**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 87 residents. The facility identified 16 residents at risk for elopement (an incident in which a cognitively impaired resident with poor or impaired decision-making ability/safety awareness leaves the facility without the knowledge of staff) in the South building. The sample included four residents with three sampled for accidents. The facility failed to identify likely avenues of exit, including windows, and failed to ensure the windows were secured to prevent residents at high risk for elopement from exiting the facility through the window. Resident (R) 1 was severely cognitively impaired and a high risk for elopement due to her dementia (progressive mental disorder characterized by failing memory, confusion). On 02/17/23 at 08:21 PM, Certified Medication Aide (CMA) R attempted to administer R1's medications, but R1 was agitated and refused. At 08:28 PM, R1 climbed out her bedroom window and walked, in the dark, approximately one mile to the local drug store. The temperature outside was 37 degrees Fahrenheit (F). At 08:59 PM, local law enforcement (LE) received a call from the local drug store that R1 was at the drug store, confused, and did not know where she came from or where she lived. LE went to the drug store at 09:09 PM, and eventually brought R1 to the facility's North building where facility staff informed LE, R1 was not on the resident roster. Another LE officer alerted the officer with R1, that R1 was a resident from the South building. The officer brought R1 to the facility's South building where staff confirmed R1 had exited via a window. Upon return at approximately 09:52 PM, R1 was agitated. The facility failure placed R1 in immediate jeopardy. Findings included: - R1 admitted to the facility on [DATE]. The Diagnoses tab of R1's Electronic Medical Record (EMR) documented diagnoses of dementia without behavioral disturbances and Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure). The admission Minimum Data Set (MDS) dated 06/19/22, documented R1 had a Brief Interview for Mental Status (BIMS) score of three, which indicated severe cognitive impairment. R1 was independent with no help for bed mobility; independent with setup help only for transfers, walking, and toileting; and supervision with setup help only for locomotion and dressing. The Quarterly MDS dated 12/20/22, documented R1 had a BIMS score of three which indicated severe cognitive impairment. R1 required supervision with setup help for all Activities of Daily Living (ADL). The Cognitive Loss/Dementia Care Area Assessment (CAA) dated 07/28/22, documented R1 had cognitive impairment. The Elopement Care Plan dated 09/16/22, documented R1 was at risk for elopement related to cognitive status, mobility status, and assessment indicating at risk or high-risk potential for wandering/elopement. The Care Plan directed the staff were educated on elopement potential, triggers, and preventative measures and staff kept R1's routine consistent to alleviate confusion. The Care Plan dated 02/10/23, documented R1 was an elopement risk/wanderer related to dementia and a desire to live elsewhere. Staff distracted R1 from wandering by offering pleasant diversions, structured activities, food, conversation, television, and books. The Assessments tab of R1's EMR documented a Wandering/Elopement Risk Scale on 01/04/23 documented a score of 12, which indicated high risk for wandering. The facility's Investigation dated 02/22/23, documented on 02/17/23 R1 left the building by climbing out of her window at 08:28 PM. R1 reported to the police that she jumped out of the window because the staff would not let her go through the front door. Earlier that evening, R1 took a shower and was fully dressed in warm clothes, a jacket, and shoes. R1 was still wearing her warm clothes including a jacket when the police [NAME] her back to the facility at 09:52 PM. At 08:21 PM, CMA R attempted to give R1's her medications, but R1 was agitated and refused. Staff last saw R1 at 08:21 PM, eight minutes prior to her exiting out of the window. R1 walked to the local drug store. Video footage at the local drug store showed R1 walked on the sidewalk, crossed the parking lot and entered the store at 08:48 PM, 20 minutes after she exited the facility. R1 asked the cashier at the drug store to call the police because she was lost. Upon return to the facility, R1 was agitated but after she had time to calm down, she allowed an assessment. R1 was negative for injury, interviewed, and immediately placed on one-to-one supervision. R1's baseline was disorientation to facility name, year, and full situation with periods of lucid mentation. On 02/18/23, R1's window screen was found hidden under her bed. She reported to staff she did not go out the door because staff would have stopped her. R1 did not recall the event very well. In an undated Witness Statement, Certified Nurse Aide (CNA) N stated she showered R1 at about 04:30 PM. After dinner around 07:00 PM, several nurses were in and out of R1's room trying to give her medications. CNA N stated R1 was threatening nurses, cussing them out, and telling them to get out of her room. She stated she last saw R1 around 08:00 PM. In a Witness Statement on 02/22/23, CNA M stated she saw R1 cursing at the nurse telling her she did not live there and that she was being held hostage. After several attempts from the CMA, she still refused medications, went