**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interviews, observation, review of maintenance logs, and review of facility policy, the facility failed to ensure a resident was free from accidents/hazards. This resulted in Actual Harm when Resident #66 utilized the first-floor restroom on 12/15/24 and while washing his hands, the floating handwashing sink fell on him resulting in a laceration to the left knee that required 17 sutures, the use of antibiotics for infection prevention and continued wound care. This affected one (#66) of three residents reviewed for accidents. The facility census was 101. Findings included: Review of the medical record for Resident #66, revealed an admission date of 11/11/24. Diagnoses included toxic encephalopathy, schizophrenia, chronic viral Hepatitis-C, visual hallucinations, auditory hallucinations, alcohol abuse, drug induced akathisia, muscle weakness and dysphagia. Review of the admission Minimum Data Set (MDS) assessment for Resident #66 dated 11/18/24, revealed Resident #66 had moderate cognitive impairment and the resident required moderate assistance with transfers and sitting to standing. Review of an incident report titled Skin Tear dated 12/15/24 at 11:23 A.M. and authored by Licensed Practical Nurse (LPN) #233 revealed a Certified Nursing Assistant (CNA) reported Resident #66 was bleeding. There was blood noted in the elevator when Resident #66 returned from smoking. A large laceration that was approximately three inches long by one inch wide was noted on the resident's left shin below the knee and a small cut was noted under the resident's right eye. Resident #66 stated when he went to smoke, he used the bathroom downstairs and the sink broke and cut him. The area was cleansed, and steri- strips, an abdominal (ABD) pad along with kerlix were applied. Resident #66's vital signs were obtained, and the resident's physician was notified. Review of an alert note for Resident #66 dated 12/15/24 at 1:18 P.M., and authored by LPN #272, revealed Resident #66's family was in the facility and observed an open area to the resident's left lower extremity. The family called nine-one-one (911) and Resident #66 was transported to the hospital. The physician was made aware. Review of a physician order for Resident #66 dated 12/15/24, revealed the resident was ordered to have the left shin cleansed with normal saline, patted dry, ABD applied, covered with kerlix every day and monitor the steri-strips for placement. The order was discontinued 12/29/24. Review of the hospital record for Resident #66 dated 12/15/24, revealed Resident #66 was going to the bathroom at his skilled nursing facility when the ceramic sink fell from the wall hitting his knee and causing a laceration. Resident #66's family reported a provider at the facility applied steri-strips and stated the resident did not need to go to the hospital, and he did not require any sutures. Resident #66's family stated they noticed Resident #66's leg was continuing to bleed and the family insisted the resident come to the emergency department for evaluation. Resident #66 was positive for joint pain and had a five-centimeter (cm) laceration noted to the left knee and there was active bleeding noted. The laceration was closed with 17 sutures, Bacitracin applied and then gauze and Coban applied. Resident #66 was discharged from the hospital on [DATE] and to follow-up with his primary care provider and have the sutures removed in 12-14 days. Review of the hospital After Visit Summary (AVS) for Resident #66 dated 12/15/24, revealed Resident #66 was seen for an extremity laceration. The resident was diagnosed with a laceration of the lower left extremity which required sutures, and the sutures were to be removed in 12 to 14 days. Review of a MDS note for Resident #66 dated 12/16/24 at 9:47 A.M., revealed Resident #66's care plan was updated related to a skin tear. Care plan goals and interventions were in place at that time. Review of a care plan for Resident #66 dated 12/16/24, revealed Resident #66 had impaired skin integrity related to a skin tear to the left knee and bruising to the right eye. Interventions included apply treatments as ordered, educate the resident, family and caregivers of causative factors and measures to prevent skin injury, include the resident and responsible party in the treatment plan, update the treatment plan as indicated by change in condition or treatment, measure area every week, and observe the wound for signs and symptoms of infection. Review of a hardware store receipt dated 12/16/24 revealed items including a white wall mount sink, drywall repair panels, a drain, and bath faucet were purchased. Review of a health status note for Resident #66 dated 12/29/24 at 6:53 P.M., and authored by LPN #150, revealed the hospital discharge orders from 12/15/24, indicated the resident's sutures were to be removed in 12-14 days and today was day 14. An order was not located in the paper chart or in the electronic medical record (EMR). Resident #66's physician was contacted and verified Resident #66's sutures were to be removed. This nurse found a small dehiscence (opening of a wound), serous sanguineous fluid leaking and there was a lot of heat and swelling to the area. Resident #66's physician gave an order to start Resident #66 on doxycycline (antibiotic) 100 milligrams (mgs) twice a day for ten days and to leave the wound open to air. Review of a health status note for Resident #66 dated 12/29/24 at 6:58 P.M., and authored by LPN #150, revealed LPN #150 and another nurse on the unit attempted to remove the sutures from the left lower extremity. It was noted the wound edge was thought to be closed and well approximated (wound edges close together) except for a small 1 cm by 1 cm opening that began to open up during the suture removal process. Resident #66 stated the process was becoming painful and was afraid the wound would open more, and the resident requested LPN #150 and the other nurse to stop and wait to be seen by the physician in the morning. The nurse reached out to the physician. Review of a physician order for Resident #66 dated 12/29/24, revealed an order for the sutures to be removed from his left lower extremity or knee. The order was discontinued 12/30/24. Review of a health status note for Resident #66 dated 12/30/24 at 3:32 P.M., revealed Nurse Practitioner (NP) #151 provided new orders including cleanse the wound area with normal saline, pat dry, apply bordered gauze daily and as needed. Resident #66 and the resident's sister were notified. Review of a wound care note for Resident #66 dated 12/30/24 and authored by NP #151, revealed the resident was seen for an initial evaluation and management of the wound to the left lower extremity. Resident #66 was alert with cognitive impairment and resided in the memory care unit. Resident #66 denied pain. The staff attempted to apply a dry dressing for a small amount of bleeding to protect the wound but Resident #66 refused multiple times. The nurse reported that the sutures were removed, and Resident #66 was placed on doxycycline on 12/30/24. The wound was listed as in-house acquired, traumatic in etiology and it had full thickness. The wound was 1 cm in length by 4 cm in width and 0.1 cm in depth. Resident #66 was to have a bordered foam dressing three times a week and as needed. Review of a physician order for Resident #66 dated 12/31/24, revealed an order to have the left knee cleansed with normal saline, patted dry, and covered with bordered gauze daily and as needed. The order was discontinued 01/15/25. Review of a physician order for Resident #66 dated 12/31/24, revealed an order for doxycycline 100 mg give one tablet by mouth two times a day for infection prevention for ten days until finished. The order was discontinued 01/10/25. Review of a wound care physician note for Resident #66 dated 01/06/25 and authored by NP #151, revealed the resident was seen for a wound follow up on his left lower extremity. The wound was listed as improved. The wound was 1.5 cm in length by 3.5 cm in width by 0.1 cm in depth. Resident #66 was to have a bordered foam dressing three times a week and as needed. Review of a health status note for Resident #66 dated 01/09/25 at 5:29 P.M., revealed the resident was to continue antibiotics for his wound. Resident #66 was afebrile (without fever) and removed his bandage three times that shift. Resident #66 was educated on keeping the wound clean and dry and the resident taped on a piece of gauze and told the nurse to leave it