**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement written policies and procedures that prohibit and prevent abuse of residents, for 1 of 10 residents (Resident #2) reviewed for abuse. 1. The facility failed to ensure residents were free from abuse. *On 03/29/25 HSK A had a verbally aggressive argument with Resident #2 over cigarettes. Resident #2 told HSK A she wished she would shut up and HSK A got up from her chair and told Resident #2 to make her shut up. 2. The facility failed to ensure allegations of abuse were reported to the Abuse Coordinator Immediately. *HSK B wrote a concern form and left it in the mailbox outside of the HR door on 03/29/25 about the witnessed verbal exchange between Resident #2 and HSK A. 3. The facility failed to report allegations of abuse to HHSC within two hours of being notified of the abuse allegation. *The Administrator did not report the allegation of verbal abuse on 03/31/25. The Administrator reported the allegations of verbal abuse to HHSC on 04/01/25. 4. The facility failed to implement measures to protect residents and prevent additional abuse incidents during the investigation when they did not immediately suspend HSK A. *HSK A continued to work in the facility 03/29/25, 03/30/25, 03/31/25. She was suspended on 04/01/25 and returned to work on 04/03/25, while the investigation was ongoing and continued to work on 04/04/25 and 04/05/25. *The facility confirmed the allegation of abuse on 04/07/25 but did not terminate HSK A until 04/09/25 after being directed to by their corporate management. An Immediate Jeopardy (IJ) was identified on 05/08/25 at 2:30 p.m. The IJ template was provided to the facility on [DATE] at 3:35 p.m. While the IJ was removed on 05/09/25, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy and a scope of isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures could place residents at risk of unreported abuse, neglect, exploitation, and a decreased quality of life. Findings included: Record review of the facility's Abuse, Neglect, and Exploitation policy dated 2023 indicated It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation . Policy Explanation and Compliance Guidelines: 1. The facility will develop and implement written policies and procedures that: a. Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property; b. Establish policies and procedures to investigate any such allegations; . 3. The facility will provide ongoing oversight and supervision of staff in order to assure that its policies are implemented as written. III. Prevention of Abuse, Neglect and Exploitation The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves: . B. Identifying, correcting and intervening in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property is more likely to occur with the deployment of trained and qualified, registered, licensed, and certified staff on each shift in sufficient numbers to meet the needs of the residents, and assure that the staff assigned have knowledge of the individual residents' care needs and behavioral symptoms; C. Assuring an assessment of the resources needed to provide care and services to all residents is included in the facility assessment; D. The identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect; E. Ensuring the health and safety of each resident with regard to visitors such as family members or resident representatives, friends, or other individuals subject to the resident's right to deny or withdraw consent at any time and to reasonable clinical and safety restrictions; F. Providing residents, representatives, and staff information on how and to whom they may report concerns, incidents and grievances without the fear of retribution; and providing feedback regarding the concerns that have been expressed; G. Addressing features of the physical environment that may make abuse, neglect, exploitation, and misappropriation of resident property more likely to occur; and H. Assigning responsibility for the supervision of staff on all shifts for identifying inappropriate staff behaviors. I. Identification of Abuse, Neglect and Exploitation A. The facility will have written procedures to assist staff in identifying the different types of abuse - mental/verbal abuse, sexual abuse, physical abuse, and the deprivation by an individual of goods and services. This includes staff to resident abuse and certain resident to resident altercations.VI. Protection of Resident The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to: A. Responding immediately to protect the alleged victim and integrity of the investigation; . VII. Reporting/Response A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. 2. Assuring that reporters are free from retaliation or reprisal; . Record review of Resident #2's face sheet dated 05/09/25 indicated Resident #2 was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), major depressive disorder (persistent feeling of sadness and loss of interest), anxiety (persistent worry and fear about everyday situations), hemiplegia (one-sided paralysis) and hemiparesis (one-sided muscle weakness) following cerebral infarction affecting right dominant side, and cerebral infarction (stroke). Record review of Resident #2's annual MDS assessment dated [DATE] indicated she was able to make herself understood, sometimes understood others, and had moderate cognitive impairment (BIMS-8). Record review of Resident #2's care plan dated 05/08/25 indicated Resident #2 had a psychosocial well-being problem related to verbal aggression while interacting with staff. Interventions included initiate referrals as needed or increase social relationships, provide a safe environment, and and when conflict arises residents to a calm safe environment. Record review of a facility investigation dated 04/07/25 and completed by Administrator L indicated the incident occurred on 03/29/25 at 1:00 p.m. and was reported to HHS on 04/01/25 at 12:00 p.m. The AP was identified and confirmed as HSK A. The witness was identified as HSK B. The allegation was noted as HSK A was being verbally aggressive with Resident #2 over the purchase of cigarettes. HSK A was suspended during the investigation. HSK B was in-serviced on timely reporting of abuse allegation on 04/01/25. The findings were confirmed. The facility's investigation included documentation completed by Administrator L: 3/31/2025 HSK A communicated with the administrator that she bought cigarettes for a resident and she did not want the residents to share them. I let HSK A know that she should not purchase cigarettes for the residents, if the residents want cigarettes they are to ask their family to purchase them or our activity director, when she goes shopping. 4/1/2025 - On April 1, 2025 HSK A was not working in the facility. The administrator called her at home to discuss the argument that HSK A got into at the facility on 3/29/2025. HSK A was suspended until the investigation could be completed. HSK A was in serviced on abuse, conflict resolution, resident rights and purchasing items for residents 4/3/2025- HSK A returned to work and met with AIT II regarding incident that occurred on 3/29/2025. Abuse, conflict resolution, residents rights and purchasing items for residents was discussed again. was returned to her duties on the floor. The resident safe surveys included with the investigation did not address verbal abuse by staff. Record review of an Employee Concern Form dated 03/29/25 at 1:00 p.m., completed by HSK B indicated At 1:00 p.m. smoke time I was giving Resident #4 her two cigarettes and I told Resident #2 you don't have any did you call someone and she said yeah I still waiting. Couple of minutes goes by and Resident #2 goes I'm not hiding anymore give me a cigarette talking to Resident #4. HSK A turns and goes not if its the cigarettes a bought I am not buying you cigarettes to just hand them out. I said well Resident #2 when you have cigarettes and Resident #4 don't don't share with her if that's the case. That's not fair to you. HSK A gives she share with her just not the cigarettes I bought. She can do whatever she wants with the cigarettes she buys with her money. HSK A started to get loud and angry. Resident #2 had enough and told HSK A to shut up. HSK A got out of her chair and tells Resident #2 to make her shut up. You will have to get out of your chair to shut me up. Then Resident #3 told HSK A to calm down. After that HSK A left. Resident #2 said I wish I can punch her and then looked at Resident #4 and goes I want to punch you for not having my back and then Resident #2 started to cry and shake. Record review of a Service Recovery Opportunity form dated initially dated 3/31/25, (the date was amended by Administrator L on 04/01/25), completed by Administrator L on 04/05/25 indicated HSK A became verbally abusive with Resident #2 about cigarettes. HSK A was suspended during the investigation. This was the first time HSK A had an argument with a resident. HSK A was inserviced on abuse, managing conflict and resident rights. HSK A confirmed she got upset with with Resident #2. Record review of a progress note dated 04/01/25 at 10:01 a.m., completed by the SW indicated On April 1, 2025, I spoke with Resident #2 regarding the incident between she and HSK A. Resident #2 