**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review it was determined the facility failed to keep residents free from hazards, provide appropriate monitoring and supervision for residents with known substance use disorder and a history of illicit drug use, ensure staff possessed adequate knowledge and training regarding substance use, and follow up on recommendations from a fall investigation for 2 of 8 sampled residents (#s 3 and 217) reviewed for accidents and positioning/mobility. This failure was determined to be an immediate jeopardy situation which resulted in a serious adverse outcome for Resident 217, and placed residents at risk for injury, drug overdose, and death. Findings include: The facility's February 2023 policy titled Resident Possession and Use of Illegal Substances indicated the following: -The possession and use of illegal substances by residents will not be tolerated; and -Facility staff will have knowledge of signs, symptoms, and triggers of possible illegal substance use. 1. Resident 217 was admitted to the facility in 3/2025 with diagnoses including encounter for surgical aftercare following surgery on the nervous system and lower back pain. A review of Resident 217's [DATE] Nursing Admission/readmission Evaluation/Assessment revealed she/he was alert and oriented and had a history of polysubstance use but denied current use. No evidence was found in Resident 217's care plan to indicate her/his history of polysubstance use. A progress note dated [DATE] at 7:57 PM indicated Resident 217 was found unresponsive in the facility's parking lot. Facility staff administered an intramuscular dose of Narcan (a medication used to reverse the effects of an opioid overdose) to Resident 217 to reverse the effects of a suspected opioid overdose, called 911 and sent her/him to the hospital emergency department. Resident 217's physician was notified of this incident and placed Resident 217's order for Oxycodone on hold pending a face to face meeting with Resident 217 on [DATE]. A review of Resident 217's [DATE] post visit hospital summary revealed she/he was seen in the emergency department for approximately two hours where she/he was monitored following an opioid overdose in the parking lot of the facility. A review of Resident 217's electronic health record revealed she/he returned to the facility on [DATE] at 11:44 PM. No evidence was found to indicate the facility initiated monitoring for opioid use after she/he returned from the hospital. A Social Services progress note written by Staff 16 (Social Services Director) dated [DATE] at 10:28 AM indicated Resident 217 was clearly upset and agitated about her/his medication being changed due to her/his opioid use. Resident 217 stated she/he may have to self-medicate and may blow out of here. A review of the facility reported incident investigation completed on [DATE] revealed Resident 217 was not in the facility during rounds on [DATE] at 4:30 AM and staff attempted to reach her/him by calling her/his cell phone. Resident 217 was found unresponsive on the floor of her/his bathroom on [DATE] at 6:30 AM. On [DATE] at 11:30 AM Staff 27 (LPN) stated Resident 217 left the facility with her/his friends almost daily. Staff 27 stated there were times when Resident 217 was barely rousable and the facility did not have a procedure to assess residents after being out of the facility. Staff 27 stated he attempted to resuscitate Resident 217 during the incident on [DATE] but was unsuccessful and Resident 217 was pronounced dead. Staff 27 stated he found drug paraphernalia including a lighter, burnt aluminum foil, a metal straw with a rubber tip and a powdery substance on the floor with Resident 217. Staff 27 further indicated he did not receive training related to SUD (substance use disorder). On [DATE] at 12:00 PM, Staff 10 (CNA) stated she was not aware of Resident 217's drug use and staff had not been asked to keep an eye on [her/him]. Staff 10 stated she did not receive any training regarding Resident 217's drug use. On [DATE] at 12:08 PM, and at 1:33 PM Staff 9 (CMA) stated she was unaware of any residents with polysubstance abuse or SUD. Staff 9 stated after the incident where Resident 217 overdosed in the facility parking lot, her/his oxy was discontinued. Staff 9 stated Resident 217 changed drastically after this and she/he began to refuse other medications. Staff 9 stated staff were not asked to monitor Resident 217 or do extra rounds or anything. Staff 9 stated on [DATE], Resident 217 was found deceased in her/his bathroom. Once the police left, the housekeeper was asked to clean the room and found drug paraphernalia hidden in Resident 217's bathroom. Staff 9 further stated she was not provided any education on identifying signs and symptoms related to the suspicion of drug use. On [DATE] at 12:09 PM Staff 20 (CMA) stated he was made aware of Resident 217's SUD on [DATE] by the emergency medical technicians who responded to incident. Staff 20 stated prior to the incident, he did not receive any training on how to identify signs and symptoms related to the suspicion of drug use or how and when to monitor a resident with a diagnosis of SUD if they spent time away from the facility. On [DATE] at 12:33 PM, Staff 8 (Housekeeper) stated he was tasked to clean Resident 217's room after she/he died but did not know about SUD precautions. Staff 8 stated he found a lighter, a piece of aluminum foil and bag of white powder in Resident 217's bathroom, which he picked up using a paper towel, placed in a plastic bag and handed to Staff 27. On [DATE] at 2:05 PM Staff 16 (Social Services Director) acknowledged Resident 217 was sent to the hospital emergency department following an opioid overdose in the facility's parking lot and she/he was upset that her/his Oxycodone was being held as a result. Staff 16 acknowledged Resident 217 talked about self-medicating and may blow out of here as she indicated in the [DATE] progress note. Staff 16 stated staff were uneducated related to interventions and monitoring for SUD residents. Staff 16 stated she participated in a Substance Use/Abuse Training on [DATE]. Staff 16 further stated she was instructed to provide training which included signs and symptoms of SUD and possible signs of an overdose to the licensed nursing staff only but did not include CNAs or any other staff. On [DATE] at 3:06 PM Staff 1 (Administrator) acknowledged Resident 217 passed away from the incident which occurred on [DATE]. Staff 1 stated it was a group decision to educate the nurses rather than the CNAs because the nurses would be doing the assessments. 