alone. Review of a physician order for Resident #66 dated 01/13/25, revealed an order to cleanse the area to the left knee wound, apply collagen to the wound bed, lightly pack the wound with Vashe (a wound Solution intended for cleansing, irrigating, moistening, debridement and removal of foreign material) soaked moistened gauze, and covered with a bordered gauze every day and as needed. Review of a wound care physician note for Resident #66 dated 01/13/25 and authored by NP #151 revealed the resident was seen for a wound follow up on his left lower extremity. The wound was listed as improved. The wound was 1.2 cm in length by 2.5 cm in width by 0.3 cm in depth. Resident #66 was to have a collagen sheet applied to the wound bed, lightly pack the wound with Vashe soaked gauze and cover with a bordered gauze every day. Observations of the facility on 01/16/25 from 7:32 A.M. to 2:00 P.M. revealed no concerns related to accidents/hazards. There was a public restroom located on the first floor that had a floating porcelain sink affixed to the wall. The sink was noted to be sitting on a bracket that was affixed to the wall with a strip of caulking on the top of sink. Interview with Resident #66 on 01/16/25 at 8:10 A.M., revealed he independently walked into and used the first-floor bathroom around the end of December 2024. Resident #66 stated he went to wash his hands, and the handwashing sink fell on him and cut open his left knee. Resident #66 reported that his left knee was bleeding, and he was sent out to the hospital to get stitches. Resident #66 stated he was not aware of his family being notified of the injury but stated they were at the hospital with him. Resident #66 reported that he had a current dressing on his left knee, but his stitches had been taken out. Resident #66 stated his pain was not too bad. Observation of Resident #66 at the time revealed the resident was lying in bed, appeared clean, and the resident was observed to have a bordered dressing on his left knee that was not labeled or dated. Interview with the Administrator on 01/16/25 at 10:19 A.M., revealed the staff took Resident #66 to smoke on 12/15/24 and the staff noticed Resident #66 was bleeding when they got on the elevator to go back up to the resident's unit on the second floor. The Administrator stated Resident #66 reported the sink cut him. Resident #66's physician was notified, and the physician gave an order for a dressing to the wound, but the resident's family was not satisfied and wanted him sent out to the hospital. The Administrator stated Resident #66 was sent to the hospital, and he obtained sutures to his left knee. The Administrator reported the bathroom sink was found lying on the floor when staff looked in the bathroom and the bathroom was locked so other residents could not enter it. Interview with the Director of Nursing (DON) on 01/16/25 at 12:54 P.M., revealed she received a phone call on 12/15/24 from the nurse notifying her the first-floor bathroom handwashing sink fell on Resident #66 cutting his left knee. The DON stated the physician was notified, and the physician ordered staff to cleanse the area with normal saline, pat dry, apply an ABD pad and apply kerlix. The DON stated Resident #66's family was not notified because Resident #66 was his own responsible party, but his family came to the facility later that day and requested that he go out to the hospital. The DON stated that Resident #66 returned to the facility from the hospital with stitches. Attempted interview with LPN #233 on 01/16/25 at 12:56 P.M. was unsuccessful. A message was left to return the call, and no return call was received. Interview with Maintenance Director #800 on 01/16/25 at 12:58 P.M., revealed Maintenance Director #800 was notified on 12/15/24 the sink in the first-floor bathroom fell off the wall and cracked. Maintenance Director #800 reported the sink was on the floor in several pieces and the pipes were still attached to the sink but were not leaking. Maintenance Director #800 stated he replaced the sink with a new floating sink, replaced the dry wall, replaced the drains and applied new caulking. Maintenance Director #800 reported the sink that fell on Resident #66 was a floating sink and floating sinks will tilt if someone puts too much weight on the sink. Maintenance Director #800 stated any floating sink could possibly fall off the wall because floating sinks sit on an anchor with caulking but are not directly bolted to the wall. Observation of wound care for Resident #66's left knee wound on 01/17/25 at 9:34 A.M., revealed LPN #236 washed her hands, donned a gown and gloves. LPN #236 removed an undated bordered dressing from Resident #66's left knee. LPN #236 doffed her gloves, washed her hands and donned a new pair of gloves. LPN #236 cleansed the area with Vashe wound solution, applied collagen to the wound bed, packed the wound with Vashe moist gauze and covered the wound with a bordered gauze. LPN #236 then labeled the dressing with the date and her initials. Interview with Activities Aide (AA) #801 on 01/17/25 at 1:02 P.M., revealed she took Resident #66 to smoke outside on the first floor of the facility on 12/15/24. AA #801 stated Resident #66 finished smoking, and he went to the bathroom on the first floor by himself. AA #801 reported Resident #66 came out of the bathroom and she was not aware that anything occurred in the bathroom because she did not hear anything as she was watching the bathroom door from a distance. AA #801 stated Resident #66 was wearing dark pajama pants, and she initially did not see any blood. AA #801 reported they went back upstairs from smoking, and she saw a few red drops in the elevator, but she thought it was juice. AA #801 stated Resident #66 stated he was going to talk to the nurse, and she went on about her day but later found out that the sink fell on Resident #66 in the downstairs bathroom and cut his left knee. Review of the facility's investigating and reporting accidents and incidents policy dated December 2009 revealed all accidents and incidents involving residents, employees, visitors, and vendors occurring in the facility shall be investigated and reported to the administrator. This deficiency represents non-compliance investigated under Complaint Number OH00161103.

Based on observation, interview, record review, review of a police report, review of facility document, and policy review, the facility failed to protect the resident's right to be free from sexual abuse by a visitor for one (Resident #137) of three resident's reviewed for abuse. This resulted in Actual Harm on 04/09/24 when Resident #48's significant other, Family Member (FM) #16, touched Resident #137's breasts and private area and exposed his genitalia to the resident on a patio in the facility courtyard where residents smoked. FM #16 admitted to the police that he committed the actions against the resident, despite Resident #137 telling him, No. The failure resulted in Resident #137 being tearful and so traumatized by this event, that it felt like she was raped. Findings included: Medical record review revealed the facility admitted Resident #137 on 07/01/22. According to the admission Record, the resident had a medical history that included diagnoses of cerebral infarction (stroke), schizoaffective disorder bipolar type, tobacco use, depression, generalized anxiety disorder, hemiplegia (paralysis or weakness) affecting the left nondominant side, need for assistance with personal care, and unsteadiness on feet. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/02/24, revealed Resident #137 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident had intact cognition. The MDS revealed the resident required supervision or touching assistance (the helper provided verbal cues and/or touching/steadying and/or contact guard assistance as the resident completed the activity) with walking and with upper body dressing. The MDS also indicated the resident had limited range of motion of the upper and lower extremities on one side and utilized a walker. According to the MDS, Resident #137 had no physical, verbal, or other behavioral symptoms. The MDS indicated the resident smoked during the assessment period. Resident #137's Care Plan included a focus area initiated on 04/03/24 that indicated the resident was at risk for injury related to smoking. The Care Plan revealed the resident smoked tobacco-cigarette products and did not need supervision when smoking. A police report dated 04/09/24 revealed at approximately 1:03 P.M. on 04/09/24, a police officer was dispatched to the facility in response to a Morals/Sex Offenses complaint that occurred from 10:30 A.M. to 11:00 A.M. on 04/09/24. The report revealed upon arrival, the Administrator notified the police officer that Resident #137 had reported that FM #16 inappropriately touched the resident. The report revealed the Administrator had security camera footage from the courtyard of the incident involving Resident #137 and FM #16; however, the video did not have an audio recording aspect. According to the report, the camera footage revealed FM #16 was sitting across from Resident #137 at a table located in the outdoor smoking area (courtyard) of the facility. The report revealed FM #16 was seen standing up and walking toward Resident #137 and positioned himself to stand behind Resident #137 as the resident sat in a chair. The report revealed camera footage showed FM #16 placed his hands and arms across Resident #137's shoulder and FM #16's hands were in motion around Resident #137's breasts for approximately 30 seconds as the resident sat there motionless. According to the police report, FM #16 was then observed moving over to the left side of Resident #137 where FM #16 reached into his own pants. The report revealed FM #16 was observed manipulating something in front of his pants with his left hand. According to the report, Resident #137 briefly looked down at FM #16's private area, slightly leaning away from FM #16, and then looked at FM #16's face. The police report revealed FM #16 placed his right hand on Resident #137's shoulder and slightly pulled the resident toward him. The report revealed FM #16 then zipped up his pants and looked around before placing his right hand and arm inside Resident #137's shirt and began to rub the resident's breast and private area for approximately 25 seconds. According to the police report, once again, Resident #137 sat there motionless and stared forward at the table in front of her. The report revealed FM #16 continued to rub Resident #137's back and hair as the resident stared forward at the table in front of them. The report revealed that it should be noted that a male was seen in the video outside near both parties during a portion of the incident; however, staff advised that the male suffers from mental disabilities and would not be able to give a statement of what occurred. According to the police report dated 04/09/24, Resident #137 stated she was outside smoking when FM #16 began to touch her bare breasts underneath her shirt with bare hands. The report revealed Resident #137 stated FM #16 then proceeded to rub Resident #137's private area through her pants. The report revealed Resident #137 stated she told FM #16, No, multiple times while the actions were occurring. Per the report, Resident #137 stated FM #16 revealed his genital area and stated, I want you to do me a favor, walk to the bathroom and I'll follow you so you can give me a [oral sex]. The report revealed after Resident #137 said no, FM #16 walked away. According to the report, Resident #137 stated she was so traumatized by this event, that it felt like [the resident] was raped. The report revealed that Resident #137 stated she had been at the facility for physical therapy since 03/26/24 and had seen FM #16 outside in the smoking area. The report revealed Resident #137 stated she had several conversations with FM #16 and never felt threatened in any way. The report revealed Resident #137 stated FM #16 usually smelled like alcohol but seemed highly intoxicated that day. The report revealed when the officer asked Resident #137 to complete a written statement, the resident hesitated and agreed that the verbal testimony recorded on the officer's body worn camera would suffice so she did not have to go through the trauma of rearticulating the story again. The report revealed Resident #137 advised the officer that she wanted to pursue charges against FM #16. According to the police report dated 04/09/24, the officer left the facility and later arrested FM #16. The report revealed FM #16 stated to the officer that he was at the facility and confirmed standing behind Resident #137 and touching her bare breasts. FM #16 also confirmed hearing the resident say no multiple times but continued to touch the resident's private area through her pants. According to the report, FM #16 stated that Resident #137 still did not approve of FM #16's actions so he stood by the resident's side and showed his genitalia to Resident #137. Observations on 07/08/24 through 07/11/24, revealed a sign posted at the nurse's station of the memory care unit (MCU) that indicated FM #16 is NOT allowed on the premises of the facility. If he/she is in the building you will need to call the police. If you have any questions, please let me know. During an interview on 07/10/24 at 12:05 P.M., the Assistant Director of Nursing (ADON) stated Resident #48 was a long-term resident and FM #16 previously visited them daily. The ADON stated the allegation was reported to the Director of Nursing (DON) and the Administrator and they watched the security footage and called the police who then arrested FM #16. The ADON stated FM #16 was found guilty in a court of law for being sexually inappropriate with Resident #137 due to exposing themselves and groping the resident on the patio. The ADON stated FM #16 was out of jail on probation at the current time but was no longer allowed on the premises. During an interview on 07/10/24 at 12:35 P.M., Resident #32 and Resident #73 stated they were not on the patio when the incident occurred between FM #16 and Resident #137. Per Resident #32 and Resident #73, Resident #137 told them that FM #16 exposed themselves, put their arms down the resident's shirt, and requested they go to the bathroom together. An interview with the DON on 07/10/24 at 3:44 P.M. revealed on 04/09/24, the previous activity director told her that Resident #32 and Resident #73 notified her that FM #16 had inappropriately touched Resident #137 on the smoking patio. The DON stated she watched the video camera footage which showed FM #16 behind Resident #137 with his hands down the resident's shirt and FM #16 exposed himself to the resident. Per the DON, she immediately talked to Resident #137 who confirmed the action was not warranted and wanted to involve the police. The DON stated the facility filed a police report and FM #16 was arrested that day and was then court ordered to not be allowed on the premises moving forward. During an interview on 07/29/24 at 11:23 A.M., the DON stated prior to the incident, FM #16 was a frequent visitor of Resident #48 and visited daily from 8:00 A.M. until approximately 1:00 P.M. to 2:00 P.M. The DON stated that prior to the incident, FM #16 would occasionally go out and smoke and there had never been any issues. According to the DON, FM #16 was arrested the day of the incident and after FM #16 was initially released from jail, they allowed FM #16 supervised visits in the common area with Resident #48. The DON stated the visits were shorter than before, lasted for a week or two, and FM #16 was not allowed to go out and smoke with the residents. The DON stated FM #16 visited around lunch time to feed Resident #48. She stated FM #16 came to the main entrance, checked in with the receptionist, and someone called for staff to bring Resident #48 downstairs to the common area. The DON stated when FM #16 left, the receptionist had staff come down to get Resident #48. The DON stated no one sat with FM #16, but the receptionist and Human Resources/Business Director were in their offices with the door open. During an interview on 07/29/24 at 11:27 A.M., the Administrator stated the immediate actions taken were for FM #16 to be trespassed from the facility. The Administrator stated the police later found and arrested FM #16. The Administrator stated a few weeks after the incident, FM #16 was arrested for another incident and after FM #16 went to court, FM #16 was not allowed to be in the facility at all. During an interview on 07/29/24 at 1:03 P.M., the Receptionist stated that initially after the incident when FM #16 wanted to come to the facility, the visits had to be supervised. The Receptionist stated that when FM #16 came for the supervised visits, she called, and staff brought Resident #48 to visit FM #16 in the common area. The Receptionist stated that after FM #16 had a court date, FM #16 was not allowed in the facility at all. During an interview on 07/29/24 at 1:12 P.M., the Human Resource (HR) Manager stated