said, She apologized to me for being upset and me crying. She said, And I apologized to her for what I said. Resident #2 could not recall what she said to HSK A or what HSK A said to her. She said, I know she had never talked to me like that before. She said, I don't recall what she said, but its not the way we normally talk. Resident #2 said, my mind is not that good and I can't recall. Resident #2 continued talking to me and she eventually recalled that the incident was about the sharing of cigarettes. Resident #2 said that she asked Resident #4 for a cigarette and HSK A said no because she had purchased the cigarettes with her own money. So, Resident #2 was upset that she could not get a cigarette because she and Resident #4 shares cigarettes. She said, she (HSK A) was going on about everything under the moon. She said that she told HSK A to hush and leave her alone. She don't recall what HSK A said. Resident #2 was upset with Resident #4 for not standing up for her. She said, I was crying and Resident #4 gave me the cigarette when HSK A left. Resident #2 told me that she is not scared of HSK A. She said, She is my friend and we apologized. She feels safe here at the facility and she knows who to report abuse too. She said HSK A is a good person. Record review of a progress note dated 04/07/25 at 4:02 p.m., completed by the SW indicated On April 7, 2025, I asked Resident #2 about the interaction between her and HSK A on smoke break. Resident #2 at first said she didn't recall what it was about, but they both apologized and it's over. I inquired further and Resident #2 said, She went off on a rampage. She did not want Resident #4 to share her cigarettes with me. Resident #2 told me that HSK A purchases cigarettes for Resident #4 using her own money (HSK A's money), so she did not want Resident #4 to share the cigarettes with her. Resident #2 said, HSK A and I kept going back and forth I told HSK A to shut up. Resident #2 did not recall what HSK A said, but I told her what the witness reported. She said yes, HSK A did say make me. Resident #2 said she cried because HSK A had never spoken to her like that before. She said, We are friends and both have apologized. I thought this was over. I explained that anytime there is an incident between staff and a resident we must make sure that the resident is safe, and no harm is caused. Resident #2 said, I'm okay, HSK A and I have made up. It's over. Record review of HSK's time record indicated she worked 03/29/25, 03/30/25, 03/31/25, 04/03/25, 04/04/25/, and 04/05/25. During an interview on 05/07/25 at 10:00 a.m., Administrator L said she was the abuse coordinator. She said allegations of abuse were reportable to her or her designees immediately and to HHS C within 2 hours. She said the facility was reporting on 04/01/25 an allegation of verbal abuse by HSK A towards Resident #2 on 03/29/25. She said HSK B witnessed the verbal abuse on 03/29/25 and put a note under the HR door but did not report the incident immediately to her (Administrator L) as required. She said HSK A was suspended when the facility was made aware of the incident on 03/31/25. She said the verbal abuse was confirmed. She said AIT TT was out on FML. During an interview on 05/07/25 at 12:46 p.m., Administrator L said the allegations of abuse was reported on 04/01/25. She said she did not report on 03/31/25 because she was working on the investigation and she could not give a logical reason for not reporting. She said HSK A was supposed to be suspended pending the facility investigation. She said HSK A worked work on 03/30/25, 03/31/25, 04/03/25, 04/04/25/, and 04/05/25. HSK A did not respond to a call from the surveyor on 05/07/25 at 2:35 p.m. During an interview on 05/07/25 at 2:45 p.m., Resident #2 said HSK A made her upset and spoke to her with a mean tone about borrowing cigarettes. She said she wanted her to shut up and HSK A said she (Resident #2) would have to get up from her wheelchair to make her shut up. She said she felt sad and upset when HSK spoke to her. She said at the time it was abuse but they had made up and there was no further problems. She said HSK A was not working at the facility anymore. She said she was o.k. and no other staff ever spoke to her with a mean or mad tone. During an interview on 05/08/25 at 10:55 a.m., HR HH said she found a concern form written by HSK B, under her office door, on 03/31/25. She said she scanned the form and emailed it to Administrator L. She said she followed up with the Administrator L on 04/01/25 (but she did not recall what time) and that was when Administrator L realized the form had a second page where the verbal abuse was documented. She said Administrator L then reported the allegations of abuse to HHSC. She said the facility's protocol would include immediate suspension for staff. She said confirmed allegations of abuse could result in disciplinary action that could include termination. She said if staff were not suspended and continued to work, residents were at risk of further abuse. During an interview on 05/08/25 at 11:13 a.m., HSK Director II said she arrived to work on 03/31/25 and HSK B handed her a copy of the concern form she had left under the HR office door. She said she (HSK B) did not want to report the incident. She said she read the form and then went to Administrator L's office with HSK B. She said all staff were trained on abuse. She said HSK B said she did not know she should call the Administrator. She said HSK A's employment was handled by the administrator. She said she was not told to suspend HSK A. She said HSK worked her regular scheduled day rotation. She said if staff were not suspended and continued to work, residents were at risk of further abuse. During an interview on 05/08/25 at 12:56 p.m., HSK B said the incident of verbal abuse occurred on 03/29/25 during the 1:00 p.m. smoke break. She said the staff were advised residents were not supposed to share their cigarettes. She said HSK A had bought cigarettes for Resident #4. She said HSK A told Resident #4 not to share, that she was only buying for Resident #4. Resident #2 said she wished HSK A would shut up. HSK A got up form her chair and told Resident #2 she would have to get out of her chair to make her shut up. She said Resident #3 told HSK A to calm down. She said Resident #2 said she wished she could punch HSK A in the face. Resident #2 was upset and crying. She said she did not report the incident immediately to the abuse coordinator/Administrator L, the DON, or her supervisor. She said HSK A continued to work after the incident. She said she was scared of what HSK A would do if she knew she had reported. She said she was trained on abuse and reporting. She said residents were at risk of further abuse if it was not reported immediately. During an interview on 05/09/25 at 10:10 a.m., Resident #3 said HSK A was having words with Resident #2 over some cigarettes. He said HSK A was disrespectful and angry. He said they called each other BITCH. He said HSK A said if Resident #2 got up from her chair she would whoop her ass. He said he told HSK A she should not talk to her elders like that. He said he was not interviewed about the incident. He said he had not heard HSK A speak to residents that way before. During an interview on 05/09/25 at 12:29 p.m., Resident #4 said HSK A and Resident #2 were arguing about cigarettes. She said HSK A had purchased the cigarettes for her (Resident #3) and was mad because Resident #4 was going to share with Resident #2). She said HSK A said she wanted to whoop Resident #2's ass because she was arguing with her. She said she knew HSK A all her life and she had a temper. She said she never heard HSK A talk to residents that way before. She said she would report abuse to the Administrator or the DOM immediately. During an interview on 05/09/25 at 12:40 p.m., Administrator L said she did not conduct interviews with Resident #3 or Resident #4. She said she thought the SW would have conducted the interviews when she did the safe surveys. During an interview on 05/09/25 at 1:03 p.m., the SW said she was not sure if she wrote interviews down for Resident #3 or Resident #4. She said she remembered talking to Resident #4 but not Resident #3. She said Resident #4 did not report HSK A said she wanted to whoop Resident #2's ass. She said she would have reported the allegation to the Administrator immediately. During an interview on 05/09/25 at 1:18 p.m., HSK B said she did not hear HSK A say she wanted to whoop Resident #2's ass. She said she would still be scared to report if she did hear the threat. During an interview on 05/09/25, at 1:51 p.m., Administrator L said she was retrained on abuse on 05/08/25. She said not following the facility policy for abuse prevention, reporting, and investigation placed the residents were at risk for re-occurrence of abuse or the incident could have escalated. This was determined to be an Immediate Jeopardy on 05/08/25 at 2:30 p.m. The Administrator was notified and provided with the IJ template on 05/08/25 at 3:35 p.m. and a Plan of Removal was requested. The facility's plan of removal was accepted on 05/09/25 at 12:41 p.m. and included the following: Immediate actions after incident- Housekeeping Staff A Terminated: Although the staff member was