unit, spoke with Employee D and learned that the psych evaluation was never completed. Employee D revealed that the psych consult, requested by Social Service, was never completed due to the lack of communication between Nursing, Social Service, Hospice services and Psych consult services. Employee D stated that the psychiatric consultant had the understanding that Resident #337 was receiving hospice services, including psychosocial support, and deferred the assessment. Employee D confirmed that at the time the psychiatric consultant deferred the psychiatric evaluation for Resident #337, the resident was not receiving hospice services and had received no psychosocial services or support since the resident's statement on 6-21-13 that she wanted to commit suicide. An interview was conducted on 6-27-13 at 4:00 p.m. with Resident #337. The medically fragile female was observed lying in her bed listing slightly to her right side. The resident was noted to have contractures of her right arm and hand. After a period of discussion, the resident was asked if she remembered making the statement, "If I could find a way to commit suicide, I would"? The resident responded, "Who told you that? I might have said that or said I wish I was dead. Every once in a while, I think about it but not all the time." The resident stated, "I'm not happy. I don't even know why I am here. But I wasn't trying to kill myself." The resident was asked if she had ever thought about a particular plan or way to commit suicide. She stated, "No. It 's like a thought that slides into my head then out of my head." The resident was asked if she was in any discomfort at the present time or needed anything. She replied,"No". On 6-27-13 at 5:55 p.m. Resident #337's psychiatric evaluation was completed. Per the psychiatric progress note, the resident denied suicidal ideation at the time of the assessment and stated she must have been misunderstood. 2. A brochure from the American Association of Marriage and Family Therapists, titled " Suicide in the Elderly" , contains a list of suicide warning signs: ? Loss of interest in things or activities that are usually found enjoyable ? Cutting back of social interactions, self-care grooming ? Experiencing or expecting a significant personal loss ? Feeling hopeless or worthless ? Putting affairs in order, giving things away, or making changes in a will ? Preoccupation with death or lack of concern for personal safety ? Remarks such as "This is the last you'll see me " or "I won't be needing anymore appointments. " ? The most significant indicator is an expression of suicidal intent. "Problems with public notions of what is, and is not, acceptable with regard to suicide and the belief that old age equals depression, contribute to the lack of appropriate treatment of [REDACTED]. A trained mental health practitioner, such as a family therapist, who is experienced with handling issues of the elderly, including depression and high risk for suicide, can offer services to help the suffering adult ... " (American Association for Marriage and Family Therapy, Alexandria, Virginia -3061) 3. An Interview was conducted on 6-28-13 at 11:00 a.m. with the facility SSD (Social Service Director) to determine if there were any other facility residents who had required Social Service referrals related to suicidal ideation. The SSD was asked to provide the surveyors with a list of psychiatric referrals related to suicidal thoughts or ideations since the last facility survey in April 2012. A Psychiatric Consults Log was provided with one referral in March 2013 and three referrals related to suicidal ideation in June of 2013 which included resident #337 as well as two additional residents, resident #325 and resident #145. The SSD was asked to give an overview of the referral process for residents needing psych services. She stated that when SS (Social Services) received a referral request or was notified that an issue existed with a resident that required a psych evaluation, a referral was then made to the psych consultant service. She stated that, in the event of a reported suicidal ideation, "typically" a SW would talk with the resident and assess for a plan, emotional state, etc. The SW would then communicate with nursing as to the monitoring needs of the resident. The SSD noted that a Psych service representative was in the facility weekly " but for someone having suicidal thoughts we will call them and they will come in immediately". She was asked if there was a written policy for the resident to be assessed by the SW. She stated she did not think it was a written policy, but that "we usually do it so we can have more information to give to the doctor (psych consultant)". The SSD was asked what the facility policy was regarding notification when a resident verbalized a desire to self-harm. She stated that the staff was to contact the physician, notify SS, DON (Director of Nursing), RM (Risk Manager), and the ADON (Assistant Director of Nursing). She stated the staff member should talk with the person and/or make a referral. She stated again that if there was a verbalized suicidal ideation, psych consult services would come in "within hours". She noted that Nursing would monitor with more frequent checks to assure resident safety. She stated if the resident had an actual plan, the staff was supposed to make sure the resident couldn't act on it. She noted that the staff may have to do 1:1 observations if needed, before psych services came in, to maintain the resident's safety. SSD was asked if in-servicing was provided to all staff members related to dealing with suicidal residents. She noted that facility in-service education was done electronically. She stated she was not sure if suicidal ideation was covered in the new employee orientation. She stated if a breakdown in communication was identified, individual department heads might hold specific in-services for their department. She stated she was not aware of any actual suicide attempts at the facility. 4. Resident #325 was identified on the Psychiatric Consult log for June 2013. A consult was noted as requested on 6-18-13 due to "increased confusion, suicidal thoughts" and completed on 6-24-13. According to the medical record, Resident #325 was a [AGE] year old male admitted to the facility on [DATE] with diagnoses, per the face sheet, which included cerebral artery infarct, hypertension and muscle weakness. Per a hospital history and physical, dated 4/19/13, the resident complained of dizziness and headaches and was sent by his PCP (Primary Care Physician) to a local hospital for evaluation and subsequently diagnosed with [REDACTED]. After stabilization at the local hospital the resident was transferred to a local rehabilitation facility for extensive therapy services and then to the long term care facility for skilled services on 4-26-13. A review of the Nursing Data Collection assessment for Resident #325, dated 4-26-13, revealed the following: Section D, Mood and Behavior, Item (1) Indications for Depression was documented as "None of above". Item (3) Sad Mood was documented as "None of above". Section (5) Psychotropic Medications included a selection for antidepressant use which was not checked. The box for "None of above" was checked. The Initial Social Service Assessment, dated 4-29-13, noted that the resident was alert, oriented and able to make his needs known. The resident stated that he did not suffer from depression, anxiety or insomnia. No memory issues were noted and he was described as independent in making decisions. physician progress notes [REDACTED]. A review of Resident #325's care plans on 6-28-13, 6-29-13 and 6-30-2013 revealed that there were no care plans developed to address the use of antidepressants. There was no evidence of non-pharmacological interventions in place to offer the resident when the resident exhibited depressive or anxiety behaviors. There were no care plans available for review that addressed the resident's verbalization of wanting to cause harm to himself. There was no documentation on the resident's chart related to suicidal thoughts identified by the facility as noted on the June Psychiatric Consults log. In addition, there was no evidence of a request for a psychiatric evaluation related to suicidal thoughts found on the chart. An interview was conducted on 6-28-13 with Employee A, a facility SW. She was asked to provide a copy of the request for psychiatric services related to suicidal thoughts for Resident #325. She stated that the referral was generated due to comments made at a Utilization Review meeting on 6-18-2013. She stated it was reported to her by the Rehabilitation Manager that an unknown therapist had heard the resident make statements about wanting to "cut his arm off"and "end it". Employee A was asked if she spoke with Resident #325 or did any type of assessment after she learned of the resident's verbalization of wanting to hurt himself. Employee A stated she did not. When Employee A was asked why it took six days to have the Psych evaluation completed for the resident, the employee responded that she thought it wasn't urgent. She stated when she made the referral to have the psych evaluation done she told them it was not urgent. She stated that was the reason the psychiatric service did not come out immediately, but waited until they made their weekly rounds on the following Monday, 6-21-13. Employee A was asked how she made the determination regarding the urgency of the resident's suicidal ideation when she did not conduct an assessment of Resident #325. She stated she based her determination on the information that was shared with her at the Utilization Review meeting. She stated, "The way it was presented to me, he didn't have a plan". An interview on 7-1-13 at 9:45 am with the Rehabilitation Manager revealed that, on 6-18-13, she had attended a Utilization Review Meeting. At some point prior to the meeting, the Rehab Manager received a report from an unidentified therapist that Resident #325 was showing increased confusion. It was reported to her that he was having "delusional thoughts about cutting his arm off and ending it " . She stated she had questioned the therapists working with the resident, but was unable to identify the therapist who reported the resident's comments to her. She confirmed that she shared the reported comments of Resident #325 with the Social Worker during the meeting on 6-18-13. A review of the Psychiatric Service Outpatient progress note for Resident #325, dated 6-24-13, noted that the resident "denies depression, denies suicidality. Reports occasional frustration with P.T. (Physical Therapy) and wanting to go home ....no changes today, continue current treatment plan." An interview was conducted on 6-30-2013 at 12:04 pm with Employee E, an RCM on the unit where Resident #325 resided. Employee E was asked if she was aware of the resident wanting to cause self- harm. Employee E stated she was not aware of it until the Psych consultant was on the unit and asked her for the resident's room number. Employee E was asked if Social Service had informed her of the concerns and suicidal comments reported by therapy on 6-18-13. Employee E stated she was not made aware of any concerns or suicidal thoughts verbalized by Resident #325. A review of the Nurse's notes from 4-26-13 through 6-29-13 reflected no documentation referencing the resident wanting to cause self-harm. There was no documentation that the resident was monitored for safety or that his environment was assessed to ensure there were no objects that could be used for self-harm. On 6-30-13 at approximately 12:00 p.m. Resident #325 was observed sitting up in his wheelchair interacting with staff members in the dining room. The resident was well groomed and dressed in clothing appropriate for the season and time of day. 5. Resident #145 was identified on the facility Psychiatric Consults log for June 2013. Documentation showed that a consult was requested for the resident on 6-24-13 for " suicidal comments " and the resident was seen by the consultant on 6-24-13. A record review showed that Resident #145 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Nursing Data Collection assessment dated [DATE] noted in section 8, Physical Assessment that Resident #145 had short term memory problems and was moderately impaired in decision making, with cues and/or supervision required. In section D, Mood and Behavior, item (1) Indications of Depression - None of above was selected. Item (3) Sad Mood - None of above was selected. Item (5) Psychotropic Medications - None of above was selected. Review of a Social Service assessment dated [DATE], page 1, revealed the resident was alert, oriented and was able to verbalize his needs and wants to the staff. There was also documentation of dementia with periods of confusion which required redirection at times. Page 3 of the Social Service Assessment noted in the section titled Psychosocial Information and Social Practices/Behavior that the resident denied any issues with depression. Social Service Notes revealed a psychiatric referral was made on 5-6-13 and the resident was seen on that date. Social Services Care Plan Review Notes, dated 5-23-13, noted the wife's statement that the resident had shown a rapid decline in cognition with increased paranoid behavior. An undated Behavior Monitoring flow sheet for the identified behaviors of Agitation and Psychosis was noted on the medical record. A Behavior Monitoring flow sheet for June 2013 was found for identified behaviors of Mood Swing and Paranoia. On the form for Mood Swings, documentation was noted on the 7-3 shift on 6-23-13 and 6-24-13. Interventions noted on 6-23-13, per the Intervention Codes listed on the left side of the form, included #7- Give food, #8- Give fluids, and #15 - medication. Per the MAR (Medication Administration Record) for June 23, 2013, no prn (as needed) medications were documented as given. The resident had an order for [REDACTED]. The only dose recorded on the MAR was on 6-15-13. There was no nursing note entry for 6-23-13 on the 7-3 shift. A Weekly Summary was noted for 6-25-13 which documented Mood/Behaviors as "restless, resists care and meds at times. " A MDS (Minimum Data Set), dated 5-2-13, showed a BIMS (Brief Interview for Mental Status) score of 9 out a possible 15. Section D -Resident Mood Interview showed that the resident was coded 0 = No for symptoms of "feeling down, depressed or hopeless" and for "thoughts that you would be better off dead, or of hurting yourself in some way". Section G - Functional Status noted that the resident was independent with transfers in his room as well as ambulation on the unit. He required supervision for locomotion off the unit. Balance during transitions and walking noted that the resident was not steady, but able to stabilize without staff assistance and utilized a walker