**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure residents had adequate supervision and assistive devices to prevent accidents for one (#51) of five residents reviewed out of 32 sample residents. Resident #51, who was at risk for falls and had a history of falls, experienced 21 falls between 1/13/25 to 5/15/25. The facility's interdisciplinary team (IDT) met after the falls to determine a root cause for the resident's falls and implement interventions. However, the facility's review of the falls was not always timely. The root cause identified for 19 of the resident's 21 falls was poor safety awareness, however, the facility did not identify a more specific root cause in order to determine if the fall interventions were appropriate and effective for preventing further falls. However, the facility failed to ensure multiple documented interventions were initiated and the resident was observed, during the survey, without several of the observations in place (see observations below). On 4/21/25, the resident experienced a fall which resulted in a laceration to his left eyebrow and a laceration to his chin. He was sent to the emergency department (ED) for evaluation and returned to the facility with five stitches on his left eyebrow and three stitches on his chin. The facility documented an intervention after the 4/21/25 fall for the medical director to review the resident's medication to see if any medications were possibly contributing to the resident's falls. However, there was no documentation to indicate this was completed and the resident continued to experience falls. Specifically, the facility failed to consistently review Resident #51's falls in a timely manner, identify specific root causes of the falls and ensure documented interventions were initiated and consistently in place. Findings include: I. Facility policy and procedure The Fall Management policy and procedure, dated 2/29/24, was provided by the nursing home administrator (NHA) on 5/22/25 at 2:52 p.m. It read in pertinent part, A fall reduction program will be established and maintained, to assess all residents to determine their risk for falls. A plan of care will be implemented based on the resident's assessed needs. Individualized care plan interventions will be implemented for those residents found to be at high risk for falls. Interventions are to be re-evaluated when a resident falls for efficacy. Document in the electronic medical record (EMR) the resident's response to interventions and revise interventions if they were not successful. II. Resident #51 A. Resident status Resident #51, age [AGE], was admitted [DATE]. According to the May 2025 computerized physician orders (CPO), diagnoses included Steele-[NAME]-[NAME] syndrome (a rare neurodegenerative disease that affects balance, eye movement, speech and swallowing), progressive supranuclear ophthalmoplegia (inability to move one's eyes at will), limitation of activities due to disability, muscle weakness, repeated falls, cognitive communication deficits, abnormalities of gait and mobility, other frontotemporal neurocognitive disorder (changes in behavior, personality and language) and history of falls. The 2/17/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. Resident #51 required extensive assistance with transfers and toilet use. The MDS assessment indicated the resident had had two or more falls since his prior assessment. B. Observations On 5/19/25 at 10:10 a.m. Resident #51's door was open. He was in bed, however, the resident's call light was on the floor behind his headboard. Resident #51 slowly rolled to the edge of the bed to reach for his call light. The resident had to stretch and roll close to the edge of his bed to reach the call light. He pushed the call light for assistance to reposition himself. An unidentified certified nurse aid (CNA) responded and asked from the doorway what Resident #51 needed. Resident #51 was difficult to understand. The unidentified CNA asked if he wanted water and said she would be back with water. The resident slowly repositioned himself. -The unidentified CNA did not notice the resident's close proximity to the edge of the bed. Observations of Resident #51's room on 5/19 at 10:10 a.m. did not reveal a helmet, grip tape on the resident's floor or a call don't fall sign in the resident's room (see care planned fall interventions below). C. Resident interviews Resident #51 was interviewed on 5/19/25 at 10:00 a.m. He said he had many falls and does not always use the call light because it was not answered in a timely manner. He said he had waited at least 45 minutes or more before anyone came in to help him. Cross-reference F550 for failure to respond to call lights in a timely manner. Resident #51 was interviewed a second time on 5/22/25 at 1:00 p.m. He said he did not know where his helmet was. D. Resident representative interview Resident #51's representative was interviewed on 5/21/25 at 10:50 a.m. Resident #51's representative said she had witnessed staff (via a camera in the resident's room) leaving Resident #51 standing in his room alone and shutting the door. She said Resident #51 had a floor to ceiling transfer pole that was removed a couple of months ago. Resident #51's representative said she and the resident's other representative had requested the transfer pole be reinstalled because the resident had had more falls since the pole was removed. Resident #51's representative said the resident would go many hours before a staff member checked on him. E. Record review The at risk for falls care plan, initiated 9/7/23 and revised 4/15/25, revealed Resident #51 was at risk for falls related to his progressive supranuclear ophthalmoplegia and history of falls. He had unsteady balance during transfers. Resident #51 became frozen (temporary inability to move) and had a hard time processing what he needed to do next. Resident #51 preferred to keep his room dark and preferred to not wear socks and shoes. Pertinent interventions included ensuring the resident's call light was within reach and encouraging him to use it, promptly responding to all requests for assistance, placing a call don't fall sign in the resident's room, frequent rounding, placing grip tape on the floor near the resident's bed, physical therapy (PT) to evaluate and treat as ordered or needed, checking the resident after meals for toileting, snacks and hydration and reminding Resident #51 to lock his wheelchair brakes, ask for assistance