terminated on 4/9/25, this was confirmed and documented today (5/8/25) as part of the facility's response to the identified IJ. -Housekeeping Staff B was in-serviced and educated on timely reporting by Administrator on 3-31-25 and 5-8-25. -Safe surveys on 10 residents completed on 4-1-25. All residents were presented with a safe survey on 5/9/2025 with no concerns. -Notification to the Medical Director and Ombudsman occurred on 5/8/25. Notification provided by Administrator. Resident Safety Review - 5/8/2025 -Resident #2 was assessed 5-1-25 for psychological needs by MD and was stable. --Resident #2 reassessed for psychological needs on 5-8-25 and was stable per MD. -Monitoring for emotional distress will be performed each shift for 72 hours and documented in resident's electronic medical record. -Resident assessed with PHQ9 on 5-7-25 and no depression identified. Systemic Corrections as of 5/8/25: -Policy Re-Education: Today, all department heads were re-educated on the abuse prevention policy, immediate reporting expectations, and responsibilities of supervisors in escalating concerns during ad hoc QAPI. Education Performed by: Regional Nurse. The training focused on immediate recognition and escalation of suspected abuse, the mandated timelines for reporting (immediately to the Abuse coordinator), and the proper chain of command. It reinforced that all staff are required to report abuse immediately to the Abuse Coordinator and that supervisors must act if front-line staff do not. This ensures no delay in response, removing the immediacy of the risk. -The administrator was in-serviced on reporting Abuse within an 2 hour period of learning of the allegation. We reviewed the latest provider letter (PL 2024-14) This provider letter provides guidance or reporting incidents to HHS, most importantly, reporting abuse immediately, but not later than two hours after the incident occurs or suspected. -Ad Hoc QAPI performed 5-8-25 Staff In-Service - 5/8/2025 - Completed by Admin or designee -All facility staff, including nursing, therapy, dietary, housekeeping, and administration, will receive training on Abuse, Neglect, Exploitation, Timely Reporting of Abuse to the Abuse Coordinator (by calling or in person) training provided via (named online training portal) or in person by DON or designee. The in-service included detailed instruction on recognizing signs of abuse/neglect, the importance of immediate reporting, and specific methods for doing so-either by directly notifying the Abuse Coordinator in person or via phone.(Abuse coordinator phone number is posted around the facility) It emphasized that any failure to report can result in disciplinary action. The training also outlined steps for immediately removing suspected abusers from duty to protect residents, thereby addressing the urgency of response. -A post-training exam with a required 100% passing score is required. Staff unable to attend the in-service will not be permitted to work until training is completed. All staff in serviced on 5/8/2025 via care feed or in person. Monitoring and Oversight Initiated 5/8/25: -Abuse Coordinator Duties Reinforced: The Abuse Coordinator started completing daily audits of all incident/concern reports for timely response and follow-up. -Leadership Review Process: A weekly leadership team huddle (Administrator, DON, ADON, Social Worker) was implemented on 5/8/25 to review all allegations of abuse and ensure prompt interventions. -Reporting Compliance Audit: A retrospective review of all abuse allegations from the past 30 days was initiated on 5/8/25, no abuse allegations reported in the last 30 days, confirm compliance and identified any gaps. Audit will be completed by: Administrator. Staff Accountability on 5/8/25: -Supervisory Staff Counseling: Abuse Coordinator who failed to act or report in a timely manner have been counseled and educated on policy requirements by corporate staff on 5-8-25. Counseling included a review of F607 policy requirements: mandatory reporting timelines, how and when to escalate abuse concerns, documentation expectations, and suspension protocol when allegations arise. Reinforcing these requirements ensures supervisors do not delay action, directly removing the risk of ongoing or unreported abuse. -Disciplinary Action Initiated: Disciplinary procedures for involved parties have been initiated per HR guidelines, effective 5/8/25. Sustained Prevention Measures (Beginning 5/8/25): -Ongoing Monthly Abuse Training: Scheduled for the second week of each month, beginning in May for three months. -The Administrator and DON, or designee, will review all reportable 3 times a week for 30 days, then once a week for 60 days to ensure appropriate reporting procedure was followed, and appropriate interventions were initiated. -Any discrepancies will be addressed immediately and reviewed during weekly clinical stand-ups and monthly QAPI meetings. On 05/09/24 the state surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Record review of HSK A's personnel file indicated she was terminated on 04/09/25, this was confirmed and documented on 05/08/25. Record review of HSK B's training record indicated she was in-serviced and educated on timely reporting by Administrator on 03/31/25 and 05/08/35. Record review of safe surveys indicated all cognitive residents were presented with a safe survey on 05/09/25 with no concerns identified. Record review of Resident #2's assessments indicated Resident #2 was assessed 05/01/25 for psychological needs by MD JJ and was stable. Resident #2 reassessed for psychological needs on 05/08/25 and was stable per MD JJ. Resident #2 was assessed with PHQ9 on 05-07-25 and no depression was identified. Record review of staff training indicated as of 05/08/25: -Policy Re-Education: All department heads were re-educated on the abuse prevention policy, immediate reporting expectations, and responsibilities of supervisors in escalating concerns during ad hoc QAPI by RN KK. The training focused on immediate recognition and escalation of suspected abuse, the mandated timelines for reporting (immediately to the Abuse coordinator), and the proper chain of command. All staff were required to report abuse immediately to the Abuse Coordinator and that supervisors must act if front-line staff do not. This ensured no delay in response, removing the immediacy of the risk. -The administrator was in-serviced on reporting Abuse within a 2 hour period of learning of the allegation. The latest provider letter (PL 2024-14) was reviewed. Record review of staff in-service dated 05/08/25 and 05/09/25 indicated all facility staff, including nursing, therapy, dietary, housekeeping, and administration were trained by the the Administrator or the DON or through online portal on on Abuse, Neglect, Exploitation, Timely Reporting of Abuse to the Abuse Coordinator (by calling or in person). The in-service included detailed instruction on recognizing signs of abuse/neglect, the importance of immediate reporting, and specific methods by directly notifying the Abuse Coordinator in person or via phone. (Abuse coordinator phone number was posted around the facility). It emphasized that any failure to report could result in disciplinary action. The training outlined steps for immediately removing suspected abusers from duty to protect residents and addressed the urgency of response. Record review of post-training exams indicated all staff trained passed with a required 100% passing score. Staff unable to attend the in-service would not be permitted to work until training was completed. Record review of the facility's Reporting Compliance Audit dated 05/08/25 indicated no abuse allegations reported in the previous 30 days. Record review of staff counselling indicated the Administrator/Abuse Coordinator was counselled and educated on policy requirements by corporate staff on 05/08/25. Counseling included a review of F607 policy requirements: mandatory reporting timelines, how and when to escalate abuse concerns, documentation expectations, and suspension protocol when allegations arise. Reinforcing these requirements ensures supervisors do not delay action, directly removing the risk of ongoing or unreported abuse. Disciplinary procedures were initiated per HR guidelines, effective 05/08/25. Record review of a resident list reflected 100% resident rounds was initiated on 05/08/25 and completed on 05/09/25 to determine if further allegations of abuse were alleged. No additional concerns were identified. During interview conducted on 05/08/25 and 05/09/25, there were no additional incidents of abuse reported by residents. Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, and #10, indicated they would report to the Administrator or DON immediately. During interviews conducted on 05/09/25 between 12:50 p.m. and 2:50 p.m. indicated (Administrator L, DON, ADON, SW, CNA D, Receptionist O, BOA S, CMA/CNA T, MR U, CNA BB, CNA CC, DA LL, PTA MM, LS NN, RN OO, CNA PP, RN QQ, LVN RR, HSK SS ) from all shifts (6:00 a.m.-6:00 p.m., 6:00 p.m.-6:00 a.m., 6:00 a.m.-2:00 p.m., 2:00 p.m. -10:00 p.m., and 10:00 p.m.-6:00 a.m., 8:00 a.m.