2. On [DATE] at 9:31 AM Staff 16 provided additional information to the survey team which revealed an additional five residents (#s 18, 37, 61, 119 and 417) who resided in the building that had SUD who did not have baseline care plans to address their history of SUD and potential relapse and reuse. On [DATE] at 11:26 AM, Staff 14 (CNA) stated the facility trained staff on different tasks, but could not recall a specific training for SUD. She stated there were monthly in-service meetings, but had not yet had one regarding SUD. On [DATE] at 11:30 AM Staff 15 (LPN) stated she was not aware of Resident 217 having issues with drug use. She stated she received training online, but could not recall if there was a training regarding signs and symptoms of drug use and monitoring for drug use. She stated she had not received education on how to provide information to residents related to the risk of drug use. On [DATE] at 11:30 AM, Staff 13 (CNA) reported she was aware Resident 217's overdose in her/his bathroom and passed away however the only training she recalled was a sign posted in the breakroom to be aware of different things. On [DATE] at 11:47 AM, Staff 11 (CNA) reported she was aware Resident 217's overdose in her/his bathroom and passed away but was unaware the resident used drugs before that day. Staff 11 stated the facility did not provide any trainings related to SUD after the incident related to Resident 217. On [DATE] at 12:28 PM, Staff 31 (Agency CNA) and at 1:36 PM Staff 32 (CNA) stated they did not receive any training regarding SUD or monitoring for signs and symptoms of SUD. On [DATE] at 1:38 PM Staff 12 (CNA) stated she had not received any information recently about monitoring for suspicious behavior or drug related materials for residents with SUD. On [DATE] at 1:50 PM Staff 51 (CNA) stated she was not aware any residents used recreational drugs prior to [DATE] when staff provided training. On [DATE] at 2:05 PM Staff 16 (Social Services Director) stated staff were uneducated related to interventions and monitoring for SUD residents. Staff 16 stated she participated in a Substance Use/Abuse Training on [DATE]. Staff 16 further stated she was instructed to provide training which included signs and symptoms of SUD and possible signs of an overdose to the licensed nursing staff only but did not include CNAs or any other staff. On [DATE] at 3:06 PM Staff 1 (Administrator) stated it was a group decision to educate the nurses rather than the CNAs because the nurses would be doing the assessments. Staff 1 acknowledged no other staff disciplines were provided education regarding residents with SUD. On [DATE] at 4:18 PM Staff 1 (Administrator) and Staff 50 (Regional [NAME] President) were informed of the failure to identify the need to initiate interventions related to SUD and to educate direct staff on how to identify and safely care for residents with SUD. The failure constituted a situation of immediate jeopardy to the health and welfare of residents. A plan of correction was requested to immediately ensure residents with SUD were identified, their care plans were revised to include interventions and monitoring related to SUD and staff were educated on how to identify and treat residents with SUD. On [DATE] at 7:42 PM an acceptable facility IJ removal plan was submitted by the facility. The plan indicated the facility would implement the following actions: -All residents' records would be reviewed to identify other residents with history of or active substance use disorder. -Residents identified with active, suspected or history of substance use will be identified and listed in a binder found at the nursing stations. The residents name plates outside their room will have a sticker placed to alert staff of potential hazards associated with active substance use disorder. -Residents identified with history of, or active substance use disorder will be offered substance use treatment services. -Residents identified with history of, or active substance use disorder will be assessed upon return from independent offsite outing for suspected substance use. -Residents who are assessed upon return from independent offsite outing or identified as active substance use will have an incident report generated and law enforcement notification if required. -Staff, including temporary or agency staff, will be educated to location of binder with residents identified with suspected or history of substance use disorder. -Staff, including temporary or agency staff, will be in-serviced to substance use disorder and signs of abuse related to drug use, what to do if suspected active use, and reporting suspected drug paraphernalia, as well as facility policy on resident possession and use of illegal substances. -Residents that are identified with drug paraphernalia or signs/symptoms of active drug use will be placed on alert monitoring, MD notification, POC task will be placed to alert CNA for increased monitoring for drug paraphernalia, law enforcement notification if required. In addition an incident report will