**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review, the facility failed to provide adequate supervision and assistive devices to ensure the safety of its residents for 1 of 9 sampled residents (Resident (R)9). The findings include: Review of the facility policy titled, Safety and Supervision of Residents, revised 07/2017, revealed the interdisciplinary team (IDT) was to analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents. Further review of the policy revealed the IDT care team was to target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. Review of the facility policy titled, Managing Fall and Fall Risk, revised 03/2018, revealed the facility should develop a resident-centered fall prevention plan in effort to reduce identified risk factor(s) of falls for each resident at risk or with a history of falls. Futher review of the policy revealed if falling recurred despite initial interventions, staff were to implement additional or different interventions, or indicate why the current approach remained relevant. Review of the facesheet for R9 revealed the facility admitted the resident on 05/14/2025, with diagnoses that included urinary tract infection, traumatic brain injury, unsteadiness on feet, and repeated falls. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed R9 to have a Brief Interview for Mental Status (BIMS) score of three out of 15, indicating severe cognitive impairment. Review of the progress note dated 05/15/2025 at 10:27 AM, revealed R9 had been restless all morning and attempted to get out of bed to mow and continued to pull at abdominal binder and percutaneous endoscopic gastrostomy (PEG) tube. Review of the progress note dated 05/16/2025 at 11:51 PM, revealed R9 had been found lying on the floor in front of his wheelchair at 6:30 PM on 05/15/2026. Continued review revealed R9 had been unable to give a description of what happened due to confusion. Further review of the progress note revealed R9 stated he hit his head. In addition, review revealed R9 was sent to the emergency room (ER) for evaluation due to his history of a brain bleed. Review of the facility document titled, FSI Fall Scene Investigation Report,dated 05/16/2025, revealed the contributing factors of R9's fall were the amount of assistance in effect and mood or mental status. Further review of the document revealed the care plan had been updated, with the addition of a perimeter defining mattress. Review of the facility document titled, FSI Fall Scene Investigation Report dated 05/17/2025, revealed R9 sustained a fall on 05/17/2025 at 6:00 PM when the nurse observed the resident sliding out of bed onto the floor after he had been trying to get out of bed unassisted all shift. Per review, the contributing factors of the fall were noted as confusion related to a history of traumatic brain injury. Continued review revealed the document listed the initial intervention to prevent falls as being Fall mat placed to right side of bed. Further review of the document revealed the care plan had been updated with the addition of a fall mat on the floor on the right side of R9's bed. Review of the progress note dated 05/17/2025 at 8:38 PM, revealed R9 had been found in his room sitting on the bed, and had pulled his PEG tube out and the PEG tube was lying on the floor beside his continuous positive airway pressure (CPAP) machine. The PEG site was noted to be bleeding and R9 had been confused and hallucinating. Further review of the progress note revealed R9 was taken to the ER via EMS to be evaluated. Review of the progress note dated 05/23/2025 at 11:55 PM, revealed R9 continued to be confused and pulled his abdominal binder off and pulled on his PEG tube. Review of the IDT note dated 05/29/2025 at 3:35 PM, revealed R9 sustained a fall on 05/28/2025 at 7:55 PM. Per review of the note, R9 had been found lying on his back on the floor between his bed and the window with no injuries noted. Review of the facility document titled, FSI Fall Scene Investigation Report dated 05/28/2025, revealed the contributing factors to R9's fall were mood and mental status. Further review of the document revealed the resident' scare plan was revised with the addition of changing the room configuration with the right side of the bed against the wall. Review of the facility document titled, FSI Fall Scene Investigation Report, dated 05/29/2025, revealed R9 had an unwitnessed fall on 05/29/2025 at 9:05 PM. Per review, R9 fell across from the nurse's station, while attempting to transfer from his wheelchair to a regular chair and tripped over the foot rests of wheelchair. Continued review revealed staff had placed R9 in the wheelchair across from the nurse's station so they could keep an eye on the resident. Further review of the document revealed R9's care plan had been updated with the addition of removing the leg rests when sitting in his wheelchair. Review of the facility document titled, FSI Fall Scene Investigation Report, dated 06/03/2025, revealed R9 had an unwitnessed fall on 06/03/2025 at 6:30 AM. Per review, R9 had been found crawling in the hallway without a brief on and told staff he was looking for his puppy that got out of the house. Continued review revealed the contributing factor to fall R9's had been confusion. Further review of the document revealed R9's care plan had been updated with the addition of offering the resident a stuffed puppy for comfort. Review of the health status note dated 06/03/2025 at 10:45 AM, revealed the 300-hall Unit Manager (UM) documented speaking with R9's wife about the resident's frequent falls, anxiety, and not being able to sit still. Per review, the UM noted suggesting to the family they get a sitter or come spend more time in the facility with R9. Further review revealed R9's wife told the UM she was not able to provide a sitter or spend more time in the facility. Review of the facility document titled, FSI Fall Scene Investigation Report dated 06/06/2025, revealed R9 sustained a fall. Per review, on 06/06/2025 at 11:15 AM, the resident fell out of his wheelchair onto the floor while in the dining room attempting to self-transfer. Further review of the document revealed R9's care plan was updated with the addition of anti- roll backs placed on the wheelchair. Continued review of R9's electronic health record (EHR) revealed the resident was hospitalized on [DATE] due to pulling out his PEG tube earlier that morning. Review further revealed R9 returned to the facility at approximately 3:00 PM on 06/11/2025 after having the PEG tube replaced. Observation on 06/12/2025 at 8:30 AM, of R9 in his room revealed the resident lying on the bed with eyes closed and a one-to-one (1:1) supervision person present. Review of the 1:1 sitter logs for R9 revealed the resident had been on 1:1 supervision since 06/11/2025 at 3:30 PM (approximately the time he returned from the hospital). In interview with the Physical Therapy Assistant (PTA) 1 on 06/11/2025 at 9:30 AM, she stated she only treated R9 one time, and that had been for in-room treatment. She said R9 had not wanted to participate in the therapy. PTA 1 explained she had to get R9's wife to help him to participate in his therapy. She further stated that physical therapy was usually only helpful with improvement if the resident was able to follow direction and consistency. In interview on 06/11/2025 at 9:45 AM, the medical Nurse Practitioner (NP) stated R9 was on of her patients in conjunction with the doctor. She stated she had not been able to get a lot of information from R9 as he was not cognitive intact. The NP reported calling R9's wife to speak with her and a family friend about the resident. She said since R9 has been at the facility he had been pulled out his feeding tube a couple of times. The NP explained they had used an abdominal binder to keep R9's feeding tube out of reach. She stated as R9 had kept wheeling his wheelchair while attached to his feeding pump, they had changed his tube feedings to bolus feeding to keep him from pulling at it. The NP reported to her knowledge, R9 has not fallen, but had been found crawling on the floor. She stated the family wanted the facility to use restraints, such as side rails and lap buddies; however, they never ordered restraints at the facility. The NP said resident rights indicated a resident had the right to be free from restraints and also had the right to fall. She explained she asked the doctor for more information on all the options for R9 and said she did not think the resident was a good fit for the facility. The NP