-4:00/5:00 p.m., and 3:00 p.m. -11:00 p.m.) were in-serviced on and could verbalize understanding of in-service on immediate notification of allegations to facility abuse coordinator or designee when not in facility or available, investigating allegations of abuse and neglect, reporting of abuse neglect and misappropriation, and notification of proper local and state entities. During an interview on 05/09/25 at 2:10 p.m. the DON was able verbalize understanding of in-service on the abuse prevention policy, immediate reporting expectations, and responsibilities of supervisors in escalating concerns. She indicated the training focused on immediate recognition and escalation of suspected abuse, the mandated timelines for reporting (immediately to the Abuse coordinator), and the proper chain of command. She said all staff were required to report abuse immediately to the Abuse Coordinator and that supervisors must act if front-line staff do not. She said this ensured no delay in response, removing the immediacy of the risk. During an interview on 05/09/25 at 1:51 p.m., Administrator L indicated she was retrained on 05/08/25 on the facility's abuse and reporting policy and the most current provider letter. She indicated the training focused on immediate recognition and escalation of suspected abuse, the mandated timelines for reporting (immediately to the Abuse coordinator), and the proper chain of command. The Administrator was notified the Immediate Jeopardy was removed on 05/09/25 at 2:50 p.m., the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm with a scope of isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, which included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 10 residents (Resident #1) reviewed for care plans. The facility failed to develop and implement Resident #1's care plan to prevent suicide or self harm after she said she wanted to kill herself on 10/23/24. An Immediate Jeopardy (IJ) was identified on 05/07/25 at 4:35 p.m. The IJ template was provided to the Administrator on 05/07/25 at 4:54 p.m. While the immediacy was removed on 05/08/25 at 4:55 p.m., the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm with a scope of isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place residents at risk for self-harm or death. Findings included: Record review of Resident #1's face sheet dated 05/07/25 indicated she was a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included cerebral infarction (stroke), hemiplegia (one-sided paralysis) and hemiparesis (one-sided weakness) following cerebral infarction affecting right dominant side, diabetes (high blood sugar), major depressive disorder (persistent feeling of sadness and loss of interest), generalized anxiety disorder (excessive worrying), mood disorders (mental illness), persistent mood (affective) disorders (continuous long-term for of depression), and insomnia(sleep disorder). Record review of Resident #1's annual MDS assessment dated [DATE] indicated she was usually able to make herself understood and usually understood others. She was cognitively intact (BIMS-13). Her psychiatric/mood disorders included anxiety, depression and bipolar disorder (mental health disorder). Record review of Resident #1's care plan dated 08/24/24 indicated she had antidepressant medication related to major depressive disorder and insomnia. Interventions included administer medications as ordered, arrange psych consult, follow up as indicated, monitor/document/report PRN any risk for harm to self, suicidal plan, past attempt at suicide, risky actions, intentionally harming or tried to harm self, refusing to eat or drink, refusing medications or therapies, sense of hopelessness or helplessness, impaired judgment or safety awareness. There was no care plan related to major depressive disorder, suicidal thoughts or self-harm after the 10/23/24 incident. Record review of Resident #1's progress note dated 10/23/24 at 12:17 p.m., completed by LVN FF indicated Resident #1 asked if the facility had helium in the building. LVN FF asked Resident #1 why she needed helium. Resident #1 stated, So I can end it now. I just want to kill myself. My family member UU don't want anything to do with me, My family member only comes when I need something. I just want to die. Nothing to live for. LVN FF stayed with Resident #1. The SW and DON were notified. Record review of Resident #1's progress note dated 10/23/24 at 12:37 p.m., completed by the SW, indicated Resident #1 she just wanted to end it, because of her family member XX not wanting to speak with her or with the family member YY. The SW asked Resident #1 if she had a plan and Resident #1 said no, she just want to end it all. Resident #1 agreed to go to the behavior hospital due to her mood. Spoke with the DON and informed Resident #1 would go on 15 minute watch until SW was able to contact (named psychiatry) for assessment. (Named psychiatry) notified and waiting for call back. Record review of Resident #1's progress note dated 10/23/24 at 1:37 p.m., completed by LVN FF indicated (named psychiatry) on-call called facility and was given report on Resident #1's condition. (Named psychiatry) on-call stated, have SW call back and set up tel psych visit. SW notified. 15 minute checks continue. Record review of Resident #1's progress note dated 10/23/24 at 2:01 p.m. completed by SW indicated Tele-health visit attempted with on-call psychiatrist. Left message for return call. Record review of Resident #1's progress note dated 10/23/24 at 14:28, completed by LVN GG indicated LVN GG was doing 2:00 p.m. monitoring check when he noticed Resident #1 with an object in her left hand. LVN GG noticed Resident #1 had blood coming from her right wrist area. LVN GG took away the object and notified the charge nurse. The DON and ADON were notified. Resident #1 had sliced right wrist with the object. DON cleansed right wrist area and the wounds were superficial. LVN GG and and staff will continue to monitor Resident #1. Record review of Resident #1's progress note dated 10/23/24 at 2.29 p.m., completed by LVN GG indicated while the DON and ADON were giving care, Resident #1 allowed LVN GG to remove and look for sharp objects. A pencil, pen and mirror were removed from the room. Record review of Resident #1's progress note dated 10/23/24 at 2:49 p.m., completed by the DON, indicated she observed Resident #1 with small amount of blood on sheets. She assessed Resident #1's right wrist and noted two superficial cuts approximately 1 to 1.5 inches in length and less than 0.1 mm deep. The cuts were not bleeding. The DON asked Resident #1 what happened and Resident #1 stated she just wanted to the pain to stop. The DON asked Resident #1 what pain she was referring to (physical or emotional) Resident #1 stated the pain in her bladder. LVN C stated she had changed Resident #1's catheter earlier (time noted at 12:13 p.m. per progress note) due to complaints of discomfort. Resident #1 stated that it helped but the pain was back. Upon assessing resident cath noted small amount of urine in collection bag. Palpation of abdomen completed. Resident noted with tenderness. The DON removed cath in attempt to change for obstruction per MD order. Upon suprapubic catheter being removed large amount of urine. The DON removed cath in attempt to change for obstruction per MD order. Upon suprapubic catheter being removed large amount of urine flowed from suprapubic site. Resident #1 refused to have suprapubic cath re-placed back but did allow the DON to straight cath her at suprapubic site. Approximately 500 ml drained from bladder. Bladder palpated with no s/s discomfort and Resident #1 stated it does feel better. The DON and ADON spoke with Resident #1 about why she had cut herself. Resident first stated because of the pain in her bladder but upon conversation with the resident, she revealed she was having issues with her family member YY . Resident #1 stated that her family was upset with her for calling her family member YY her babies. The DON and ADON attempted to re-assure Resident #1 that although her family was upset at the moment, they would resolve their issues and her family member YY would want her to be around. Resident #1 was tearful during conversation. The DON explained to Resident #1 she would be sent to ER for evaluation not only of her mental health but also of her urinary retention. Resident #1 agreeable to go to hospital since they would be assessing her bladder. Resident #1 left in room with 1:1 sitter pending ems arrival to facility. Record review of Resident #1's progress note dated 10/23/24 at 2:29 p.m. indicated the DON assessed Resident #1 for other marks or cuts. All other skin intact. Resident #1 denied cutting self anywhere else. Record review of Resident #1's progress note dated 10/23/24 at 2:45 p.m., completed by ADON indicated Staff notified ADON & DON of Resident #1's attempt to self-harm. Upon arrival to room observed x2 staff at bedside: one nurse applying pressure to right wrist, second nurse at foot of bed. DON cleaned with NS and band aide applied to area. Resident #1 complained of pain to lower quadrant of abdomen and suprapubic catheter. Suprapubic catheter removed. Placed with 1:1 sitter. Call placed to 911 for transport to ER due to attempt to self-harm and complaint pain d/t urinary retention. Record review of Resident #1's progress note dated 10/23/24 at 2:42 p.m., completed by the DON indicated