to her room, and slammed the door. In a Witness Statement on 02/22/23, CMA S stated she last saw R1 sometime before 08:30 PM when she last attempted to give R1 her night medications. She stated R1 was not in a good mood and that was the second time she had attempted to give R1 her medications. CMA R stated she told the nurse who told CMA R to chart on R1's behaviors. In a Witness Statement on 02/22/23, Licensed Nurse (LN) G stated she was finishing up her charting around 09:45 PM when CNA O reported the police were at the door. The police came in with R1, reported she was picked up at the drug store, and brought to the facility. She stated staff did not know R1 was not in the building. The staff informed the charge nurse, LN I, and took R1 to her room where her left window was open without a screen in place. According to the Kansas State University Historical Weather website, the temperature in the area of the facility on 02/17/23 at 08:00 PM was 37.3 degrees Fahrenheit (F), the temperature at 09:00 PM was 36.0 degrees F, and the temperature at 10:00 PM was 35.3 degrees F. The Narrative Report provided by LE, documented on 02/17/23 at 08:59 PM, LE was dispatched to the drug store for an older female who was not sure how she ended up at the store. Upon arrival at 08:59 PM, LE contacted R1 near the front of the store and she explained that she walked from a medical facility to the store, but she could not recall where her family lived, her phone number, or any information to help locate her home. LE contacted a facility in the area and they stated R1 was not a resident there. LE then transported R1 to the facility's North building where they provided LE with a resident roster which did not show R1 as a resident. LE received a call from another LE officer who informed the LE office with R1 that she was a resident at the South building. LE transported R1 to the South building of the facility where staff told LE R1 left her room through a window. On 02/28/23 at 11:50 AM, the surveyor observed the area outside of R1's left window. The area directly in front of the window had a rock garden with a bush to the side of the window. The parking lot was located straight ahead and had uneven terrain with potholes and loose gravel. On 02/28/23 at 03:35 PM, the surveyor observed the South building of the facility was located one block from the highway. The posted speed limit was 45 miles per hour (mph) until the highway turned into the city's Main Street where it was 35 mph. The drug store was located 0.9 miles from the South building and R1 had to cross the highway/street to get to the drug store. On 02/28/23 at 11:37 AM, Administrative Nurse D stated administration looked at the facility's cameras and saw what time R1 left the building. She stated the times reported in the Investigation were the correct times. On 02/28/23 at 12:38 PM, Administrative Staff A stated she received a call from Administrative Nurse D stating a resident was brought back to the facility by police. She stated R1 climbed out of the window and staff did go to her room and saw the window was open. R1 was placed on one-to-one supervision at that time and maintenance came in to secure her window the next morning. Administrative Staff A stated she verified with the drug store whose camera showed R1 crossed their parking lot and entered the drug store at 08:48 PM. She stated R1 asked the drug store to call the police because she was lost. The last time staff saw R1 was around 08:21 PM and the cameras showed she exited the window at 08:28 PM. On 02/28/23 at 01:52 PM, Administrative Staff A stated it may have crossed the facility's mind at one point that a resident could open a window, but since it was not a normal way to elope, they did not really think about it. On 02/28/23 at 02:25 PM, CNA O stated if a resident was an elopement risk and actively exit seeking, the resident was closely monitored. He stated if they were agitated, staff redirected them. CNA O stated if a resident was missing, the staff completed a full head count, checked outside, and the nurse gave any further instructions. On 02/28/23 at 02:46 PM, LN H stated if a resident was exit seeking, the provider was notified, and staff monitored the resident closely with one-to-one supervision. She stated if a resident eloped, staff searched all over the building outside and inside, did a full head count to figure out who was missing, and notified administration, family, provider, and the police. On 02/28/23 at 02:50 PM, Administrative Nurse D stated if a resident was actively exit seeking, staff were expected to report that to administration so they could establish if there was a potential for elopement. She stated the resident was placed on one-to-one and if it was a change in condition, the provider was notified for possible orders. Administrative Nurse D stated if a resident eloped, a head count was conducted, staff looked outside, and the administrator and herself was notified. On 03/01/23 at 11:11 AM, CNA M stated she last saw R1 around 08:30 PM when CMA R attempted to give her medication. She stated R1 would not take her medication and R1 stated the facility was holding her hostage. CNA M stated R1 went into her room and slammed her door. CNA M thought she went to bed. She stated it was close to 10:00 PM when the police were at the door, saying R1 went out of the window. R1 wore jeans, a sweatshirt, and shoes. She stated when R1 was agitated like