as an assistive device. An Interdisciplinary Note on 5-4-13 noted that the resident used a walker to ambulate, but often did not wait for assistance and was a fall risk. Staff assistance needed for toileting and dressing. Further record review showed a nursing note entry at 3:30 a.m. on Sunday 6-23-13 which stated, "When changing resident, CNAs (Certified Nursing Assistants) heard resident talking about wishing he could kill himself. Roommate then confirmed to CNAs that he says things like that every night. Social Services Referral filled out for Psych consult'. Following documentation of the event in the medical record, there was no evidence that an assessment was done related to the resident's mental status at the time of the event. There was no evidence that the resident's environment was assessed to ensure there were no objects that could be used for self-harm. There was no documentation that the physician or family was notified of the resident's statement of suicidal thoughts. Two attempts were made to contact the nurse who had made the record entry on 6-23-13. On a review of the employee file, she was identified as working for the facility on a "prn" (as needed) basis on the week-end night shift. Both contact attempts were unsuccessful. A call-back number was provided with a request for the nurse to contact the surveyor. At the time of exit on 7-1-13, no return call had been received. A review of care plans located on the medical record showed a care plan, dated 5-3-13, which stated " Resident at risk for mood decline and at risk for side effects of medication related to a [DIAGNOSES REDACTED]. Psych to evaluate and treat as indicated. " There were no updates noted since 5-18-13. There was no documentation related to the resident's verbalized suicidal thoughts on 6-23-13 and no added approaches for management or monitoring related to the resident's suicidal ideation. A Psychiatric Progress Note, dated 6-24-13, was noted on the chart. The assessment was completed over twenty four hours after Resident #145 first verbalized suicidal thoughts. The note was documented as a "follow-up" and there was no specific documentation related to suicidal ideation. A telephone interview was done on 7-5-13 at approximately 10 a.m. with the psychiatric consultant. She clarified that she was already scheduled to see Resident #145 for a follow-up visit related to a recent medication change when she was given the new referral on 6-24-13 related to "suicidal thoughts". She stated she coded the visit as a follow-up for that reason, but did assess the resident for suicidality at that time. Resident #145 was observed at approximately 4:00 p.m. on 6-28-13 sitting in a wheelchair at the nursing station. He appeared appropriately dressed and groomed. An attempt was made to interview the resident who was confused and oriented to person only at that time. He was unable to participate in a meaningful interview about the documented events on 6-23-13. 6. An interview was conducted on 6-28-13 at 2:20 p.m. with the NHA (Nursing Home Administrator) and DON. The NHA was asked about his expectations of his staff regarding residents who verbalize suicidal ideations. The NHA stated the following: "If a staff member received a report of resident verbalizing suicidal thoughts, it should be reported to the resident's physician. The charge nurse should be contacted to do an assessment - don't just report it to the next shift. Find out if the resident has a plan and a way to carry it out. Get a psych evaluation. If it's an actual threat, provide 1:1 monitoring or q15min (every 15 minute) checks. If there was no plan confirmed, continue with the psych evaluation and notification of the resident's PCP and family". The NHA noted that the psych service was "pretty quick", usually responding the same day. He stated that Social Service was a part of the referral process. 7. On 6-28-13 at approximately 2:35 p.m., a telephone interview was conducted with one of the facility psychiatric consultants, an ARNP (Advanced Registered Nurse Practitioner) who provided the assessments for residents #337, #325 and #145. The consultant was asked about her expectations of the facility staff when residents verbalized suicidal ideations or plans to harm themselves. The consultant stated the nurse should immediately evaluate the resident, call the PCP and contact psych for a consult. If immediate danger was determined, one on one observation should be started. 8. On 6-28-13 at approximately 2:32 p.m. an unsuccessful attempt was made to contact the facility Medical Director. His office stated that he was not on -call and would not be back in the office until Monday 7/1/13. The name of an on-call physician was given, but an alternate contact number for the Medical Director was not provided. Following the unsuccessful call, the NHA and DON were asked for an alternate number to contact the Medical Director. They provided the name and number of a "designee" physician they contacted when the Medical Director could not be reached. 9. At approximately 3:00 p.m. on 6-28-13, a phone interview was conducted with the Medical Director's "designee". He stated that he was in practice with the Medical Director and assisted him with associated responsibilities at the facility. He was then asked about his expectations of the facility staff if a resident verbalized suicidal ideations. He stated "the nurse should assess the resident for how serious the resident was. The degree of ideation would determine the level of response. The nursing staff should attempt to determine from the resident if there was a plan or method. Talk with the resident, notify their supervisor and call psych services". He noted the first priority was to keep the resident safe. 10. A second interview was conducted on 7-1-13 at approximately 10:00 a.m with Employee A, a facility Social Worker. She was asked who was responsible to update resident care plans following Social Service referrals. She stated that it was the responsibility of the assigned Social Worker. She stated that the goal was to update care plans as soon as new information was obtained. 11. The facility policy titled, "Suicide Threats", 2001 MED-PASS, Inc. (Revised December 2007) with a second Policy Revised date of 1/17/13 was reviewed. The Policy Statement noted, "Resident suicide threats shall be taken seriously and addressed appropriately". Policy Interpretation and Implementation contained seven items as follows: (1) Staff shall report any resident threats of suicide immediately to the Nurse Supervisor/Charge Nurse. (2) The Nurse Supervisor/Charge Nurse shall immediately assess the situation and identify if the resident has a plan or the means to carry out the suicidal ideation. (3) After assessing the resident in more detail, the Nurse Supervisor/Charge Nurse shall notify the resident's Attending Physician and responsible party, and shall seek further direction from the physician. (4) If threat validated, all nursing personnel and other staff involved in caring for the resident shall be informed of the suicide threat and instructed to report changes in the resident's behavior immediately. (5) As indicated, a psychiatric consultation or transfer for emergency psychiatric evaluation may be initiated through social services. (6) If the resident remains in the facility, staff will monitor the resident ' s mood and behavior and update care plans accordingly, until a physician has determined that a risk of suicide does not appear to be present. (7) Staff shall document details of the situation objectively in the resident's medical record. 12. There was no evidence that facility staff followed the facility policy in response to suicidal ideation by Resident #337, Resident #325 and Resident #145. No assessments were documented at the time that each resident verbalized suicidal thoughts. There was no communication between Social Services, Nursing and Therapy departments to ensure that all staff members caring for the residents were aware of each resident's at-risk status. There was no documentation that safety monitoring was discussed or conducted for any of the three residents. 13. A review was conducted of a PubMed article abstract titled, "Death ideas, suicidal thoughts, and plans among nursing home residents". The article was originally published in the June 2009 issue Journal of Geriatric Psychiatry and Neurology. (PubMed is a free resource for over 22 million citations for biomedical literature that is developed and maintained by the National Center for Biotechnology Information (NCBI), at the U.S. National Library of Medicine (NLM), located at the National Institutes of Health (NIH).) The article stated that "Recent studies have shown that suicides are at least as frequent among Nursing Home (NH) residents as they are among older people in the general population. One hundred seventy-two participants were surveyed with a response rate of 59.7%. Five sample questions were asked to investigate the presence of death- and suicidal thoughts, plans and behaviors in different time periods. Among the NH residents, 30.8% admitted having had death or suicidal thoughts or plans during the month prior to the interview. The oldest-old residents (85+y) more frequently reported death-suicide ideation. This high frequency of death and/or suicidal feelings and thoughts among older NH residents should be carefully considered when planning and implementing health care programs in these facilities." 14. The facility initiated measures to remove Immediate Jeopardy on 6-28-13. The measures were as follows: The facility policy titled "Suicide Threats" was revised and renamed "Suicide Prevention". The revised policy listed warning signs for suicidal thoughts and specified immediate reporting to the DON, NHA and SSD who would then direct the procedure. The revised policy included a Suicide Risk Assessment Tool to assess the identified at-risk resident's risk of harm to self. The revised policy also included monitoring forms for q15minute and/or 1:1 monitoring as indicated based on the results of the Suicide Risk Assessment Tool. A copy of the revised policy was placed in the MAR on each medication cart at each nursing station. A copy of the revised policy was given to each employee as part of in-service education. In- service education was provided to all facility employees in all departments including nursing, housekeeping, dietary, social services and therapy services. Per the NHA, an education module dealing with suicide in the elderly was to be added to the facility annual mandatory in-service requirement, as well as to new employee orientation education. An Ad Hoc QA meeting was scheduled to address cited deficiencies and develop a monitoring plan to maintain compliance. On 7-1-13 at approximately 1:00 PM, the DON and NHA stated 100% of the facility staff had been in-serviced on the new Suicide Prevention Policy. Sign-in sheets were provided to show employee participation in the in-ser

Based on observation, interview and record review, the facility failed to ensure that timely support services were rendered, including evaluation, to promote mental and psychosocial stability for residents who were identified as at risk for suicide. This affected three of four residents reviewed for suicidal ideation. Residents #325, #337 and #145 expressed suicidal thoughts on 6-18-2013 (#325), 6-21-2013 (#337) and 6-23-2013 (#145), within six days of each other. Resident #325 appeared on a Psychiatric Consult log for June 2013 after Social Services received a report on 6-18-2013 that he had verbalized suicidal thoughts during a therapy session. The resident was not provided a psychological evaluation until 6-24-2013, six days after the initial report of suicidal ideation. Following the report to a social worker on 6-18-2013, there was no documentation that Social Services communicated the resident's suicidal thoughts to the nursing staff or informed nursing that a psychological consult had been requested. There was no documentation that the physician or family was made aware of the resident's suicidal thoughts. There was no evidence of an assessment of the resident's mood immediately following the verbalized suicidal thoughts to determine the psychosocial needs of Resident #325 and no evidence of an environmental safety assessment. Resident #337 verbalized a desire to commit suicide on 6-21-2013. The facility waited 72 hours before requesting a psychological evaluation on 6-24-2013. During that time there was no evidence of an assessment of the resident's mood or mental state to determine the resident's immediate psychosocial needs or evidence or an environmental safety assessment. Due to failure of Social Services to follow-up on the initial psychiatric consult request, the psychological evaluation, ordered on 6-24-2013, was not done until 6-27-2013, six days following the resident's documented suicidal ideation. The facility was not aware that the psychological assessment for resident #337 had not been completed until questioned by the survey team on 6-27-2013. Resident #145 was overheard by nursing staff on 6-23-2013 as he expressed a desire to kill himself. Following documentation of the event in the medical record, there was no evidence that an assessment was done to determine the resident's mental status at the time of the event, or evidence of an environmental safety assessment. There was no documentation that the physician or family was notified of the resident's statements. A written request for a psychological consult was sent to Social Services on Sunday 6-23-2013, but was not received until the Social Services staff arrived on Monday morning 6-24-2013. The psychological evaluation was not completed for more than 24 hours following the initial documentation of suicidal thoughts by Resident #145. The facility response to these residents at risk for suicide resulted in the determination of Immediate Jeopardy on 7-1-2013. The finding of Immediate Jeopardy was found to be removed on 7-1-2013 at 3:45 p.m. and the scope and severity reduced to an E. Findings included: 1. Resident #337 was admitted from a hospice facility on 6-14-13 with [DIAGNOSES REDACTED]. The Medical Certification for Nursing Facility, Home and Community Based Waiver form 3008 dated 6-13-13 stated in section D - Additional Orders - (local hospice) to follow. An undated hand-written note was noted on the medical record which contained demographic information about the resident, including that she was "coming from hospice" and was to receive hospice services from a local provider while in the facility. The following assessment documentation was noted on a hospital note, dated 6-10-13: "[AGE] year old woman with hospice [DIAGNOSES REDACTED]. Six months or less prognosis should the disease take expected course. Given my current assessment, findings and progression of her terminal condition, I expect a