EMS arrived at facility. ADON informed EMS of Resident #1's situation. Resident #1 in room with 1:1 sitter. The DON and CNA D assisted resident to change gown and pullup. During resident changing full body skin assessment performed no redness, cuts, scratches or open areas noted except area previously noted to right wrist that was covered with clean dry dressing. Resident no longer tearful. Resident laughing with staff. Resident #1 asked EMTs if they had handcuffs because she wanted to cuff herself to her [positioning] rail so she wouldn't have to go anywhere. When the EMTs told her they were not police so they did not have cuffs she said ok and stood to transfer to stretcher. Resident #1 left with EMS. Record review of Resident #1's progress note dated 10/23/24 at 3:23 p.m., completed by the SW indicated the SW spoke with (named psychiatry provider) and informed the (named psychiatry provider) Resident #1 was transferred to ER and behavioral health due to self harm. Record review of Resident #1's progress note dated 10/23/24 at 6:33 p.m., completed by the SW indicated the hospital psychiatrist asked if Resident #1 was aware that she was going to behavioral hospital, because she was not wanting to go. He stated that resident was competent and a mental health warrant would need to be filed. The SW spoke with Resident #1 and she said, she wants to sleep in her own bed. SW explained due to her trying to harm herself it was our recommendation that she went to the behavioral hospital. She said that she only did it because she thought no one cared. SW asked if she still believed that, she answered, 'No. SW encouraged Resident#1 to go to Behavioral Hospital to get the help she needed. Resident #1 agreed to go to the behavioral hospital. Record review of Resident #1's progress note dated 11/05/25, completed by LVN E indicated Resident #1 returned to the facility in stable condition. Record review of Resident #1's behavioral hospital records dated 11/01/25 indicated she was admitted on [DATE]. Her admitting diagnoses included bi-polar disorder, current episode depressed, severe, without psychotic features. Resident #1 stated she had nothing to live for because family was not involved with her. Resident #1 indicated she had past history 4 suicide attempts b OD on pills. Resident #1 indicated she recently cut her right wrist for attention. Record review of Resident Monitoring Tool dated 10/23/24 indicated: -1:00 p.m. asking for helium -1:15 p.m. asking for helium -1:30 p.m. asking for DON -1:45 p.m. asking for helium -2:00 p.m. cut her wrist -2:15 p.m. one on one -2:30 p.m. one on one -2:45 p.m. one on one Record review of psychological services dated 11/26/25 completed by LCSW M indicated .ongoing conflict with family member UU and family member XX continued to wear on her. Sadness surrounding family betrayal.Plan: follow up next session on things discussed . Record review of the facility's staff training for Depression dated 10/23/24 indicated: What to do if a resident states they want to harm themselves or attempts to harm themselves. -If a resident states they want to harm themselves or they want to die: -Notify the charge nurse -Charge nurse should evaluate the resident: -Ask the resident what they said to the employee reporting the self harm/ideation -Ask the resident if they have intention to harm themselves -If the resident states they have intention to harm themselves, ask the resident how they plan to harm themselves. -If resident has no plan, initiate 15 minute checks to monitor resident then notify MD or psych services if following, social worker and DON/ADON -If resident has a plan, initiate 1:1 with resident (have a staff member remain with the resident) then notify MD or psych services (if following), social worker and DON/ADON. What to do if a resident states they want to harm themselves or attempts to harm themselves. -If a resident is observed harming or attempting to harm themselves. -Intervene and ensure the resident is safe -Stay with the resident and have another staff member notify the charge nurse, social worker or DON/ADON immediately. -Charge Nurse will call 911. During an interview on 05/07/25 at 10:00 a.m., the DON said on 10/23/24, Resident #1 asked LVN FF if the facility had helium because she wanted to end her life. She said Resident #1 was placed on 15 monitoring per the facility policy at the time of the incident because she did not have a plan to hurt herself. She said a room sweep to check for items she might use to herself was not completed. She said LVN GG was conducting a 15 minute check and found Resident #1 attempted to cut her right wrist with microblade razor on 10/23/24. She said staff was trained on the facility policy at the time that included 15 minute checks if the resident did not have a plan. She said she attended a corporate DON meeting in November of 2024 and the facility's policy was changed to 1-1 supervision after suicide threat or attempts. She said she believed all staff were trained on the updated policy after Resident #1 attempted to cut her wrist. She said residents were at risk of self-harm, injury or death without adequate supervision following suicide ideation or attempts. During an interview on 05/07/25 at 11:55 a.m., Resident #1 said when she asked for helium, she wanted to kill herself because of her family problems and she was very sad. She said when she when she cut her wrist, she used a microblade razor she had ordered off (named on-inline shopping provider). She said no one was listening to what she was saying. She said her family did not support her. She said she received the therapy she needed at the behavior hospital. She said she no longer had any plans to harm herself. During an interview on 05/07/25 at 12:07 p.m., LVN GG said he was completing a 15 minute check on Resident #1 and found her with blood on her wrist. He said she had a razor in her left hand. He said he removed the razor and called for assistance. He said He said he could not recall a room search was completed for additional dangerous objects. He said he did not complete the facility's depression training. He said he could not recall training on the facility's updated suicide policy. He said residents were at risk of self-harm, injury or death without adequate supervision following suicide ideation or attempts. During an interview on 05/07/25 at 1:12 p.m., the DON said Resident #1's care plan should include behaviors. She said Resident #1's care plan should address self-harm from the incident on 10/23/24. She said the SW reviewed behavior and psychiatric care plans quarterly and updated them as required. She said the IDT meeting minutes should be located in Resident #1's progress notes but was not able to locate any documentation regarding updating Resident #1's care plan. During an interview on 05/07/25 at 1:36 p.m., the SW said she was advised Resident #1 requested helium to end her life. She said Resident #1 was upset due to family stress. She said Resident #1 was placed on 15 minute checks. She said she was not sure why Resident #1 was placed on 1-1 supervision. She said Resident #1 asked for helium but could not access helium. She said she could not recall being trained on depression or suicide prevention. She said she did not recall reviewing Resident #1's care plan for follow-up care. She said residents were at risk of self-harm, injury or death without adequate supervision following suicide ideation or attempts. During an interview on 05/07/25 at 1:52 p.m., previous Administrator J said Resident #1's care plan should have been updated by the previous MDS coordinator. He said the incident was discussed in the morning meeting and the previous MDS coordinator was aware of the incident. He said weekly IDT meeting were held to discuss acute incidents that required a care plan. He said he was unaware the care plan was not updated. Record review of the facility's policy Care plan Revisions Upon Status Change dated 2023 indicated The purpose of this procedure is to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change. Policy Explanation and Compliance Guidelines: 1. The comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change. 2. Procedure for reviewing and revising the care plan when a resident experiences a status change: a. Upon identification of a change in status, the nurse will notify the MDS Coordinator, the physician, and the resident representative, if applicable. B. The MDS Coordinator and the Interdisciplinary Team will discuss the resident condition and collaborate on intervention options. c. The team meeting discussion will be documented in the nursing progress notes. d. The care plan will be updated with the new or modified interventions. e. Staff involved in the care of the resident will report resident response to new or modified interventions. f. Care plans will be modified as needed by the MDS Coordinator or other designated staff member. g. The Unit Manager or other designated staff member will communicate care plan interventions to all staff involved in the resident's care. h. The Unit Manager or other designated staff member will conduct an audit on all residents experiencing a change in status, at the time the change in status is identified, to ensure care plans have been updated to reflect current resident needs. 