be generated and resident assessment completed. On [DATE] at 10:51 AM it was determined the immediacy was removed after verification of completion of the IJ removal plan. 3. Resident 3 was admitted to the facility in 2/2012 with diagnoses including hemiplegia (a condition characterized by paralysis on one side of the body). Resident 3's [DATE] Care Plan revealed the following: -The resident required extensive assistance from two or more people to transfer into a car. -The resident was cleared to go out of the facility with Witness 1 (Family Member), and she had received car transfer training. Resident 3's [DATE] Annual MDS revealed the resident was severely cognitively impaired and experienced upper and lower extremity impairment on one side. A [DATE] Witnessed Fall Investigation revealed the following: -Resident 3 was lowered to the ground during an attempted transfer to the car with Witness 1. -The resident did not sustain any injuries. -A PT referral was placed for transfer training. A [DATE] PT Discharge Summary indicated Resident 3 was not tested for car transfers. On [DATE] at 11:36 AM Witness 1 stated she took Resident 3 out of the facility for an outing on [DATE]. Witness 1 stated it was getting harder and harder to transfer the resident and she could not recall the last time she received any training or education on how to safely transfer the resident into her car. On [DATE] at 11:32 AM Resident 3 was observed in her/his room in bed. Resident 3 stated she/he loved activities, including going outside and visits with Witness 1. On [DATE] at 11:55 AM Staff 30 (CNA) stated Resident 3 went out of the facility every Saturday with Witness 1. Staff 30 stated the resident went out most recently on [DATE] with Witness 1, and Witness 1 transferred the resident into the car independently. On [DATE] at 1:45 PM Staff 42 (Director of Rehab) stated Resident 3 received PT following her/his fall in 3/2025 but the resident and Witness 1 did not receive any education or training regarding car transfers. Staff 42 further stated he was unaware the resident continued to go out of the facility with Witness 1 following her/his fall in 3/2025. On [DATE] at 12:12 PM Staff 2 (Regional Clinical Support) stated Witness 1 should have received car transfer training following Resident 3's fall on [DATE] and did not.

1. Based on observation, interview and record review it was determined the facility failed to ensure safety interventions and supervision were in place and followed to protect residents from elopement from the facility for 1 of 1 sampled resident (# 56) reviewed for elopement. This failure, determined to be an immediate jeopardy situation, resulted in Resident 56 eloping from the facility into heavily trafficked areas and placed residents at risk of avoidable accidents and death. Findings include: The facility's 6/2017 Elopement/Wandering Policy and Procedure revealed the following: -Residents deemed at risk to elope, that reside in an Expressions Unit, or have cognitive deficits will be accompanied by family, responsible party, or a facility staff member when leaving the facility for appointments/outings. -Residents evaluated as at risk for elopement would be in staff eyesight at all times when on facility outings. If staff are unable to keep the resident in line of sight, a designated staff member would accompany the resident on the outing to assist in maintaining resident safety. -Facilities with no elopement prevention system (i.e., wanderguard ((a safety monitoring device)) would place the resident on one-to-one care until their symptoms resolved or further evaluation could be completed to assist in maintaining resident safety. Resident 56 was admitted to the facility in 12/2023 with diagnoses including cancer. Resident 56 was discharged from the facility on 1/22/24. Resident 56's 12/21/23 admission MDS indicated the resident was moderately cognitively impaired (BIMS of 9), required supervision to partial/moderate assistance with ambulation, used a walker, a manual wheelchair and received hospice care. The Cognitive Loss/Dementia CAA indicated the resident experienced forgetfulness, confusion and cognitive fluctuations. Resident 56's 12/22/23 Elopement Risk Evaluation indicated the resident was cognitively impaired with poor decision-making skills, ambulated independently, expressed the desire to leave, go home or repeatedly pack, had wandered in the past month, was actively seeking to leave the building and was at risk to wander/elope. Records revealed on 12/26/23 Resident 56 eloped around 10:27 PM and was out of the facility for approximately 30 minutes before being found four blocks away from the facility by the facility's security company. The recorded temperature on 12/26/23 ranged from 41 to 48 degrees F. Following this incident, the facility's investigation recommended one-to-one supervision for Resident 56 until a wanderguard could be used. Resident 56's 12/27/23 Elopement Risk Evaluation indicated the resident was cognitively impaired with poor decision-making skills, ambulated independently, did not understand the need to inform staff if she/he left the facility, was actively seeking to leave the building and her/his wandering placed her/him at risk of getting to an unsafe place. A 1/3/24 Care Conference Note indicated Resident 56 wanted to discharge home but was encouraged to remain at the facility due to her/his cognition and memory deficits. The note also indicated the resident continued to receive one-to-one supervision due to elopement with safety concerns related to cognition and memory deficits. A 1/3/24 SLUMS (St. Louis University Mental Status) Examination completed by Staff 51 (Hospice Social Worker) revealed a score of eight out of 30, indicating the resident experienced dementia. A 1/4/24 Physician Order indicated Resident 56 was allowed