that, she left her alone and she normally came back out and asked if she had taken her medication. On 03/02/23 at 10:56 AM, CMA S stated she last saw R1 a little before 08:30 PM in her room when she tried to give R1 her night medications. R1 had refused her medications twice and she left to give her time to cooldown. She stated she asked CMA R to try to give R1 her medications. She could not recall what R1 was wearing the last time she saw her. The facility's Elopements and Wandering Residents policy, revised 2/20/23, directed residents were assessed for elopement and unsafe wandering upon admission and throughout their stay. Interventions to increase staff awareness of the resident's risk, modify the resident's behavior, or to minimize risks associated with hazards were added to the resident's care plan and communicated to appropriate staff. The facility failed to identify likely avenues of exit, including windows, and failed to ensure the windows were secured to prevent residents at high risk for elopement from exiting the facility through the window. R1 exited the facility via a window and walked on rough terrain to the local drug store located almost a mile away and on the other side of a busy street when the temperature was 37 degrees F outside. The facility failure placed R1 in immediate jeopardy. The facility submitted a plan for removal of the immediate jeopardy to the state agency, which included the following: 1. R1 was immediately placed on one-to-one supervision upon return to the facility and remained on one-to-one until her transfer to a facility with a memory care unit on 02/18/23 2. On 02/20/23, the facility ordered supplies that allowed the facility to properly adjust windows. The supplies were received on 02/27/23 and the facility windows were secured for North and South buildings as of 02/28/23. 3. The facility provided education to the South building staff on 02/20/23 and provided education to the North building staff from 02/20/23 to 02/23/23. 4. The South building completed an elopement drill on 02/23/23, and the North building on 02/28/23. After removal of the immediate jeopardy, the deficient practice remained a D scope and severity.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 88 residents with 33 residents at the North campus. The sample included one resident reviewed for elopement (when a cognitively impaired resident exits the facility without staff knowledge or supervision). Based on observation, record review, and interview, the facility failed to provide adequate supervision to prevent an elopement for Resident (R)1, who was cognitively impaired, at high risk for elopement, and at risk for falls due to an unsteady gait. On 01/01/23 at approximately 03:00 PM, R1 sat in the dining room with other residents. At 03:30 PM staff responded to the dining room door alarm. Staff observed R1's empty wheelchair next to the dining room door. Another resident in the area told staff R1 exited the facility through the dining room door. Licensed Nurse (LN) H and LN I, the 200-hall nurse, went in opposite directions around the facility to look for R1. They met at the midpoint, but had not located R1. LN I went back inside the facility to call the alert for the missing person while LN H circled the facility again. After circling the facility, a second time, LN H located R1 on the sidewalk in front of the facility approximately 15 minutes to 30 minutes after staff identified R1 was missing. R1 stated he had walked to the park. LN H escorted R1 back into the facility. The facility staff failed to provide adequate supervision and allowed R1 to wander outside of the facility without staff knowledge or supervision. This deficient practice placed R1 in Immediate Jeopardy. Findings included: - R1's Electronic Medical Record (EMR), under the Diagnosis tab recorded diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), muscle weakness, abnormalities of gait and mobility, weakness, and attention and concentration deficit. The admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of seven, which indicated moderately impaired cognition. R1 required supervision with set up help only for bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. R1 walked in his room and the corridor and locomotion on and off the unit independently with set up help only. The MDS recorded R1 had no behaviors. The Discharge Assessment-Return Not Anticipated MDS dated [DATE] recorded R1 had a BIMS of seven, which indicated severe cognitive impairment. The Cognition Care Area Assessment (CAA) dated 12/08/22 documented staff were to monitor for signs and symptoms of acute mental status changes to help treat the underlying condition. The Falls CAA dated 12/08/22 documented staff to anticipate and meet R1's care needs so that R1 did not attempt to unsafely perform activities of daily living (ADL) cares without staff assistance. The Morse Fall Scale for R1 dated 12/05/22 documented R1 was at high risk for falling. R1 had a history of falls and exhibited a weak gait. R1 was forgetful of his own safety limits The Wandering/Elopement Risk Scale dated 12/05/22 documented a score of 14, which indicated a high risk for elopement. The Elopement Care Plan initiated on 12/05/22 directed staff to engage R1 in active conversation as a form of redirection. Education for healthcare decision makers and staff of elopement potential, triggers and preventative measures. The admission Summary dated 