3. The MDS Coordinator will determine whether a Significant Change in Status Assessment is warranted. If so, the assessment will be completed according to established procedures. An Immediate Jeopardy (IJ) was identified on 05/07/25 at 4:35 p.m. The IJ template was provided to the Administrator on 05/07/25 at 4:54 p.m. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The following Plan of Removal (POR) submitted by the facility was accepted on 05/08/25 at 12:24 p.m.: Resident-Specific Interventions - 5/7/2025 - Completed by DON or designee -Resident #1's care plan was updated to reflect resident centered behavioral health status, including the initiation of a psychiatric virtual visit and ongoing behavioral observations. Facility-Wide Audit - 5/7/2025 - Completed by Social Worker, DON, ADON -A 100% audit of current residents using the PHQ-9 screening tool began on 5/7/2025 and will be completed by 9:00 PM. PHQ-9 is a clinically validated screening tool used to assess and monitor depression severity in individuals. No other residents identified as high risk for suicide or behavioral health needs via the PHQ-9 screening tool, question 9. -Care plans are being updated, if warranted by the PHQ- 9 screening tool, to reflect PHQ-9 results and ensure individualized, resident-centered care. Staff Training - 5/7/2025 -Nursing administration staff received in-service training on care plan update protocols, provided by the regional compliance nurse. Training will be completed by 9:00 PM. QAPI Review - 5/7/2025 -An ad-hoc QAPI meeting was held with the Medical Director, Administrator, Director of Nursing, and the interdisciplinary team to evaluate current systems related to care planning and suicide prevention. Local ombudsmen notified. -QAPI will continue to review care plan compliance and quality monthly. Ongoing Monitoring - Effective 5/7/2025 -The Director of Nursing or designee will monitor the 24-hour report (generated through Point Click Care based on progress notes entered into the residents chart) and PHQ-9 completion daily for 14 days then 5 times per week for 3 months for any depression or suicidal thoughts and care plans will be updated as needed. -Any discrepancies will be addressed immediately and reviewed during weekly clinical stand-ups and monthly QAPI meetings. Monitoring of the Plan of Removal included the following: Record review of Resident #1's care plan dated 05/07/25 indicated Resident #1 had diagnoses of major depressive disorder, insomnia, and history of suicidal thoughts/self harm. Interventions included administer medications as ordered, conduct depression questionnaire on 05/07/25. Monitor/document/report PRN any risk for harm to self: suicidal plan, past attempt at suicide, risky actions, intentionally harming or tried to harm self, refusing to eat or drink, refusing med or therapies, sense of hopelessness or helplessness, impaired judgment or safety awareness. Monitor/record/report to MD PRN risk for harming others: increased anger, labile mood or agitation, feels threatened by others or thoughts of harming someone, possession of weapons or objects that could be used as weapons. Observe/report PRN any s/sx of depression, including: hopelessness, anxiety, sadness, insomnia, anorexia, verbalizing, negative statements, repetitive anxious or health-related complaints, tearfulness. If the resident expresses suicidal thoughts or ideas, staff will be assigned one-on-one care, and the Primary Physician and Abuse Coordinator will be notified immediately for further intervention(s) and guidance. If the resident expresses suicidal thoughts or ideas, staff will inspect the immediate area/room for items that could be used for self-harm and remove such items if found upon inspection. Record review of Residents #2, #3, #4, #5, #6, #7, #8, #9, and #10's care plans indicated no concerns. Record review of the facility audit completed by the DON, ADON, and SW for all residents dated 05/07/25 indicated there were no additional residents identified that required care plan updates. Record review of Staff Training dated 05/07/25 indicated nursing administration staff received in-service training on care plan update protocols, provided by the regional compliance nurse. During an interview on 05/08/25 at 3:52 p.m., the ADON said resident care plans would be updated as needed for acute events. She said the acute events would be reviewed in morning meeting During an interview on 05/08/25 at 3:48 p.m., the SW said she would review and update resident care plans as directed by the DON or designee. During an interview on 05/08/25 at 4: 22 p.m. the DON said she or her designee would monitor the 24 hour report daily and update resident care plans as needed. She said she would conduct weekly audits to ensure updated care plans were maintained. She said and identified issues would be address at the weekly IDT meeting. Interviews conducted on 05/08/25 from 2:55 p.m. through 4:54 p.m. with staff (Administrator L, LVN E, LVN P, MDS/LVN V), indicated they were aware of the facility's policy and protocols for care plans and care plan revisions. The Administrator was informed the Immediate Jeopardy was removed on 05/08/25 at 4:55 p.m. The facility remained out of compliance at a scope of isolated with the potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 of 10 residents (Resident #1) reviewed for accidents and supervision. The facility failed to provide adequate supervision after Resident #1 expressed suicidal ideations on 10/23/24. Resident #1 was placed on 15 minute monitoring. She attempted to cut her right wrist with a microblade razor (used for face shaving) between the 15 minute monitoring checks. An Immediate Jeopardy (IJ) was identified on 05/07/25 at 4:35 p.m. The IJ template was provided to the Administrator on 05/07/25 at 4:54 p.m. While the immediacy was removed on 05/08/25 at 4:55 p.m., the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm with a scope of isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place residents at risk of not receiving appropriate supervision and interventions for suicidal thoughts and attempts which could lead to residents sustaining serious injury or even death. Findings include: Record review of Resident #1's face sheet indicated she was a [AGE] year old female who was admitted to the facility on [DATE]. Her diagnoses included cerebral infarction (stroke), hemiplegia (one-sided paralysis) and hemiparesis (one-sided weakness) following cerebral infarction affecting right dominant side, diabetes (high blood sugar), major depressive disorder (persistent feeling of sadness and loss of interest), generalized anxiety disorder (excessive worrying), mood disorders (mental illness), persistent mood (affective) disorders (continuous long-term for of depression), and insomnia(sleep disorder). Record review of Resident #1's annual MDs assessment dated [DATE] indicated she was usually able to make herself understood and usually understood others. She was cognitively intact (BIMS-13). Her psychiatric/mood disorders included anxiety, depression and bipolar disorder (mental health disorder). Record review of Resident #1's care plan dated 08/24/24 indicated she had antidepressant medication related to major depressive disorder and insomnia. Interventions included administer medications as ordered, arrange psych consult, follow up as indicated, monitor/document/report PRN any risk for harm to self, suicidal plan, past attempt at suicide, risky actions, intentionally harming or tried to harm self, refusing to eat or drink, refusing medications or therapies, sense of hopelessness or helplessness, impaired judgment or safety awareness. There was no care plan related to major depressive disorder, suicidal thoughts or self-harm. Record review of Resident #1's progress note dated 10/23/24 at 12:17 p.m., completed by LVN FF indicated Resident #1 asked if the facility had helium in the building. LVN FF asked Resident #1 why she needed helium. Resident #1 stated, So I can end it now. I just want to kill myself. My family member UU don't want anything to do with me, My sister only comes when I need something. I just want to die. Nothing to live for. LVN FF stayed with Resident #1. The SW and DON were notified. Record review of Resident #1's progress note dated 10/23/24 at 12:37 p.m., completed by the SW, indicated Resident #1 she just wanted to end it, because of her family member XX not wanting to speak with her or with the great grand children. The SW asked Resident #1 if she had a plan and Resident #1 said no, she just want to end it all. Resident #1 agreed to go to the behavior hospital due to her mood. Spoke with the DON and informed Resident #1 would go on 15 minute watch until SW was able to contact (named psychiatry) for assessment. (Named psychiatry) notified and waiting for call back. Record review of Resident #1's progress note dated 10/23/24 at 1:37 p.m., completed by LVN FF indicated (named psychiatry) on-call called facility and was given report on Resident #1's condition. (Named psychiatry) on-call stated, have SW call back and set up tel psych visit. SW notified. 