to go on one walk per day, accompanied by facility staff if available. The walk was not to exceed two hours, and if the resident failed to return to the facility, hospice was to be notified. A review of the facility's 12/2023 and 1/2024 Daily Staffing Rosters (CNA daily staffing assignments) revealed Resident 56 inconsistently received one-to-one supervision from 12/27/23 through 1/9/24. The 1/9/24 Daily Staffing Roster indicated the resident no longer required one-to-one supervision as of evening shift. Records revealed on 1/9/24 at approximately 5:40 PM Resident 56 eloped from the facility. No one-to-one supervision or wanderguard was in place at the time of her/his elopement. The recorded temperature on 1/9/24 ranged from 34 to 52 degrees F. The facility is located on a busy street, with the exit of the facility located approximately 50 feet from the street with no barrier. The resident was located at her/his apartment on 1/10/24 at 12:16 PM by her/his friend. Resident 56 was brought back to the facility by a neighbor on 1/11/24 at 7:15 AM. The facility's 1/10/24 Incident Report and Investigation indicated nursing staff had great concern about Resident 56's safety when she/he was out in the community. The report indicated staff were concerned about the resident leaving the facility independently due to her/his fluctuating cognition. The report also revealed the resident's account of her/his 1/9/24 elopement, during which she/he left the facility, caught the first bus, ended up at the chaotic airport, got a ride from a police officer to a public transit station, took a different bus, got off at the wrong station and walked in circles until she/he located her/his apartment. Resident 56's heath record revealed a wanderguard was not put in place until 1/13/24. On 1/22/24 at 8:55 AM Resident 56 was observed in her/his room in bed. Resident 56 stated she/he was going to leave the facility today one way or another. On 1/22/24 at 10:34 AM Staff 5 (LPN) stated he was unsure if Resident 56 was able to leave the facility unsupervised and was unsure of what to do should the resident elope. On 1/22/24 at 10:36 AM Staff 6 (CNA) and at 11:04 AM Staff 7 (RN) stated they were unaware of Resident 56's elopements and of any safety interventions in place to prevent an elopement. On 1/22/24 at 12:05 PM Staff 3 (LPN/Care Manager) stated the facility requested a one-to-one caregiver from hospice for Resident 56 prior to the resident's 1/9/24 elopement and were told hospice could not accommodate this request. Staff 3 stated the facility provided Resident 56 with one-to-one supervision when they had extra staff available. Staff 3 further stated she did not think the resident was safe to leave the facility unattended and that was why she requested a wanderguard. On 1/22/24 at 12:36 PM Staff 2 (DNS) stated she had concerns regarding the 1/4/24 Physician Order as she did not believe Resident 56 was able to remember to sign out from the facility or return in two hours time. Staff 2 stated the facility did not have the staff to provide one-to-one supervision should the resident leave. Staff 2 stated that one-to-one supervision was necessary and should have been in place for Resident 56. Review of Resident 56's health record revealed lack of evidence to support the facility protected the resident from an elopement as evidenced by the following: -Staff failed to consistently implement one-to-one supervision for Resident 56, who was assessed to be cognitively impaired, following her/his elopement on 12/26/23 and prior to the resident receiving a wanderguard. -Staff failed to question a physician order they felt was inappropriate and unsafe related to Resident 56 leaving the building for two hours at a time, unsupervised. -The facility failed to educate all staff of Resident 56's potential to elope and of interventions to prevent elopement. On 1/22/24 at 6:45 PM Staff 1 (Administrator), Staff 43 (Director of Operations) and Staff 52 (Regional Support Nurse) were informed of the immediate jeopardy (IJ) situation related to the facility's failure to protect Resident 56 from elopement from the facility. An IJ template was provided and an immediate IJ removal plan was requested. On 1/22/24 at 8:09 PM the facility submitted an acceptable removal plan. The IJ Removal Plan indicated the facility would implement the following actions: -Resident 56 was discharged from the facility. -Immediate evaluation of all residents in the facility conducted to determine if any other residents have been affected. -Education provided to all staff on elopement prevention and intervention, including current residents who were identified at risk. On 1/23/24 at 9:59 AM Staff 2 (DNS) provided verification that licensed staff received the required training and education and confirmed evaluations had been completed and interventions put in place for other residents identified as at risk to elope. On 1/23/24 at 10:20 AM the immediacy was removed. 2. Based on observation, interview and record review it was determined the facility failed to follow care plan interventions, assess for care plan effectiveness, identify and implement new fall interventions and provide adequate supervision needed to prevent falls for 1 of 4 sampled residents (# 8) reviewed for falls. This placed residents at risk for injury. Findings include: Resident 8 was admitted to the facility in 7/2019 with diagnoses including vascular Parkinsonism (a brain condition that causes slow movements, stiffness and tremors). Resident 8's 1/6/23 Annual MDS indicated the resident had no cognitive impairments, required extensive assistance of two staff for transfers and toileting and was not steady moving from a seated to standing position. Resident 8 was frequently incontinent of bladder, always incontinent of bowel and was not on a toileting program. Resident 