reported she thought R9 needed more 1:1 care. She stated she did not want to chemically restrain R9, but he would be better off if we can just keep him calm. The NP said R9's Exelon patch and Namenda (used to treat Alzheimer's disease), and his Buspar (an anti-anxiety medication) had all been increased. She further stated she thought the staff at the facility were really good about figuring out the cause of residents' falls and putting necessary interventions in place. In interview with Certified Nursing Assistant (CNA) 6 on 06/11/2025 at 10:33 AM, she stated she normally worked in restorative care, and was not familiar with R9. She stated typical fall prevention interventions used at the facility included placing mats on the floor by the bed in a resident's room; putting up signs in their room to remind them to use their call light; and rearranging items in the room to facilitate safer movement. CNA 6 said seatbelts for wheelchairs, and bed and/or chair alarms were not used. She further stated if someone were to fall, she would let the nurse know immediately, document what happened, and make a falls report documenting what we saw and what we know. In interview with the 300-hall UM on 06/11/2025 at 10:45 AM, she stated she was familiar with R9, and thought his confusion was contributing to his falls. She stated he did not know what he was doing, and they had tried everything but restraints. The UM said she had talked to R9's wife and requested the wife hire a sitter to sit with the resident, or for family to come in and spend more time with him to try to help prevent falls. She stated the wife told her she came up here as much as she could. The UM explained R9's wife thanked them for doing everything they could for R9. She stated she thought R9 should be in a neurorestorative or brain injury center. In interview with PTA 2 on 06/11/2025 at 12:11 PM, she stated she had been working with R9, who was physically not bad and usually was very cooperative and very strong. She stated his strength was the problem because he was strong enough to move around by himself which had been leading to his falls. PTA 2 reported R9 was just so confused and had delusional conversations. She stated R9 overestimated himself and did not know where he was or what was going on, and did not remember when he fell. PTA 2 said the Pommel cushions (used to maintain proper hip and leg alignment) being used in some residents' wheelchairs were to prevent contractures and not used to prevent someone from falling out of a wheelchair. In interview on 06/11/2025 at 1:35 PM, the Director of Nursing (DON) stated she believed R9's behavior stemmed from his TBI. She said the facility had done everything to try to prevent R9's falls including: placing him on a perimeter defining mattress; moving his bed so he could see out into the hallway; keeping his bed low to the floor and placing a mat on the floor beside his bed; and placing his bed up against the wall. The DON reported R9 was very strong and very fast, and when he was up in his wheelchair, they kept him sitting beside the nurse's station. She stated they used non-skid socks for R9 when up; took the footrests off of his wheelchair to prevent him from tripping over them; and had him seen by psychiatry (psych) for medication adjustments and recommendations. The DON said they could have a resident on 1:1; however, that was not long-term and they had asked if the family could come more. She reported when R9 returned from the hospital the IDT team would have a meeting to talk about other options to protect him. In additional interview on 06/12/2025 at 8:49 AM, the 300-hall UM stated recommendation had been made that R9 needed a 24/7 (24 hours a day times 7 days a week) sitter after talking with the clinical team. She said with R9 having so many falls, they were struggling with what to do next for him. The UM reported R9 had been falling frequently, pulling his PEG tube out, and having behaviors. She stated she felt he needed 1:1 care to prevent further falls and to keep him from pulling his PEG tube. The UM explained since R9 returned from the hospital yesterday, he had a sitter, just for the transition from the hospital. She stated it was up to the clinical team on how long the transition period would be and that decision was based on the resident's behavior and adjustment after returning to the facility from the hospital. The UM said R9 had a sitter while he was in the hospital; however, the facility had not provided any 1:1 services before yesterday. She stated they had been trying to take him to activities to provide diversionary activities and said they knew R9 had owned a radio station, so he had an Alexa (virtual assistant speaker) in his room. The UM further stated to assist R9 with toileting to prevent falls the aides were rounding on him every 2 hours to encourage toileting. In interview with the Assistant Director of Nursing (ADON) on 06/12/2025 at 9:00 AM, she stated the facility traditionally did not provide 1:1 care services. She stated R9 only had a sitter right now to help him adjust during the transition from the hospital where he had 1:1 supervision. The ADON said she felt R9 needed 1:1 supervision due to what he had been through. She reported since the family was not able to get a 24/7 sitter for R9, it was the facility's responsibility to keep him safe. The ADON further stated they had not gotten a sitter for R9 yet because they were exhausting all other options. In an interview with the DON on 06/12/2025 at 11:11 AM, she stated that the recommendation to the family for hiring a 24/7 sitter was based on R9's behavior and pulling his PEG tube out. She stated that they started him on one-on-one supervision when he got back from the hospital to assist with his transition back to the facility from the hospital and he had a sitter while in the hospital. She stated that she feels like 6 falls and pulling his PEG tube out twice would not warrant a sitter. She stated that if the family cannot hire a sitter or be present more with the resident, then it is the responsibility of the facility to keep him safe. She stated that depending on his behaviors is how long he will be on one-to-one supervision. She stated that R9 is followed by a nurse practitioner, seen by neurology, and they have an in-house psychiatric nurse practitioner. She stated that they review his medication regimen more often than is required. In an interview on 06/12/2025 at 11:50 PM, the facility's Administrator stated that she did not know when the recommendation was made for a 24/7 sitter to R9's the family. She said staff had been trying to increase their supervision of R9 by keeping him up by the nurse's desk. The Administrator reported staff had been trained to guide and direct residents so they could be comfortable in the least restrictive manner. She explained she did not know what dictated having a 24/7 sitter. The Administrator stated it was always the facility's responsibility to keep residents safe. She said the facility usually did not accept residents who came from the hospital on 1:1 care; however, as R9 was already been our patient, 1:1 care was provided for him to transition from the hospital. The Administrator further stated her expectations was for staff to follow the resident's care plan interventions to assist in reducing the risk of fall and injury.