15 minute checks continue. Record review of Resident #1's progress note dated 10/23/24 at 14:01, completed by SW indicated Tele-health visit attempted with on-call psychiatrist. Left message for return call. Record review of Resident #1's progress note dated 10/23/24 at 14:28, completed by LVN GG indicated LVN GG was doing 2:00 p.m. monitoring check when he noticed Resident #1 with an object in her left hand. LVN GG noticed Resident #1 had blood coming from her right wrist area. LVN GG took away the object and notified the charge nurse. The DON and ADON were notified. Resident #1 had sliced right wrist with the object. DON cleansed right wrist area and the wounds were superficial. LVN GG and and staff will continue to monitor Resident #1. Record review of Resident #1's progress note dated 10/23/24 at 2.29 p.m., completed by LVN GG indicated while the DON and ADO were giving care, Resident #1 allowed LVN GG to remove and look for sharp objects. A pencil, pen and mirror were removed from the room. Record review of Resident #1's progress note dated 10/23/24 at 2:49 p.m., completed by the DON, indicated she observed Resident #1 with small amount of blood on sheets. She assessed Resident #1's right wrist and noted two superficial cuts approximately 1 to 1.5 inches in length and less than 0.1 mm deep. The cuts were not bleeding. The DON asked Resident #1 what happened and Resident #1 stated she just wanted to the pain to stop. The DON asked Resident #1 what pain she was referring to (physical or emotional) Resident #1 stated the pain in her bladder. LVN C stated she had changed Resident #1's catheter earlier (time noted at 12:13 p.m. per progress note) due to complaints of discomfort. Resident #1 stated that it helped but the pain was back. Upon assessing resident cath noted small amount of urine in collection bag. Palpation of abdomen completed. Resident noted with tenderness. The DON removed cath in attempt to change for obstruction per MD order. Upon suprapubic catheter being removed large amount of urine. The DON removed cath in attempt to change for obstruction per MD order. Upon suprapubic catheter being removed large amount of urine flowed from suprapubic site. Resident #1 refused to have suprapubic cath re-placed back but did allow the DON to straight cath her at suprapubic site. Approximately 500 ml drained from bladder. Bladder palpated with no s/s discomfort and Resident #1 stated it does feel better. The DON and ADON spoke with Resident #1 about why she had cut herself. Resident first stated because of the pain in her bladder but upon conversation with the resident, she revealed she was having issues with her family member YY. Resident #1 stated that her family was upset with her for calling her great family member YY her babies. The DON and ADON attempted to re-assure Resident #1 that although her family was upset at the moment, they would resolve their issues and her great-grandchildren would want her to be around. Resident #1 was tearful during conversation. The DON explained to Resident #1 she would be sent to ER for evaluation not only of her mental health but also of her urinary retention. Resident #1 agreeable to go to hospital since they would be assessing her bladder. Resident #1 left in room with 1:1 sitter pending ems arrival to facility. Record review of Resident #1's progress note dated 10/23/24 at 2:29 p.m. indicated the DON assessed Resident #1 for other marks or cuts. All other skin intact. Resident #1 denied cutting self anywhere else. Record review of Resident #1's progress note dated 10/23/24 at 2:45 p.m., completed by ADON indicated Staff notified ADON & DON of Resident #1's attempt to self-harm. Upon arrival to room observed x2 staff at bedside: one nurse applying pressure to right wrist, second nurse at foot of bed. DON cleaned with NS and band aide applied to area. Resident #1 complained of pain to lower quadrant of abdomen and suprapubic catheter. Suprapubic catheter removed. Placed with 1:1 sitter. Call placed to 911 for transport to ER due to attempt to self-harm and complaint pain d/t urinary retention. Record review of Resident #1's progress note dated 10/23/24 at 2:42 p.m., completed by the DON indicated EMS arrived at facility. ADON informed EMS of Resident #1's situation. Resident #1 in room with 1:1 sitter. The DON and CNA D assisted resident to change gown and pullup. During resident changing full body skin assessment performed no redness, cuts, scratches or open areas noted except area previously noted to right wrist that was covered with clean dry dressing. Resident no longer tearful. Resident laughing with staff. Resident #1 asked EMTs if they had handcuffs because she wanted to cuff herself to her [positioning] rail so she wouldn't have to go anywhere. When the EMTs told her they were not police so they did not have cuffs she said ok and stood to transfer to stretcher. Resident #1 left with EMS. Record review of Resident #1's progress note dated 10/23/24 at 3:23 p.m., completed by the SW indicated the SW spoke with (named psychiatry provider) and informed the (named psychiatry provider) Resident #1 was transferred to ER and behavioral health due to self harm. Record review of Resident #1's progress note dated 10/23/24 at 6:33 p.m., completed by the SW indicated the hospital psychiatrist asked if Resident #1 was aware that she was going to behavioral hospital, because she was not wanting to go. He stated that resident was competent and a mental health warrant would need to be filed. The SW spoke with Resident #1 and she said, she wants to sleep in her own bed. SW explained due to her trying to harm herself it was our recommendation that she went to the behavioral hospital. She said that she only did it because she thought no one cared. SW asked if she still believed that, she answered, 'No. SW encouraged Resident#1 to go to Behavioral Hospital to get the help she needed. Resident #1 agreed to go to the behavioral hospital. Record review of Resident #1's progress note dated 11/05/25, completed by LVN E indicated Resident #1 returned to the facility in stable condition. Record review of Resident #1's behavioral hospital records dated 11/01/25 indicated she was admitted on [DATE]. Her admitting diagnoses included bi-polar disorder, current episode depressed, severe, without psychotic features. Resident #1 stated she had nothing to live for because family was not involved with her. Resident #1 indicated she had past history 4 suicide attempts b OD on pills. Resident #1 indicated she recently cut her right wrist for attention. Record review of Resident Monitoring Tool dated 10/23/24 indicated: -1:00 p.m. asking for helium -1:15 p.m. asking for helium -1:30 p.m. asking for DON -1:45 p.m. asking for helium -2:00 p.m. cut her wrist -2:15 p.m. one on one -2:30 p.m. one on one -2:45 p.m. one on one Record review of psychological services dated 11/26/25 completed by LCSW M indicated .ongoing conflict with family member UU and family member XX continued to wear on her. Sadness surrounding family betrayal.Plan: follow up next session on things discussed . Record review of the facility's staff training for Depression dated 10/23/24 indicated: What to do if a resident states they want to harm themselves or attempts to harm themselves. -If a resident states they want to harm themselves or they want to die: -Notify the charge nurse -Charge nurse should evaluate the resident: -Ask the resident what they said to the employee reporting the self harm/ideation -Ask the resident if they have intention to harm themselves -If the resident states they have intention to harm themselves, ask the resident how they plan to harm themselves. -If resident has no plan, initiate 15 minute checks to monitor resident then notify MD or psych services if following, social worker and DON/ADON -If resident has a plan, initiate 1:1 with resident (have a staff member remain with the resident) then notify MD or psych services (if following), social worker and DON/ADON. What to do if a resident states they want to harm themselves or attempts to harm themselves. -If a resident is observed harming or attempting to harm themselves. -Intervene and ensure the resident is safe -Stay with the resident and have another staff member notify the charge nurse, social worker or DON/ADON immediately. -Charge Nurse will call 911. During an interview on 05/07/25 at 10:00 a.m., the DON said on 10/23/24, Resident #1 asked LVN FF if the facility had helium because she wanted to end her life. She said Resident #1 was placed on 15 monitoring per the facility policy at the time of the incident because she did not have a plan to hurt herself. She said a room sweep to check for items she might use to herself was not completed. She said LVN GG was conducting a 15 minute check and found Resident #1 attempted to cut her right wrist with microblade razor on 10/23/24. She said staff was trained on the facility policy at the time that included 15 minute checks if the resident did not have a plan. She said she attended a corporate DON meeting in November of 2024 and the facility's policy was changed to 1-1 supervision after suicide threat or attempts. She said she believed all staff were trained on the updated policy after Resident #1 attempted to cut her wrist. She said residents were at risk of self-harm, injury or death without adequate supervision following suicide ideation or attempts. During an interview on 05/07/25 