8 had multiple falls due to self-transferring as a result of either not asking for assistance or not waiting for help. Resident 8's 10/9/23 Quarterly MDS indicated the resident had no cognitive impairments and was dependent on staff for moving from a sitting to a standing position, for chair to bed transfers and when being transferred to and from the toilet. Resident 8 was frequently incontinent of bowel and bladder and was not on a toileting program. Resident 8's 1/7/24 Annual MDS indicated the resident had moderate cognitive impairments and required substantial to maximal staff assistance for moving from a sitting to a standing position, during a chair to bed transfer and when being transferred to and from the toilet. In addition, Resident 8 experienced numerous falls due to impulsivity and over-estimating her/his abilities. Resident 8 was frequently incontinent of bowel and bladder and was not on a toileting program. Resident 8's 1/11/24 fall risk assessment indicated the resident was a high fall risk. There were no fall risk assessments found in Resident 8's health record for 2023. Multiple fall risk assessments for 2022 all identified Resident 8 as a high fall risk. Resident 8's 1/2024 Care Plan indicated the resident was at risk for falls related to a history of falls, weakness secondary to a stroke, unsteady balance, poor safety judgement and not calling for assistance which resulted in the resident self-transferring. The following fall preventions were in place: -PT evaluate/treat as ordered and PRN. Initiated on 7/8/19. Revised on 2/4/21. -Review information on past falls and attempt to determine cause of falls. Record possible root causes and remove any potential causes if possible. Educate the resident, family, caregiver and interdisciplinary team as to causes. Initiated on 7/8/19. -Resident 8 was to wear non-skid footwear when transferring. Initiated on 7/6/19. -Resident 8's call light and personal items were to be within reach. Initiated on 7/6/19. -Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needed prompt responses to all requests for assistance. Initiated on 8/1/19. -Educate the resident, family and caregiver about safety reminders and what to do if falls occurred. Initiated 8/1/19. -Offer caregiver training to the resident's family for transfers from the wheelchair to the toilet and off of toilet. Encourage the resident's family to call staff for assistance with resident's care as needed to prevent the resident from falling. Initiated on 8/1/19. -Anticipate and meet the resident's needs. Staff to place belongings within reach and offer any items to the resident prior to leaving her/his room and after care. Staff to encourage the resident to call for assistance by using her/his bedside call light. Initiated on 8/27/19. -Remind the resident often to call for help. Continue rounding focused on toileting. Offer toilet trips before and after meals. Initiated on 1/23/20. -Assure the resident's urinal was emptied and cleaned after each use. Offer her/him help if she/he allows on each round to prevent the resident's unsafe activity. Initiated on 8/14/20. -Remind the resident to call for assistance. Keep the resident's bedside table next to the resident's bed and important items within reach. Initiated on 1/20/21. Revised on 2/4/21. -Call [Witness 1 (Family)] to notify of the resident's desire to self-transfer. Initiated on 2/2/21. -Fill out Risk and Benefits for self-transfers and remind the resident to call for assistance. Initiated on 2/2/21. -Remind the resident to call for assistance. Initiated on 2/2/21. -Staff to answer call lights in a timely manner. Remind the resident to call for help. Initiated on 2/4/21. -Bilateral grab bars for mobility. Initiated on 7/19/21. -Keep bedside table close to the patient when she/he is in bed to ensure commonly use items are easily located. Initiated on 12/6/21. - The CNAs were to ensure the call light was reset so the resident was able to call for assistance. Initiated on 12/14/21. -Staff to continue with the current care plan. Encourage the resident to ask for help and use her/his call light. Continue with frequent checks, monitoring, offering toileting, ensuring commonly used items and the resident's call light was within reach. Initiated 12/19/21. -Patient to use an easy touch call light so that all call light activity was captured. Initiated on 3/21/22. -Nursing staff to monitor for unmet needs and assist the patient as needed. If the patient was wearing a jacket indoors, offer to help remove it as the patient may be too warm. Initiated on 1/24/22. -Please keep the resident's urinal at the bedside for when the patient is unable to wait for help with toileting. Ensure the urinal is emptied to prevent spilling. Initiated on 7/29/22. -Staff to do frequent monitoring and checks. Remind resident to wait for help. Initiated on 6/9/23. -Offer toileting before meals and at bedtime. Initiated on 3/20/23. -Reminder placed in the resident's bathroom to remind the resident to use the call light. Initiated on 4/3/23. -Staff were to do frequent monitoring and checks. Remind the resident to wait for help. Initiated 6/9/23. -Offer the resident toileting after meals. Initiated on 6/15/23. -CNA to transfer the resident into bed before bedtime. She/he prefers to go to bed between 8-9:15 PM. Initiated on 9/8/23. -Resident needs assistance with transfers on and off electric wheelchair and toilets. Initiated on 1/5/24. From 1/21/23 through 1/24/24, Resident 8 experienced seven falls in the facility. Fall investigations revealed the following: -1/21/23 at 4:39 AM: Fall Investigation revealed Resident 8 experienced an unwitnessed fall in her/his room while attempting a transfer from her/his bed to her/his wheelchair. Resident 8 stated she/he fell while self-transferring to her/his wheelchair. Resident 8 was