continued decline and demise in a matter of days to weeks. Inpatient level of care, to manage pain. However in light of symptom improvement, social worker to begin disposition planning with possible change in level of care very soon. Anxiety, intermittent. Managing with [MEDICATION NAME] 0.5-1mg (milligram) every 4 hours as needed. We will address any further symptoms as they arise. " The Nursing Data Collection, dated 6-14-13, noted on page 1, Neuro/Cognitive section, that the resident had a short term memory problem, was aware that she was in a nursing home and was modified independent for decision making with some difficult in new situations. On page 2, item (1) Indications for Depression was checked " none of above " . Item (3) Sad Mood was checked " none of above " . The section titled ADLs (Activities of Daily Living) noted that the resident required extensive assistance with all ADLs. The narrative entry stated the resident was alert and oriented with some confusion. No acute distress noted. The Nursing Interim Care Plan dated 6-14-13 showed a check by the section titled Problem: Needs to adjust to Health Care Center and routine. Goal: Demonstrate appropriate coping techniques through the next review. Approaches: Continuity of care is given. Give as many choices as possible and control of daily routine. Welcome resident to activities. Psych consult as needed. There were no additional interim care plans noted related to anxiety or other potential psychosocial issues. A 24 Hour Flow Sheet/New admitted d 6-14-13 for the 3p to 11p shift noted the following documentation in the Neurological/Psychosocial section: "Oriented - to person, place and time. Mental- impaired memory." The 6-15-13 Flow Sheet for the 11p to 7a shift noted Mental - "cheerful, impaired memory." The 7a to 3p shift Flow Sheet for 6-15-13 noted Mental- "cheerful." The 3p to 11p Flow Sheet for 6-15-13 noted Mental - "confused, depressed." The 11p - 7a Flow Sheet for 6/16/13 noted Mental- "confused, depressed." The 6-16-13 Flow Sheet for the 7a to 3p shift and the 3p to 11p shift showed no Mental documentation in the Neurological/Psychosocial section. The 6-17-13 Flow Sheet showed no documentation for Mental status in the Neurological/Psychosocial section for any of the three shifts on that date. There was no documentation that the nursing staff reported to the physician the documented change in the resident's mental state from "cheerful" on the day shift on 6-15-13 to"depressed" on the evening of 6-15-13. There was also no documentation related to any additional assessment, monitoring or change in care approaches following the documented change in mental state. A care plan, dated 6-21-13, noted that the resident was being seen by hospice [MEDICAL CONDITION] with mets (metastasis). The goal stated that the resident would receive hospice services to achieve the desired level of comfort and maintain quality of life. Approaches included that the hospice nurse was to visit every two weeks and prn (as needed). Further record review revealed an Interdisciplinary Note from nursing, dated 6-21-13, which stated that the resident's POA (Power of Attorney) was upset and reported to the evening nurse that the resident had told her,"If I could find a way to commit suicide, I would". The nursing note continued to say that the physician had been called and the nurse was waiting on a return call. The nurse documented that the resident was "very depressed" and that [MEDICATION NAME] was given per order. The note stated ,"Will continue to monitor, call light placed in reach". There were no additional notes entered on 6-21-13 related to any additional assessment, the type and extent of monitoring provided or any other information about a return call by the physician. There was no evidence that the resident's environment was assessed to ensure that there were no objects that could be used by the resident to cause self-harm. The next nursing note found for Resident #337 was not entered until 6-25-13 at 1:36 a.m. and made no reference to the suicidal ideation documented on 6-21-13. Employee D, a Resident Care Manager (RCM) on the resident ' s unit was interviewed on 6-27-13 at approximately 1:44 p.m. Employee D was shown the Nurse's Note dated 6-21-13 and asked if she were aware that the resident had verbalized suicidal thoughts. She stated she had not been previously aware of the incident. Employee D contacted Employee A, a facility Social Worker, and was informed that a psychiatric evaluation was completed on Resident #337 on 6-24-13. An interview was conducted with Employee A on 6-27-13 at approximately 2:13 p.m. Employee A revealed that on 6/24/13 there was a referral placed in her box for Resident #337 requesting a consult for psychiatric services. The SS (Social Services) referral form was dated 6-21-13 and requested a psychiatric consult for the reason listed as "Depression". Comments on the referral form stated "Resident's POA very concerned because resident is talking about suicide. Requests for psych consult." The form was signed by the nurse who had documented the incident in the nursing notes on 6-21-13. A handwritten note on the bottom right corner stated "Text to (psychiatric provider) in building currently". Employee A was asked if she spoke with Resident #337 after learning of the resident's suicidal thoughts and/or assessed the resident for depression or increased anxiety. Employee A revealed she had not done so. Employee A was asked whose responsibility it was to assess the resident at that time. Employee A stated it was the responsibility of the nursing department. Employee A was asked if the psych evaluation requested on 6-24-13 had been done. She stated it was completed on that same day, 6-24-13. Employee A was asked to obtain a copy of the psych evaluation as there was no copy on the resident's chart for review. Employee A called the unit, spoke with Employee D, and learned that the evaluation was never completed. Employee D explained that the psychiatric consultant noted on the chart that the resident was receiving hospice services. Per Employee D, the consultant did not complete the evaluation, as psychosocial support for hospice clients was provided by hospice providers. When Employee D contacted the local hospice provider for copies of hospice care plans, it was discovered that the physician order [REDACTED]. Employee D confirmed that Resident #337 was not receiving any hospice services at the time that the psychiatric referral was made and then deferred. Employee D stated she would make the hospice referral now and was also observed to write an order on 6-27-13 at 2:45 p.m. for a psychiatric evaluation to be done on Resident #337. The resident had received no psychosocial support services since admission on 6/14/13 and no psychiatric assessment following her suicidal comments on 6/21/13. An interview was conducted with Employee B at 3:40 p.m. on 6-27-13. She confirmed that she was the nurse who made the record entry on 6-21-13 that Resident #337 had verbalized suicidal thoughts. The employee stated that the resident's POA (Power of Attorney) came up to her after visiting the resident in the sun room that day. She described that the POA appeared upset, "looking like she wanted to cry". She stated that the POA reported to her that the resident said, "If I could find a way to commit suicide, I would". Employee D stated she talked with the resident the next day, but did not make a note in the chart. She stated, "I wanted to see if she mentioned anything. I asked her if she was feeling better about being here. She said she didn't need to be here because she could take care of herself". Employee B was asked if she went to the resident's room to assess the resident on the evening of 6-21-13. She stated that she spoke with the resident that night, but that she did not ask her about "that word". Employee B stated that the resident "looked like her usual self - she was depressed. I called the doctor and told him what the POA said. Since she didn't say anything to me, I can't really act on it". Employee B was asked about the resident's demeanor and appearance on the evening of 6-21-13. Employee B stated that the resident "looked sad, but she looked sad when she came in". Employee B was asked if the resident"s physician gave any new orders that night. She stated that he ordered [MEDICATION NAME] for the resident. She was asked to show the new order received on 6-21-13. After searching the chart for an order, Employee B stated, "I gave her some [MEDICATION NAME] that was ordered when she came in. It was already on the MAR (Medication Administration Record)". Employee B was asked again if she spoke with the physician that evening, as her note referenced that she was waiting for him to return her call. Employee B stated she did speak with the physician, but that she forgot to write a follow up note documenting her conversation with him. Employee B was asked if she reported the resident's comments about suicide to the DON (Director of Nursing), RCM (Resident Care Manager), NHA (Nursing Home Administrator) or RM (Risk Manager). She responded, "I know some places you call and report. But it can't be hearsay. It must come from the resident. That'swhy I talked with her. She was feeling better about not having pain, but she was not happy about being here". She was asked if she questioned the resident about having a plan to commit suicide. She responded,"No!" Employee B was asked if she had received any in-service education about how to handle residents who talked about suicide. She stated, "Yes, but I'm not sure if I've been to one here. I've only been here since November". She was asked if the facility education gave directions as to what should be done when a resident talks about suicide. She stated, "I'm not sure about here, but I"ve heard in other places that you should notify the DON and put the resident on a watch. But I knew the resident in the community before she came here. I used to work in a grocery store and she was one of my regular customers. She's always been sad". Employee B was asked if she reported the incident to anyone else. She stated she reported it to the oncoming nurse in shift report. She was shown the Social Services referral form and asked if she had made the referral. She initially was hesitant, but then replied that she had completed the referral form that was received in the Social Services office. During an interview on 6-27-13 at 4:00 p.m., Resident #337 was asked if she remembered making the statement "If I could find a way to commit suicide, I would"? She responded, "Who told you that? I might have said that or said I wish I was dead. Every once in a while, I think about it but not all the time." When the resident was asked if she was unhappy, she stated, "I'm not happy. I don't even know why I am here. But I wasn't trying to kill myself'. The resident was asked if she had ever thought about a particular plan or way to commit suicide. She replied, "No. It's like a thought that slides into my head then out of my head". An interview was conducted with the ADON (Assistant Director of Nursing) on 6-27-13 at 4:20 p.m. The survey team informed her of the findings related to the facility's response to Resident #337 following her statement regarding suicidal thoughts. The ADON was unaware that the psych evaluation had been ordered and not completed for Resident #337 until discovered by the survey team. She was asked to comment on the response of Employee B to the resident at the time of the incident. She was also asked about the facility policy related to residents with suicidal thoughts and what the facility expectations were for the staff in that situation. The ADON asked if she could obtain the facility policy before continuing the interview. The ADON left to get the policy put did not return. At 5:00 p.m. the ADON was located by a member of the survey team and a copy of the facility policy titled "Suicide Threats" was provided. At 5:55 p.m. on 6-27-13, Resident #337's psychiatric evaluation was completed. The psych note was reviewed by the DON and surveyor. Per the psych consult note, the resident denied suicidal ideation at the time of the evaluation. She stated that she must have been misunderstood. 2. Resident #325 appeared on the Psychiatric Consults log for June 2013 for a referral request related to "increased confusion, suicidal thoughts". Medical record review showed that the resident was a [AGE] year old male admitted on [DATE] with [DIAGNOSES REDACTED]. Per a hospital history and physical, dated 4/19/13, the resident complained of dizziness and headaches and was sent by his PCP (Primary Care Physician) to a local hospital for evaluation and subsequently diagnosed with [REDACTED]. During his hospitalization the resident attempted to transfer and walk on his own and fell to the floor. He sustained a head injury as well as a scalp laceration. After stabilization at the local hospital the resident was transferred to a local rehabilitation facility for extensive therapy services and then to the long term care facility for skilled services on 4-26-13. On admission to the facility, the resident's medication orders included [MEDICATION NAME] XR 75 mg (milligrams) Q12h (every 12 hours) for the [DIAGNOSES REDACTED]. A review of the Nursing Data Collection assessment for Resident #325, dated 4-26-13, did not reflect the resident's use of an antidepressant. Documentation revealed the following: Section D, Mood and Behavior, Item (1) Indications for Depression was documented as "None of above". Item (3) Sad Mood was documented as "None of above". Section (5) [MEDICAL CONDITION] Medications included a selection for antidepressant use which was not checked. The box for "None of above" was checked. The Initial Social Service assessment dated [DATE] noted that the resident was alert, oriented and able to make his needs known. The resident stated that he did not suffer from depression, anxiety or [MEDICAL CONDITION]. No memory issues were noted and he was described as independent in making decisions. Physician Progress Notes dated 5-1-13, 6-11-13 and 6-13-13 revealed that the resident had additional [DIAGNOSES REDACTED]. A review of the MDS (Minimum Data Set), dated 6-8-2013, showed that the resident had a BIMS (Brief Interview for Mental Status) score of 15 out of a possible 15. Section D, Resident Mood Interview noted that the resident was coded 0 = No for "feeling down, depressed or hopeless". He was coded 0 =No for "thoughts that you would be better off dead or of hurting yourself in some way". Section G, Functional Status documented that the resident required extensive assistance of one for transfers and all ADLs (Activities of Daily Living) except eating. Functional limitation of ROM (Range of Motion) was noted on the right side. A review of the Psychiatric Consult log for June 2013 showed that a referral had been made