12/05/22 at 06:04 PM documented R1 stated several times he wanted to go to his apartment to turn the heater on. Staff attempted to orient R1 to the call light and were not successful as R1 was perseverating on returning to his apartment. The Behavior Note dated 12/06/22 at 10:03 AM documented R1 was confused and did not remember that he was supposed to stay in his room due to quarantine because R1 had the flu. The note recorded R1 was found in the dining room approximately 10 minutes before the note entry without a mask on. A Skilled Note dated 12/6/22 at 12:29 PM documented R1 has exceptions noted with his mood. R1 was anxious and had wandering behavior. An Administration Note dated 12/10/22 at 04:42 PM documented R1 declined his Coreg (medication used to treat heart failure or high blood pressure) that evening stating I don't want it, I don't need it and I don't want to be here anymore. The note recorded R1 was shaking his finger aggressively at the nurse and staff were unable to calm R1 at that time. A PMR Follow Up dated 12/14/22 at 07:07 AM documented R1 wheeled himself down the hall in his wheelchair. R1 was confused, at his baseline, and said he wanted his coat so he could leave. The note recorded staff tried to redirect the resident but R1 insistent on getting his coat to leave. A Skilled Note dated 12/20/22 at 12:16 PM documented R1 was agitated and/or irritable, R1 had delusions (belief that is clearly false and that indicates an abnormality in the affected person's content of thought) and R1 had wandering behavior. A Skilled Note dated 12/21/22 at 01:27 PM documented R1 had a fluctuating mood, R1 was agitated and/or irritable, had delusions and wandering behavior. An Incident Note dated 01/01/23 at 04:44 PM documented LN H was notified by LN I that R1 walked out through the dining room doors, and the alarm was going off. LN H immediately went to the dining room. The alarm was still going off. R2 confirmed to LN H that R1 walked out the door. R1's wheelchair was in front of the door. LN H and LN I both went outside to look for R1. Both nurses met after circling the building. LN I went back inside to do room checks. LN H called the Director of Nursing (DON) and the Assistant Administrator. LN H then called LN J, and a code gold (missing person code) was initiated. LN H circled the building a second time. R1 was located on the sidewalk in front of building. R1 stated he went for walk to the park. R1 was brought back into building. R1 denied any pain. A Witness Statement, dated 01/01/23, from LN H documented LN I notified LN H, at approximately 03:30 PM on 01/01/23, that a resident had walked out the dining room door. LN I stated the alarm was going off. LN H went to dining room to find R1's wheelchair in front of door. Both LN H and LN I went out to look for R1. LN I went left and LN H went right. After the first round LN H and LN I met up in the middle. LN I went back inside to do a head count. While searching, LN H also notified the DON, the assistant administrator, and LN J. A code gold was also activated. LN H found R1 on the sidewalk in front of the building after she went around a second time. R1 had on shoes, jeans, shirt, and a coat. R1 stated he went to the park. LN H walked R1 back into facility. R1 denied pain and no injuries were found on assessment. Administration was notified, family was notified, physician was notified, and R1 was placed on 15-minute checks. A Witness Statement, dated 01/01/23, from LN I documented CNA M said R2, in the dining room, told LN I that R1 left the building from the dining room. LN I walked with CNA M and found R1's wheelchair empty, sitting in front of the door. The door alarm was going off, but it wasn't very loud, and LN I could not get it to cancel. LN H had the master code to cancel the alarm. LN H and LN I went outside to look for R1, LN I and LN H split directions and LN H found the resident on the sidewalk. LN H walked the resident back inside. R1 was in a good mood and very confused. R1 did not have a wanderguard on. The Facility Investigation dated 01/05/23 recorded on 01/01/23 LM H saw R1 in the dining room around 03:00 PM. At around 03:30 PM the dinging room door was alarming. LN H noted R1's empty wheelchair by the dining room door. The investigation recorded R1 left the facility at 03:30 PM and was brought back to the building at 03:45 PM by LN H. Administrative nurse D interviewed R1, and R1 stated he knew he went for a walk and went to see if an old barbeque placed that used to be in town was still there, and when it was not, he came back to the facility. The investigation noted R1 had memory impairment, but usually with objects or appointments. He was able to find his room. The investigation recorded the resident had a BIMS of eleven (moderate cognitive impairment) but was not confused and wondering. A Witness Statement, dated 01/18/23, by LN G, on duty at the time of the elopement, documented sometime in the afternoon after lunch time LN G came out of an unidentified resident's room into the hallway and saw a bunch of [unidentified] staff at the nurse's station; an [unidentified] Certified Nurse's Aide (CNA) approached LN G and said, someone eloped. Another [unidentified] staff member said R1 got out of the dining room door; when LN G asked about the alarm that would have gone off, CNA M told LN G she cleared the alarm and had not actually gone to look at the door. LN G immediately called LN H, and LN H