instructed to call for help. The report indicated this was the 37th fall for Resident 8. It was concluded that Resident 8 had a history of falls, was impulsive and attempted to self-transfer. Recommendations were that all fall interventions were in place, continue to monitor and minimize risk of injury. No new fall care plan interventions were put in place. -3/17/23 at 9:30 AM: Fall Investigation revealed Resident 8 was found on the floor in her/his bathroom after attempting to self-transfer without assistance. The report indicated this was the 37th fall for Resident 8. The report recommended that the care plan be updated to offer toileting before meals and at bedtime. This was consistent with care plan interventions initiated on 1/23/20 and 12/19/21. No new fall care plan interventions were put in place. -3/30/23 at 8:45 AM: Fall Investigation revealed Resident 8 was found sitting on her/his bathroom floor. It was concluded that Resident 8 self-transferred herself/himself to the bathroom and attempted to toilet herself/himself without assistance. The report indicated this was Resident 8's 38th fall. A new fall care plan intervention was put into place to put a reminder sign in Resident 8's bathroom to call for assistance. Resident 8 was referred to PT services. -6/9/23 at 4:20 PM: Fall Investigation revealed Resident 8 was found on the floor near the head of her/his bed after activating the call light. The resident was provided reminders to use the call light and fall prevention was provided. Recommendations were to continue with the current fall interventions. No new fall care plan interventions were put in place. -9/5/23 at 9:00 PM: Fall Investigation revealed Resident 8 was found on the floor in her/his bathroom after going to the bathroom on her/his own and attempting to self-transfer to the toilet. It was concluded that Resident 8 was unaware of her/his own limitations, had a significant history of falling and self-transferred against facility advice. The report indicated this was Resident 8's 42nd fall. A new fall care plan intervention was put into place to transfer the resident to bed before bedtime and the resident preferred to go to bed between 8:00 PM and 9:15 PM. -9/17/23 at 12:49 PM: Fall Investigation revealed Resident 8 was found on the floor in her/his room. Resident 8's CNA left for lunch, returned from lunch and was completing rounds when the CNA found the resident on the floor. The report indicated this was Resident 8's 43rd fall. Recommendations were to continue with the current fall interventions and adhere to any therapy recommendations for the wheelchair cushion. No new fall care plan interventions were put in place. 1/1/24 at 9:53 AM: Fall Investigation revealed Resident 8 was found on the floor of her/his bathroom. The resident stated she/he activated the call light, no one came so she/he self-transferred to the bathroom and slipped off the toilet. It was concluded that Resident 8 self-transferred without assistance, was impulsive and did not wait for staff assistance. The report indicated this was Resident 8's 44th fall. Resident 8 was instructed to use the call light for safety. Recommendations were to continue with the current fall interventions. No new fall care plan interventions were put in place. A review of Resident 8's 1/1/24 through 1/24/24 Call Light Tracking Sheet revealed the following call light response times: -1/1/24 at 10:32 AM: call light response time 17 minutes; -1/1/24 at 11:04 AM: call light response time 16 minutes; -1/2/24 at 4:40 PM: call light response time 37 minutes; -1/3/24 at 4:09 PM: call light response time 16 minutes; -1/4/24 at 11:29 PM: call light response time 17 minutes; -1/6/24 at 8:24 AM: call light response time 41 minutes; -1/7/24 at 12:59 PM: call light response time 38 minutes; -1/7/24 at 8:15 PM: call light response time 24 minutes; -1/8/24 at 11:33 AM: call light response time 25 minutes; -1/8/24 at 6:54 PM: call light response time 26 minutes; -1/10/24 at 11:22 AM: call light response time 24 minutes; -1/10/24 at 9:16 PM: call light response time 27 minutes; -1/11/24 at 4:50 PM: call light response time 16 minutes; -1/11/24 at 6:49 PM: call light response time 1 hour 6 minutes; -1/11/24 at 9:54 PM: call light response time 20 minutes; -1/12/24 at 10:03 AM: call light response time 55 minutes; -1/12/24 at 11:59 AM: call light response time 20 minutes; -1/14/24 at 2:44 AM: call light response time 17 minutes; -1/14/24 at 12:39 PM: call light response time 28 minutes; -1/14/24 at 6:30 PM: call light response time 16 minutes; -1/15/24 at 2:05 PM: call light response time 23 minutes; -1/15/24 at 7:34 PM: call light response time 17 minutes; -1/18/24 at 7:22 PM: call light response time 24 minutes; -1/18/24 at 9:21 PM: call light response time 39 minutes; -1/19/24 at 8:39 PM: call light response time 15 minutes; -1/20/24 at 2:08 AM: call light response time 40 minutes; -1/20/24 at 7:29 AM: call light response time 19 minutes; -1/20/24 at 12:56 PM: call light response time 43 minutes; -1/20/24 at 6:38 PM: call light response time 25 minutes; -1/21/24 at 6:43 PM: call light response time 18 minutes; -1/21/24 at 9:43 PM: call light response time 18 minutes; -1/22/24 at 5:15 PM: call light response time 53 minutes; -1/22/24 at 6:13 PM: call light response time 20 minutes; -1/24/24 at 11:10 AM: call light response time 21 minutes. Random observations between 1/22/24 through 1/30/24 between the hours of 7:30 AM and 9:30 PM revealed the following concerns: -Resident 8 had a sign on her/his door directing staff to keep the door closed at all times. -Resident 8 was frequently in her/his room, alone, with the door closed. -Resident 8's bed was in a high position on all observations. -When Resident 8's door was open, Resident 8 was not visible from the hallway. -Numerous staff frequently walked by Resident 