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and review of facility policy, the facility failed to provide and ensure Resident (R) 84 received necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being. R84's level 1 Pre-admission Screening and Resident Review (PASRR) indicated a level 2 PASRR was needed. The level 2 PASRR indicated R84 MUST receive psychiatric (psych) services on a monthly basis. However, the facility failed to ensure R84 received the required monthly psych services. Therefore, on [DATE] at 2:10 AM, R84 was found lying on her bed with oxygen tubing wrapped 4-5 times around her neck, and was pronounced deceased . Review of the death certificate dated [DATE], revealed R84's cause of death was noted as Ligature Asphyxiation, rubber oxygen tubing used to intentionally obstruct airway, and the death was ruled a suicide. The findings include: Review of the facility policy titled, Behavioral Assessment, Intervention, and Monitoring, dated 03/2019, revealed residents were to receive and the facility was to provide behavioral health services as needed to attain or maintain their highest practicable physical, mental, and psychosocial well-being. Continued review revealed provision of behavioral health services were to be provided in accordance with the resident's comprehensive assessment and plan of care. Review revealed behavioral health services were to be provided by qualified staff who had the competencies and skills necessary to provide appropriate services to the residents. Continued review of the policy Behavioral Assessment, Intervention, and Monitoring dated 03/20219, revealed under the assessment section all residents were to receive a Level 1 PASRR screening prior to admission. Per review, if the level 1 PASRR indicated an individual might meet the criteria for a mental disorder, intellectual disability, or related condition, he or she was to be referred to the State PASRR representative for the level 2 PASRR screening process. Review revealed the level 2 PASRR evaluation was to be used when conducting the resident's assessment and development of the care plan. Additional review of the Behavioral Assessment, Intervention, and Monitoring, dated 03/2019, revealed under the management section, the (facility's) Interdisciplinary Team (IDT) was to evaluate residents' behavioral symptoms to determine the degree of severity, distress, and potential safety risk to the resident and develop a plan of care accordingly. Per policy review, under the monitoring section, if a resident was being treated for altered behavior or mood, the IDT team was to seek and document any improvements or worsening in the individual's behavior, mood, and function. Further policy review revealed the IDT team was to monitor the resident's progress .until stable, with interventions adjusted based on the impact on behavior and other systems symptoms. Review of R84's closed record, Resident Face Sheet, revealed the facility admitted the resident on [DATE] with diagnoses to include; schizoaffective disorder, bipolar type, generalized anxiety disorder and major depressive disorder, recurrent, mild. Review of the facility's admission Minimum Data Set (MDS) Assessment for R84 dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating intact cognition. Continued MDS review of section D for mood, revealed a score of 21, which indicated R84 had been assessed as being severely depressed. Review of the Quarterly MDS assessment dated [DATE], of section D for mood, revealed a score of 10, which indicated R84 was assessed as being moderately depressed. Review of R84's Comprehensive Care plan dated [DATE], revealed the facility developed a focus problem for Depression/Mood State related to dysfunctional grieving, depression related to life changes, medical conditions, and psychiatric conditions. Review revealed the goal for R84 was management of her depression symptoms at an acceptable level to her through the next review date with a revision date of [DATE]. Review further revealed the interventions included encouraging R84 to verbalize feelings and offer emotional support. Continued review of R84's Comprehensive Care Plan revealed the facility also developed a Psychotic Disorder, altered thought process, related to bipolar effective disorder and schizoaffective disorder dated [DATE]. Review revealed the goal was to manage R84's symptoms of altered thought process through the next review date, revised on [DATE]. Per review , the interventions included: attempting to identify stressors contributing to R84's behaviors and removing them if possible; administering her medication as ordered; and providing a mental health consult when ordered. Further review revealed the interventions additionally included: observing for signs and symptoms of change in R84's condition and notifying the Physician as needed, and providing emotional support and reassurance. Review of the hospital record information dated [DATE], prior to R84's admission to the facility, revealed, the patient had a historical note of illicit drug use and advanced depression. Continued review revealed following medical stabilization, the intent was for R84 to transition to a facility; however, underlining suicidal gestures and actual indigestion of a foreign body (wedding rings). Per review, R84 was to be transitioned to the mental health unit for ongoing medical management and interventions. Further review revealed diagnoses for R84 included a history of Post Traumatic Stress Disorder (PTSD), psychosis, anxiety disorder, major depressive disorder, recurrent and bipolar disorder. Review of the Nursing Facility PASRR level 1 dated [DATE], under section 6 revealed the nursing facility staff were to refer the applicant to the Community Mental Health Center for completion of a Level 2 PASRR. Review of the PASRR, Level 2, Comprehensive Evaluation for Serious Mental Illness and Intellectual Disability/Related Conditions, dated [DATE], revealed the evaluation had been completed online. Per review, the PASRR representative had attempted to contact the facility for additional information on [DATE] at 10:25 AM, and 3:45 PM, on [DATE] at 8:15 AM, and on [DATE] at 10:00 AM, with no success, and no way to leave a voicemail. Continued review revealed under Section 8, determination revealed R84 met criteria for serious mental illness; however, did not require specialized services and the resident's total care needs could be met in the nursing facility. Review of a document titled, Notification of Recommended Services, for R84, and for the nursing facility, revealed the PASRR professional recommended completing the evaluation, and the resident had mental illness. Continued review revealed the recommended services to best meet R84's individual needs MUST be part of the care plan to ensure continuity of care and stabilization of depressive symptoms. Further review revealed R84 was to receive individual behavior or mental health services therapy on a monthly basis. Review of the physician order dated [DATE], revealed an order for R84's consults included consults as needed for neuro-psych, psychiatric and treatment as needed for the resident's health and comfort. Review of records from an outside psychiatric (psych) provider dated 02/2022 through [DATE], revealed R84 failed to keep the following appointments on: [DATE], [DATE], [DATE] and [DATE] and on [DATE]. Continued review revealed R84 was discharged from the outside provider's services for failure to adhere to her treatment plan and no call no show for appointments. Further review of revealed the last psych treatment scheduled for R84 was on [DATE]. Review of the consent form for the facility's psych services provider revealed that on [DATE], the Social Services Director (SSD) documented R84, had refused to be seen by the facility's psych service group. However, further review of the form revealed no documented evidence the document had been signed by R84. Review of the Progress Note dated [DATE] at 10:47 AM, revealed, R84 had been sitting on the side of her bed sobbing. Continued review of the Note revealed the nurse asked R84 if she needed someone to talk to, and the nurse also told the resident the facility had a Social Worker or the nurse would listen to the resident. Further review revealed R84 stated as sobbing heavily, I will be alright I need no one at this time to tell my business to. Additional review revealed no documented evidence the nurse attempted to further address R84's behaviors, nor contacted the medical provider or psych services provider for additional interventions. Review of the Behavior Note dated [DATE] at 12:23 AM, revealed R84 had been crying and was visibly upset while talking on the phone with her husband. Per review, the Registered Nurse (RN) and aides provided emotional support for the resident, with PRN (as necessary) medications (meds) for anxiety given and documented. Further review revealed R84's behavior/emotional status observed by the nurse had been reported to the supervising nurse. Additional review revealed however, no documented evidence the supervising nurse addressed R84's emotional stated, nor notified the medical or psych provider of the resident's behaviors. Review of a Behavior Note dated [DATE] at 5:46 AM, revealed R84 had been up most of the night, silently crying. Per review, when the nurse asked R84 what was the matter, the resident just said, I am just thinking about life. Continued review revealed R84's scheduled Alprazolam (generic for Xanax, an anti-anxiety medication) given. Further review revealed the nurse would report R84 to social services and the clinical director for her behavioral concern. Additionally, review revealed R84 calmed down and slept soundly from 3:00 AM to 6:00 AM. Review of the