for Resident #325 for "increased confusion, suicidal comments". There was no documentation on the resident's medical record to indicate when the suicidal comments were made or to whom. There was no referral form found on the chart for a psychiatric consult. Employee A, a facility Social worker, was interviewed on 6-28-13 at 11:20 a.m. She was asked how referrals were requested for psychiatric consults. She stated that nursing usually made the referral request on a Social Services Referral "pink slip". She was asked if she could provide a copy of the referral for Resident #325. When she was unable to locate a copy of the referral in the computer, she recalled that the referral was generated due to a report from a therapy staff member. She stated that during a Utilization Review meeting on 6-18-2013, it was relayed to her by the Rehabilitation Manager that an unknown therapist had reported the resident had made comments about "cutting his arm off " and "ending it". She produced a paper titled Utilization Review Meeting with hand-written notes in the bottom left corner. Beside the typed name of Resident #325 was written "requesting U/A (urinalysis) and psych eval.". An upward arrow was noted followed by "increased confusion and suicidal comments. Pt. (patient) making comments about chopping arm off and ending it". Employee A was asked if she spoke with the resident or did any type of assessment after she learned of the resident's statements about wanting to hurt himself. She stated that she did not. She was asked why it took six days to have the psychiatric evaluation completed. Employee A stated that she did not think that the situation was urgent. She stated when she made the referral to the psychiatric services provider on 6-18-13, she informed them that it was not an urgent request. She stated that was the reason the psychiatric service did not come out immediately, but waited until their scheduled weekly rounds the following Monday 6-21-13 to see the resident. Employee A was asked how she made the determination regarding the urgency of the resident's suicidal ideation without an assessment of the resident.. She stated, "The way it was presented to me, he didn't have a plan". A review of a Psychiatric Service Outpatient progress note dated 6-24-13 revealed a consult for "increased confusion and suicidal comments". The documentation stated that the resident was in no distress and denied suicidality and that the current treatment plan was to be continued. On 6-30-13 at approximately 12:00 p.m. Resident #325 was observed sitting up in his wheelchair interacting with staff members in the dining room. The resident was well groomed and dressed in clothing appropriate for the season and time of day. In an interview on 6-30-2013 at 12:04 pm, Employee E, an RCM on the unit where Resident #325 resided, was asked if she was aware of the resident wanting to cause self- harm. Employee E stated she was not aware of it until the psychiatric consultant was on the unit and asked her what room the resident was in. Employee E was asked if Social Service had informed her of the suicidal comments that were reported by therapy on 6-18-13. Employee E stated she was not aware of any concerns or suicidal thoughts verbalized by resident #325. There was no documentation in the medical record that showed an assessment was done to determine the resident's mental status at the time he made suicidal comments. There was no evidence that safety monitoring was discussed or implemented. There was no documentation that an environmental assessment had been done to ensure that there were no objects that could be used by the resident to cause self-harm. An interview on 7-1-13 at 9:45 am with the Rehabilitation Manager revealed that on 6-18-13, she had attended a Utilization Review Meeting and shared the statements made by resident #325 about " ending it " . She stated that she had made the hand written comments on the document provided by Social Services. She noted that, prior to the Utilization Review meeting, concerns about the resident ' s increased confusion and possible delusional statements about wanting to cut his arm off were discussed in the therapy department. She stated she could not recall which therapist had given her the information. She stated she had questioned the therapy staff, but had not been able to identify the source of the report made to her. A review of care plans for resident #325 on 6-28-13, 6-29-13 and 6-30-2013 revealed that there were no care plans developed to address the use of antidepressants or to manage the resident's [DIAGNOSES REDACTED]. There were no care plans available for review that addressed the resident's comments related to self harm and suicidal thoughts.. 3. Resident #145 also appeared on the Psychiatric Consults for June 2013 related to "suicidal thoughts". Medical record review showed that the resident was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Nursing Data Collection dated 5-2-13 noted in section 8, Physical Assessment, that the resident had short term memory problems and was moderately impaired in decision making, with cues and/or supervision required. In section D, Mood and Behavior, item (1) Indications of Depression - None of above was selected. Item (3) Sad Mood - None of above was selected. Item (5) [MEDICAL CONDITION] Medications - None of above was selected. A MDS (Minimum Data Set), dated 5-2-13, showed a BIMS (Brief Interview for Mental Status) score of 9 out a possible 15. Section D0200 titled Resident Mood Interview revealed documentation that the resident was coded 0 = No for symptoms of "feeling down, depressed or hopeless" and for "thoughts that you would be better off dead, or of hurting yourself in some way". Section G of the MDS -Functional Status- noted that the resident was independent with transfers in his room as well as ambulation on the unit. He required supervision for locomotion off the unit. Balance during transitions and walking noted that the resident was not steady, but able to stabilize without staff assistance and utilized a walker as an assistive device. An Interdisciplinary Note on 5-4-13 noted that the resident used a walker to ambulate, but often did not wait for assistance and was a fall risk. Staff assistance was needed for toileting and dressing. An Initial Social Service Assessment, dated 5-3-13, page 1, stated that the resident was alert, oriented and able to communicate his needs to the staff verbally. It was noted that he had a [DIAGNOSES REDACTED]. Prior Level of Functioning noted that the resident used a walker and a cane. Page 3 noted in the section titled Psychosocial Information and Social Practices/Behavior that the resident denied any issues with depression. Care Plan Review Notes, dated 5-23-13, noted the wife's statement that the resident had shown a rapid decline in cognition with increased paranoid behavior. Social Service Notes documented that a psychiatric referral was made on 5-6-13 and the resident was seen on that date. A note on 6-24-13 stated "seen by psych group" - no reason given. An undated Behavior Monitoring flow sheet for the identified behaviors of Agitation and [MEDICAL CONDITION] was noted on the medical record. A Behavior Monitoring flow sheet for June 2013 was found for identified behaviors of Mood Swing and Paranoia. On the form for Mood Swings, documentation was noted on the 7-3shift on 6-23-13 and 6-24-13. Interventions noted on 6-23-13 per the Intervention Codes listed on the left side of the form included #7- Give food, #8- Give fluids, and #15 - medication. Per the MAR (Medication Administration Record) for June 23, 2013, no prn (as needed) medications were documented as given. The resident had an order for [REDACTED]. The only dose recorded on the MAR was on 6-15-13. There was no nursing note entry for 6-23-13 on the 7-3 shift. A Weekly Summary was noted for 6-25-13 which documented Mood/Behaviors as "restless, resists care and meds at times". A nursing note entry at 3:30 a.m. on Sunday 6-23-13, however, stated, "When changing resident, CNAs (Certified Nursing Assistants) heard resident talking about wishing he could kill himself. Roommate then confirmed to CNAs that he says things like that every night. Social Services Referral filled out for Psych consult". There was no additional documentation to indicate that further assessment was done of the resident's mood or mental status at that time or to determine if additional monitoring was needed to ensure the resident's safety. There was no evidence that the environment was assessed to ensure that there were no objects that could be used for self-harm. Despite previous documentation by SS and the Admission nurse that the resident had denied feelings of depression on admission, nursing staff did not respond to a change in the resident's mental state when he verbalized a desire to kill himself. Two attempts were made to contact the nurse who made the record entry on 6-23-13. On a review of the employee file, she was identified as working for the facility on a "prn" (as needed) basis on the week-end night shift. Both contact attempts were unsuccessful. A call-back number was provided with a request for the nurse to contact the surveyor. At the time of exit on 7-1-13, no return call had been received. Resident #145 was observed at approximately 4:00 p.m. on 6-28-13 sitting in a wheelchair at the nursing station. He appeared appropriately dressed and groomed. An attempt was made to interview the resident who was confused and oriented to person only at that time. He was unable to participate in a meaningful interview about the documented events on 6-23-13. 4. An interview was conducted with the Social Services Director on 6-28-13 at 11:00 a.m. She was asked to describe the referral process. She stated that when the office received the request for referral form, the referral was processed and the provider notified. She noted that in the event of a reported suicidal ideation, "typically a SW (Social Worker) will talk with the resident and assess for a plan and the resident's emotional state". The SW would then communicate to nursing as to any monitoring that may be needed. She noted that a psychiatric service consultant was in the building weekly, but would come in immediately if needed for someone having suicidal thoughts. She was asked about the facility policy for staff response to a resident with suicidal thoughts. She stated "the procedure was to contact the physician, notify SS, the DON, RM and ADON. The staff member should talk with the resident and/or make the referral. If suicidal ideation is reported, the psychiatric service will come in. Nursing would monitor with more frequent checks to assure safety. If the resident has an actual plan, the staff must ensure they can't act on it. Staff may do 1:1 monitoring if needed before the psychiatric service comes in". She was asked if there was a policy for SS to interview a resident before a psych referral is made. She stated she did not think it was a written policy, but that "it is usually done to have more information to give to the doctor " when the referral is made. 5. A Psychiatric progress note showed that Resident #145 was seen on 6-24-13 by the psychiatric service. The consult was documented as a " follow-up " and there was no specific documentation related to suicidal ideation. An interview was conducted with Employee A on 7-1-13 at 10 a.m. to determine what information was given to the psychiatric service when a consult was requested. She noted that there was a log book on both nursing stations for the psychiatric service. She noted that the resident's information was entered in the log book along with the reason for the referral. She stated the information was available to the psych provider on weekly rounds. She stated that the referral was called directly to the provider if it was considered an immediate threat. She was asked who made the decision as to what constituted an "immediate threat". She stated that the decision was made by nursing and SS, and sometimes therapy. She was asked if the referrals for residents #337, #325 and #145 were called to the psychiatric service as "immediate threats". She stated that for residents #337 and #145, the consultant was in the building on the morning that the referral requests were received. She stated she spoke with the consultant directly at that time to give the referral information. She stated again that the situation with resident #325 was not considered an immediate threat based on the information provided to her on 6/18/13 at the Utilization Review meeting. 6. An interview was conducted o

Based on observations, record review, resident and staff interviews and a review of the nursing home administrator job description, it was determined that the facility failed to be administered in a manner that used resources to maintain the highest practicable mental and psychosocial well-being for residents who expressed thoughts of self-harm or suicide. This practice affected three (#337, #325 and #145) of four residents reviewed for suicidal ideation. The administration did not ensure that needed mental health services, support and monitoring for resident safety were provided in accordance with facility policy and accepted industry standards of care related to the recognition and management of residents with suicidal ideation. Resident #325 was identified to Social Services on 6-18-13 after being heard to express a desire to harm himself and "end it". A psychiatric evaluation was not completed until 6-24-13, six days following the report of the resident's suicidal ideation to the facility social worker. Resident #337 was documented as verbalizing suicidal thoughts on 6-21-13. A psychiatric evaluation was not ordered until 6-24-13. Due to a transcription error of a related physician's order and failure of the Social Services Department to follow up on the initial referral, the psychological evaluation was not done until 6-27-13, six days following the resident's documented suicidal ideation. Resident #145 expressed a desire to kill himself on 6-23-13. A psychiatric evaluation was not done for over 24 hours after the resident's documented suicidal ideation. There was no evidence to indicate that any type of mental health assessment was done or that emotional support was provided to any of the three identified residents at the time that each resident verbalized severe emotional distress through suicidal thoughts and no evidence of environmental safety assessments to prevent self-harm. The practice of failure to ensure the prevention of self-harm and to ensure the timely provision of appropriate services and treatment for [REDACTED]. The finding of Immediate Jeopardy was found to be removed on 7-1-13 at 3:45 p.m. and the scope and severity reduced to an E. Findings included: 1. A review of the position description for Nursing Home Administrator for the facility dated 10-11-2009 revealed the following Primary Purpose and Job Function: "The purpose of this position is to provide leadership to the organization by planning, organizing, implementing, evaluating, and directing the facility's nursing, social services, medical records, case management, programming, MDS (Minimum Data Set), and spiritual care processes. The Nursing Home Administrator is responsible for the creation and maintenance of a culture of respect and responsiveness for both residents and staff and ensures the accomplishment of quality, clinical, financial, staff satisfaction and strategy outcomes." Essential Functions and Accountabilities included: ? Plans, organizes, evaluates and directs day to day functions according to policies, procedures and applicable regulatory, statutory and accreditation requirements. ? Assists in the development, use, enforcement and updates of policies and procedures to assure continued compliance ? Selects, encourages and evaluates staff, contractors, medical directors, and consultants to supervise and support Health Care Center processes and programs. ? Assures that the residents rights to fair and equitable treatment, self-determination, individuality, privacy, property and civil rights are well established and maintained at all times." The section titled, "Working Conditions" included the following statements: "Involved with residents, family members, personnel, visitors, government agencies/personnel, etc., under all conditions and circumstances. Communicates with the medical staff, nursing personnel and department supervisors." 