to change the room temperature and clean up spills. Review of Resident #51's electronic medical record (EMR) revealed the resident had 21 falls from 1/13/25 through 5/15/25. Review of Resident #51's falls between 1/13/25 and 5/15/25 revealed the following: 1. Fall incident on 1/13/25 - unwitnessed The 1/13/25 fall investigation documented Resident #51 was lying on the floor next to the bed, naked with dried blood over his left eyebrow. Resident #51 said he fell during the night. The resident's eyebrow was cleaned with saline and steri-strips were applied. The IDT risk management review note, dated 1/21/25, documented the root cause was poor safety awareness and a diagnosis of progressive supranuclear ophthalmoplegia. The intervention was to offer a helmet. -However, a helmet was not observed in the resident's room during the survey (see observations above). -The IDT risk management review of the fall was not completed until eight days after the fall and after Resident #51 had sustained another fall on 1/15/25 (see below). 2. Fall incident on 1/15/25 - unwitnessed The 1/15/25 fall investigation documented Resident #51 was sitting on the floor by the dresser. The wheelchair was away from him and the wheelchair brakes were not on. Resident #51 said he was fixing stuff on top of his dresser. The resident had no injury. The IDT risk management review note, dated 1/21/25, documented the root cause was poor safety awareness and the resident's wheelchair brakes were unlocked. The intervention was to add anti-rollback devices to the resident's wheelchair. -The IDT risk management review of the fall was not completed until six days after the fall. 3. Fall incident on 1/21/25 - unwitnessed The 1/21/25 fall investigation documented Resident #51 was sitting at the bathroom door with fecal matter smeared across the floor and his hands. Resident #51 had an abrasion on his left shoulder. Resident #51 said he fell.The IDT risk management review note, dated 1/23/25, documented the root cause was diagnosis of progressive supranuclear ophthalmoplegia and poor safety awareness. The intervention was to remind Resident #51 to call for assistance, motion sensor lights in the room and increased rounds. -The IDT risk management review of the fall was not completed until two days after the fall 4. Fall incident on 2/10/25- unwitnessed The 2/10/25 fall investigation documented Resident #51 was sitting on the floor with his wheelchair in front of him and his legs under the wheelchair. Resident #51 said he was not hurt. Resident #51 had a scratch to the skin on his back. The IDT risk management review note, dated 2/10/25, documented the root cause was poor safety awareness. The intervention was to remind Resident #51 to lock his brakes before standing from his wheelchair. 5. Fall incident on 2/11/25 - unwitnessed The 2/11/25 fall investigation documented Resident #51spilled a pitcher of water, slipped and fell in his room. The resident had no injury. The IDT risk management review note, dated 2/23/25, documented the root cause was the wet floor. Interventions were to ensure the floor was free from spills and remind Resident #51 to notify staff immediately of spills so they could be cleaned up. -The IDT risk management review of the fall was not completed until ten days after the fall. 6. Fall incident on 2/24/25 - unwitnessed The 2/24/25 fall investigation documented Resident #51 was sitting on the floor holding the transfer pole with his helmet on. Resident #51 said he fell from his wheelchair. The resident had no injury. The IDT risk management review note, dated 3/5/25, documented the root cause was poor safety awareness and a diagnosis of progressive supranuclear ophthalmoplegia. The intervention was to conduct more frequent rounds. -The IDT risk management review of the fall was not completed until nine days after the fall and after the resident had sustained another fall on 2/25/25 (see below). 7. Fall incident on 2/25/25 - unwitnessed The 2/25/25 fall investigation documented Resident #51 was sitting on the floor behind his door. Resident #51 said he fell. The resident had no injury. The IDT risk management review note, dated 3/5/25, documented the root cause was poor safety awareness and a diagnosis of progressive supranuclear ophthalmoplegia. The intervention was to encourage the resident to wear shoes or grip socks when out of bed or with transfers. -The IDT risk management review of the fall was not completed until eight days after the fall. 8. Fall incident on 3/16/25 - unwitnessed The 3/16/25 fall investigation documented Resident #51 was lying on his right side in the center of his room. Resident #51 said he wanted to get up. The resident had no injury. The IDT risk management review note, dated 3/18/25 documented the root cause was poor safety awareness. The intervention was to educate the Resident #51 on the use of his call light when he needed assistance and to put his shoes on before getting out of bed. -The IDT risk management review of the fall was not completed until two days after the fall. 9. Fall incident on 3/21/25 - unwitnessed The 3/21/25 fall investigation documented Resident #51 was sitting on the floor in his room near his refrigerator. Resident #51 said he was trying to open the refrigerator. The resident had no injury. The IDT risk management review note, dated 4/7/25, documented the root cause was poor safety awareness. The interventions were rounding or answering his call light, encouraging Resident #51 to inform staff of all his needs so he would not need to get up independently. -The IDT risk management review of the fall was not completed until 17 days after the fall. 10. Fall incident on 3/24/25 - unwitnessed The 3/24/25 fall investigation documented Resident #51 was sitting on the floor, wearing only a shirt, by the side of the bed. It appeared as though Resident #51 lost his balance and fell/sat down after using the bathroom. The area next to his bed was frequently wet from Resident #51 urinating in the trash can. Resident #51 said he sat down on the floor. The IDT risk management review note, dated 4/15/25, documented the root cause was poor safety awareness. The intervention was to encourage Resident #51 to not sit on the floor and take rest breaks when tired. -The IDT risk management review of the fall was not completed until 22 days after the fall. 11. Fall incident on 4/8/25 - unwitnessed The 4/8/25 fall investigation documented Resident #51 was standing up holding on to his dresser and fell. Resident #51 did not explain why he was standing holding on to the dresser or how he fell. He hit his head on the door. The IDT risk management review note, dated 4/8/25, documented the root cause was the diagnosis of progressive supranuclear ophthalmoplegia and poor safety awareness. The intervention was to encourage the dresser to be moved. 