Health Note dated [DATE] at 9:27 AM, documented by a Licensed Practical Nurse (LPN), revealed R84 had increased tearfulness this shift. Continued review revealed LPN sat with R84 to tried to comfort her and let her know we were here if she needed someone to talk to. Further review revealed the information regarding R84 was placed in the Advanced Practice Registered Nurse (APRN) book so the APRN could assess the resident when doing rounds tomorrow. Review of a Progress Note, documented by the APRN on [DATE], revealed she assessed R84 who had increased anxiety. Continued review revealed per nursing staff R84 had been more tearful and anxious at times recently. Further review revealed the patient reported she had just recently found out that she would be moving out of the nursing facility and was anxious about the upcoming changes and about living by herself. Review of the Behavior Note dated [DATE] at 4:15 PM, revealed, R84 came to the nurse and stated, I think I'm having a manic episode. Per review, R84 told the nurse, I'm going crazy. Continued review revealed the nurse noted having previously given R84 a PRN (as needed) Benadryl related to itching. Further review revealed the nurse contacted the Nurse Practitioner (NP) with no new orders received at that time. In addition, review revealed the nurse informed R84 she was due for her scheduled 6:00 PM Xanax soon, and the resident verbalized understanding and went back to her room. Review of the Progress Note dated [DATE] at 5:45 PM, revealed R84 came to the nurse's station requesting more nerve medication, stating her nerves were really bothering her. Review revealed the NP was notified and the nurse was given a one-time only order for Vistaril (antihistamine also used to treat anxiety) 50 milligrams (mg) by mouth. Continued review revealed R84 expressed she was not happy with that medication, and stated, This isn't going to do anything, I need something to knock me out. Further review revealed R84 ended up taking the (Vistaril) medication, and the nurse told the resident to wait for medicine the to kick in and see how she felt when it did. Review of the Progress Note dated [DATE] at 7:57 PM, revealed a one-time physician's order for an extra dose of Xanax 1 mg related to the resident's anxiety. Further review revealed R84 stated, I'm crawling out of my skin. Review of the Progress Note dated [DATE] at 8:45 PM, revealed R84 was standing at the nurses' station calm and stating, I've got to have something. Per review, the nurse informed R84 she could not have her pain meds until 9:30 PM, with the resident stating, I'm on edge. Continued review revealed the nurse informed R84 she just had Xanax and the only other thing we can do was to send her to hospital. Review further revealed R84 stated, I don't want to go to the hospital, and then returned to her room at that time. Review of the Progress Note dated [DATE] at 5:01 AM, revealed at approximately 2:10 AM, R84 was found lying on her bed with oxygen tubing wrapped four to five times around her neck. Review of the Kentucky Certificate of Death for R84 dated [DATE], revealed it listed the cause of the resident's death as Ligature Asphyxiation, rubber oxygen tubing used to intentionally obstruct airway. Further review revealed R84's death was ruled a suicide. In interview On [DATE] at 8:55 AM, Certified Nursing Assistant (CNA) 5 stated she had worked the night R84 passed away. Per CNA 5's interview, she and CNA 6 had been sitting at the nurse's station that night and R84 was walking down the hall and said, Hi girls, as she headed to the kitchen to get some tea. She stated she saw R84 go back to her room and there were no indicators the resident was in any distress or was in a bad mood. The CNA stated she had seen R84 have mood changes before after phone calls with her spouse. She stated R84 sometimes also seemed different and distant. CNA 5 further stated R84 told her (CNA 5) that her spouse had promised to come get her out of the facility and take her home. In interview on [DATE] at 9:08 AM, CNA 6 stated she had not seen changes in R84 the night of the event. In interview on [DATE] at 9:52 AM, Registered Nurse (RN) 2 stated she had been working at the facility since September of 2022, as the night shift nurse. She stated R84 had been cognitively intact and able to ambulate independently. RN 2 said she witnessed R84 occasionally having crying spells but on the night of the event, there had been no indications she was depressed. She stated that night R84 discussed her upcoming appointment to be cleared for cataract surgery and said she was pleased her son was coming to take her to that appointment. The RN stated R84 had been up around 12:30 AM to go get tea from the kitchen and had greeted staff sitting at the nurse's station on her way to the kitchen. She stated R84 returned to her room after getting the tea. RN 2 stated at approximately 2:10 AM, when she entered R84's room to obtain her vital signs she found the resident lying on the bed with her oxygen tubing looped around her neck five or six times. She additionally stated she assessed R84 and found no pulse, so she yelled for help and initiated cardiopulmonary resuscitation (CPR). In an interview with the facility's former Social Services Director (SSD) 1 on [DATE] at 8:50 PM, she stated she did not have a degree in social work; however, had been in the position of SSD from April of 2022 to April of 2023. Former SSD 1 stated she received no training for her role as SSD. She stated the facility had limited resources and the Social Services Assistant (SSA) was a former Certified Nursing Assistant (CNA). Per former SSD 1's interview, she had not been working at the facility when R84 was admitted and had no knowledge of the resident's history. The former SSD stated she thought she should have been informed of R84's psych history. She stated she was not aware R84 was supposed to have been receiving mental health services monthly and was not aware of R84 had seen an outside provider. Former SSD 1 stated that she had been responsible for completion of the Patient Health Questionnaire (PHQ) 9 indicators for the Depression Scale. She said if a resident scored high on the PHQ 9 she referred the resident to psych services, and the NP and Director of Nursing (DON) and that was all she knew who to report to. The former SSD stated she could not recall the date she completed the PHQ 9 for R84; however, the resident had scored high, so she referred her to the facility's psych provider, which she refused. The former SSD further stated she could not recall if she had documented the discussion but she did document it on the resident's consent form. During an telephonic (phone) interview with the facility's former SSD 2 on [DATE] at 9:52 AM, she stated she had a bachelors degree in human services and had left employment at the facility in [DATE]. She stated she did not do anything with the PASRR's and the Business Office Manager (BOM) completed a resident's PASRR on admission and notified her of the results. Former SSD 2 stated she was not aware of the results of R84's level 2 PASRR or of any recommendations made. She stated she had no knowledge of R84 seeing an outside psych provider for mental health services. Former SSD 2 also stated she was not made aware of most of the clinical things that occurred in the facility. During an interview with the former DON on [DATE] at 12:11 PM, she stated on admission to the facility R84 had declined psych services from the facility's psych provider. The DON stated R84 reported she would continue with the outside provider she was familiar with. She stated she was unsure if that had been documented in the resident's medical record though. The former DON stated R84 had been her own person, and had made her own appointments and arranged for her own transportation. She stated the facility should have been monitoring R84's behaviors or for changes on the medication administration record (MAR); however, that had not occurred. The former DON stated R84 had been a private person who kept to herself, and she did not know if they would have seen/observed anything different with the resident. During an interview with the Medical Director on [DATE] at 12:11 PM, he stated R84 had been a new patient to him when she was admitted to the facility. The Medical Director stated he had not been aware of R84's mental health history until he reviewed her chart following her admission. He stated he did not recall being informed of R84 missing her scheduled mental health appointments or of her not