2. Resident #337 was an [AGE] year old female who was admitted to the facility on [DATE] per the facility face sheet [MEDICAL CONDITION] to the brain, breasts, lungs and spine. The resident had additional [DIAGNOSES REDACTED]. On 6-27-13 while reviewing the resident's medical record, it was noted in several of the resident's care plans that hospice services were being provided. A Care Plan, dated 6-21-13, was identified as a Risk for Skin Breakdown Care Plan. In the Problem/Need section it was stated: "Resident is incontinent of bowel and has an indwelling foley catheter for urine. She has a terminal dx [MEDICAL CONDITION] with metastasis. She is seen by Hospice. She is at risk for skin breakdown due to weakness, incontinence, pain and dx [MEDICAL CONDITION]." Under the approach section of the same care plan it stated: "Air mattress provided by Hospice." A Care Plan, dated 6-21-13, was identified as a Pain and Comfort Care Plan. In the Problem/Needs section it stated: "Resident is being seen by Hospice [MEDICAL CONDITION] with metastasis. She wishes to be kept comfortable. She is on routine pain medication for pain. She is at risk for increased pain ". The Goal & Target Date section stated: "Resident will receive Hospice Services to achieve the desired level of comfort and maintain quality of life." The Approaches section stated: "Hospice nurse to visit Q (every) two weeks and prn (as needed)." Transfer orders, dated 6-13-2013, received from the referring agency revealed the resident was to continue receiving hospice services from a local provider following admission to the facility. An AHCA (Agency for Health Care Administration) form 3008 dated 6-13-13, showed Section (D) Additional Orders: local Hospice to follow. A handwritten paper in the resident's record, containing an undated condition report with the resident's name and care needs prior to the resident 's admission to the facility, revealed the resident was to receive hospice services from a local provider while at the facility. Employee D, one of the Resident Care Managers (RCM) on the resident's unit, was asked if she could locate the resident's care plans from the local hospice agency. Employee D contacted the local hospice and discovered that the facility had not contacted the local agency to inform them of the physician order for [REDACTED]. On 6-27-13, Employee D relayed the admission order to the local provider to initiate hospice services. Further review of the resident's record revealed on 6-21-13 at 8:55 p.m. a nursing note was written by Employee B which stated, "POA (Power of Attorney) in to visit this evening. States that " I am very concerned because she (resident) told me, " If I could find a way to commit suicide I would. " Called (primary care physician) to notify of residents (sp) status, waiting on return call. Resident is very depressed, gave [MEDICATION NAME] per orders. Will continue to monitor. Call light placed in reach. " There was no documentation that the resident's emotional state was assessed or evaluated at the time of the report. There were no additional notes related to monitoring to ensure the resident's safety or that the environment was assessed to ensure there were no objects that could be used for self-harm. There was no documentation that a return call was received from the physician. The next nursing note entry was dated 6-25-13, some four days later, which contained no reference to the resident's suicidal comments. On 6-27-13 at 1:44 p.m. Employee D (RCM) was asked if she was aware that Resident #337 had verbalized suicidal thoughts. Employee D stated she was not. Employee D called a facility Social Worker, Employee A. She learned that on Monday 6-24-13, three days after the resident verbalized [MEDICAL CONDITION], Employee A found a referral dated 6-21-13 in her office requesting that psychiatric services see the resident. An interview with Employee A was conducted at approximately 2:13 p.m. on 6-27-13. She was asked if she was aware that Resident #337 had verbalized [MEDICAL CONDITION]. She stated that she was aware of the situation. Employee A went on to say that, on the morning of 6-24-13, a referral had been placed in her box for Resident #337 to have a consult for psychiatric services. Employee A was asked, after learning of the resident ' s suicidal thoughts, if she spoke with the resident and/or assessed her for depression or increased anxiety. Employee A revealed she had not. Employee A was asked whose responsibility was it to assess the resident for depression or mood problems. Employee A stated that it was the responsibility of nursing. Employee A was asked if the psychiatric evaluation had been completed for Resident #337. She stated it was completed on the same day it was requested, which was 6-24-13. She was asked to obtain a copy of the psych evaluation for the surveyor to review as there was no copy in the resident's chart. Employee A called the unit, spoke with Employee D and learned that the psych evaluation was never completed. Per Employee D, as the resident was thought to be receiving hospice services (including psychosocial services), the psychiatric consultant did not complete the evaluation. As previously determined, the resident was not receiving the hospice services at the time that the psychiatric referral was requested and deferred. Employee D was observed to write an order for [REDACTED]. An interview on 6-27-13 at 3:40 p.m. was conducted with Employee B. She was asked if she was the nurse who made the entry on 6-21-13 regarding Resident #337 verbalizing [MEDICAL CONDITION]. She stated that she was. The employee revealed that the resident's POA came up to her after visiting the resident in the sun room that day. She stated the POA came back upset, "looking like she wanted to cry" and said the resident told her, "If I could find a way to commit suicide, I would. " Employee B went on to say that she talked with the resident the next day, but did not make a note in the chart. She stated, "I wanted to see if she mentioned anything. I asked her if she was feeling better about being here. She said she didn't need to be here because she could take care of herself." Employee B was asked if she assessed the resident on the evening of 6-21-13. She stated that she had spoken with the resident but that she did not ask her about "that word". Employee B stated, "She looked like her usual self - she was depressed. I called the doctor and told him what the POA said. Since she didn't say anything to me, I can't really act on it." Employee B was asked about the resident's demeanor and appearance. Employee B stated, "She looked sad, but she looked sad when she came in." Employee B was asked if the resident's MD gave any new orders that night. She stated that he ordered [MEDICATION NAME]. She was asked to show the new order. After searching the chart for an order, Employee B stated, "I gave her some [MEDICATION NAME] that was ordered when she came in. It was already on the MAR (Medication Administration Record). " Employee B was asked again if she spoke with the MD that evening as her note referenced that she was waiting a return call from the MD. Employee B stated she did speak with the MD but forgot to write a follow up note. Employee B was asked if she reported what the resident said to the DON (Director of Nursing), RCM (Resident Care Manager), NHA (Nursing Home Administrator) or RM (Risk Manager). She responded, "I know some places you call and report. But it can't be hearsay. It must come from the resident. That's why I talked with her. She was feeling better about not having pain, but she was not happy about being here." She was asked if she questioned the resident about having a plan to commit suicide. She responded, "No! " Employee B was asked if there had been any education about dealing with residents who made comments about wanting to commit suicide. She stated, "Yes, but I'm not sure if I've been to one here. I've only been here since November." She was asked if the facility education covered what to do if a resident talks about suicide. She stated, "I'm not sure about here, but have heard in other places that you should notify the DON and put the resident on a watch. But I knew the resident in the community before she came here. I used to work in a grocery store and she was one of my regular customers - she's always been sad." An interview was conducted on 6-27-13 at 4:00 p.m. with Resident #337. The resident was asked if she remembered making the statement "If I could find a way to commit suicide, I would"? She responded, "Who told you that? I might have said that or said I wish I was dead. Every once in a while, I think about it but not all the time." The resident was asked if she was unhappy. She stated, "I'm not happy. I don ' t even know why I am here. But I wasn't trying to kill myself." The resident was asked if she had ever thought about a particular plan or way to commit suicide. She stated, "No. It's like a thought that slides into my head then out of my head." On 6-27-13, the psychiatric consultant service completed the consult for Resident #337 at approximately 5:45 p.m. The report stated that the resident denied suicidal ideation at the time of the consult and stated she must have been misunderstood. 2. An interview was conducted on 6-28-13 at 11:00 a.m. with the Social Service Director (SSD). She was asked about the process in the Social Services department for making a referral for psychiatric services. She stated that when Social Services received a written request for referral or was notified of an issue requiring a psych evaluation, the referral was then communicated to the psychiatric consultant. She stated that if it was reported that a resident verbalized suicidal ideation, typically a Social Worker (SW) would talk with the resident and assess for a plan, the resident's emotional state, etc. The SW would then communicate with nursing as to the resident 's monitoring needs. She stated it was not a written policy for the SW to assess before submitting a referral, but that it was "usually done in order to provide as much information as possible" to the psych consultant. The SSD noted that there was a psychiatric service provider in the building weekly and that they could also be contacted immediately. The SSD was asked about the facility policy regarding who should be contacted when a resident expressed suicidal thoughts. She replied that the staff member should contact the physician, SS, DON, RM, and ADON. She noted that the staff member should talk with the individual and make a referral. If [MEDICAL CONDITION] were verbalized, the psychiatric service provider would be contacted and could come in "within hours". The SSD was asked to provide a list of psychiatric referrals related to suicidal thoughts or ideations since the last facility survey in April 2012. A Psychiatric Consults log was provided for March 2013 with one resident identified. The log provided for June 2013 log contained three resident names which included Resident #337. The two additional residents were identified as Resident #325 and Resident #145. 