12. Fall incident on 4/10/25 - witnessed by family member The 4/10/25 fall investigation documented Resident #51 was outdoors with his sister and he fell out of his wheelchair. Resident #51's sister explained he was not well positioned in his chair. There was a bruise on his left knee. The IDT risk management review note, dated 4/11/25, documented the root cause was poor safety awareness. The intervention was to educate family when they took Resident #51 out of the building to ensure he was properly seated in the wheelchair. 13. Fall incident on 4/11/25 - unwitnessed The 4/11/25 fall investigation documented Resident #51 was sitting on the floor by his bed and he was not wearing shoes. Resident #51 said he wanted to get up. The resident had no injury. The IDT risk management review note, dated 4/11/25, documented the root cause was poor safety awareness and the diagnosis of supranuclear ophthalmoplegia. The intervention was placing grip tape on the floor near the bed. -However, observation during the survey revealed there was no grip tape on the resident's floor (see observations above). 14. Second fall incident on 4/11/25 - unwitnessed The 4/11/25 fall investigation documented Resident #51 was sandwiched between the closed bathroom door and his wheelchair. Resident #51 could not tell how he ended up behind the wheelchair. The resident had no injury. The IDT risk management review note, dated 4/11/25, documented the root cause was the diagnosis of supranuclear ophthalmoplegia and poor safety awareness. The intervention was to place a call don't fall sign in his room. -However, observations during the survey revealed there was no call don't fall sign posted in his room (see observations above). 15. Fall incident on 4/17/25 - witnessed The 4/17/25 fall investigation documented Resident #51 was leaning towards his night stand to place a water pitcher when he leaned forward, hitting his stomach against the night stand and lost his balance. He fell onto his left side without hitting his head. He had a skin tear to his left knee, pain rated at a 5 out of 10 to the left knee and a small bruise on his abdomen. He had Xrays taken of his left hip and lumbar spine, which were negative for any injury. The IDT risk management review note, dated 4/18/25, documented the root cause was poor safety awareness and the diagnosis of progressive supranuclear ophthalmoplegia. The intervention was the dresser was moved. -However the intervention was documented for the 4/8/25 fall (see above) and not completed until 4/18/25. 16. Fall incident on 4/19/25 - unwitnessed The 4/19/25 fall investigation documented Resident #51 was sitting and holding the bathroom door handle in his left hand. Resident #51 did not say how he fell. He had redness on the left elbow. The IDT risk management review note, dated 4/24/25, documented the root cause was poor safety awareness. The intervention was to review history on the resident's previous falls to track trends. Resident #51 fell multiple times of day and the falls tended to be between meals. Staff was to check on the resident after meals to see if he needed toileted, snacks or hydration. -The IDT risk management review of the fall was not completed until five days after the fall and after the resident had sustained another fall on 4/21/25 (see below). 17. Fall incident on 4/21/25 - unwitnessed The 4/21/25 fall investigation documented Resident #51 was sitting on the floor between the doorway and the wheelchair was to his left. Resident #51 said he was trying to get to the doorway to stand up and hold on. Resident #51 had a laceration to his left eyebrow and a laceration to his chin. He was sent to the ED for evaluation. Resident #51 returned with five stitches on his left eyebrow and three stitches on his chin. The IDT risk management review note, dated 4/25/25, documented the root cause was poor safety awareness. The intervention was to refer to the medical director for review of Resident #51's medications to determine if any medications were contributing to the resident's falls. -The IDT risk management review of the fall was not completed until four days after the fall and after the resident had sustained another fall on 4/24/25 (see below). -Additionally, there was no documentation to indicate the facility had notified the medical director to review the resident's medications and/or what the findings of the review were if it was completed. 18. Fall incident on 4/24/25 - unwitnessed The 4/24/25 fall investigation documented Resident #51 was on the floor behind the door which prevented staff from fully opening the door. The wheelchair was tipped over on its side and leaning on the resident. Resident #51 was unable to provide a description of the fall. The resident had no injury. The IDT risk management review note, dated 4/28/25, documented the root cause was poor safety awareness and disease process. The intervention was to offer hipsters, which Resident #51 declined, and the use of a helmet. -However, the helmet had been identified as an intervention after the resident's fall on 1/13/25 (see above) and a helmet was not observed in the resident's room during the survey (see observations above). -The IDT risk management review of the fall was not completed until four days after the fall. 19. Fall incident on 5/7/25 - unwitnessed The 5/7/25 fall investigation documented Resident #51 was behind the door in his room. The resident had urinated on the floor and slipped on the urine when he tried to transfer from bed to chair. The urinal was not within reach. Resident #51 said he tried to transfer from his bed to the wheelchair. The resident had no injury. The IDT risk management review note, dated 5/9/25, documented the root cause was poor safety awareness and the diagnosis of progressive supranuclear ophthalmoplegia. The intervention was to keep the urinal near the resident on the trash can, per resident preference. -The IDT risk management review of the fall was not completed until two days after the fall and after the resident had sustained another fall on 5/8/25 (see below). 