she was not aware of any other incidents with FM #16. The HR Manager stated she observed FM #16 during supervised visits and only recalled FM #16 coming in about three times. The HR Manager stated presently FM #16 was not allowed back into the facility and she thought FM #16 served jail time. During an interview on 07/29/24 at 1:24 P.M., Licensed Practical Nurse (LPN) #18 stated initially after the incident, FM #16 had supervised visits with Resident #48 in the common area. LPN #18 stated FM #16 only visited a few times. LPN #18 stated that after the incident, signage was also placed at the nurses' station indicating FM #16 was not allowed at the facility. LPN #18 stated FM #16 had not been back to the facility to visit. During an interview on 07/29/24 at 1:37 P.M., Resident #137 stated they were outside smoking alone when FM #16 came out to smoke. Resident #137 stated FM #16 placed their hands down their shirt, and they asked FM #16 to stop. Resident #137 stated they told the DON, and the police were immediately called. Resident #137 stated, as a result of the incident, FM #16 received five years of probation, had to do anger management, and was listed as a sexual offender. Resident #137 stated she felt safe after FM #16 was arrested. According to Resident #137, on one occasion after the incident, they saw FM #16 downstairs at the facility with Resident #48. Resident #137 stated it bothered her that FM #16 was there, but once she let staff know, Resident #137 did not see FM #16 anymore. During an interview on 07/29/24 at 1:43 P.M., Resident #75 stated they observed FM #16 putting their hands over the shoulder and breasts of Resident #137 and Resident #137 was laughing. Resident #75 stated they left afterwards. Resident #75 stated they had never seen FM #16 doing anything to anyone else. During an interview on 07/29/24 at 4:25 P.M., the Social Services Director (SSD) stated she was called in when the Administrator reported the incident to the police. The SSD stated she sat with Resident #137 when the police officer interviewed the resident. The SSD stated Resident #137 was tearful when talking with the officer. The SSD stated she met with Resident #137 for about three days after the incident and she also referred Resident #137 for psychiatric services, but the resident discharged not long after the incident. The SSD stated Resident #137 started having problems with a few of the other residents about the incident, but Resident #137 continued to go outside and smoke. During an interview on 07/30/24 at 4:02 P.M., the Administrator stated her expectation was for the facility to be free from abuse and the residents were protected and safe. A facility policy titled, Abuse, Neglect, Exploitation & Misappropriation of Resident Property, dated 2016, indicated, the facility will not tolerate Abuse, Neglect, Exploitation of its residents or the Misappropriation of Resident Property. This deficiency represents non-compliance investigated under Complaint Number OH00154929.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of facility investigations, review of hospital documentation, observations, staff interviews, and policy review, the facility failed to provide adequate interventions and/or supervision to ensure a resident who was assessed as being cognitively impaired and at risk for elopements did not elope from the facility. This resulted in Actual Harm when Resident #04 eloped from the secured memory care unit on 01/23/24 without staff knowledge, and was found outside the facility by a generator. Resident #04 sustained injuries from a fall that occurred during the elopement which required hospital evaluation and treatment for the placement of a suture to a lip laceration and for treatment of a right thigh contusion. This affected one (#04) of three residents reviewed for elopement risk. The census was 84. Findings include: Review of Resident #04's medical record revealed an admission dated 01/10/24. Diagnoses included anxiety disorder, major depressive disorder, iron deficiency anemia, and mental disorder. Resident #04 was admitted for a respite stay. Resident #04 resided in the secured memory care unit on the second floor of the facility. Review of an admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #04 was severely cognitively impaired with a brief interview for mental status (BIMS) score of two out of 15. Resident #04 was assessed as wandering daily. Review of an Elopement Evaluation dated 01/10/24 revealed Resident #04 was at risk for elopement. Resident #04 scored eight out of a possible nine. Scores above one were at risk for elopement. Review of a Secured Unit Evaluation dated 01/10/24 revealed Resident #04 was approved for admission to the secure unit. Resident #04 was evaluated as habitually wandering and would be able to wander out of the facility and not find their way back. Review of a care plan initiated on 01/10/24 revealed Resident #04 was at risk for wandering and elopement and at for risk for falls and fall related injury. Review of Resident #04's physician orders dated 01/12/24 revealed the resident may reside on secured care unit related to decreased cognitive awareness and safety. Review of progress notes revealed on 01/10/24 Resident #04 was moved from a first-floor room to the secure memory care due to wandering concerns. While on the memory care unit, Resident #04 was documented as wandering, exit seeking, and resisting care. On 01/23/24 Resident #04 was documented as being treated after a fall. Resident #04's upper lip was bleeding, and she had a swollen right knee. Resident #04 was sent to the emergency room (ER) per her daughter's request. Further review of the progress notes and medical record revealed there was no documentation of Resident #04's elopement on 01/23/24. Review of the facility's investigation revealed Resident #04 was last seen by staff in the secured memory care unit on 01/23/24 at 7:30 A.M. At 7:40 A.M., memory care staff Licensed Practical Nurse (LPN) #140, State Tested Nursing Assistant (STNA) #130, and STNA #160 were not able to locate Resident #04 so they began searching the secured memory care unit. No exit alarms had sounded. Resident #04 was found outside the back of the facility by Activity Aide (AA) #120 that was entering the building. Resident #04 was standing by the facility trying to exit from inside the chain link fence that surrounded the generator. Resident #04's hair braids got stuck in a metal loop and AA #120 helped free them. AA #120 called for assistance to dietary staff. Dietary Director (DD) #150 met LPN #140 and STNA #130 who were looking for Resident #04 exiting the elevator. Resident #04 was treated for a bleeding lip and right knee injury. Resident #04's daughter and physician were informed. Review of Hospital emergency room (ER) documentation dated 01/23/24 revealed Resident #04 was assessed for post-fall injuries. Resident #04's upper lip had a small laceration of less than five millimeters (mm) that was repaired with one suture. Resident #04 complained of right leg pain. X-rays to the right leg were negative for any acute injury. Resident #04 was diagnosed with right thigh contusion. A magnetic resonance imaging (MRI) scan of Resident #04's head was negative for any acute injury. Resident #04 was admitted to the ER at 12:00 P.M. and discharged at 2:24 P.M. During an interview on 01/31/24 at 10:25 A.M. the Director of Nursing (DON) confirmed Resident #04 eloped from the memory care unit and was found outside the back of the facility on 01/23/24 by AA #120 who was coming into work. No exit alarms had been activated. The DON stated the facility conducted an investigation into the elopement but was unsure how Resident #04 had eloped from the secured memory care unit located on the second floor and exited the facility. Exit alarms were checked by maintenance and were found to all be working correctly. No video surveillance was available. Resident #04's Wanderguard (alarm device to prevent elopement) was checked and was functioning. Observations of Resident #04 in the secured memory care unit on 01/31/24 at 10:55 A.M., 3:01 P.M. and 3:50 P.M. revealed she was confused and unable to be interviewed. A Wanderguard was in place to Resident #04's left ankle. During an interview on 01/31/24 at 11:30 A.M. with AA #120 she stated that she found Resident #04 outside the back of the facility on 01/23/24 when walking from the parking lot. Resident #04 was first seen inside of a chain link fence barrier around the facility's generator. Once AA #120 recognized Resident #04 