stated R1 was located and coming back towards the building with her. During the phone call, a code gold was called over the intercom and then code gold cleared called almost immediately after. LN G went to the dining room and saw R1's wheelchair parked in front of the door that faces the street on the east side of the building. Shortly after, LN G observed LN H, LN J and R1 walking up the stairs to the main entrance to the rehab door. A Witness Statement, dated 01/18/23, documented on LN J worked as a house supervisor on the hospital side on 01/01/23. LN J received a call at reception from LN H. LN H stated R1 had eloped, and LN H was outside. As LN H was on the phone with LN J, LN H spotted the resident. LN J asked if LN H still needed LN J's assistance. LN H stated LN H might need help bringing the resident in. LN J went outside, LN H was with R1. R1 walked willingly inside. LN J walked with LN H and R1 inside the building According to Wunderground.com, the weather at the time of the elopement was 61 degrees Fahrenheit (F.). Observation on 01/17/23 at 04:40 PM revealed the facility was in an [NAME] area along a heavily trafficked road with four lanes of traffic. The posted speed along that stretch of the road was 35 miles per hour. R1's exact route was unknown although per observation, the resident would have had to walk across a side street to go to the park area. From the doorway that the resident exited, a sidewalk went down and around the building where there were parking lots. The area had many houses between the facility and the park. The front of the facility, where the resident was found, was on the four-lane highway. In an interview on 01/17/23 at 04:14 PM Administrative Nurse D stated R1 had not eloped. In an interview on 01/18/23 at 11:54 AM LN I reported that staff had looked for the R1 a good 20 to 30 minutes. LN I stated that when R1 was brought back into the building, R1 was very confused. LN I said at shift change R1 also wandered into another residents room on the wrong hallway. On 01/18/23 at 03:50 PM Administrative Nurse D stated R1 had no behaviors or wandering or exit seeking. Administrative Nurse D further stated the elopement assessment done upon R1's admission, which recorded R1 as an elopement risk, was done in error and contained inaccurate assessment information. Administrative Nurse D said R1 was alert and oriented. Administrative Nurse D revealed that she was unaware of the assessment findings of R1's Elopement/Wandering Risk Scale (dated 12/05/22) until 01/17/23. On 01/18/23 at 04:00 PM Administrative Staff A stated that R1 was able to tell staff where he was going and he came back willingly. Administrative Staff A further stated R1 was not an elopement risk. On 01/18/23 at 04:12 PM Administrative Nurse D stated R1 was alert and oriented and just chose to go out by himself. Administrative Nurse D said the resident was city. The facility Elopement and Wandering Residents policy implemented 02/01/20 documented the facility ensured that residents who exhibited wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. The policy further documented that alarms are not a replacement for necessary supervision. Staff were to be vigilant in responding to alarms in a timely manner. The facility failed to provide adequate supervision to prevent an elopement for R1, who was cognitively impaired, at high risk for elopement, and at risk for falls due to an unsteady gait. R1 wandered outside of the facility without staff knowledge or supervision. This deficient practice placed R1 in Immediate Jeopardy. After the elopement, the facility placed R1 on 1:1 until 01/02/23. All residents were accounted for, R1 was assessed. The facility provided education and in-service to staff regarding elopement which was completed by 01/04/23. The facility conducted an elopement drill on 01/04/23. The corrective actions were completed prior to the onsite survey so the deficient practice was cited at past noncompliance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 57 residents. The sample included four residents reviewed for accidents. Based on record review, interview, and observations, the facility failed to acknowledge and implement a plan of care to address Resident (R) 1's personal history of trauma, increased depression, as well an actual suicide attempt. On 10/20/22 staff identified R1 in his room with a trash bag over his head in an effort to suffocate himself. R1 stated he wanted to die due to his decreased mobility and increased need for assistance. R1 was sent to the hospital for psychiatric treatment and returned to the facility on [DATE]. Upon return, the facility failed to initiate a plan of care, which addressed R1's recent actual suicide attempt or the causative factors. On 11/02/22 staff conducted a multidisciplinary care plan meeting where they reviewed R1's traumatic history and history of suicide in R1's immediate family. On 11/03/22 at 08:20 AM staff found R1, again, with a plastic bag over his head, tied at the neck. The facility's failure to acknowledge the recent suicide attempt, the history of familial suicide, and the increased depression resulted in a second actual suicide attempt. This deficient practice placed R1 in Immediate Jeopardy Findings included: - R1's Electronic Medical Record (EMR), under the Diagnosis tab recorded diagnoses of acquired absence of left leg below knew, Asperger's (a neurodevelopment disability that affects the ability