receiving mental health services until after her death. The Medical Director stated it did happen sometimes that he was not made aware of changes in residents. The Medical Director further stated he was not aware of R84 interactions with her spouse that affected her mood and did not see that as a problem. He additionally stated he did not think R84's medications would have contributed to her having suicidal ideations. During an interview with the Administrator on [DATE] at 2:01 PM, she stated that she had been the facility's Administrator for about two and a half years. She stated her knowledge of R84 included the resident having been a nurse at one time and that she had experienced a hard home life with her spouse. The Administrator stated she had not been aware R84 had a history of mental health issues until her death on [DATE]. She stated R84 had been her own person, made her own decisions and had a BIMS score of 15, indicating she was cognitively intact. The Administrator said she did not recall any concerns with psych issues for R84 and had never met the resident's spouse. She stated she was unsure of how communication should have occurred between the outside psych provider and the facility in regards to the mental health appointments that R84 had attended with them. The Administrator further stated she did not recall receiving any documentation from the preferred provider about appointments or of them discharging R84 from their services. In continued interview on [DATE] at 2:01 PM, the Administrator stated the SSD might have set up appointments for psych telehealth for R84; however, nursing should have been made aware of that information. She stated when residents made threats of self harm or indicated signs and symptoms of self harm, that would be a significant change for a resident. The Administrator additionally stated the facility would initiate 1:1 supervision for residents with that behavior, and proceed with transfer to a behavioral health unit or to the emergency room (ER) for evaluation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and review of the facility's Medical Director's responsibilities, it was determined the Medical Director failed to resident care policies for behaviors were implemented and failed to coordinate the medical care within the facility for 1 of 22 sampled residents, (R)84. The facility admitted R84 to the facility on [DATE] and the level 1 Pre-admission Screening and Resident Review (PASRR), indicated a level 2 was indicated. The level 2 PASRR indicated R84 MUST receive psychiatric (psych) services on a monthly basis. However, the facility's Medical Director was not aware of that information and therefore, failed to ensure the facility provided R84 with the recommended psych services. On [DATE] at 2:10 AM, R84 was found in her bed with oxygen tubing wrapped 4-5 times around her neck and was pronounced deceased at 2:43 AM. Review of R84's Certificate of Death dated [DATE], revealed the cause of death as Ligature Asphyxiation, rubber oxygen tubing used to intentionally obstruct airway, and the death was ruled a suicide. The findings include: Review of the facility policy titled, Medical Director dated 07/2016, revealed the Medical Director was a licensed Physician in the State and was to be responsible for ensuring adequate and appropriate Physician services. Per review, the Medical Director's functions included: acting as a consultant to the Director of Nursing (DON) in matters relating to resident care services. Further review revealed the Medical Director was also to help assure residents received adequate services appropriate to meet their needs, and helping assure residents' care plans accurately reflected the medical regimen. Review of the facility's, Medical Director Service Agreement, signed by the Medical Director on [DATE], revealed the Medical Director agreed to coordinate medical care, participate in the development and updating of patient care policies, and was responsible for seeing the policies were executed. Continued review revealed the Medical Director was also responsible for the overall coordination of the medical care provided in the facility to ensure the adequacy and appropriateness of the medical services provided to patients. Further review revealed the Medical Director additionally shared responsibility for assuring the facility was providing appropriate care as required and was responsible for evaluating and taking appropriate steps to correct any possibility of inadequate medical care. Review of the closed record for R84 revealed the facility admitted the resident on [DATE], with diagnoses that included: major depressive disorder, recurrent, mild; schizoaffective disorder, bipolar type; and generalized anxiety disorder. Review of the Quarterly Minimum Data Set (MDS) Assessment for R84 dated [DATE], revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating intact cognition. Record review revealed the Medical Director had been R84's primary care Physician (PCP). Review of R84's Comprehensive Care plan dated [DATE], revealed the facility developed a care plan for Depression/Mood State related to depression, dysfunctional grieving, depression related to life changes, medical condition and psychiatric conditions. Per review, the facility also developed a care plan for Psychotic Disorder, altered thought process, related to bipolar effective disorder and schizoaffective disorder dated [DATE]. Continued review revealed the interventions for those care plans included: encouraging R84 to verbalize feelings and offer emotional support; and attempt to identify stressors contributing to R84's behaviors and remove them if possible. Further review revealed to administer R84's medication as ordered; provide a mental health consult when ordered; observe for signs and symptoms of change in her condition and notify the Physician as needed. Review of the records from an outside behavioral health services provider revealed R84 failed to keep her appointments on [DATE], [DATE], [DATE] and [DATE]. Continued review revealed the outside behavioral health services provider discharged R84 on [DATE], to adhere to her treatment plan by keeping her appointments. Review of the consent form dated [DATE], from the facility psychiatric (psych) services provider revealed the Social Services Director (SSD) documented R84 refused to be seen by the facility psych service group. However, further review revealed no documented evidence the outside behavioral health services provider was contacted for R84's treatment or of the Medical Director being notified of the resident's refusal of the facility's psych service provider. Review of the handwritten document titled, Nursing Facility Initial Visit, revealed the Medical Director saw R84 on [DATE]. Continued review revealed the Medical Director noted R84 had a past medical history of schizoaffective disorder, and anxiety. Further review revealed the Medical Director documented R84 had no apparent distress and under Assessment noted the resident's depression and schizoaffective disorders were stable. Review of the handwritten document titled, Progress Note, dated [DATE], revealed the Medical Director completed a nursing home follow-up visit with R84. Per review, the Medical Director noted R84's fatigue, depression, and anxiety were stable. Review further revealed the Medical Director documented R84's medications had been reviewed and the facility was to continue the same. Review of the handwritten document titled, Progress Note, dated [DATE], revealed the Medical Director completed a nursing home follow-up visit with R84. Further review revealed the Medical Director documented R84 continued to have fatigue, her depression was stable, and her medications were reviewed. Review of the Nursing Progress Note dated [DATE], documented by Registered Nurse (RN) 2 revealed she had witnessed R84 to occasionally have crying spells which she was going to report to social services. However, further review of R84's medical record revealed no documented evidence of RN following up with social services. Additional record review revealed R84 had been seen by the APRN on [DATE], related to having increased anxiety. Review of the handwritten document titled, Progress Note, dated [DATE], revealed the Medical Director completed a nursing home follow-up visit with R84. Review further revealed the Medical Director noted R84 was stable with her anxiety, and her medications were reviewed. Review of the handwritten document titled, Progress Note, dated [DATE], revealed the Medical Director