she opened an entrance door located by the generator and called for dietary staff to help. Dietary Director (DD) #150 responded and went for help. AA #120 walked with Resident #04 and tried to convince her to go back into the facility. Human Resource (HR) #200 and LPN #140 responded and were able to get Resident #04 back into the facility. Resident #04's lip was bleeding, and her pants were ripped. During an interview on 01/31/24 at 12:30 P.M., STNA #130 stated that she was passing out breakfast trays on 01/23/24. STNA #130 stated Resident #04 was standing near the food tray cart. STNA #130 went down the hall to deliver another resident's breakfast tray and when she came back to get another tray, LPN #140 asked if she had seen Resident #04. STNA #130 along with LPN #140 and STNA #160 started searching the secured memory care unit for Resident #04. STNA #130 stated Resident #04 was not found in the unit, so STNA #130 and LPN #140 went downstairs to see if therapy staff had come and took her out of the unit. While exiting the elevator, STNA #130 stated DD #150 informed them Resident #04 was found outside back of the facility. STNA #130 went with LPN #140 to get Resident #04 back into the facility. Resident #04's lips were bleeding, and she had a tear on her black jeans. STNA #130 stated no exit alarms had been activated. During a phone interview on 01/31/24 at 2:20 P.M., LPN #140 stated that on 01/23/24 at approximately 7:30 A.M. she observed Resident #04 sitting in the common area talking to another resident. LPN #140 stated on 01/23/24 at approximately 7:40 A.M. Resident #04 was unable to be found and all resident rooms and bathrooms were searched on the secured memory care unit. LPN #140 stated when Resident #04 was unable to found on the secured care unit, LPN #140 and STNA #130 went downstairs on the elevator to see if therapy staff had taken her and not informed them. LPN #140 stated no exit alarms in the memory care unit had been activated. While exiting the elevator, DD #150 approached and informed LPN #140 that Resident #04 was outside the facility with AA #120. LPN #140 stated Resident #04's lip was bleeding, and her jeans were ripped. LPN #140 treated Resident #04's lip and knee. LPN #140 called Resident #04's daughter and her physician. Resident #04 reported to LPN #140 that she fell downstairs chasing a boy. During an interview on 01/31/24 at 2:20 P.M., the Administrator and DON both confirmed Resident #04 had eloped from the secured memory care unit and was found behind the facility on 01/23/24. The Administrator and DON stated the facility conducted an investigation, but it was unable to be determined how Resident #04 eloped from the unit. The Administrator and DON stated there was no video surveillance of the elopement. The Administrator and DON confirmed Resident #04 was treated at the hospital for injuries she sustained from a fall during the elopement. Review of an undated facility policy titled The Oaks of [NAME] Kettering regarding Missing Residents revealed staff shall investigate all cases of missing residents. Staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the Charge Nurse or DON. This deficiency represents non-compliance investigated under Complaint Number OH00150572.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident interview, staff interview, review of hospital records, review of staff statements, review of hospice notes, review of an Emergency Medical Services (EMS) run report, observations, and policy review, the facility failed to provide adequate behavioral health services for one Resident (#78) who voiced suicidal ideations. This resulted in Immediate Jeopardy and the potential for serious life-threatening injury, harm, impairment, and/or death, when Resident #78 told Hospice Nurse #150 maybe someday they'll come in and find me hanging, was left unsupervised on 10/17/22 from 2:43 P.M until 3:28 P.M. and was subsequently found unresponsive with a call light cord wrapped around his neck. This affected one (#78) of three residents (#09, #25, and #78) identified by the facility as receiving behavioral health services. The facility census was 85. On 11/29/22 at 5:15 P.M., the Administrator, Director of Nursing (DON) #163, and [NAME] President (VP) of Clinical Compliance and Reimbursement #160 were notified Immediate Jeopardy began on 10/17/22 at 2:08 P.M., when Resident #78 told Hospice Nurse #150 maybe someday they'll come in and find me hanging. Hospice Nurse #150 asked if Resident #78 would like Hospice Nurse #150 to call Resident #78's mother to explain the situation, and Resident #78 stated he would leave a note. After the visit with Hospice Nurse #150 on 10/17/22, Resident #78 was left unsupervised from 2:43 P.M. until 3:28 P.M. On 10/17/22 at 3:28 P.M., Resident #78 was found in his room in his bed, which was in a high position, with a cord wrapped around his neck. Resident #78 was unresponsive at that time, the cord was removed, a sternal rub was completed, and Narcan (medication used to reverse the life-threatening effects of a known or suspected opiate overdose) was administered. Resident #78 became responsive and was subsequently sent to the hospital on [DATE] at 3:44 P.M. and was admitted to the inpatient psychiatric unit. The Immediate Jeopardy was removed on 11/30/22, when the facility implemented the following corrective actions: • On 10/17/22, former DON #51, Assistant Director of Nursing (ADON) #49, and Wound Nurse Licensed Practical Nurse (LPN) #25 assessed all in house residents which included all hospice residents for feelings of self-harm, hopelessness, or suicidal ideation. This was completed on 10/17/22. Additionally, all in house residents had a current Patient Health Questionnaire-9 (PHQ-9) [a questionnaire which aids in screening, diagnosing, monitoring, and measuring the severity of depression] reviewed by former DON #51, ADON #49, and Wound Nurse LPN #25. This was completed on 10/17/22. There were no significant findings on all above assessments. • On 10/17/22, Corporate Nursing Team [NAME] President (VP) of Clinical Compliance and Reimbursement #160 and Registered Nurse (RN) Corporate Nurse #161, former DON #51, ADON #49, and Wound Nurse LPN #25, reviewed the medical records of all in house residents to identify any like residents. There were no significant findings. • On 10/17/22, a root cause analysis was started by former DON #51, ADON #49, Wound Nurse LPN #25, and VP of Clinical Compliance and Reimbursement #160. The findings were that Resident #78 had a long history of alcohol abuse. It was alleged that Resident #78 was consuming alcohol while on hospice services. Hospice Nurse #150 came in and spoke with Resident #78. Resident #78 made a statement that maybe one day they would find him dead. Upon assessment of all records, it was determined that Resident #78's suicide attempt was due to changes in service and feeling of loss of control due to inability to stop consuming alcohol. This was completed on 10/18/22. • On 10/17/22, VP of Clinical Compliance and Reimbursement #160 implemented a formal suicide prevention policy. • On 10/17/22, the Administrator, Director of Rehabilitation/Occupational Therapist (OT) #99, former DON #51, ADON #49, Dietary Director #19, and Housekeeping Director #28, immediately started all staff education on the Suicide Prevention Policy. The facility was using agency staff. Former DON #51 provided the staffing agency with copies of the Suicide Prevention Policy on 10/17/22 and 10/18/22 for education with agency staff prior to working in the facility. All education was completed on 10/18/22. Central Supply Director #02 sent a follow up email to the staffing agency on 11/29/22 regarding the Suicide Policy. All new employees are educated by the DON/designee on suicide prevention during new hire orientation prior to providing resident care. • On 10/18/22, an ad hoc Quality Assurance and Performance Improvement (QAPI) committee meeting was held by Medical Director/Primary Care Physician (PCP) #155, Administrator #03, DON #51, ADON #49, and VP of Clinical Compliance and Reimbursement #160. The plan of correction was reviewed and agreed upon. • On 11/09/22, an all-staff meeting was held, and suicide prevention was reviewed with all staff. The education was provided by ADON #49 • Audits were completed four to five times weekly with review of all in house residents progress notes for increased behaviors, suicidal ideations or feelings of hopelessness, and all hospice residents are reviewed for potential discharges and change in levels