to effectively interact and communicate with people), difficulty in walking, anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear) disorder, major depressive disorder (major mood disorder), muscle weakness, history of falling, and mixed receptive-expressive language disorder (neurodevelopmental condition in which both the receptive and expressive areas of communication may be affected in any degree, from mild to severe). The admission Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. R1 indicated no concerns during his mood interview, and no behaviors. R1 was independent with no setup needed from staff for activities of daily living (ADL), except R1 required supervision with walking in the corridor. R1 took antidepressants (class of medication used to treat depression) seven out of seven days through the look back period. The ADL Care Area Assessment (CAA) dated 06/19/22 documented the care plan would make sure that staff were aware of R1's current ADL needs and preferences. The Psychotropic CAA dated 06/19/22 documented psychotropic (affects mood and thought) drugs would be addressed in R1's care plan to be monitored for all side effects and potential therapeutic benefits of medications. R1's Care Plan dated /revised on 06/21/22 directed staff to know R1 had a self-care deficit and required limited staff assistance with his care needs. It directed staff to encourage R1 to discuss his feeling about self-care deficit as needed. R1's plan of care recorded on 06/29/22 directed R1 was independent for meeting his emotional, intellectual, physical, and social needs through meaningful activities program both self-directed and in groups. It directed staff R1 enjoyed self-initiated activities such as watching televisions in his room and playing with his tablet on the internet. R1's Care Plan dated 07/07/22 and revised on 08/24/22 directed staff R1 required assistance with ADL related to increased risk for falls. It directed staff to recognize early signs of anxiety, treat or change environment (decrease stimulations, remove from loud setting). R1's Care Plan lacked any interventions to address suicidal ideation and actual suicide attempts, prior to 11/22/22. The care plan further lacked resident-centered interventions related to R1's history of personal trauma related to suicide and abuse. The Social Services Note dated 08/02/22 at 02:40 PM documented R1's family reported that R1 had a counselor every couple of weeks at his previous facility. R1's family further reported that R1 started talking of suicide after he lost his leg. The Skilled Note dated 08/04/22 04:08 PM documented R1 had behaviors. R1 was anxious, agitated, with fluctuating mood. The Skilled Note dated 08/10/22 at 07:48 AM documented R1 was anxious and agitated. The Skilled Note dated 08/11/22 at 04:51 AM documented R1 had exceptions noted with mood and was noted with behaviors, was anxious, and agitated. The Skilled Note dated 08/14/22 at 03:56 PM documented R1 had exceptions noted with mood and noted behaviors. R1 was anxious, agitated and/or irritable. The Incident Note dated 08/14/22 at 06:25 PM documented R1 fell in his room and reported his body was failing him. The Social Service Note dated 08/19/22 at 11:57 AM documented R1's family member was worried about R1 being able to see the psychologist. The note further documented R1 was put on the weekly list. The Skilled Note dated 08/19/22 at 01:20 PM documented R1 had exceptions noted with mood and behaviors. R1 was anxious, have agitation and/or irritable. The Skilled Note dated 08/20/22 at 10:08 PM documented R1 was agitated and/or irritable. The Skilled Note dated 08/21/22 at 10:08 AM documented R1 had exceptions noted with mood and behaviors. R1 was anxious, agitated, and tearful. The Skilled Note dated 08/22/22 at 10:08 AM documented R1 had exceptions noted with behaviors, displayed disruptive behaviors, was resistant of cares and had delusions. The Skilled Note dated 08/23/22 at 12:21 PM documented R1 had exceptions noted with behaviors, displayed disruptive behaviors, was resistant to cares and had delusions. The Skilled Note dated 08/25/22 at 01:14 PM documented R1 had exceptions noted with mood and with behaviors. R1 was noted to be anxious, agitated, and/or irritable. The Skilled Note dated 08/26/22 at 08:25 AM documented R1 had exceptions noted with mood, and with behaviors. R1 was noted to be anxious, agitated, and/or irritable. The Skilled Note dated 08/27/22 at 12:18 PM documented R1 had exceptions noted with mood. The Skilled Note dated 08/28/22 at 10:18 AM documented R1 had exceptions noted with mood and behaviors. R1 was anxious, agitated, and/or irritable. The Skilled Note dated 08/29/22 at 11:47 PM documented R1 had exceptions noted with mood and behaviors. R1 was anxious, agitated, and/or irritable. The Skilled Note dated 08/30/22 at 10:18 AM documented R1had exceptions noted with mood. R1 was anxious. The Psychological Diagnostic Interview dated 09/01/22 documented R1's mother made statements about wanting to die, and being anxious, agitated, and depressed. R1 had a past psychiatric history. R1 reported that his father was abusive to his mother and siblings, and that R1's mother completed suicide. R1 reported worsened anxiety and depression after the most recent hospital stay. R1 had perseverative and obsessive thoughts and repeated his statements often, including wanting to die. Nursing staff indicated that the statements