8's room without checking on the resident to ensure she/he was safe. -Resident 8 was left alone in her/his bathroom with the bathroom door and the room door closed. -There were at least three observations where no staff checked on Resident 8 for over one hour. The facility failed to follow care plan interventions, re-assess current interventions and develop new interventions to ensure Resident 8 was adequately supervised and her/his falls were unavoidable. On 1/23/24 at 11:19 AM Witness 1 (Family) reported Resident 8 activated her/his call light for help but staff did not come in a timely manner so Resident 8 gets up on [her/his] own and falls. Witness 1 stated long call light response times were worse on evening shift. On 1/25/24 at 1:30 PM and 1/30/24 at 9:50 AM Resident 8 stated she/he used her/his call light to get help but staff often took a long time to respond. Resident 8 stated she/he waited for 10 to 15 minutes and after 15 minutes if staff did not answer the call light, she/he got up and, as a result, had many falls. On 1/29/24 at 9:35 AM and 11:49 AM Staff 30 (CNA) and Staff 31 (NA) reported they were unaware if Resident 8 was considered a high fall risk. On 1/29/24 at 12:05 PM Staff 32 (CNA) stated the most important fall intervention for Resident 8 was to ensure her/his call light was answered timely because if Resident 8 had to wait too long, she/he got up on her/his own. 1/29/24 at 2:37 PM Staff 10 (LPN/Care Manager) and Staff 18 (Regional RN) acknowledged an analysis was not completed of Resident 8's falls to determine any patterns or trends related to the resident's numerous falls. Staff 10 and Staff 18 acknowledged many of Resident 8's fall interventions were repetitive or not effective. Staff 10 and Staff 18 stated they identified problems with Resident 8's fall interventions and were going to review the resident with the interdisciplinary team to determine more appropriate interventions to keep the resident safe and prevent avoidable falls. 1/30/24 at 2:38 PM Staff 1 (Administrator) stated she expected Resident 8's care plan to have active, helpful and proper interventions in place to prevent Resident 8 from falling. Staff 1 stated Resident 8 had many lengthy call light response times and she expected staff to respond to call lights in under five minutes. Refer to F725.

Based on observation, interview and record review it was determined the facility failed to ensure a resident with a diagnosed mental disorder and documented history of suicide attempts received the necessary behavioral health care and services needed to prevent suicide attempts for 1 of 5 sampled residents (# 52) reviewed for unnecessary medications. This failure, determined to be an immediate jeopardy situation, resulted in Resident 52 attempting suicide and placed residents at risk for avoidable accidents and death. Findings include: Resident 52 was admitted to the facility in 11/2023 with diagnoses including delirium (confusion), dementia with a behavioral disturbance and severe major depressive disorder with psychotic features. An 11/2/23 Progress Note revealed Resident 52 was found with her/his call light cord wrapped around her/his neck, following which the resident was provided with one-to-one supervision. An 11/3/23 Encounter Psych Initial Visit Note completed by Staff 13 (Psychiatric NP) indicated Resident 52 continued to experience suicidal thoughts. The note further indicated the plan was to continue to implement the safety plan, including reducing the availability of items for self-harm and for the resident to report self-harm urges to staff. Resident 52's 11/8/23 admission MDS indicated the resident was cognitively intact and she/he experienced moderately severe depression, delusions, inattention and disorganized thinking. The MDS assessment also indicated the resident exhibited physical and verbal behaviors directed towards others and other behavioral symptoms not directed towards others which significantly interfered with the resident's care and participation in activities/social interactions. The Self-Care and Mobility CAA indicated the resident required one-to-one supervision and the resident's food was brought in on paper plates and bowls with plastic silverware due to safety concerns related to suicidal ideation with an attempt. An 11/29/23 Provider Note completed by Staff 11 (Physician Assistant) indicated Resident 52 had not experienced any suicide attempts and it was appropriate to wean her/him off of one-to-one supervision. The note further indicated the resident had an appointment with Staff 13 on 12/5/23 and Staff 11 asked if the appointment could occur sooner. An 11/30/23 Encounter Psych Progress Note completed by Staff 13 indicated Resident 52 remained quite depressed and anxious and continued to receive one-to-one supervision due to a recent history of wrapping the call light cord around her/his neck when she/he first admitted to the facility. The note indicated staff were to contact Encounter Telehealth if Resident 52 experienced increasing symptoms, a mental status change, side effects and/or for any questions/concerns. An 11/30/23 Progress Note written by Staff 10 (LPN) indicated Resident 52 was going to be trialed off one-on-one supervision during daytime hours outside of the time period from 10:00 AM to 2:00 PM. This note also indicated if the resident appeared to be unsafe, she/he was to immediately be put back on one-to-one supervision and the provider was to be notified. A 12/5/23 Progress Note written at 12:25 PM by Staff 10 revealed one-to-one supervision was discontinued as Staff 9 (Medical Director) deemed Resident 52 to be safe. A 12/5/23 Progress Notes revealed Resident 52 was found with her/his blanket wrapped around her/his neck with the fitted sheet from her/his bed over her/his head. The sheets and blankets were removed