20. Fall incident on 5/8/25 - unwitnessed The 5/8/25 fall investigation documented Resident #51 was sitting in the hallway by his room. Resident #51 was unable to give a description of what happened. The resident had no injury. The IDT risk management review note, dated 5/9/25, documented the root cause was poor safety awareness and progressive supranuclear ophthalmoplegia. The intervention was to educate the resident to utilize his wheelchair and keep it near him when he stood up and not to walk away from it. 21. Fall incident on 5/15/25 - unwitnessed The 5/15/25 progress note documented the resident was found on the floor. The resident had no injury. -There was no IDT risk management review documented for the fall. -Out of Resident #51's 21 reviewed falls, the facility documented the same root cause for 19 of the falls. There was no follow up documentation to indicate what interventions had been successful or why an intervention was discontinued. III. Staff interviews CNA #3 was interviewed 5/20/25 at 3:45 p.m. CNA #3 said the Kardex (quick reference guide for patient care), which was on the computer, informed staff about who was a fall risk. CNA #3 said Resident #51's wellness varied from day to day and on bad days he needed more assistance with his activities of daily living (ADL) and transfers. He said the resident used his call light at times. CNA #3 said Resident #51 was a fall risk and she tried to check on him every one to one and a half hours. CNA #2 was interviewed on 5/22/25 at 9:25 a.m. CNA #2 said she knew a resident was a fall risk if there was a fall mat in the room or the bed was in the lowest position. CNA #2 said she was notified of fall risks in morning report. She said if a resident was a fall risk, staff should check on the resident at least every two hours and if they were a high fall risk, staff should check on the resident every 30 minutes to an hour. CNA #2 said she documented it when she checked on a resident, however, she could not find that documentation on the computer. She said the Kardex was on the computer, but she did not carry a paper copy with her The NHA was interviewed on 5/22/25 at 2:08 p.m. The NHA said there was no specific fall committee who reviewed resident falls. She said falls, root causes and interventions were discussed every morning at the department head meeting. She said there was no floor staff present at the meetings. The NHA said if fall interventions did not work, the intervention would be discontinued and resolved on the care plan. She said Resident #51 had a transfer pole in his room but it had been removed because it was identified as contributing to his falls. The NHA said the resident had had less falls since the removal of the transfer pole on 3/18/25. The NHA said there had not been a recent referral to PT or occupational therapy (OT) for Resident #51, however, she said a therapy referral would be appropriate for the resident due to all of his falls. -However, Resident #51 had nine falls from 1/13/25 to 3/16/18 and 12 falls from 3/18/25 through 5/15/25. There was no documentation in the EMR why the pole was removed or the effectiveness of removing this intervention. Resident #51's representative requested the transfer pole back on 4/11/25. The care plan had an intervention of referring to PT as indicated. The director of nursing (DON) was interviewed on 5/22/25 at 4:07 p.m. The DON said falls were discussed at the department head meeting every morning. She said the meeting did not include floor staff. She said she or the NHA communicated any changes related to residents' fall interventions that were discussed in the department head meeting to the floor staff. The DON said she expected the floor staff to verbally notify in-coming shifts of any changes to residents' fall interventions. The DON said the floor staff were responsible for logging onto the computer to look for communications related to resident changes which had been posted by her or the NHA. The DON said she did not monitor when floor staff checked the computers for the updates. The DON said that if frequent checks were an intervention, ideally those would be completed every 15 minutes, but residents should be checked on at least every hour. She said the nurses and CNAs were to perform the frequent checks. The DON said there was no documentation system in place to track if frequent checks were completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide the necessary mental health care and services to attain or maintain the highest practicable physical, mental and psychosocial well being for one (#16) of three residents reviewed for mental health out of 32 sample residents. Resident #16, was admitted on [DATE] and readmitted on [DATE], with diagnoses of bipolar disorder and dissociative disorder. The resident had a previous reported history of suicidal ideation with self-harm. Resident #16 had documented behaviors of becoming easily agitated, verbally reactive and frequently calling emergency medical services (EMS) for all issues. Resident #16 had a behavioral care plan in place, which included monitoring mood/behavior and consulting with behavioral health services. However, the resident did not have a safety plan in place based on a past history of making suicidal ideations or triggering behaviors when her manic behaviors were escalating, including exhibiting an inability to sleep, crying and becoming easily agitated. On 2/4/25 Resident #16 self-inflicted cuts to her wrists with a pair of scissors after spending 45 minutes on the phone with the mental health crisis center. Resident #16 was sent to the hospital for her suicidal ideation and attempt to cut her wrists with scissors. Resident #16 returned from the hospital on 2/13/25 with a safety plan that included identifying warning signs, identifying internal coping strategies, identifying people and social settings that provided distraction and identifying people to ask for help during crisis, making the environment safer with no access to firearms, no access to medications and removing scissors out of her room and giving them to staff. -However, the facility failed to include the crisis/safety plan interventions in the care plan after the resident returned to the facility on 2/13/25. On 2/22/25 Resident #16 called the mental health crisis center again and asked them to call EMS for her. She told the mental health crisis center she did not feel safe and felt like killing herself. Resident #16's room was checked by facility staff for sharp