had increased more recently. R1 indicated this was related to not wanting to be in the state that R1 was currently in and R1's current functioning. Treatment goals were discussed with nursing staff about R1's suicidal ideation, psychosis, anxiety and depression. It was suggested R1 eat in a less populated area for meals, as increased social interactions seemed to be a trigger for R1's anxiety. The Skilled Note dated 09/01/22 at 02:12 PM documented R1 had exceptions noted with mood and behaviors. R1 was anxious, agitated, and/or irritable. The Administration Note dated 09/01/22 at 02:48 PM documented R1 complained of his body not working and discussed with psychiatrist about issues. The Skilled Note dated 09/02/22 at 02:12 PM documented R1 had exceptions noted with mood and behaviors. R1 was anxious, agitated, and/or irritable. The Skilled Note dated 09/03/22 at 01:12 PM documented R1 had exceptions noted with mood and behaviors. R1 was agitated and/or irritable. The Behavior Note dated 09/07/22 at 07:53 AM documented R1 was approached by staff and immediately started screaming R1 could not take the anxiety any longer, R1's body was failing him and R1 just wanted to be put out of misery. R1 continued stating the facility just needed to ship R1 to an insane asylum. Staff informed R1 the doctor would be contacted. The Behavior Note dated 09/07/22 at 08:52 AM documented R1 frequently exhibited behaviors stating he had demons inside of his body and that his body was failing him. The note further documented that attempts at redirections were usually unsuccessful. The Behavior Note dated 09/07/22 at 08:59 documented R1 requested an exorcism. The Nurses Note dated 09/07/22 at 07:36 PM documented R1 was started on an antipsychotic medication (class of medications used to treat severe mood and mental disorders). Staff attempted to notify the practitioner to request an order for 14 day as needed Ativan (medication used to treat anxiety) due to R1's increased anxiety. The call went to voicemail. The Nurses Note dated 09/07/22 at 08:28 PM documented the Psychiatric Nurse Practitioner ordered Hydroxyzine (medication used to treat anxiety) 10 milligrams three times a day. The Skilled Note dated 09/08/22 at 02:14 PM documented R1 had exceptions noted with mood and behaviors. R1 had anxiety, agitation, and/or irritable. The Skilled Note dated 09/09/22 at 02:14 PM documented R1 had exceptions noted with mood and behaviors. R1 had anxiety, agitation, and/or irritable. The Skilled Note dated 09/10/22 at 12:12 PM documented R1 had exceptions noted with mood. R1 had anxiety and agitation. The Skilled Note dated 09/18/22 at 11:25 AM documented R1 had exceptions noted with mood and behaviors. R1 had noted anxiety, agitation, and/or irritable. The Skilled Note dated 09/19/22 at 11:25 PM documented R1 had exceptions noted with mood and behaviors. R1 had anxiety, agitation, and/or irritable. The Psychotherapy Progress Note dated 10/06/22 documented a treatment plan goal that staff would report a 50 percent reduction in R1's statements related to wanting to die. The Nurses Note dated 10/15/22 at 06:10 AM documented R1 made the discouraged statement that he was never going to get better. The Behavior Note dated 10/18/22 at 10:16 PM documented R1 was attention seeking during that shift. R1 asked repetitively if he should use his walker or wheelchair for mode of ambulation. R1 sat in the hallway versus sitting in the recliner in R1's room, which was his usual behavior. The IDT Weekly Note dated 10/20/22 at 10:12 AM documented R1 had an increase in behaviors displaying more signs and symptoms of depression. The Incident Note dated 10/20/22 at 05:39 AM documented R1 had taken a trash bag and placed it over his head and was attempting to suffocate himself. An unidentified nursing staff ripped the bag so R1 could breathe. When staff asked R1 what was going on, R1 reported he had no reason to live anymore. R1 further reported that his lack of being able to do ADL and being a vegetable was the reason R1 wanted to die. R1 was brought to the nurse's station, and Administrative Nurse E was notified. The eInteract SBAR Summary on 10/20/22 at 05:40 AM documented R1 was sent out for a psychiatric evaluation and was admitted for inpatient psychiatric stay. The Nurses Note dated 10/20/22 at 07:55 AM documented R1 was placed on one on one, and the mental health nurse practitioner ordered to send R1 out for a psychiatric evaluation due to R1 having a plan and following through with a suicidal attempt. R1's family was notified and stated going out was good as R1 had become more depressed and that antidepressants were not working. The Social Services Note dated 10/20/22 at 02:19 PM documented R1's family reported R1's mother had committed suicide. The Admission/Readmission/Quarterly Assessment Note dated 10/31/22 at 12:45 PM documented R1 readmitted to the facility from the hospital after a psychiatric stay. R1 was orientated to call light, bed controls, and telephone location and use. The Multidisciplinary Care Conference dated 11/02/22 at 11:12 AM documented R1's vision was adequate with glasses, hearing was limited, and he had an appointment later that month to follow up. R1 could communicate his needs and wants. R1 had occasional incontinence due to urgency. R1 used a wheelchair for mobility since his return from the hospital and worked with therapy to improve mobility. R1 required limited assistance needed for