completed a nursing home follow-up visit with R84 and her anxiety was stable. Review of the Nursing Progress Note dated [DATE] at 5:01 AM, documented by Registered Nurse (RN) 2 revealed the RN entered R84's room to obtain vital signs around 2:00 AM. Per review, upon entering the room RN 2 observed the resident lying on the bed with her oxygen tubing wrapped around her neck five to six times. Continued review revealed the RN called for assistance from Certified Nursing Assistants (CNAs) and two other nurses in the facility. Further review revealed Cardiopulmonary Resuscitation (CPR) was initiated by the charge nurse, RN 3. Additionally, review revealed Licensed Practical Nurse (LPN) 3 notified Emergency Medical Services (EMS) and CPR was continued until their arrival. EMS arrived and took over the CPR, and connected R84 to the defibrillator; however, the resident was asystole (no pulse). Review of the Death Certificate for R84, received from the County Coroner's office, dated [DATE], revealed the resident's presumed time of death was at 2:43 AM. Continued review revealed R84's manner of death was suicide with a history of depression. Additionally, review revealed R84's cause of death was noted to be Ligature Asphyxiation, using rubber oxygen tubing, to intentionally obstruct the airway. In an interview with the Coroner on [DATE] at 4:24 PM, she stated she responded to the facility's report of a suicide on [DATE]. She stated upon her arrival, R84 was deceased and she observed the resident to have four deep grooves in the neck from the oxygen tubing. The Coroner stated R84 also had discoloration around the neck, petechial hemorrhages to both eyes, a red face, and her chest area was blanched. She stated R84 had bleeding from the nose and both ears which was not uncommon. The Coroner stated there was no evidence to indicate R84 had made any adjustments to the tubing or attempted to self release the tubing. She further stated it would have taken only one to two minutes of hard pressure to the neck before the resident expired. Review of the facility's investigation revealed it included witness statements from staff that were working at the time of the incident. Per review, of the facility's interviews, located in the investigation, with RN 2, LPN 3, CNA 5 and CNA 6 revealed all staff reported they observed no changes in R84 on the night of the event. Continued review of the investigation revealed RN 2 said R84 had a scheduled appointment on [DATE] with a pulmonologist and seemed excited to be going out with her son for the appointment. Additionally, review revealed following the investigation it was determined R84 had self inflicted an injury which resulted in her death on [DATE]; however, there was no indication that staff could have predicted her actions. Review of the Ad Hoc Meeting documentation dated [DATE] at 1:56 PM, revealed the Medical Director was present via telephone call. Continued review revealed a discussion was held during the meeting regarding the recent event of a self-inflicted death (R84's) and the ongoing investigation related to the incident. In an interview with CNA 5 on [DATE] at 8:55 AM, she stated she had observed mood changes in R84 following phone calls with her spouse and/or children. The CNA stated sometimes R84 seemed different and distant and had told her (CNA 5) that her spouse had promised to come get her out of the facility and take her home. During an interview with CNA 6 on [DATE] at 9:08 AM, she stated she did not wish to discuss the event regarding R84's death. She stated it was devastating, the worst thing she had experienced as a CNA. CNA 6 did state however, she had not seen changes in R84 that day. In an interview with RN 2 on [DATE] at 9:52 AM, she stated she started working at the facility in September of 2022, as the night shift nurse on the 100 hall where R84 resided. She stated R84 had been cognitively intact and ambulated about ad lib. The RN said she had witnessed R84 to occasionally have crying spells. She stated on the night of the event, there had been no indications that R84 was depressed and the resident had discussed with her (RN 2) the upcoming appointment on [DATE], her son was taking her to. Per RN 2's interview, R84 returned to her room after getting tea from the kitchen. She stated at approximately 2:15 AM, when she (RN 2) entered the room to obtain the resident's vital signs, she saw R84 lying on the bed with her oxygen tubing looped around her neck four or five times. In an interview with the former Social Services Director (SSD) on [DATE] at 8:50 PM, she stated had been the facility's SSD from April, 2022 to April, 2023; however, she did not have a degree in social work. The former SSD stated she had been responsible for completion of the Patient Health Questionnaire (PHQ) 9 indicators for Depression Scale. Per the former SSD's interview, if a resident scored high on the PHQ 9 she referred them to psych services and to the Nurse Practitioner (NP) and DON. She said R84 had scored high on the PHQ 9 that had been completed, but she was unable to recall the date it was performed. The SSD stated she informed the DON of R84's high PHQ 9 score. The former SSD stated she referred R84 to the facility's psych services; however, the resident did not want to see that psych services. She said she did not attempt to refer R84 to an alternative psych provider for psych services. The former SSD stated she did not recall R84 having any kind of telehealth visits, including psych, scheduled through the facility and she never attempted to offer the resident further psych services. In interview with the former DON on [DATE] at 9:30 AM, she stated she received a call from LPN 3 stating R84 had wrapped her oxygen tubing around her neck and was deceased . She stated she called the Administrator and headed to the facility where the Coroner and law enforcement were upon her arrival. In additional interview on [DATE] at 12:11 PM, with the former DON, she stated on admission to the facility R84 had declined receiving psych services from the facility. Per the former DON, R84 told staff she would continue with a different provider as she was familiar with them. She stated R84 was her own person, made her own appointments and had her own transportation. The former DON stated she was not aware until R84 died that she had not been receiving services from her preferred psych provider. She further stated R84 had a toxic relationship with her spouse who she went out of the facility with often. The former DON also stated R84 and her spouse would sometimes argue on the phone and after that the resident sometimes seemed sad. During an interview with the Medical Director on [DATE] at 12:11 PM, he stated R84 had been a new patient to him when she was admitted to the facility. The Medical Director stated he had not been aware of R84's mental health history until he reviewed her chart after admission. He stated he had been R84's PCP; however, did not recall being informed of R84 missing her scheduled mental health appointments and but stated, sometimes things got missed. Per the Medical Director's interview, he had not been aware of R84 interactions with her spouse that affected her mood. He stated he did not think her medications would contribute to suicidal ideations. He stated the death of R84 was gut wrenching and devastating. The Medical Director stated the facility held a Quality Assurance Performance Improvement (QAPI) meeting following the event involving R84 which he attended. In interview on [DATE] at 2:01 PM, the Administrator stated her knowledge of R84 was that the resident had been a nurse at one time and had experienced a hard home life with her spouse. She stated she was not aware of R84's mental health history until her death on [DATE]. The Administrator stated she did not recall any concerns with psych issues related to R84. She stated she not sure of how communication should have happened between the resident, the preferred psych provider and the facility in regards to the mental health appointments Resident 84 had and did not go to. The Administrator stated she would have had expected the mental health provider however, to communicate with the facility when appointments were scheduled for R84 or when the resident failed to show for those appointments. She stated she also would have expected the mental health provider to communicate with the facility when they discharged R84 from their services. The Administrator stated she did not recall receiving any documentation from the resident's preferred (psych) provider however. Per the Administrator's interview, the SSD might have set up appointments for telehealth psych visits, but the nursing department should have been made aware of such appointments. She stated when residents exhibited threats of self harm or indicated any signs/symptoms of self harm that was a significant change. The Administrator said if that occurred the facility would initiate one to one supervision of the resident and proceed with transfer of the resident to a behavioral health unit or to the emergency room (ER) for evaluation. She stated she did not feel R84 had experienced a significant change prior to her suicide. The Administrator stated when the social worker completed the PHQ 9 indicator for depression scale and it was high she expected the social worker to notify the DON and/or the Physician or NP of the results, so it could be discussed with the clinical team.