3. Resident #325 was a [AGE] year old male with admitting [DIAGNOSES REDACTED]. Per a hospital history and physical, the resident complained of dizziness and headaches and was transferred by his PCP (Primary Care Provider) to a local hospital for evaluation and subsequently diagnosed with [REDACTED]. During his hospitalization , the resident attempted to transfer and walk on his own and fell to the floor. He sustained a head injury as well as a scalp injury. After stabilization at the local hospital the resident was transferred to a local rehabilitation facility for therapy services. He was then transferred to the long term care facility for skilled services on 4-26-2013. Per the resident's admission Physician Order sheet dated 4-26-13, he was ordered [MEDICATION NAME] XR 75 mg (milligrams) every 12 hours for depression. A review of the resident's Admission Data Collection assessment completed by the Admissions Nurse, a Licensed Practical Nurse, and dated 4-26-2013 showed that the resident's antidepressant use was not captured. Section D, Mood and Behavior, item 1) Indications for Depression was listed as None of above and item 5) [MEDICAL CONDITION] medication used was listed as None of above. physician progress notes [REDACTED]. An interview with Employee A, a facility Social Worker, was conducted on 7-1-13 at 9:55 a.m. Employee A was asked how was she made aware of Resident #325 ' s verbalization of wanting to cause harm to himself. The Social Worker stated that it was reported to her at a Utilization Review meeting that occurred on 6-18-2013 that a physical therapy staff member had heard the resident making comments about wanting to "cut his arm off" and "end it. " Employee A was asked if she assessed the resident after learning of his suicidal comments. Employee A stated that she did not. Employee A was asked who was responsible for making an assessment when a resident verbalized harming themselves, or showed increased signs of depression. She stated that Nursing was responsible for any assessment. Employee #A was asked why it took 6 days before a psychiatric consult was done for Resident #325. Employee A stated that, from the information that was given to her during the Utilization Review meeting, she felt the resident was not in danger. She stated, "The way it was reported to me, he didn't have a plan." She stated that she determined that the consult could wait until the psychiatric consultant was in the building for scheduled weekly rounds, which was on 6-24-13, six days after the report that the resident made suicidal comments. A review of the medical record for Resident #325 showed no documentation related to suicidal thoughts or ideations as listed on the Psychiatric Consults log for June 2013. There was no documentation related to a resident assessment following suicidal ideation, monitoring for resident safety and no evidence that the resident's environment was assessed to ensure there were no objects that could be used for self-harm. A review of the resident ' s Nursing Interim Care Plan completed on admission revealed the resident's [DIAGNOSES REDACTED]. Care Plans on the resident's medical record were reviewed on 6-28-13, 6-29-13 and 6-30-2013. There were no Care Plans developed for the use of antidepressant medication. In addition there was no evidence of any non-pharmacological interventions in place to offer the resident when he exhibited depressive behaviors. Further review revealed there were no Care Plans available that addressed the resident's verbalization of wanting to cause self-harm. On 6-30-13 at approximately 12:00 p.m. Resident #325 was observed sitting up in his wheelchair interacting with staff members in the dining room. The resident was well groomed and dressed in clothing appropriate for the season and time of day. An interview with Employee E, an RCM on the resident's unit, was conducted on 6-30-13 at 12:04 p.m. She was asked if she was aware of that the resident had made statements about harming himself. Employee E stated she became aware of it when the psychiatric consultant was in and asked her for the resident's room number. Employee E was asked if Social Services had informed her that therapy staff reported Employee #325 made comments about harming himself. She stated she was not given that information. Employee E was asked if a resident had a [DIAGNOSES REDACTED]. Employee E stated that she "did not do anything with the Care Plans". She stated that "the other two RCMs do them ". She was asked when she last looked at the resident's care plan and she stated she was not sure. Employee E was asked what she would do if a CNA (Certified Nursing Assistant) reported to her that a resident wanted to harm him or herself. She shared that she would ask the CNA for more details about the event. She stated that after talking with the CNA, she would have a better feel of the event. She stated she would ask the CNA to keep a close check on the resident. She would let the floor nurse know, she would assess the resident and then notify the DON and SSD. 4. Resident #145 was identified on the June Psychiatric Consults log for "suicidal thoughts" on 6-24-13. Medical record review showed that the resident was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Nursing Data Collection Assessment, dated 5-2-13, noted in section 8, Physical Assessment, that the resident had short term memory problems and was moderately impaired in decision making, with cues and/or supervision required. In section D, Mood and Behavior, item (1) Indications of Depression - None of above was selected. Item (3) Sad Mood - None of above was selected. Item (5) [MEDICAL CONDITION] Medications - None of above was selected. Review of a Social Service assessment dated [DATE], page 1, revealed the resident was alert, oriented and was able to verbalize his needs and wants to the staff. There was also documentation of dementia with periods of confusion which required redirection at times. Page 3 of the Social Service Assessment noted in the section titled Psychosocial Information and Social Practices/Behavior that the resident denied any issues with depression. Social Service Notes revealed a psychiatric referral was made on 5-6-13 and the resident was seen on that date. Social Services Care Plan Review Notes dated 5-23-13 noted the wife's statement that the resident had shown a rapid decline in cognition with increased paranoid behavior. An undated Behavior Monitoring flow sheet for the identified behaviors of Agitation and [MEDICAL CONDITION] was noted on the medical record. A Behavior Monitoring flow sheet for June 2013 was found for identified behaviors of Mood Swing and Paranoia. On the form for Mood Swings, documentation was noted on the 7-3 shift on 6-23-13 and 6-24-13. Interventions noted on 6-23-13 per the Intervention Codes listed on the left side of the form included #7- Give food, #8- Give fluids, and #15 - medication. Per the MAR (Medication Administration Record) for June 23, 2013, no prn (as needed) medications were documented as given. The resident had an order for [REDACTED]. The only dose recorded on the MAR was on 6-15-13. There was no nursing note entry for 6-23-13 on the 7-3 shift. A Weekly Summary was noted for 6-25-13 which documented Mood/Behaviors as "restless, resists care and meds at times." An MDS (Minimum Data Set), dated 5-2-13, showed a BIMS (Brief Interview for Mental Status) score of 9 out a possible 15. Section D0200 titled Resident Mood Interview revealed that the resident was coded 0 = No for symptoms of "feeling down, depressed or hopeless" and for "thoughts that you would be better off dead, or of hurting yourself in some way." Section G Functional Status noted that the resident was independent with transfers in his room as well as ambulation on the unit. He required supervision for locomotion off the unit. Balance during transitions and walking noted that the resident was not steady, but able to stabilize without staff assistance and utilized a walker as an assistive device. An Interdisciplinary Note on 5-4-13 noted that the resident used a walker to ambulate, but often did not wait for assistance and was a fall risk. Staff assistance needed for toileting and dressing. A nursing note entry at 3:30 a.m. on Sunday 6-23-13 stated, "When changing resident, CNAs heard resident talking about wishing he could kill himself. Roommate then confirmed to CNAs that he says things like that every night. Social Services Referral filled out for Psych consult". Following documentation of the event in the medical record, there was no additional documentation that an assessment was done related to the resident's mental status at the time of the event. There was no evidence that the resident's environment was assessed to ensure there were no objects that could be used for self-harm. There was no documentation that the physician or family was notified of the resident's statements. The written request for a psychological consult was sent to Social Services on Sunday 6-23-13, but was not received until the Social Services staff arrived on Monday morning 6-24-13. The psychological evaluation was not completed for more than 24 hours following the initial documentation of resident #145's suicidal thoughts. Two attempts were made to contact the nurse who had made the record entry on 6-23-13. On a review of the employee file, she was identifed as working for the facility on a "prn" (as needed) basis on the week-end night shift. Both contact attempts were unsuccessful. A call-back number was provided with a request for the nurse to contact the surveyor. At the time of exit on 7-1-13, no return call had been received. A review of care plans located on the medical record showed a care plan, dated 5-3-13, which listed that the resident was at risk for mood decline and at risk for side effects of medication related to a [DIAGNOSES REDACTED]. Approaches included to observe for changes in mood and behavior with psych to evaluate and treat as indicated. There were no updates noted since 5-18-13. There was no additional care plan noted related to the resident's verbalized suicidal thoughts or approaches for monitoring related to the same. Resident #145 was observed at approximately 4:00 p.m. on 6-28-13 sitting in a wheelchair at the nursing station. He appeared appropriately dressed and groomed. An attempt was made to interview the resident who was confused and oriented to person only at that time. He was unable to participate in a meaningful interview about the documented events on 6-23-13. 5. A telephone conversation was conducted on 6-28-13 at 2:35 p.m. with the psychiatric consultant who provided services to the resident. She was asked about her expectations for staff response to a resident who expressed suicidal thoughts. She stated that the nurse should evaluate the resident, report immediately to the PCP and contact psychiatric services for a consult. If it was determined that there was an immediate danger, 1:1 monitoring should be done. A follow-up conversation on 7-5-13 at approximately 10 a.m. revealed that the consultant was already scheduled to see Resident #145 for a follow-up visit when she was given the new referral on 6-24-13. She stated she coded the visit as a follow-up for that reason, but did assess the resident for suicidality at that time. 6. An interview was conducted on 6-28-13 at 2:20 p.m. with the NHA (Nursing Home Administrator) and DON. The NHA was asked about his expectations of his staff regarding residents who verbalize [MEDICAL CONDITION]. The NHA stated the following: "If a staff member received a report of a resident verbalizing suicidal thoughts, it should be reported to the resident's physician. The charge nurse should be contacted to do an assessment - don't just report it to the next shift. Find out if the resident has a plan and a way to carry it out. Get a psych evaluation. If it's an actual threat, provide 1:1 monitoring or q15min (every 15 minute) checks. If there was no plan confirmed, continue with the psych evaluation and notification of the resident's PCP and family." The NHA noted that the psych service was "pretty quick", usually responding the same day. The NHA and DON were asked what type of in-service was provided to the staff related to suicidal prevention. They stated that education on that topic was a part of the new employee orientation as well as the annual evaluation. The NHA stated an electronic program was utilized for staff education. The staff member logged in to complete the required in-service and the staff education coordinator could access the record for compliance. The DON noted that an in-house presentation was done "recently" by an ARNP (Advanced Registered Nurse Practitioner) related to suicidal residents. At approximately 3:00 p.m., the NHA returned to clarify that suicide prevention was not a part of the computerized new orientation or annual training for the staff. He stated that an education module on suicide prevention could be added to the facility in-service schedule. 7. On 6-28-13 at approximately 2:30 p.m. an unsuccessful attempt was made to contact the PCP provider for Resident #337. A call back number was provided. On 6-28-13 at 4:00 p.m. a second attempt was made to contact the physician. A call back number was again provided. On 6-30-13, the PCP was contacted by phone at approximately 1:00 p.m. He was asked if he recalled being notified on 6-21-13 that Resident #337 had expressed a desire to commit suicide. He stated he could not confirm or deny whether he received a call on that date without checking phone records. He asked if a psych evaluation had been ordered for the resident. He stated that if he were told that a resident expressed a desire to commit suicide, he would give an order for [REDACTED]. He noted that if the situation warranted, he would give orders for a hospital transfer under a Baker Act. 8. On 6-28-13 at approximately 2:32 p.m. an unsuccessful attempt was made to contact the facility Medical Director. His office stated that he was not on -call and would not be back in the office until Monday 7/1/13. The name of an on-call physician was given, but an alternate contact number for the Medical Director was not provided. Following the unsuccessful call, the NHA and DON were asked for an alternate number to contact the Medical Director. They provided the name and number of a " designee " physician they contacted when the Medical Director could not be reached. When asked about the "designee's " official capacity with the facility, they stated that he was in practice with the Medical Director and was his "designee" . At approximately 3:00 p.m. on 6-28-13, a phone interview was conducted with the Medical Director's "designee." He stated that he was in practice with the Medical Director and assisted him with associated responsibilities at the facility. He was asked if he served in an official capacity with the facility and he replied that he did. He noted that he frequently attended the monthly Performance Improvement facility meetings. He was then asked about his expectations of the facility staff if a resident verbalized [MEDICAL CONDITION]. He stated "the nurse should assess the resident for how serious the resident was. The degree of ideation would determine the level of response. The nursing staff should attempt to determine from the resident if there was a plan or method. Talk with the resident, notify their supervisor and call psych services." He noted the first priority was to keep the resident safe. 9. A review of the facility policy titled "Suicide Threats", 2001 MED-PASS, Inc. (Revised December 2007) with a second Policy Revised date 1-17-13 was conducted. The Policy Statement noted "Resident suicide threats shall be taken seriously and addressed appropriately". Policy Interpretation and Implementation contained seven items as follows: (1) Staff shall report any resident threats of suicide immediately to the Nurse Supervisor/Charge Nurse. (2) The Nurse Supervisor/Charge Nurse shall immediately assess the situation and identify if the resident has a plan or the means to carry out the suicidal ideation. (3) After assessing the resident in more detail, the Nurse Supervisor/Charge Nurse shall notify the resident's Attending Physician and responsible party, and shall seek further direction from the physician. (4) If threat validated, all