ADL. He ate well. R1 would peripherally observe activities and enjoyed food related to activities. R1 had no changes in cognition and he stated he did not have as much anxiety. He remained a full code (wanted resuscitative measures if pulse and/or respirations ceased). R1's mother committed suicide, his father was abusive and died of heart attack at [AGE] years old. R1 started therapy services that week with emphasis on ambulation, transfers, balance, safety, ADLs, cognition, and eating/swallowing. R1's care plan was reviewed and updated. The Behavior Note dated 11/03/22 at 08:22 AM documented R1 was found in his room with a plastic bag tied over his head. R1 was kept under one-on-one supervision. R1 stated he was not choosing to feel that way and wanted to find out why he did feel that way. The Behavior Note dated 11/03/22 at 08:50 AM documented R1 reported he was depressed and lost his will to fight. The Transfer to Hospital Summary note dated 11/03/22 at 09:34 AM documented the Psychiatric Nurse Practitioner was contacted and ordered R1 to be sent out for treatment. R1 was transferred to the hospital. The Admission/Readmission/Quarterly Assessment Note dated 11/21/22 at 04:20 PM documented R1 arrived at the facility via wheelchair. R1 was oriented to the call light, place, person, and situation. The Behavior Note dated 11/27/22 at 08:33 AM documented staff administered hydroxyzine as ordered related to restlessness, wandering away from the table, and refusing to eat after receiving insulin (hormone given to control blood sugar levels). R1 received education to eat related to hisreceived insulin. R1 stated his body was already dead, to call the hospital, and that R1 was going to put a bag over his head. The staff notified the Psychiatric Nurse Practitioner who ordered hydroxyzine 20 milligrams three times a day for R1. The staff placed R1 on one-on-one as soon as he made the statement. The notarized Witness Statement by Certified Medication Aide (CMA) R dated 12/08/22 documented CMA R had pulled her medication cart right beside R1's room. A second unidentified staff member came to the medication cart to ask for something but stopped right outside of R1's room and motioned to CMA R that R1 had a bag over his head. CMA R pushed the unidentified staff member aside and went to R1 and removed the bag from R1's head. At that time, CMA R took R1 to the social worker office and notified Social Services X of what had happened. On 12/08/22 at 09:10 AM Administrative Nurse E stated that R1 should have had something in his care plan about his suicidal ideation. Administrative Nurse E verified there was nothing on the care plan to alert staff about concerns with R1's suicidal ideation. She further verified that direct care staff working with R1 would not have known what to do with no directives on the [NAME] (tool used to summarize care needed for each resident) for the nursing staff, especially agency staff. On 12/08/22 at 10:31 AM Administrative Nurse D stated she expected R1's care plan to be updated to reflect his suicidal ideation. Administrative Nurse D further stated that when R1's family member reported R1 was suicidal, Administrative Nurse D expected that to have been added to the care plan immediately and added to the [NAME] so that the staff were aware of the concerns for R1. On 12/08/22 at 10:25 AM Consultant GG reported it would make sense to have interventions in place to prevent future attempts at suicide for R1. The Behavior Management and Monitoring Plan policy implemented 02/01/20 documented residents who exhibit behavioral concerns may require a behavior management plan to ensure they are receiving appropriate services and interventions to meet their needs. Behaviors should be documented clearly and concisely by facility staff. Documentation should include specific behaviors, time and frequency of behaviors, observation of what may be triggering behaviors, what interventions were utilized, and the outcomes of the interventions. Behaviors should be identified and approaches for modification or redirection should be included in the comprehensive plan of care. Target Behaviors, that are individualized to each resident, will be monitored each shift by Licensed Nursing as indicated. The facility failed to acknowledge and implement a plan of care to address R1's personal history of trauma, increased depression as well an actual suicide attempt. The facility's failure to acknowledge the recent suicide attempt, the history of familial suicide and the increased depression resulted in a second actual suicide attempt. This deficient practice placed R1 in Immediate Jeopardy. On 12/08/22 the facility initiated the following actions to remove the immediacy: 1. R1's care plan was revised by Director of Nursing to include his suicidal history and individualized interventions. 2. Current residents with a past history of suicidal ideation were identified through active diagnosis and interview. Individualized care plans were implemented by Director of Nursing. 3. Education was provided to active staff on facility suicide prevention policy and education added to new-hire and agency training. 4. An individualized behavior monitoring task has been added to the TAR for residents with an active diagnosis of suicidal ideation. 5. Ad Hoc QAPI meeting was held. After the corrective actions were completed and the immediacy removed, the deficient practice remained at a scope and severity of D.