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the policy titled, Isolation - Categories of Transmission-Based Precautions with a revision date of September 2022, revealed transmission-based precautions were initiated when a resident developed signs and symptoms of a transmissible infection. Continued review revealed transmission-based precautions were also initiated when a resident arrived for admission with symptoms of an infection, had a laboratory confirmed infection, or was at risk of transmitting infection to other residents. Per policy review, revealed transmission-based precautions were additional measures that protected other residents, staff, and visitor from being infected. Further review revealed the three types of transmission-based precautions were contact, droplet and airborne. In addition, review revealed for droplet precautions Masks are worn when entering the room. Record review for R45 revealed the facility admitted the resident on 04/01/2022, with diagnoses that included: Chronic Diastolic (Congestive) Heart Failure; Hypertensive Heart and Chronic Kidney Disease with Heart Failure. Review of R45's Physician's orders revealed R45 was placed in droplet isolation precautions on 08/04/2024, related to COVID positive test result, every shift for 10 days. Review of R45's care plan revealed a focus area of COVID 19 Active infection: Risk for worsening respiratory symptoms related to positive COVID 19 test as of 08/04/2024 initiated on 08/04/2024. Per review, the interventions included droplet isolation precautions with appropriate personal protective equipment (PPE) in accordance with PPE optimization guidelines initiated on 08/04/2024. Further review revealed the interventions also included, Single room droplet isolation precautions. All care to be performed in room, with an initiation date of 08/08/2024. During observation of meal service on the Lower Town unit on 08/14/2024 at 12:43 PM, CNA 4 was observed to enter R45's room, without donning a N95 mask, who was to be on droplet precautions for being COVID positive. Continued observation revealed CNA 4 was wearing a gown, gloves, and a face shield that was tipped backward at the level of the nose, leaving the mouth exposed. Per observation, CNA 4 had no face mask observed in use. Further observation revealed Droplet Precautions signage posted and visible outside R45's room and PPE available outside the room that included gowns, gloves and N95 masks. In interview with CNA 4 on 08/14/2024 at 12:45 PM, she stated it was important to wear a mask, but there were no masks located in the PPE bin that was located outside of R45's room. The State Survey Agency (SSA) Surveyor observed the PPE container, located outside R45's room, with CNA 4 and N95 masks were visualized as accessible and available in the second drawer of the PPE container. In interview with LPN/UM 2 on 08/14/2024 at 12:43 PM, she validated CNA 4 had not been wearing a mask when inside R45's room, who was COVID positive and on droplet isolation precautions. LPN/UM 2 stated it was important for staff to wear an N95 mask in a room of a resident on droplet precautions for infection control purposes and for preventing spread of the infection. In interview on 08/16/2024 at 3:32 PM, the DON stated it was her expectation for staff to use PPE as indicated to prevent the spread of COVID infection. Based on observation, interview, record review, and review of the facility policy, it was determined the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 22 sampled residents (R)87 and R45. 1. During observation of provision of direct care for R87, the two nurse aides failed to follow the enhanced barrier precautions (EBP) for the resident who was on EBP related to having an indwelling Foley catheter. 2. During observation of meal service CNA 4 entered R45's room, without donning an N95 mask (disposable filtering facepiece respirator) when entering a known COVID positive resident's room that was designated to have Droplet Precautions. The findings include: Review of the facility policy titled, Enhanced Barrier Precautions (undated), revealed it was the intent of the policy to protect residents who were the most susceptible for infections. Continued review revealed the use of EBP triggered for any resident in the facility with an open wound, an indwelling device, or who was colonized with multi drug resistant organisms. Review of the medical record for R87 revealed the facility admitted the resident on 08/09/2024, with diagnoses that included: right middle cerebral artery cerebral infarction, Type 2 diabetes mellitus, and Atrial fibrillation. Resident #87 medical record reflected urinary retention requiring indwelling Foley catheter placement which required enhanced barrier precautions. EBP supplies are in place in the hallway outside of the room entry door of Resident #87. The hallway has the standard PPE setup in place with gowns and gloves. Review of R87's comprehensive care plan revealed the facility care planned the resident on 08/09/2024, for a problem for R87 being placed on EBP due to an indwelling Foley catheter. Continued review revealed the goal as R87's risk for infection to be managed through the next review date. Further review revealed the interventions included using a gown and gloves for high contact activities, such as transferring R87 and providing the resident's hygiene care. Observation on 08/15/2024 at 4:34 PM, of CNA 14 and CNA 15 providing incontinent care for R87, revealed the aides had not followed the EBP's for wearing a gown when providing incontinent care (a high contact activity) for the resident. In interview at the time of observation, Certified Nursing Assistant (CNA) 15 stated she had forgotten to wear a gown as R87 needed to be changed and the resident did not want to wait. In interview on 08/16/2024 at 10:22 AM with CNA 15 she stated she had seen R87's care plan in the [NAME] during report and that information was also shared by the nursing staff as well. She stated a nurse reported to her that R87 had been placed on EBP, prior to the observation of care. The CNA stated she was provided in-service education when EBP began at the facility, and also had re-education yesterday (08/15/2024) and again today about the EBP process. CNA 15 stated, I should have worn a gown, closed the curtain, and washed my hands, which were the main things she should have done during R87's care. She stated she was aware if the resident's care plan and EBP guidelines were not followed, a spread of infection could take place for that resident. In interview 08/15/2024 at 11:34 AM, the Assistant Director of Nursing (ADON) stated she served as the facility's Infection Preventionist (IP). The ADON stated the facility had some problems in the beginning with EBP compliance by staff and getting them to understand what to do, but that had gotten better. In a follow up interview on 08/16/2024 at 10:15 AM, the ADON stated staff members involved in the care of R87 the day before, had both received initial EBP training when it was first launched at the facility. She stated both those staff members came forward yesterday to leadership and said they had made a mistake regarding EBP. Per the ADON's interview, the facility provided re-education of both staff members that day (08/16/2024). The ADON stated one of the nurse aides involved was a senior nurse aide and if she could forget to follow EBP, she (ADON) felt like the facility needed to reinforce the EBP education with everyone. She stated the [NAME] care plan was available to the nurse aides to refer to and staff members not following a resident's EBP care plan, could potentially spread infection.