for her/his safety. One-to-one supervision was reinstated for Resident 52. A 12/15/23 Encounter Psych Progress Note completed by Staff 13 indicated one-to-one supervision of Resident 52 was appropriate to be discontinued and replaced with checking on the resident every 15 minutes. This note further indicated one-to-one supervision was to be reinstituted should the resident have any additional attempts at self-harm over the weekend. The provider wanted to be contacted should any mental health or behavioral concerns arise. Records revealed frequent checks on Resident 21 were completed between 12/18/23 through 12/21/23. Resident 52's 12/2023 TAR indicated on 12/21/23 one-to-one monitoring was discontinued and changed to frequent checks. The TAR indicated one-to-one supervision was to be re-instituted if there were any further attempts to self-harm over the weekend. This order was discontinued on 1/12/24. No evidence was found in Resident 52's clinical record that a Self-Harm Care Plan was created until 1/1/24, 60 days after the resident's first suicide attempt and 27 days after her/his second suicide attempt. A 1/18/24 Progress Note written by Staff 16 (RN) revealed Resident 52 was found with robe ties around her/his neck, stating she/he was going to strangle her/himself. The note indicated robe ties were removed and close observation was provided. No evidence was found in Resident 52's clinical record that any further action was taken to address the resident's suicide attempt. Observations conducted from 1/22/24 to 1/24/24 between 7:30 AM to 8:30 PM revealed Resident 52 was not provided with one-to-one supervision. Resident 52 was observed during this time period in bed with bed linens present, including a sheet, and at times was not visible from the doorway due to the privacy curtain being extended. On 1/24/24 interviews conducted between 3:02 PM and 4:03 PM with Staff 14 (CNA), Staff 15 (CNA) and Staff 5 (LPN) stated Resident 52 did not require one-to-one supervision and they were unaware of any recent suicide attempts by Resident 52. On 1/24/24 at 2:42 PM Staff 11 (Physician Assistant) stated she was unaware of Resident 52's 1/18/24 suicide attempt or ideation. Staff 11 stated the resident should have been placed on one-to-one supervision and she and Staff 13 should have been notified of the suicide attempt. On 1/24/24 at 3:02 PM Staff 10 (LPN) stated she was not aware of Resident 52's 1/18/24 suicide attempt and ideation. Staff 10 indicated if she had known she would have instantly put her on a one-to-one and called the resident's provider, facility administrator and DNS. On 1/24/24 at 4:24 PM Staff 17 (Assistant DNS) stated the facility was unaware of Resident 52's 1/18/24 suicide attempt. Staff 17 stated one-to-one supervision of Resident 52 should have been initiated immediately after this attempt and the manager and DNS should have been immediately notified. On 1/24/24 at 5:18 PM Staff 16 (RN) stated on 1/18/24 an unknown CNA reported to him that she found Resident 52 with the string of her/his robe around her/his neck. Staff 16 stated he did not report this incident to the resident's provider because he did not think the resident was a danger to her/himself. Staff 16 stated he was not aware of any previous suicide attempts or ideations by Resident 52. Review of Resident 52's health record revealed a lack of evidence the facility provided the resident with the necessary behavioral health care and services needed to prevent suicide attempts as evidenced by the following: -Staff failed to complete a timely and comprehensive care plan related to the resident's history of and potential for suicide attempts and suicidal ideation. -Staff failed to comprehensively reassess the resident following her/his third suicide attempt and implement any interventions to prevent additional attempts. -Staff failed to notify the resident's physician and mental health provider following the resident's third suicide attempt. -The facility failed to educate all staff of Resident 52's potential for suicide attempts and suicidal ideation or interventions related to prevention. -The facility failed to consistently provide one-to-one supervision to ensure Resident 52's safety. On 1/24/24 at 7:25 PM Staff 1 (Administrator), Staff 2 (DNS) and Staff 18 (Regional RN) were informed of the immediate jeopardy (IJ) situation related to the facility's failure to implement further safety interventions, complete a comprehensive reassessment, update the resident's care plan and notify the resident's physician and mental health provider following Resident 52's third suicide attempt. IJ templates were provided and an immediate IJ removal plan was requested. On 1/24/24 at 9:26 PM the facility submitted an acceptable removal plan. The IJ Removal Plan indicated the facility would implement the following actions: -Resident 52 was placed on one-to-one supervision, her/his care plan was updated to reflect prior suicide attempts and to include appropriate interventions, Staff 9 and Staff 13 were notified of the resident's most recent suicide attempt and Staff 11 completed an assessment of the resident. -Immediate evaluation of all residents in the facility conducted by nursing management team to determine if any other residents have been affected. -Education provided to licensed staff on suicide prevention and intervention, including current residents who were identified at risk. On 1/25/24 at 10:19 AM Resident 52 was observed in her/his watching television with a staff member present. On 1/25/24 at 10:28 AM Staff 1 provided verification that licensed staff received the required training and education, confirmed assessments had been completed and care plans were updated for other residents identified as at risk for suicidal ideation and/or attempts. On 1/25/24 at 10:37 AM the immediacy was removed.