objects and she was sent to the hospital for suicidal ideation. Resident #16 returned from the hospital approximately five hours later and the facility progress notes documented a safety plan was in place. -However, the facility again failed to include the crisis/safety plan interventions in the care plan after Resident #16's return from the hospital for the second incident of suicidal ideation in less than one month. On 3/16/25 the facility again received a call from the mental health crisis center informing the facility that Resident #16 was having suicidal ideations. The nurse went to check on Resident #16 who was on the back patio with a pair of black scissors held to her left wrist and the resident had self-inflicted superficial cuts to her left wrist with a small amount of blood present. The nurse removed the scissors, placed the resident on one-to-one supervision and called the physician and EMS. The resident was transported to the hospital and admitted for suicidal ideation and bipolar mood disorder. The resident returned from the hospital on 3/27/25 after being determined to be medically and psychiatrically stable. A safety plan was not initiated and coordinated with behavioral health and interventions placed in the care plan until 4/2/25, Resident #16's third incident of suicidal ideation and her second attempt to cut her wrist with scissors in less than six weeks. Specifically, the facility failed to coordinate and implement timely person-centered behavioral and safety interventions which resulted in Resident #16 experiencing three incidents of suicidal ideation on 2/4/25, 2/22/25 and 3/16/25 and two attempts to cut her wrists with scissors on 2/4/25 and 3/16/25. Findings include: I. Facility policy and procedure The Behavioral Health Services policy and procedure, revised February 2019, was provided by the nursing home administrator (NHA) on 5/22/25 at 2:29 p.m. It read in pertinent part, The facility will provide, and residents will receive, behavioral health services as needed to attain or maintain the highest practicable physical, mental and psychosocial well being in accordance with the comprehensive assessment and plan of care. Residents who exhibit signs of emotional/psychosocial distress receive services and support that address their individual needs and goals for care. Staff training regarding behavioral health services includes, but is not limited to recognizing changes in behavior that indicate psychological distress; implementing care plan interventions that are relevant to the resident's diagnosis and appropriate to his or her needs; monitoring care plan interventions and reporting changes in condition; protocols and guidelines related to the treatment of mental disorders, psychosocial adjustment difficulties, history of trauma and post traumatic stress disorder. II. Resident #16 A. Resident status Resident #16, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the May 2025 computerized physician orders (CPO), diagnoses included bipolar disorder, dissociative identity disorder and suicide attempts. The 4/29/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She was independent with eating, toileting, personal hygiene, bed mobility and transfers. The MDS assessment indicated she did not exhibit behaviors of little interest and pleasure in doing things or feeling down and depressed or hopeless. The MDS assessment indicated she did not exhibit other behaviors that were not directed at others which included hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily waste or verbal/vocal symptoms such as screaming, disruptive sounds. B. Observations On 5/19/25 at 11:28 a.m. Resident #16 was ambulating to her room with her walker. She was yelling at the nurse standing in the hallway that someone needed to help her. She yelled expletives and yelled, I have peed in my pants. Registered nurse (RN) #2 went in to Resident#16's room and explained to Resident #16 that she had to finish checking on another resident and offered to take Resident #16 to the bathroom. On 5/21/25 at 8:30 a.m. Resident #16 was sitting on her bed in her room. Observation of the resident and her room revealed there was not a wanderguard visible on her wrists or ankles or on her walker and there was not a camera observed in her room (see 4/1/25 safety care plan below). C. Record review The mood/behavior care plan, initiated 7/3/23 and revised 3/6/25, documented Resident #16 had a history of bipolar disorder and would call EMS if she felt her needs were not being met. It documented Resident #16 had a family reported history of suicidal ideations with taking pills to try to overdose and slit her wrists. She yelled and cursed when agitated. Interventions included providing two staff members with cares (initiated 2/10/23), consulting with the behavioral/mental health services provider as needed (initiated 9/18/23), monitoring/recording the resident's mood to determine causes (initiated 9/18/23), administering medications as ordered (initiated 7/3/23), encouraging positive affirmation and short one-to-one visits when she sought out staff for concerns to not call EMS (initiated 10/10/23), moving the resident closer to the nursing station to keep in her in line of sight to assist the resident with feeling comfortable with staff assistance (initiated 1/10/24), reminding the resident when she asked for something and the staff were in the middle of a task, they would be able to assist her once completed (initiated 6/18/24), seeing the behavioral/mental health provider weekly or as needed for psychotherapy (initiated 4/1/25), encouraging the resident to express her needs/concerns and offering validation and affirmation to get over stress situations that caused her distress (initiated 4/1/25). The safety plan for suicidal ideation, initiated 4/1/25, documented Resident #16 was at increased risk for suicidal ideation due to her bipolar disorder and family reported previous history of suicidal attempts of taking pills to overdose and slitting her wrists. Interventions included increasing monitoring, frequently checking belongings in her room, changing rooms, adding a camera in her room for additional monitoring, continuing behavioral health visits, implementing a wanderguard for safety, intervening by staff as needed for safety and sending the resident out to the hospital, coordinating with behavioral health services for a crisis plan for the resident's suicidal ideations/attempts, completing triggers when