Based on observation, interview, and review of facility policy, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Observation of the walk in coolers revealed multiple food items which had been opened and were unlabeled and undated. These failures had the potential to affect 85 of the facility's 86 residents who consumed food from the kitchen. The findings include: Review of the facility policy, Food Receiving and Storage, revised 10/2017, revealed foods were to be received and stored in a manner that complied with safe food handling practices. Further review revealed all food stored in the refrigerator or freezer was to be covered, labeled, and dated with a used by date. Review of a document provided by the facility titled, United States Department of Agricultural Food Safety and Inspection Services for Food Safety Information Basics for Handling Food Safely, revised 08/2013, revealed safe steps in food handling, cooking, and storage were essential to prevent food borne illness. Continued review revealed leftover food was to be used within four days. Observation with the Dietary Manager (DM), during initial tour of the kitchen on 08/13/2024 at 6:37 AM, revealed a tray that contained five servings of banana pudding and one plate of prepared salad not labeled or dated located in a reach in cooler. Continued kitchen observation revealed the following items located in the walk in cooler: an opened, undated bag of shredded cheese 1/4 full; a small container of sloppy joe mixture, 1/4 full, dated 08/08-08/12/2024; a small container of mandarin oranges, dated 08/10-08/12/2024; a small container of sliced apples dated 08/09/2024-08/11/2024; an opened package of delicatessen (deli) turkey not labeled or dated; a container of chopped garlic 1/4 full, not labeled or dated; a large opened container of cantaloupe, 1/2 full with an opened date of 08/05/2024; and a large container of honeydew melon, 1/2 full with an opened date of 08/05/2024. The DM stated products were good for 7 days after opening. In interview with the DM on 08/13/2024 at 6:37 AM, during the kitchen tour, he stated food products were good for seven days after being opened. The DM stated food items placed in the cooler or walk-ins were also good for seven days. He further stated he expected staff to label and date all items as required. During interview with the former Registered Dietitian (RD) on 08/15/2024 at 2:28 PM, she stated the expectation was for all dietary staff to label and date items when placed in the cooler or the walk-ins. She stated all staff in the kitchen were aware items were to be labeled and dated. The RD stated items were to be dated for three days out. She further stated serving outdated food items could contribute to food borne illness. In an interview with the Administrator on 08/16/2024 at 2:01 PM, she stated she expected dietary staff to follow facility policy and procedure related to labeling and dating of stored food.

Based on observation, interview, and facility policy review, it was determined the facility failed to ensure that the resident's right to privacy and confidentiality was honored for one (1) resident not in the selected sample of nineteen (19) residents (Resident #89). Observation during a medication pass in a resident's room revealed Registered Nurse (RN) #1, discussed Resident #89's health related information in the presence of another resident. The findings include: Review of a facility policy titled, Understanding the Basic Concepts -Health Insurance Portability and Accountability Act (HIPPA), not dated, revealed HIPPA is a Federal law that has special privacy and security rules that health agencies must follow. Further review of the policy revealed privacy rules ensure a patient's personal information is not given to others without permission. Observation on 08/16/19 at 9:48 AM, revealed RN #1 spoke of a resident by name, in the presence of another resident, and revealed he/she had just fallen and she would do a skin assessment on him/her when the aides put him/her to bed. Interview with RN #1 on 08/16/19 at 9:52 AM revealed she should not have spoke of another resident by his/her name and provided personal information, in the presence of another resident. RN #1 stated she realized as soon as she spoke about the situation, it could be considered a HIPPA violation. Interview with the Director of Nursing (DON) on 08/16/19 at 2:35 PM, revealed she would expect all staff to not share a resident's personal health information in the presence of other residents.

Based on observation, interview, record review, and review of the Resident Assessment Instrument (RAI) Version 3.0 User Manual, it was determined the facility failed to ensure one (1) of nineteen (19) sampled residents received an accurate assessment, reflective of the resident's status at the time of the assessment (Resident #23). Resident #23 required to be transferred by two (2) staff with the use of a mechanical lift; however, the MDS Coordinator coded the MDS inaccurately when she coded the resident a (3) for transfers which indicated the resident was highly involved and staff provided non-weight bearing assistance instead of a four (4) which indicated the resident was dependent on staff. The findings include: Review of the RAI Version 3.0 User Manual on Coding instructions for Section G Functional Status, revealed total dependence (4) should be coded if full staff performance occurred every time during the entire 7-day look back period for Activities of Daily Living Self-Performance. Record review revealed the facility readmitted Resident #23 on 05/05/17, with diagnoses which included Acute Osteomyelitis and Heart Failure. Review of the Quarterly MDS assessment, dated 07/01/19, revealed the facility assessed Resident #23's cognition as intact with a Brief Interview for Mental Status (BIMS) score of fifteen (15), which indicated the resident was interviewable. Further review of the MDS assessment revealed in Section G Functional Status, part B. Transfers for Self-Performance, staff coded a three (3), which indicated the resident was involved with his/her transfers and staff provided weight-bearing support. However, review of the care guide, revealed a maxi-lift with two (2) staff assist were utilized in order to transfer Resident #23. Interview with Resident #23 on 08/16/19 at 8:23 AM, revealed he/she could not walk and staff used a mechanical lift in order to transfer him/her at all times. Interview with Certified Nurse Aid (CNA) #1 on 08/16/19 at 2:24 PM, revealed staff have always transferred Resident #23 with the use of a mechanical lift because the resident was not able to walk, as far as she could recall. Interview with the MDS Coordinator, on 08/16/19 at 11:44 AM, revealed the facility follows the RAI for coding Section G of the MDS. She stated Section G of the MDS related to transfers was marked in error by her. She stated Resident #23 is totally dependent upon staff for transfers and she coded a three (3) instead of a four (4) which would have indicated the resident was totally dependent on staff for transfers. Interview with the Director of Nursing (DON), on 08/16/19 at 2:35 PM, revealed she expected the MDS to be coded accurately to reflect the resident's current status.

Based on observation, interview, and facility policy review, it was determined the facility failed to ensure gloving procedures were followed related to a medication pass. Observation on 08/16/19 revealed licensed staff handled a resident's medication with her bare hands. The findings include: Interview with the Director of Nursing (DON) on 08/16/19 at 2:35 PM, revealed the facility did not have a policy that addressed handling medications with bare hands. She stated the facility followed state and federal regulations related to infection control and medication administration. Observation of a medication administration pass on 08/16/19 at 9:48 AM, revealed Registered Nurse (RN) #1, placed her bare finger in a resident's medication cup to move the pills forward prior to pouring them into the resident's mouth, and in the process touched the medications with her bare hand. Interview with RN #1 on 08/16/19 at 9:52 AM, revealed she should not have placed her bare finger in the medication cup because she touched other medications in the process and it was an infection control issue. Further interview with the DON on 08/16/19 at 2:35 PM, revealed nurses were taught they should not touch medications with their bare hands.

Based on observation, interview, and facility policy review, it was determined the facility failed to ensure food was stored, in accordance with professional standards for food service safety. Observation of the kitchen, on 08/14/19, revealed a red sanitation bucket on the kitchen floor. Review of the facility Census and Condition, dated 08/14/19, revealed eighty-three (83) of eighty-three residents received their meals from the kitchen. The findings include: Review of the facility policy, Sanitizing Food Contact Surfaces, last revised January 2017, revealed the red buckets should be placed on a lower shelf of the station and positioned as to prevent splash into food, food-contact equipment, linens, and single-serve items, or as required by state or local regulations. Observation of the kitchen during initial tour on 08/14/19 at 8:49 AM, revealed a sanitizing bucket with clean water used for wiping food spills, was on the kitchen floor. Interview with the Dietary Manager on 08/14/19 at 9:03 AM, revealed the bucket should not be on the floor, but placed on a shelf to ensure the cleaning water would not be contaminated.