Based on observation, interview and record review the facility failed to implement the care plan for 2 (#1, #4) of seven sampled residents related to transport in a wheelchair without leg rests in place which resulted in resident #1 sustaining a left ankle fracture and failure to provide supervision to resident #4 determined to be at risk for elopement. Findings include: 1. An initial observation of resident #1 was conducted, at 10:24 a.m., on 8/20/12. The resident responded verbally to the door knock and was agreeable for interview. She was alert with confusion evident. Her lower body was covered but appeared to have both lower legs elevated on pillows. The resident had no recollection of a recent injury. She stated she had a good breakfast, but preferred to remain in bed today. Review of the 72 hour charting/reports revealed an entry dated 8/2/12 10:30a.m. Residents L (left) ankle was bent back when she put her foot down while being transported in the wheel chair. An x-ray was ordered. Review of the available hospital records revealed the resident was seen 8/3/12 and diagnosed with [REDACTED]. On 8/21/12 another observation and interview was conducted at 10:30 a.m. The resident was awake, alert and verbal with confusion evident. The resident stated she gets out of bed sometimes and she believes she can stand up but was not sure. The resident ' s call light was on but she did not recall if she activated it. Staff #C (LPN) was interviewed on 8/21/12, at 10:35a.m., when she responded to the call light. She stated the resident was non-weight bearing. She did not believe the resident had been out of bed but would be transferred with a gait belt and assist of two persons. She thought the resident had not had a significant change since the fracture. An interview was conducted, on 8/21/12 at 10:40 a.m., with CNA #D assigned to resident #1 ' s care for the 7-3 shift. She stated this was not her usual assignment, she was a float. She stated information related to care can be obtained from nurses and the CNA leaving will verbally tell the next care giver about anything that occurred during their shift. Staff can also find information about the resident on the care card. She stated resident information was available in a book located on the hallway. On examination of the book, at this time, no nurse aide information sheet was available for this resident. She stated, after conference with the nurse, that the resident was not weight bearing on the left. She stated the staff propel the resident in a wheelchair. She stated this resident has to have foot rests on and they are stored in the chair when not in use. An interview with the DON and Risk Manager was conducted at 11:35 a.m., on 8/21/12, for review of the care plan and care card for resident #1. The care plan related to activities was dated 5/11/12 and documented the resident chooses not to participate in group activities at this time and prefers to remain in her room. Interventions include " Make sure foot rest is in use prior to transport. " A continued review of the resident ' s record revealed Interdisciplinary Notes, dated 8/3/12 1600 (4:00p.m.) that the resident was received back from the local hospital with an Ace wrap noted to left ankle. Resident denied pain. A typed entry on the interdisciplinary notes, undated and located under the 8/3/12 2000 (8:00p.m.) note with the date 8/4/12 0300 crossed out and marked error, containing the electronic signature of the risk manager documented as follows: " On final investigation on resident#1 Fx (fracture) of Distal Tibia, I have found it to be substantiated as an adverse, but there was no intent for harm. I interviewed both CNAs present at the time of the incident. CNA (#A) and CNA (#B) both transferred the resident into the w/c (wheelchair) currently present in the room at the time. Both CNAs looked for the leg extensions and found some in the resident ' s room but they could not put them on, for not being the right size. Both CNA decided it would be ok to push her down the hallway to give her a shower and look for other leg extensions that might fit the chair. While CNA (A) was pushing her, the resident dropped her leg and it bent backwards. CNA (A) stated " I stopped immediately and reported it to the nurse. " In which the nurse educated them on the use of leg extensions on current resident. Resident did not report any pain to ankle or foot, but due to her extreme orthopenic bones, requested an x-ray from the Doctor. The CNAs failed to think of safety first before transporting the resident down the hallway without leg extensions. New corrective actions will be taking (sp) and staff involved was educated. " An interview conducted with the risk manager 8/20/12 at approximately 3:00p.m. it was reported that resident #1 obtained a [MEDICAL CONDITION] ankle on 8/2/12 when the resident leg dropped and bent backwards while being pushed down the hallway. X-ray was ordered and results came back at 10:00 p.m. The resident received a left ankle acute oblique distal fracture with slight anterior angulation. An investigation was conducted related to the fracture and found to be substantiated as adverse, but there was no intent for harm. Corrective actions related to the injury were to educate all staff on the use of foot rests for resident wheelchairs, disciplinary actions for the two staff involved in the transport which resulted in injury for resident #1 and development of a new facility policy related to wheel chair leg rests. At approximately 10:45 a.m. on 8/21/12 a review of post hospital instructions was conducted with the nurse manager. The post hospital discharge instructions were confirmed no weight bearing left until ok by physician. The nurse manager stated normally clarification with the primary MD would be done and phone orders written by the nurse. Nursing would usually do a referral to PT for evaluation for a resident with a new fracture. On the printed physician's order [REDACTED]." . The nurse manager confirmed, at this time, that these evaluations were not requested and not done after the fracture for resident #1. 2. Review of the record for resident # 4, revealed that the resident was admitted to the facility on [DATE] after a total knee replacement. Review of the admission nursing assessment entitled " Nursing Data Collection" and dated 6/29/12, revealed that the resident was identified as having Dementia other than Alzheimer's, a short term memory problem , moderately impaired decision making and identified as a " wanderer." There was no explanation on this form or in the resident's record as to why the resident was identified as a wanderer at admission. An undated "Risk Elopement Review Form" was found in the resident's record with resident # 4's name on it. The form was blank under the section for "admitting [DIAGNOSES REDACTED]. The total score for the assessment was a 1 which indicated the resident was low risk for elopement." Interview with the Director of Nursing, on 8/20/12 at 2: 55 p.m., revealed that the form is usually completed at admission but since it did not have a date on it she could not tell when it was completed. She stated that the resident should have been coded as having a [DIAGNOSES REDACTED]. Review of care plans for resident # 4 revealed a care plan, dated 7/9/12 entitled Problem : " Resident at risk for elopement reference to poor decision making due to cognitive impairment. Resident has poor safety awareness and wanders in different rooms and hallways on the unit. Goal : Resident will be free from harm to self thru next review. Will not elope from building thru next review. Approaches: Alert staff to potential for elopement and actions to initiate. With any attempt, document circumstances, intervention, attempts and outcome. Initiate full house search for resident Notify Administrator and DON immediately upon missing resident. Initiate missing person policy Frequent resident checks PRN Assist resident with potential needs and redirect PRN" Review of resident # 4's CNA care plan, entitled " Nurse Aide's Information Sheet" revealed that resident was checked for " wanderer" and " elopement potential." Review of the record for resident # 4 revealed an interdisciplinary note, dated 8/3/12 5 p.m. and written by an LPN., which stated "Notified by dining staff via phone that Resident # 4 was leaving the building and can you come get him. Entered dining room and was led through a side door leading to find.......... patient in wheelchair past sidewalk on the grass....... Returned patient into facility. 15 minute checks started. DON, Risk Manager, Abuse Coordinator and Administrator notified. Left message for granddaughter. Dr. Notified. " Review of an interdisciplinary note, undated, revealed "Elopement on 8/3/12 16 30 p.m. Resident was admitted on [DATE] for rehab for replacement of knee. Resident was documented as having dementia and being confused on admission. Resident was being closely monitored and was added to the elopement book. Resident didn't exhibit any behaviors of exit seeking or asking to leave for the last month. On 8/3/12 resident decided to wheel himself to the main dining room and went in to eat without notifying the nurse's station. Resident ate his meal at the first floor main dining room and then asked about the bathroom. The server showed him where the bathroom was and went back to work. A little time after, the resident was seen by Dining Room Manager wheeling himself on the side walk outside. The main dining room immediately notified the nurse's station. Resident was retrieved by nurse without harm. When asked about what he was doing, he stated, ' I was looking for the bathroom.'. Resident was last seen around 1600 in health care as normal. Resident was put on 15 minute checks until he was moved upstairs the next morning. 2nd floor is more secure for long time residents." An interview was conducted with the Risk Manager, on 8/20/12 at 2: 05 p.m. He stated that the resident had not attempted to elope prior to the 8/3/12 incident. He stated that he determined that the resident had taken himself over to the Assisted Living Facility ( ALF) dining room in his wheelchair to eat dinner. He stated the resident did not normally eat dinner there but many of the nursing home residents go over there to eat. He state that the resident asked a server where the bathroom was and she directed him to the bathroom near the facility front lobby. He indicated that this was beyond the elevators for the ALF and was an employee bathroom in the lobby. He stated he assumed the resident took a wrong turn and thought he might have gone out the kitchen door. He stated no one saw the resident leave the building. He stated that the dietary staff saw the resident and he determined it was an elopement. The resident's care plan for "At Risk for Elopement" was reviewed at this time with the Risk Manager. He stated that the approach for " Frequent resident checks PRN" was the same as for any other resident and meant check on the resident every two hours. He stated they do not check any more often if the resident is an elopement risk. He stated that the approach for "alert staff to potential for elopement " meant " If you see them start to elope alert staff." An interview was conducted with a Certified Dietary Manager, on 8/20/12 at 2: 40 p.m. She stated that she was the witness who saw resident #4. She stated that he came over from the nursing home to the ALF dining room to eat. She said quite a few residents do that. She stated he asked a server where the bathroom was and she directed him the the bathroom near the conference room and lobby, past the elevators. She stated she saw him from the window of the dining room. She saw him and called over to the nursing home for help. She stated she thinks he went out the door outside of the main dining room. Observation of this door, on 8/20/12 at 2: 40 p.m. revealed it is right outside of the main dining room and is an automatic door which opens when approached. An interview was conducted with the MDS Coordinator who created the resident's Elopement Risk care plan, on 8/20/12 at 2: 20 p.m.. She stated that the approach to alert staff to potential for elopement meant to make it known to the staff that a resident was an elopement risk. An interview was conducted with the Director of Nursing, on 8/20/12 at 2: 55 p.m. . She stated that resident # 4 had his picture placed in the elopement book. She stated there are four elopement books, one on each floor of the facility, one in the lobby and one in the ALF. She stated that resident # 4 wandered about the unit, up and down the hallways, but never tried to get out of the building before the elopement on 8/3/12. She stated to her knowledge,, the resident took himself to the dining room, asked where the bathroom was, was directed to the bathroom and went the wrong way and out the automatic doors. She stated that normally the servers in this dining room would call the nursing home staff for assistance if a resident needed to use the bathroom but did not do so this time. She states she thinks it was because he asked where the bathroom was so they assumed he could go on his own. She stated that staff were in-serviced on elopement immediately after this incident. Observation in the building , on 8/20/12, revealed that facing the building from Oak street, the nursing home is located on the left side of the building and the ALF /Independent living is located on the right side of the building. The resident resided at the time of the elopement on the first floor of the nursing home. In order to exit the nursing home into the rest of the building, there is a double door that is opened by pushing on a handicap door opener. After exiting through this door, there is a long corridor which leads to the lobby area between the nursing home and the ALF area. To the right of the lobby is a corridor with two elevators which leads into an open area in the ALF section. To the left of this open area is the main dining room and straight ahead in this open area are the automatic doors leading to the outside. Based on review of the documentation and interviews with the Risk Manager and DON above, the resident would have had to propel himself unnoticed by staff through this building to exit on Pine Street. Review of the resident's record and elopement documentation revealed that the resident was noticed immediately once outside and was returned to the facility and did not sustain any injury from the event. The Risk Manager and the Director of Nursing stated that after the elopement the resident was moved to the second floor of the building for safety and fifteen minute checks were instituted for three days. They stated that the resident did not attempt to exit the second floor of the building after the incident . Review of the record for resident # 4 revealed that he was discharged to home on 8/14/12. Review of the resident's care plan for "Resident at risk for elopement reference to poor decision making due to cognitive impairment. Resident has poor safety awareness and wanders in different rooms and hallways on the unit', dated 7/9/12. On 8/20/12 at 2: 55 p.m. , the DON stated that staff are in serviced on the facility elopement policy at orientation and annually and that all staff were in serviced again after the elopement on 8/3/12. She provided documentation of in-services for dining staff, nurse's and CNA's. Review of the in service for dining staff revealed that the staff had been in serviced on 8/8/12. Review of the in service for nurse's revealed that nurse's had been in serviced on 8/13/12. Review of the in service for CNA's revealed that CNA's had been inservice on 8/16/12.