of care by RN Corporate Nurse #161 and VP of Clinical Compliance and Reimbursement #160. All in house residents are reviewed as part of the audits. All audits will be brought to the QAPI team for review for three months and then as needed. • From 10/17/22 through 10/23/22, RN Corporate Nurse #161 and VP of Clinical Compliance and Reimbursement #160 reviewed all resident progress notes for increased behaviors, suicidal ideations or feelings of hopelessness, and all hospice residents were reviewed for potential discharges and change in levels of care. There were no concerns identified. • From 10/24/22 through 10/30/22, RN Corporate Nurse #161 and VP of Clinical Compliance and Reimbursement #160 reviewed all resident progress notes for increased behaviors, suicidal ideations or feelings of hopelessness, and all hospice residents were reviewed for potential discharges and change in levels of care. There were no concerns identified. • Resident #78 returned to the facility from the hospital on [DATE]. Facility Admissions Director #04 and the Administrator remained in contact with the hospital throughout Resident #78's entire hospital stay. The Administrator required that Resident #78 be cleared from psychiatric services prior to returning to the facility. Resident #78 was discharged from the hospital as stable and at no harm/risk to himself. According to progress notes from the hospital, the hospital felt Resident #78's suicide attempt was more behavioral than an actual suicide attempt. Medical Director/Primary Care Physician (PCP) #155 was made aware of Resident #78's return to the facility by nursing staff. Psych 360 (a psychiatric ancillary service) saw Resident #78 on 11/04/22 and 11/18/22. Former DON #51 followed up with Resident #78 upon his readmission to the facility on [DATE] with no issues identified. Upon Resident #78's return to the facility, staff were made aware by former DON #51 that Resident #78 would require increased supervision. Facility nursing staff completed increased supervision until 11/04/22 when Psych 360 evaluated Resident #78, and Resident #78 was determined to be stable. Upon readmission on [DATE], Resident #78 was offered hospice services by Social Service Director #100, but Resident #78 declined and requested therapy services. Facility accommodations were made to provide therapy services for Resident #78. • From 10/31/22 through 11/06/22, RN Corporate Nurse #161 and VP of Clinical Compliance and Reimbursement #160 reviewed all resident progress notes for increased behaviors, suicidal ideations or feelings of hopelessness, and all hospice residents were reviewed for potential discharges and change in levels of care. There were no concerns identified. • From 11/07/22 through 11/13/22, RN Corporate Nurse #161 and VP of Clinical Compliance and Reimbursement #160 reviewed all resident progress notes for increased behaviors, suicidal ideations or feelings of hopelessness, and all hospice residents were reviewed for potential discharges and change in levels of care. There were no concerns identified. • From 11/14/22 through 11/20/22, RN Corporate Nurse #161 and VP of Clinical Compliance and Reimbursement #160 reviewed all resident progress notes for increased behaviors, suicidal ideations or feelings of hopelessness, and all hospice residents were reviewed for potential discharges and change in levels of care. There were no concerns identified. • From 11/21/22 through 11/27/22, RN Corporate Nurse #161 and VP of Clinical Compliance and Reimbursement #160 reviewed all resident progress notes for increased behaviors, suicidal ideations or feelings of hopelessness, and all hospice residents were reviewed for potential discharges and change in levels of care. There were no concerns identified. • On 11/30/22, the Administrator, RN Corporate Nurse #161, VP of Clinical Compliance and Reimbursement #160, and Maintenance Director #44, reviewed the call light system and determined Resident #78 would have a cordless call light system that would remain integrated into the facility call light system. Maintenance Director #44 and VP of Clinical Compliance and Reimbursement #160 removed Resident #78's long call light cord from Resident #78's room and replaced the call light with a wireless call light system. Resident #78 was also provided a wireless remote system which would allow Resident #78 to use a sound activated system which alarms at the nurse's station. All staff were immediately educated on the new call light system by the Administrator, RN Corporate Nurse #161, and VP of Clinical Compliance and Reimbursement #160. • All oncoming staff are made aware of any residents who have been identified as being at risk for suicidal ideations via staff-to-staff report. During report, staff are made aware of the risk and appropriate interventions needed to keep the resident safe. • Interviews on 11/29/22 with LPN #15, Maintenance Director #44, STNA trainee #65, and STNA #92, revealed they had been in-serviced and were aware of suicide prevention interventions. • Observation on 11/30/22 at 4:25 P.M. with the VP of Clinical Compliance and Reimbursement #160 revealed Resident #78's call light cord had been cut, which left only a fragment to pull if needed out of the wall to signal a call. Resident #78 was also provided a cordless remote which when pushed, sounded at the nurses' station. The observation revealed the call light was functional. All other call light cords in the room were removed. Resident #78 was the only resident residing in the room. The call light cord in the bathroom was cut which left only enough length to pull and activate the call light. Although the Immediate Jeopardy was removed on 11/30/22, the facility remains out of compliance at Severity Level 2 (the potential for more than minimal harm that is not Immediate Jeopardy) as the facility is in the process of implementing their corrective actions and monitoring for effectiveness and on-going compliance. Findings include: Review of the medical record for Resident #78 revealed he was originally admitted to the facility on [DATE] and was readmitted to the facility on [DATE]. Resident #78's diagnoses included, but were not limited to, major depressive disorder, alcohol abuse, paraplegia, opioid use, and alcoholic cirrhosis of the liver with ascites. Review of Resident #78's care plan, dated 06/24/22, revealed Resident #78 had a behavior problem related to the Hospice Nurse confirming Resident #78 had been drinking alcohol in his room and noted a smell of alcohol from Resident #78's room. On 08/11/22, the care plan was updated to indicate there was a potential that Resident #78 was drinking alcohol in his room. Review of Resident #78's quarterly Minimum Data Set (MDS) assessment, dated 08/26/22, revealed Resident #78 was cognitively intact. Resident #78 required limited assistance of one staff for bed mobility and dressing. Resident #78 required supervision of one staff for transfers and locomotion. Resident #78 did not walk. Resident #78 reported feeling down, depressed, or hopeless 12 to 14 days during the two-week look back period. He also reported feeling tired or having little energy for seven to 11 days during the look back period. He denied having thoughts that he would be better off dead or having thoughts of hurting himself in some way. The assessment further revealed Resident #78 received antipsychotic, antianxiety, antidepressant, and opioid medication. Review of Resident #78's care plan, initiated on 10/18/22, revealed the care plan addressed Resident #78's behavior of threats to harm himself as he attempted to inflict self-harm on 10/17/22 when he was found with a call light cord around his neck. Interventions included sending Resident #78 to the hospital on [DATE] for evaluation and admission to the psychiatric unit. Other interventions included assessing pattern, intensity, and duration of the problem behavior; attempting to determine if the behavior was associated with events; assessing for recent medication changes or changes in environment as possible causes; considering pain, discomfort, hunger, boredom, and personal needs that Resident #78 was unable to communicate as possible causes of behavior. Additional interventions included anticipate and meet needs to attempt to control behavior problems; providing calm reassurance, redirection or distractions and assessing effectiveness; providing positive reinforcement for appropriate behavior; confront gently and respectfully when behavior is inappropriate and set limits; share effective interventions