her bipolar mania started up, which included the resident not sleeping, being more anxious, heart racing, blaming everyone and being tearful, encouraging her to write in her affirmation books, encouraging her to talk to children and encouraging activities. -The safety plan was not implemented until 4/1/25, after Resident #16 experiencing three incidents of suicidal ideation on 2/4/25, 2/22/25 and 3/16/25 and two attempts to cut her wrists with scissors on 2/4/25 and 3/16/25 (see record review below). -A comprehensive review of the care plan failed to identify Resident #16 was no longer using the wanderguard or allowing a camera in her room for additional monitoring (see interviews below). -The care plan additionally failed to identify frequent 15-minute checks as the increased monitoring intervention for the resident's safety (see interviews below). The May 2025 CPO revealed a physician's order to document Resident #16's target behaviors and the interventions attempted and their effectiveness. Target behaviors included suicidal ideation, mood fluctuations with anxiety and attention seeking. Interventions to be documented included redirection, one-to-one, diversional activity, offer to call family or friends and reassurance and check for respiratory distress, ordered 12/6/24. The 1/29/25 behavioral health screening progress note documented an initial assessment regarding Resident #16's depression related to medical issues, anxiety disorder and insomnia. It documented therapeutic interventions to assist processing through thoughts and feelings. It documented assisting with reality orienting skills and pro-social skills. It documented Resident #16 was a strong advocate for her needs. The 2/3/25 behavioral health psychotherapy progress note documented therapeutic interventions to assist processing through thoughts and feelings. It documented assisting with reality orienting skills and pro-social skills. It documented the plan was to provide therapeutic and case management support and for the resident to be seen by the nurse practitioner. The 2/4/25 at 7:36 p.m. change of condition nursing progress note documented Resident #16 had cut her wrist with a pair of scissors and EMS was called for transfer of the resident to the hospital. The 2/4/25 at 11:16 p.m. nursing progress note documented Resident #16 was sent to the hospital at 7:15 p.m. via EMS for cutting her wrists. The 2/5/25 at 12:32 a.m. nursing behavior progress note documented that at 6:40 p.m. Resident #16 returned from the outside patio to her room and was on the phone talking to the mental health crisis center. The nurse then spoke with the crisis center and the crisis center told her that they had been on the phone with Resident #16 for 45 minutes because the resident had told the them she was suicidal. The nurse told the crisis center Resident #16 had not told staff at the nursing home that she was suicidal but she was now aware and would help Resident #16. Resident #16 screamed at the nurse that she was going to kill herself. The nurse asked the resident how she was planning on doing that. Resident #16 said she would do it with scissors. The nurse asked if Resident #16 had scissors and did not get a response from Resident #16. The nurse checked the resident's drawers, tables and her walker seat and pouch and asked for Resident #16 to check behind her. Resident #16 refused and threw the remote control to the television and a shoe at the nurse. The nurse called Resident #16's representative and Resident #16 refused to speak with her. The nurse then notified Resident #16's representative that Resident #16 needed to go to the hospital. The nurse called EMS from the nurses station and was placed on hold. While the nurse was on hold with EMS, Resident #16 was heard screaming that she had cut herself. The nurse hung up the phone, went to Resident #16's room and found her bleeding from her left wrist with a pair of scissors in her right hand. The nurse removed the scissors and asked a certified nurse aide (CNA) to stay with the resident. The nurse dressed the cut and applied pressure to the wrist, stayed with Resident #16 and called EMS from her personal cell phone. EMS arrived at 7:10 p.m. and transported Resident #16 to the emergency room. -Resident #16 was not placed on one-to-one supervision or kept in direct line of sight while the nurse called EMS, despite the resident having just threatened to cut herself with scissors. The 2/7/25 interdisciplinary team (IDT) risk management progress note documented Resident #16 had a self-inflicted injury with the root cause identified as an exhibited behavior after the resident's daughter did not come to the facility as she had stated she would. The 2/13/25 hospital discharge summary documented Resident #16 was admitted to the hospital wth suicidal ideation. The summary documented a safety plan that included identifying warning signs, identifying internal coping strategies, identifying people and social settings that provide distraction, and identifying people to ask for help during crisis, making the environment safer with no access to firearms, no access to medications and removing scissors out of her room and giving them to staff. It documented the resident was to follow up with the behavioral health care provider for an appointment on 2/14/25 for medication management and therapy. -However, there was no documentation in the resident's EMR to indicate the resident was seen by her behavioral health care provider on 2/14/25. The 2/13/25 hospital discharge crisis plan, signed by Resident #16 on 2/12/25, included ways for the resident to stay well, prevention measures to stay well, identification of warning signs, strategies to take her mind off negative thoughts and identification of people she would be willing to ask for help. -However, the crisis safety plan was not initiated on the resident's care plan upon the resident's return to the facility on 2/13/25 (see care plan above). A comprehensive review of the EMR failed to reveal documentation of a follow up with the behavioral health provider. The 2/22/25 behavioral nursing progress note documented nursing staff received a call from EMS at 7:35 p.m. to notify staff that EMS had received a call from Resident #16 and to check on her. Nursing staff found Resident #16 outside crying and on the phone to the mental health crisis center. She said she wanted to kill herself, she was not being treated for her depression and she felt unsafe. Resident #16 asked the crisis center to call EMS for her again. The facility nurse checked Resident #16's belonging for sharp items and was unable to locate any. Resident #16 hung up the phone and was calm and told nursing staff the paramedics were coming to get her. EMS arrived at 7:53 p.m. and transported the resident to the hospital. The 2/23/25 at 2:19 a.m. nursing progress notes documented Resident #16 had returned from the hospital at 1:52 a.m. with a safety plan. -However, the safety plan was not initiated on the resident's care plan upon the resident's return to the facility on 2/23/25 (see care plan above). The 3/16/25 nursing progress documented Resident #16 was sent to hospital at 4:30 p.m. due to attempting suicidal acts. -However, a review of the resident's electronic medical record (EMR) revealed there was no documentation of the incident prior to the resident being transported to the hospital. The 3/16/25 facility investigation documented the facility received a call from the mental health crisis center informing them that Resident #16 was having suicidal ideations. The facility nurse went to check on Resident #16 who was on the back patio with a pair of black scissors held to her left wrist and she had self-inflicted superficial cuts to her left wrist with a small amount of blood present. The nurse removed the scissors, placed the resident on one-to-one supervision and called the physician and EMS. The 3/20/25 hospital psychiatric progress note documented Resident #16 was hospitalized with a brief suicidal ideation and documented the resident's bipolar symptoms were improved and, from a psychiatric standpoint, she was no longer a danger to herself and she could return to facility. Recommendations were to continue with her current behavioral health provider The 3/27/25 hospital discharge summary documented Resident #16 presented to the emergency room with mood disorder and past attempts with suicidal ideation. Resident #16 was being followed by psychiatry, suicide precautions were discontinued and she was deemed stable to return to the facility. The 3/29/25 preadmission screening and referral program (PASRR) Level II evaluation documented Resident #16 was medically and psychiatrically stable before discharge from the hospital. It documented she had a significant history of suicidal ideation and attempts. The recommended specialized services were psychiatry case consultation, individual therapy, crisis intervention/individual safety plan, additional one-on-one engagement support and other services, including peer mentor, intensive outpatient program (IOP), and referral to the transitions program. The 4/2/25 psychosocial/social services note documented the behavioral health provider met with the facility's social worker and a clinician to discuss an action plan to prevent Resident #16 from harming herself. The plan was placed in the resident's chart. The behavioral health crisis action plan, signed by Resident #16 on 4/2/25, documented identification of triggers that were a cue for unhealthy or ineffective behaviors which included mania that made it difficult to sleep at night, anxiety and depression such as crying, heart racing, tending to blame others and no energy. It documented identification of personal warning signs such as heart racing, crying and losing sleep. It documented interventions for Resident #16 to keep her environment safer, such as going outside when the weather was cold, removing access to scissors and other sharp objects and going to activities. It documented intervention to promote well being, such as writing in a gratitude journal, attending group activities and going on outings with children. It identified people that could provide support for Resident #16. The 4/4/25 IDT risk management progress note documented Resident #16 was sent to the hospital (on 3/16/25) and the root cause was behavioral. A comprehensive review of Resident #16's EMR failed to reveal behavioral provider notes from immediately after the 2/4/25, 2/22/25 or the 3/16/25 incidents. The May 2025 CPO documented a physician's order for a wanderguard to prevent Resident #16 from going out of the facility unassisted, ordered 3/31/25 and discontinued 4/4/25. The May 2025 CPO further documented a physician's order for a wanderguard to prevent Resident #16 from leaving the facility unassisted, to be kept on her walker not her person, ordered 4/4/25 and discontinued 5/15/25. A review of Resident #16's frequent 15-minute check monitoring sheets, beginning 3/31/25 and ending 5/17/25, failed to reveal documentation of frequent monitoring of the resident on the following days: 4/4/25, 4/6/25, 4/7/25, 4/8/25, 4/9/25, 4/18/25 and 5/13/25. A comprehensive review of Resident #16's EMR did not reveal suicide risk assessments before the resident's 2/22/25 3/16/25 suicide attempts. III. Staff interviews RN #2 was interviewed on 5/21/25 at 10:36 a.m. RN #2 said Resident #16 escalated easily and reacted verbally. She said she did not observe the resident's suicidal behaviors but she had heard about the resident using scissors to cut her wrists. She said she was not sure where the resident had found the scissors. She said staff tried to do frequent checks of her room but it was difficult because staff were not allowed to search or remove anything from a resident's room without permission from the resident. She said nursing staff had been checking Resident #16 frequently for a while and she was on frequent 15-minute checks indefinitely due to her behaviors. She said the staff documented the monitoring on a paper form that she kept on her cart and it was turned in to medical records after it was filled out. She said Resident #16 used to have a wanderguard but the resident removed it from her walker and did not want it. She said staff had tried to install a camera in her room but she removed it and did not want it reinstalled. The director of nursing (DON) was interviewed on 5/21/25 at 1:45 p.m. The DON said Resident #16 had a long standing history of behaviors where she would call EMS when she became angry, anxious or things were not going her way. She said they had witnessed, on camera, her throwing herself on the floor. She said recently Resident #16 had been experiencing shortness of breath and chest pain because of her chronic obstructive pulmonary disease (COPD) and she had threatened to kill herself. She said Resident #16 had called the mental health crisis center and notified them of her suicidal