Based on observation, interview and record review the facility failed to provide an environment free of accident hazards for two (1, 4) of seven sampled residents related to the failure to follow resident care plan related to transport in a wheelchair without leg rests in place which resulted in resident #1 sustaining a left ankle fracture and failure to provide supervision to resident #4 determined to be at risk for elopement. Findings include: 1. Resident #1 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the 72 hour charting/reports revealed an entry, dated [DATE] 10:30a.m., that stated resident #1 ' s left ankle was bent back when she put her foot down while being transported in the wheelchair and an x-ray was ordered. The Radiology Report, dated [DATE], under Examination stated: Left Ankle: A distal tibial oblique fracture is seen with slight anterior angulation. The fracture appears acute. The ankle mortise is intact. Impression: 1. Acute oblique distal tibial fracture with slight anterior angulation. 2. Bones are osteopenic. A Physician ' s Interim/Telephone Order sheet, dated [DATE] with no time but noted on ,[DATE] at 11:15 a.m., stated: Send to ER for splinting left ankle or soft cast resident non ambulatory and not a candidate for surgery. A continued review of the resident ' s record revealed Interdisciplinary Notes, dated [DATE] 1600 (4:00p.m.) that the resident was received back from the local hospital with Ace wrap noted to left ankle. Resident denied pain. A typed entry on the interdisciplinary notes, undated and located under the [DATE] 2000 (8:00p.m.) note with the date [DATE] 0300 crossed out and marked error, containing the electronic signature of the risk manager documented as follows: " On final investigation on resident#1 Fx (fracture) of Distal Tibia, I have found it to be substantiated as an adverse, but there was no intent for harm. I interviewed both CNAs present at the time of the incident. CNA (#A) and CNA (#B) both transferred the resident into the w/c (wheelchair) currently present in the room at the time. Both CNAs looked for the leg extensions and found some in the resident ' s room but they could not put them on, for not being the right size. Both CNA decided it would be ok to push her down the hallway to give her a shower and look for other leg extensions that might fit the chair. While CNA (A) was pushing her, the resident dropped her leg and it bent backwards. CNA (A) stated " I stopped immediately and reported it to the nurse. " In which the nurse educated them on the use of leg extensions on current resident. Resident did not report any pain to ankle or foot, but due to her extreme orthopenic bones, requested an x-ray from the Doctor. The CNAs failed to think of safety first before transporting the resident down the hallway without leg extensions. New corrective actions will be taking (sp) and staff involved was educated. " An initial observation for resident #1 was conducted at 10:24a.m., on [DATE], the resident responded verbally to the door knock and was agreeable for an interview. She was alert with confusion evident. Her lower body was covered but appeared to have both lower legs elevated on pillows. The resident had no recollection of her recent injury. On [DATE] another observation and interview was conducted at 10:30 am. The resident was awake, alert and verbal with confusion evident. The resident stated she gets out of bed sometimes and she believes she can stand up but was not sure. The resident ' s call light was on but she did not recall if she activated it. Staff #C (LPN) was interviewed on [DATE] at 10:35a.m. when she responded to the call light. She stated the resident was non-weight bearing. She did not believe the resident had been out of bed but would be transferred with a gait belt and assist of two persons. She thought the resident had not had a significant change since the fracture. Her appetite had been good and she had been more verbal since her husband died . She previously shared a room with her husband. An interview was conducted, on [DATE] at 10:40 a.m., with CNA #D assigned to resident #1 ' s care for the ,[DATE] shift. She stated this was not her usual assignment, she was a float. She stated information related to care can be obtained from nurses and the CNA leaving will verbally tell the next care giver about anything that occurred during their shift. Staff can also find information about the resident on the care card. She stated resident information was available in a book located on the hallway. On examination of the book, at this time, no nurse aide information sheet was available for this resident. She stated, after conference with the nurse, that the resident was not weight bearing on the left. She stated the staff propel the resident in a wheelchair. She stated this resident has to have foot rests on and they are stored in the chair when not in use. An interview conducted with the risk manager [DATE] at approximately 3:00pm it was reported that resident #1 obtained a fracture of the left ankle on [DATE] when the resident leg dropped and bent backwards while being pushed down the hallway. X-ray was ordered and results came back at 10:00 p.m. The resident received a left ankle acute oblique distal fracture with slight anterior angulation. An investigation was conducted related to the fracture and found to be substantiated as adverse, but there was no intent for harm. Corrective actions related to the injury were to educate all staff on the use of foot rests for resident wheelchairs, disciplinary actions for the two staff involved in the transport which resulted in injury for resident #1 and development of a new facility policy related to wheel chair leg rests. Review of the new policy was conducted with the risk manager as well as the sign in sheets for education of staff. The policy labeled Community Wheel Chair/Leg Rests with an Effective date of [DATE] (marked over as [DATE]) and a revised date of [DATE], stated: Policy: 1. The facility shall determine (Non-mobile/Bedbound) residents to prevent safety hazards while being pushed in a wheelchair. Procedure: At Risk Residents 1.The staff will determine resident mobility status by reviewing resident care guide daily. 2. Resident Care Managers will notify staff of any changes or new safety concerns. 3. When determined that the resident is (Non-mobile/ Bedbound), leg rests must be placed on the wheel chair before transporting. An interview with the DON and Risk Manager was conducted at 11:35 a.m., on [DATE], for review of the care plan and care card for resident #1. The care plan related to activities was dated [DATE] and documented the resident chooses not to participate in group activities at this time and prefers to remain in her room. Interventions include " Make sure foot rest is in use prior to transport. " 2. Review of the facility's policy entitled " Elopement Policy", dated as revised [DATE], revealed : " Policy: Definition : Elopement is defined as any resident unable to make informed consent due to cognitive impairment or has demonstrated poor safety awareness, and leaves facility ( beyond sidewalk around facility grounds) without following/policy/procedure. Forms : Risk of Elopement Review Form Procedure: At Risk Residents 1. Director or designee will conduct an elopement risk assessment for all residents upon admission and quarterly thereafter or as needed to determine potential for elopement. Review of the record for resident # 4, revealed that the resident was admitted to the facility on [DATE] after a total knee replacement. Review of the admission nursing assessment entitled " Nursing Data Collection" and dated [DATE], revealed that the resident was identified as having Dementia other than Alzheimer's, a short term memory problem , moderately impaired decision making and identified as a " wanderer." There was no explanation on this form or in the resident's record as to why the resident was identified as a wanderer at admission. An undated "Risk Elopement Review Form" was found in the resident's record with resident # 4's name on it. The form was blank under the section for "admitting [DIAGNOSES REDACTED]. The total score for the assessment was a 1 which indicated the resident was low risk for elopement." Interview with the Director of Nursing, on [DATE] at 2: 55 p.m., revealed that the form is usually completed at admission but since it did not have a date on it she could not tell when it was completed. She stated that the resident should have been coded as having a [DIAGNOSES REDACTED]. An admission history and physical was found in the resident's record, dated [DATE]. [DIAGNOSES REDACTED]. Review of the resident's record revealed a note, dated [DATE] at 10 : 00 a.m. which stated " Care plan meeting held with granddaughter. Resident has dementia and wanders. She feels that she is not going to be able to care for him at home and is looking at ALF. Facility recommends locked unit for discharge." Review of care plans for resident # 4 revealed a care plan, dated [DATE] entitled Problem : " Resident at risk for elopement reference to poor decision making due to cognitive impairment. Resident has poor safety awareness and wanders in different rooms and hallways on the unit. Goal : Resident will be free from harm to self thru next review. Will not elope from building thru next review. Approaches: Alert staff to potential for elopement and actions to initiate. With any attempt, document circumstances, intervention, attempts and outcome. Initiate full house search for resident Notify Administrator and DON immediately upon missing resident. Initiate missing person policy Frequent resident checks PRN Assist resident with potential needs and redirect PRN" Review of resident # 4's CNA care plan, entitled " Nurse Aide's Information Sheet" revealed that resident was checked for " wanderer" and " elopement potential." Review of the record for resident # 4 revealed an interdisciplinary note, dated [DATE] 5 p.m. and written by an LPN., which stated "Notified by dining staff via phone that Resident # 4 was leaving the building and can you come get him. Entered dining room and was led through a side door leading to find.......... patient in wheelchair past sidewalk on the grass....... Returned patient into facility. 15 minute checks started. DON, Risk Manager, Abuse Coordinator and Administrator notified. Left message for granddaughter. Dr. Notified. " Review of an interdisciplinary note, undated, revealed "Elopement on [DATE] 16 30 p.m. Resident was admitted on [DATE] for rehab for replacement of knee. Resident was documented as having dementia and being confused on admission. Resident was being closely monitored and was added to the elopement book. Resident didn't exhibit any behaviors of exit seeking or asking to leave for the last month. On [DATE] resident decided to wheel himself to the main dining room and went in to eat without notifying the nurse's station. Resident ate his meal at the first floor main dining room and then asked about the bathroom. The server showed him where the bathroom was and went back to work. A little time after, the resident was seen by Dining Room Manager wheeling himself on the side walk outside. The main dining room immediately notified the nurse's station. Resident was retrieved by nurse without harm. When asked about what he was doing, he stated, ' I was looking for the bathroom.'. Resident was last seen around 1600 in health care as normal. Resident was put on 15 minute checks until he was moved upstairs the next morning. 2nd floor is more secure for long time residents." An interview was conducted with the Risk Manager, on [DATE] at 2: 05 p.m. He stated that the resident had not attempted to elope prior to the [DATE] incident. He stated that he determined that the resident had taken himself over to the Assisted Living Facility ( ALF) dining room in his wheelchair to eat dinner. He stated the resident did not normally eat dinner there but many of the nursing home residents go over there to eat. He state that the resident asked a server where the bathroom was and she directed him to the bathroom near the facility front lobby. He indicated that this was beyond the elevators for the ALF and was an employee bathroom in the lobby. He stated he assumed the resident took a wrong turn and thought he might have gone out the kitchen door. He stated no one saw the resident leave the building. He stated that the dietary staff saw the resident and he determined it was an elopement. The resident's care plan for "At Risk for Elopement" was reviewed at this time with the Risk Manager. He stated that the approach for " Frequent resident checks PRN" was the same as for any other resident and meant check on the resident every two hours. He stated they do not check any more often if the resident is an elopement risk. He stated that the approach for "alert staff to potential for elopement " meant " If you see them start to elope alert staff." An interview was conducted with a Certified Dietary Manager, on [DATE] at 2: 40 p.m. She stated that she was the witness who saw resident #4. She stated that he came over from the nursing home to the ALF dining room to eat. She said quite a few residents do that. She stated he asked a server where the bathroom was and she directed him the the bathroom near the conference room and lobby, past the elevators. She stated she saw him from the window of the dining room. She saw him and called over to the nursing home for help. She stated she thinks he went out the door outside of the main dining room. Observation of this door, on [DATE] at 2: 40 p.m. revealed it is right outside of the main dining room and is an automatic door which opens when approached. An interview was conducted with the MDS Coordinator who created the resident's Elopement Risk care plan, on [DATE] at 2: 20 p.m.. She stated that the approach to alert staff to potential for elopement meant to make it known to the staff that a resident was an elopement risk. An interview was conducted with the Director of Nursing, on [DATE] at 2: 55 p.m. . She stated that resident # 4 had his picture placed in the elopement book. She stated there are four elopement books, one on each floor of the facility, one in the lobby and one in the ALF. She stated that resident # 4 wandered about the unit, up and down the hallways, but never tried to get out of the building before the elopement on [DATE]. She stated to her knowledge,, the resident took himself to the dining room, asked where the bathroom was, was directed to the bathroom and went the wrong way and out the automatic doors. She stated that normally the servers in this dining room would call the nursing home staff for assistance if a resident needed to use the bathroom but did not do so this time. She states she thinks it was because he asked where the bathroom was so they assumed he could go on his own. She stated that staff were in-serviced on elopement immediately after this incident. Observation in the building , on [DATE], revealed that facing the building from Oak street, the nursing home is located on the left side of the building and the ALF /Independent living is located on the right side of the building. The resident resided at the time of the elopement on the first floor of the nursing home. In order to exit the nursing home into the rest of the building, there is a double door that is opened by pushing on a handicap door opener. After exiting through this door, there is a long corridor which leads to the lobby area between the nursing home and the ALF area. To the right of the lobby is a corridor with two elevators which leads into an open area in the ALF section. To the left of this open area is the main dining room and straight ahead in this open area are the automatic doors leading to the outside. Based on review of the documentation and interviews with the Risk Manager and DON above, the resident would have had to propel himself unnoticed by staff through this building to exit on Pine Street. Review of the resident's record and elopement documentation revealed that the resident was noticed immediately once outside and was returned to the facility and did not sustain any injury from the event. The Risk Manager and the Director of Nursing stated that after the elopement the resident was moved to the second floor of the building for safety and fifteen minute checks were instituted for three days. They stated that the resident did not attempt to exit the second floor of the building after the incident . Review of the record for resident # 4 revealed that he was discharged to home on [DATE]. Review of the resident's care plan for "Resident at risk for elopement reference to poor decision making due to cognitive impairment. Resident has poor safety awareness and wanders in different rooms and hallways on the unit', dated [DATE], revealed that the care plan was not revised after the resident eloped from the building on [DATE]. On [DATE] at 2: 55 p.m. , the DON stated that staff are in serviced on the facility elopement policy at orientation and annually and that all staff were in serviced again after the elopement on [DATE]. She provided documentation of in-services for dining staff, nurse's and CNA's. Review of the in service for dining staff revealed that the staff had been in serviced on [DATE]. Review of the in service for nurse's revealed that nurse's had been in serviced on [DATE]. Review of the in service for CNA's revealed that CNA's had been inservice on [DATE]. .