with other staff members; maintain routine and stress free environment; keep noise to a minimum; encourage activities and socialization; update the physician as needed regarding changes in behavior status; include Resident #78 in care; explain care before giving and segment tasks to promote Resident #78's involvement and control over care; use two care givers as indicated to provide safe care and to shorten the amount of time needed to provide care; include Resident #78 and/or resident representative in treatment plan and update regarding change in status/treatment plan. Review of Resident #78's progress note, dated 10/17/22 at 2:06 A.M., revealed Resident #78 came out of his room and went down the elevator. The note indicated a strong odor of alcohol followed Resident #78. The nurse (LPN #10) went into Resident #78's room and searched for the presence of alcohol. A water bottle was stashed in his bedside commode and was wrapped in a grocery bag. LPN #10 opened it, and there was a strong smell of vodka. LPN #10 then asked a State Tested Nursing Assistant (STNA) to smell the water bottle as a witness. The STNA confirmed the odor smelled like vodka. The water bottle was returned. LPN #10 then called the hospice provider to report the findings. LPN #10 was told a note would be left for the case manager to reach out to the facility during day shift. Review of Resident #78's progress note, dated 10/17/22 at 6:38 A.M., revealed staff reported to Primary Care Physician (PCP) #155 that Resident #78 reeked of alcohol and vodka was found in Resident #78's bedside commode. PCP #155 advised staff to discontinue all medications and all medications were discontinued. Review of Resident #78's progress note, dated 10/17/22 at 9:54 A.M., revealed LPN #15 went to check on Resident #78. The note indicated when Resident #78 turned around and saw LPN #15, he burst into tears. LPN #15 stated that she was not there to pass judgement, that she was just checking on Resident #78. Resident #78 stated that he did not do it all the time. The nurse reminded Resident #78 of his safety (concern) because of the medication that he took. Resident #78 was reminded of prior times when it was suspected he was drinking, and when talked to, Resident #78 did not admit or deny the drinking. It was explained that Resident #78 just succeeded on the first step which was admitting it. Resident #78 again admitted his drinking. Resident #78 was told that the hospice nurse would be there that day to talk with him and they would go from there. Resident #78 was informed that if he needed to talk to let LPN #15 to let her know and she would listen. Review of Resident #78's Hospice visit note, dated 10/17/22, revealed Resident #78 was seen at 2:00 P.M. The note indicated Resident #78 was alert and oriented times four. Resident #78's affect was depressed and flat. The note indicated Resident #78 reported he hurt all over. The visit summary indicated Resident #78 was in his room, seated in his wheelchair with his back to the door when Hospice Nurse #150 arrived. It was noted Resident #78 turned around and faced Hospice Nurse #150 and was crying, stating he had screwed up, and stating it was him and his wife's anniversary, which was why he used alcohol the night before and not to beat him up over his alcohol use. Hospice Nurse #150 explained that he was not judging him but did need to let him know that he did violate his signed agreement from last month at the in-patient unit. Resident #78 stated that he understood and realized that they would need to discharge him. Resident #78 asked if his medications could be tapered and Hospice Nurse #150 explained that decision was up to the facility and PCP #155, but he would ask the nurse to ask PCP #155. Resident #78 made the comment that maybe someday they'll come in and find me hanging, and then spoke about how they took my bedside commode and started laughing. The note indicated Hospice Nurse #150 told Resident #78 that if he was having any issues, that the facility would send him to the hospital to be helped if that was appropriate. Resident #78 continued to talk about how he screamed from the rooftops for help, but no one would ever help him. Hospice Nurse #150 asked Resident #78 if he wanted Hospice Nurse #150 to call his mom to explain any details regarding the current situation and Resident #78 said he would leave her a note. Resident #78 told Hospice Nurse #150 he was sorry for wasting his time and cut the assessment short. Hospice Nurse #150 left the room to inform the floor nurse (LPN #15) of Resident #78's comments about hanging, as well as about leaving a note for his mom. Hospice Nurse #150 then indicated that he found former DON #51 and informed her of Resident #78's comments, and she stated that she expected that they were going to put him on a suicide watch. The note indicated Hospice Nurse #150 called and spoke with ADON #49 who was out of the facility at that time. Review of Resident #78's progress note, dated 10/17/22 at 4:00 P.M., revealed Hospice Nurse #150 came into the facility to speak with Resident #78 and explained that hospice would be discontinuing hospice services due to Resident #78 not following the hospice care plan. Upon exiting Resident #78's room, the nurse (Hospice Nurse #150) notified LPN #15 that Resident #78 was upset and made comments that maybe someday they would find him hanged. This was reported to the (former) DON #51. Staff were assigned for supervision of Resident #78 until a psychiatric evaluation could be obtained. When staff entered Resident #78's room, he was found in the room with a cord wrapped around his neck. It was noted that Resident #78 had an order for Do Not Resuscitate Comfort Care (DNRCC). The progress note indicated a sternal rub was provided, Emergency Medical Technicians (EMT) were called, and Narcan was administered. Resident #78's response increased as interventions were provided. After Narcan was administered, vital signs were obtained, and Resident #78's pulse was 109 and his oxygen saturation rate was 88 percent (%). Resident #78's vitals stabilized. The EMT arrived and Resident #78 was sent to the hospital. The PCP and family were made aware. The facility followed up with the hospital. Resident #78 was admitted to the inpatient psychiatric unit and was stable at that time. Review of the statement, dated 10/17/22, provided by Hospice Nurse #150, revealed he met with Resident #78 on 10/17/22 at 2:00 P.M. to discuss with him the issue of his drinking the night before. Hospice Nurse #150 stated he entered the room and Resident #78 had his back to him, sitting in his wheelchair. Hospice Nurse #150 sat down and waited a minute until he turned to face him. The statement indicated Resident #78 told him he didn't need to beat him up about his drinking, to which he explained that he was not there to judge. Resident #78 spoke most of the time and stated he screwed up. Resident #78 made a comment that maybe someday they'll find me hanged, but then continued to talk about his issues with alcohol. Hospice Nurse #150 asked him if he wanted him to talk to his mother about the situation, and Resident #78 said no, I can leave her a note. Resident #78 also asked if he would be able to have his medication tapered down, and he explained that was a decision for PCP #155. Resident #78 thanked him, and Hospice Nurse #150 left the room to inform LPN #15 of Resident #78's comments. Hospice #150 told LPN #15 he was going to find DON #51 and ADON #49 to inform them, as well, of Resident #78's comments. Hospice Nurse #150 found DON #51 downstairs and informed her of Resident #78's comments, and texted ADON #49 to call him at 2:46 P.M., to which she promptly called back, as she was out of the building. Review of the statement provided by Maintenance Director #44, dated 10/17/22, revealed he walked into Resident #78's room around 2:00 P.M. and Resident #78 was crying while listening/talking to the hospice representative. Maintenance Director #44 indicated he immediately stepped out and shut the door. Maintenance Director #44 indicated Resident #78 looked very upset. Review of the statement provided by LPN #15, dated 10/17/22, revealed Hospice Nurse #150 approached her at approximately 4:30 P.M. to let her know that he had informed Resident #78 that he was going to be removed from hospice as of the next day. Hospice Nurse #150 stated that the resident (Resident #78) made statements that he should just go ahead and kill himself. At that moment she informed Hospice Nurse #150 that what he had just