ideations without telling the staff. She said Resident #16 also called EMS frequently on her own for multiple things. She said the frequent EMS calls by Resident #16 had gotten so bad that EMS would no longer automatically come to the facility. The DON said Resident #16 had been seen by a behavioral health care provider but had started a new behavioral provider less than a year ago that she preferred. She said Resident #16 would no longer allow the wanderguard or the camera in her room and staff should be doing frequent checks and documenting the checks. She said there was behavioral monitoring in place for the resident's triggers to try to capture behaviors before she escalated and started calling EMS. She said Resident #16 called EMS for perceived medical issues, not just mental health issues. She said her triggering behaviors when she was escalating were crying, not sleeping, screaming at staff and blaming others. She said the care plan and the safety plan should reflect what current interventions were in place. The DON said when Resident #16 did make suicidal ideations to staff, it should be taken seriously and the resident should be kept safe. She said the resident's suicidal ideations should trigger a suicide risk assessment to determined resident's risk and if the resident had a plan to kill herself. She said it was unclear where Resident #16 had obtained the scissors she used to cut her wrists on 2/4/25 and 3/16/25. She said staff thought she may have obtained a pair of sewing scissors from a roommate. She said she was no longer roommates with that resident. She said another pair of scissors may have been obtained from a drawer at the front desk. She said since the incident, staff now had been locking that drawer. The DON said the facility tried putting Resident #16 in a room closer to the nurses' station but she had not liked her roommate and she had to be moved to another room. She said a camera was now in place on the patio in order to monitor her because Resident #16 had demonstrated behaviors, such as calling EMS and the mental health crisis and had one of her suicidal attempts on the patio. The licensed clinical social work mentor was interviewed on 5/22/25 at 11:45 a.m. The licensed clinical social work mentor said the facility had not had a social worker for about a month but had hired a social work assistant a few weeks ago. She said after review of Resident #16's medical record, she was unable to determine if a safety plan was in place prior to the current one that was initiated on 4/2/25. She said she was unable to determine what communication was being provided by the behavioral health care providers to the facility in order to manage the resident's behaviors and her suicidal ideations. The licensed clinical social work mentor said moving forward, she was formulating a tracking tool to document when the behavioral health care providers were in the building and obtaining their notes to better enhance communication between the facility and the providers. The licensed clinical social work mentor said she had reached out to the behavioral health providers but had not received communication from them yet regarding the visit documentation for Resident #16. The NHA, who was a social worker, was interviewed on 5/22/25 at 11:55 a.m. The NHA said Resident #16 had been seeing a different behavioral health care provider prior and had started with the current provider less than a year ago. She said when a resident presented with suicidal ideations, there was a form in the EMR that walked staff through the assessment process to determine the resident's risk for suicide. She said all of Resident #16's current interventions for behaviors and the safety care plan should be updated and current with documented triggering behaviors. IV. Facility follow up On 5/24/25 at 2:52 a.m., after the survey exit, the licensed clinical social work mentor provided the following behavioral health documentation: The 3/5/25 community treatment and management (CTT) progress note documented that Resident #16 was having difficulty with insomnia due to bipolar and exacerbating her depression. It documented an increase of her antipsychotic medication (Apripiprazole) and starting trazodone (an antidepressant that also helps with insomnia). -However, the resident returned from the hospital on 2/23/25 and the note was not written until 3/5/25, 10 days after the resident's return to the facility. The 3/18/25 CTT progress note documented Resident #16 was currently hospitalized after a witnessed suicidal gesture she made in front of staff. It documented consultation with an inpatient psychiatrist and discussed a plan of care and adjustment to medication. The psychiatrist had attempted referral to inpatient psychiatric units but due to the resident being dependent on oxygen, she was unable to be admitted to inpatient units. The 4/2/25 CTT progress note documented a solution focused brief therapy note. It documented a recent suicide attempt where Resident #16 cut her wrists with scissors. It documented a well being action plan. It documented a wanderguard to prevent her from leaving the facility unsupervised. -However, the resident returned from the hospital on 3/27/25 and the note was not written until 4/2/25, six days after the resident's return to the facility. The 4/2/25 psychiatry evaluation and management progress note documented Resident #16 was diagnosed with bipolar disorder. Resident #16 was currently on Seroquel (an antipsychotic medication) that was prescribed during her hospitalization on 3/16/25. The resident was reporting better sleep and a good appetite. The 4/29/25 CTT progress note documented Resident #16's mood appeared more stabilized and she reported being hopeful. It documented there were no recent attempts of suicide. It documented Resident #16 no longer had a wanderguard or video camera in the room. Resident #16 said she had discussed it with the NHA and it had been collaboratively decided to remove them. -The note failed to identify what intervention was put in place of the wanderguard and camera to monitor and keep the resident safe. -The documentation provided by the licensed clinical social work mentor after the survey exit additionally failed to reveal documentation to indicate Resident #16 was seen by her behavioral health care provider on 2/14/25, after her first hospitalization for suicide attempt, as was documented in the 2/13/25 hospital discharge summary (see record review above).