informed her had to be told to DON #51. LPN #15 indicated she walked with Hospice Nurse #150 to find DON #51. LPN #15 then attended to one of her residents. LPN #15 stated Wound Nurse LPN #25 came to her at approximately 3:15 P.M. to let her know that they were putting Resident #78 on suicide watch. Wound Nurse LPN #25 and former DON #51 had a conversation with the person who was going to be sitting with Resident #78. Wound Nurse LPN #25, STNA #30, and LPN #15 went into Resident #78's room approximately 3:30 P.M. LPN #15 heard Wound Nurse LPN #25 state oh my God as she was entering the room. When she walked behind the curtain, she saw Wound Nurse LPN #25 taking the call light cord from around Resident #78's neck. Resident #78 was high up and was not dangling. Resident #78 was not responding so Wound Nurse LPN #25 did a sternal rub. LPN #15 ran out of the room to call a code, then realized Resident #78 was a DNRCC and told the staff to get help for Resident #78's room. She went back into the room as Wound Nurse LPN #25 was performing another sternal rub and Resident #78 seemed to be gasping for air. Resident #78 started acting as if he was going to throw up. The vitals machine was attached, but the only vital LPN #15 remembered was a pulse of 109. LPN #15 began to talk to Resident #78 as he was looking at her when the squad arrived. Review of the statement from Wound Nurse LPN #25, dated 10/17/22, revealed at approximately 3:00 P.M., DON #51 notified her they needed to place Resident #78 on suicide watch for making statements of concern. Wound Nurse LPN #25 grabbed her laptop and paperwork from her office and headed upstairs to DON #51's office. Once on the unit, the Hospitality Aide (STNA #30) was asked to sit with Resident #78, the paperwork was printed and explained to STNA #30, and they entered Resident #78's room at 3:30 P.M. Wound Nurse #25 observed Resident #78 lying in bed with a call light cord tied around his neck. The cord was immediately removed, Wound Nurse #25 yelled for assistance, 911 was called, and a crash cart was obtained. Resident #78 was assessed for pulse and breathing. Resident #78 was found to have a very shallow, faint pulse with minimal breathing. Bilateral pupils were assessed, fixed, and dilated. A sternal rub was given with no response and oxygen was placed on Resident #78. DON #51 arrived in the room and Narcan was administered into Resident #78's left nostril by DON #51. Resident #78 reacted to the administration. Resident #78 was placed on his right side for rescue positioning and vital signs were obtained. EMT arrived on the scene and took over care of Resident #78. The local police department also arrived. Resident #78 left via stretcher and all details were given to the officer. Wound Nurse #25 indicated she returned to DON #51's office and placed a call to Resident #78's power of attorney (his mother), and she was notified at 3:56 P.M. of Resident #78's transport to the hospital. Review of a statement from Agency STNA #164, dated 10/17/22, revealed around 3:30 P.M. someone called a code, and she went into the room and his (Resident #78's) eyes were black and he was gasping for air. Nurses started a sternal rub, gave him Narcan, and he improved. Nine-one-one (911) was called as soon as they called a code. Review of the EMS run report, dated 10/17/22, revealed a call was received on 10/17/22 at 3:32 P.M. and EMS was dispatched. EMS arrived at the facility at 3:39 P.M. The run report indicated the primary symptom was suicidal ideations and the provider's primary impression was a suicide attempt. The report revealed EMS was dispatched for an attempt (suicide). The report revealed the patient (Resident #78) was found with the nurse call button cord wrapped around his neck by nursing home staff. The nursing home staff took it off his neck and called 911. Nursing home staff gave the patient Narcan prior to their arrival. The report indicated the patient (Resident #78) was told that day that he would no longer be under hospice care for cirrhosis of the liver due to his continued alcohol consumption. The patient (Resident #78) was noted as being alert but not speaking to crews once on the scene. The patient (Resident #78) was flailing around on his bed and did smell of alcohol. Resident #78 was transferred to the hospital and arrived at 3:51 P.M. Review of the Emergency Department to inpatient hand off report, dated 10/17/22, revealed the chief complaint was the patient (Resident #78) presenting as suicidal with alcohol intoxication. The report noted the patient (Resident #78) came from the nursing facility after trying to commit suicide with a call light cord after being told he would no longer be in Hospice care because he was intoxicated. The final diagnoses included acute alcoholic intoxication, hyperammonemia, intentional self-harm by strangulation, and suicidal ideations. Testing results included no acute intracranial process seen from the Computed Tomography (CT) scan of the head. His CT scan of the cervical spine showed no acute fracture or subluxation. The portable x-ray of his chest showed mild subsegmental atelectasis at the right lung base, and mild vascular congestion and interstitial edema were questioned. Review of the hospital Discharge Planning Brief Note, dated 10/28/22, revealed the psychiatric nursing supervisor received a call from the Administrator at the facility. The Administrator requested that it was documented that he (Resident #78) was okay to discharge from a psychiatric standpoint and that it was ok that he has increased supervision (it was noted they generally round on patients every two hours but state they will be rounding more frequently on Resident #78 due to the recent events). The requests were deemed okay from the hospital's standpoint. Review of Resident #78's progress note, dated 10/28/22, revealed Resident #78 returned to the facility. Resident #78 was returned to the same room he was in prior to the hospitalization. Review of Resident #78's significant change MDS assessment, dated 11/04/22, revealed Resident #78 was cognitively intact. Resident #78 required supervision with no setup help for bed mobility, transfer, and locomotion on the unit. Resident #78 did not walk. Resident #78 was independent with no set up help for locomotion off the unit. The assessment revealed Resident #78 felt down, depressed, or hopeless 12 to 14 days during the two-week look back period. Resident #78 indicated he had thoughts that he would be better off dead, or of hurting himself in some way two to six days during the look-back period. The assessment further revealed Resident #78 received antipsychotic, antianxiety, antidepressant, and opioid medication. Interview with Resident #78 in his room on 11/22/22 at approximately 3:50 P.M., revealed Resident #78 had been drinking Vodka and juice and Hospice Nurse #150 told him he was being taken off Hospice care. Resident #78 indicated he had experienced depression before however he had never tried to harm himself. Resident #78 stated when Hospice Nurse #150 came to see him on 10/17/22, Hospice Nurse #150 told him that he wouldn't be getting any more pain medication and that he was being taken off Hospice care. Resident #78 indicated he was seeing a Hospice counselor every Monday prior to being at the facility; however, he did not see a counselor very often while at the facility. Resident #78 revealed after speaking with Hospice Nurse #150 on 10/17/22, it felt like a couple of hours had gone by prior to staff coming back in his room. Resident #78 indicated he had planned for his suicide attempt to work and had time to get stuff together. Resident #78 stated he thought he would be successful before anyone came back to check on him. During the interview, Resident #78 was observed to be lying in bed with the call light cord hanging on the wall next to his bed. Interview with the Administrator on 11/22/22 at 3:03 P.M., revealed she was not sure why Hospice Nurse #150 walked out of Resident #78's room and indicated maybe Hospice Nurse #150 did not take it seriously. The Administrator indicated after the staff knew what Resident #78 stated to Hospice Nurse #150, they were in the process of initiating one-on-one supervision prior to finding Resident #78 with the call light cord around his neck. The Administrator stated Resident #78 had not had a history of suicidal ideation and had never voiced it to her knowledge. The Administrator indicated Resident #78 returned from the hospital on therapy and continued to be off hospice care. Interv[TRUNCATED]