at 11:55 a.m., Resident #1 said when she asked for helium, she wanted to kill herself because of her family problems and she was very sad. She said when she when she cut her wrist, she used a microblade razor she had ordered off (named on-inline shopping provider). She said no one was listening to what she was saying. She said her family did not support her. She said she received the therapy she needed at the behavior hospital. She said she no longer had any plans to harm herself. During an interview on 05/07/25 at 12:07 p.m., LVN GG said he was completing a 15 minute check on Resident #1 and found her with blood on her wrist. he said she had a razor in her left hand. He said he removed the razor and called for assistance. He said he could not recall a room search was completed for additional dangerous objects. He said he did not complete the facility's depression training. He said he could not recall training on the facility's updated suicide policy. He said residents were at risk of self-harm, injury or death without adequate supervision following suicide ideation or attempts. During an interview on 05/07/25 at 12:52 p.m., the DON said she was not able to locate records of staff straining related to the facility updated policy for suicide prevention. During an interview on 05/07/25 at 1:12 p.m., the DON said Resident #1's care plan should include behaviors. She said Resident #1's care plan should address self-harm from the incident on 10/23/25. She said care plans were reviewed quarterly and updated. During an interview on 05/07/25 at 1:36 p.m., the SW said she was advised Resident #1 requested helium to end her life. She said Resident #1 was upset due to family stress. She said Resident #1 was placed on 15 minute checks. She said she was not sure why Resident #1 was placed on 1-1 supervision. She said Resident #1 asked for helium but could not access helium. She said she could not recall being trained on depression or suicide prevention. She said she was not aware of any changes related to the facility's suicide protocols. She said she did not recall reviewing Resident #1's care plan for follow-up care. She said residents were at risk of self-harm, injury or death without adequate supervision following suicide ideation or attempts. During an interview on 05/07/25 at 1:52 p.m., previous Administrator J said Resident #1 was not placed on 1-1 supervision on 10/23/24 after she asked if the facility had helium and indicated she wanted to end her life. He said he believed the facility spoke to the psych doctor and Resident #1 did not have an active plan. He said he could not recall if the facility conducted a search of Resident #1's room to ensure there were no items she could harm herself with. He said he believed the Medical Director recommended 15 minute checks until she was cleared by psychiatrist or they had different recommendations. He said after the incident on 10/23/24, the facility changed the policy to anytime there was an outcry, the resident would be placed on 1-1. He said he believed all the staff were trained on the facility's new suicide prevention policy. He said Resident #1's care plan should have been updated by the previous MDS coordinator. He said the incident was discussed in the morning meeting and the previous MDS coordinator was aware of the incident. He said weekly IDT meeting were held to discuss acute incidents that required a care plan. He said he was unaware the care plan was not updated. During an interview on 05/08/25 at 10:25 a.m., Activity Director K said said she did not have helium in the facility currently. She said she believed it was more than 6 months since she had a tank. She said she would keep them in her office and use it to blow up balloons. She said she did not lock her office and anyone could access the helium if they knew it was available in her office and they knew how to access it it and turn it on. Record review of the facility's Suicide Prevention policy dated 2024 indicated: It is the policy of this facility to act quickly and appropriately if a resident expresses thoughts of suicide. Definitions: Suicide - is defined as a death from injury, poisoning, or suffocation where there is evidence that the death was self-inflicted. Suicidal Ideation - is defined as self-reported thoughts about engaging in suicide-related behaviors. Policy Explanation and Compliance Guidelines:1. All staff members will immediately report any suicidal ideation to the resident's charge nurse and facility social worker. 2. Immediately notify the resident's physician if the resident presents with suicidal ideation, even if he or she isn't specific about a plan or intent. 3. If applicable, notify the resident's responsible party of the resident's suicidal ideation and any orders received from the resident's physician. 4. The resident will not be left alone. One on one care will be provided until arrangements can be made for the resident to receive emergency psychiatric care, or until the resident's physician determines that the risk of suicide is no longer present. 5. Objectively and thoroughly document the resident's mood and behaviors, as well as all actions taken, in the medical record. 6. If the resident requires inpatient psychiatric services, State specific guidelines and requirements will be followed. 7. All staff will be trained annually on risk factors and warning signs of suicide, as well as how to respond to a resident with suicidal ideation. Record review of the facility's Accidents and Supervision policy dated 2023 indicated: Policy: The resident environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes: 1. Identifying hazard(s) and risk(s). 2. Evaluating and analyzing hazard(s) and risk(s). 3. Implementing interventions to reduce hazard(s) and risk(s). 4. Monitoring for effectiveness and modifying interventions when necessary. Policy Explanation and Compliance Guidelines: The facility shall establish and utilize a systematic approach to address resident risk and environmental hazards to minimize the likelihood of accidents. 1. Identification of Hazards and Risks- the process through which the facility becomes aware of potential hazards in the resident environment and the risk of a resident having an avoidable accident. a. All staff (e.g., professional, administrative, maintenance, etc.) are to be involved in observing and identifying potential hazards in the environment, while taking into consideration the unique characteristics and abilities of each resident. b. The facility should make a reasonable effort to identify the hazards and risk factors for each resident.3. Implementation of Interventions- using specific interventions to try to reduce a resident's risks from hazards in the environment. The process includes: a. Communicating the interventions to all relevant staff b. Assigning responsibility c. Providing training as needed d. Documenting interventions (e.g., plans of action developed through the QAA Committee or care plans for the individual resident) e. Ensuring that the interventions are put into action f. Interventions are based on the results of the evaluation and analysis of information about hazards and risks and are consistent with relevant standards, including evidence-based practice g. Development of interim safety measures may be necessary if interventions cannot immediately be implemented fully h. Facility-based interventions may include, but are not limited to: i. Educating staff ii. Repairing the device/equipment iii. Developing or revising policies and procedures i. Resident-directed approaches may include: i. Implementing specific interventions as part of the plan of care ii. Supervising staff and residents, etc. iii. Facility records document the implementation of these interventions 4. Monitoring and Modification- Monitoring is the process of evaluating the effectiveness of care plan interventions. Modification is the process of adjusting interventions as needed to make them more effective in addressing hazards and risks. Monitoring and modification processes include: a. Ensuring that interventions are implemented correctly and consistently b. Evaluating the effectiveness of interventions c. Modifying or replacing interventions as needed d. Evaluating the effectiveness of new interventions 5. Supervision- Supervision is an intervention and a means of mitigating accident risk. The facility will provide adequate supervision to prevent accidents. Adequacy of supervision: a. Defined by type and frequency b. Based on the individual resident's assessed needs and identified hazards in the resident environment. An Immediate Jeopardy was identified on 05/07/25 at 4:35 p.m. The IJ template was provided to the Administrator on 05/07/25 at 4:54 p.m. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The following Plan of Removal was submitted by the facility and accepted on 05/08/25 at 12:34 p.m. Supervision and Accident Prevention Resident Safety Review - 5/7/2025 -All residents identified as high risk for suicide or behavioral health needs, via the PHQ-9 screening tool, question 9, were immediately placed on 1-1, room searched, notified physician, RP notified, and initiated mental health consultation. -Question 9 - Over the last two weeks, how often have you been bothered by thoughts that you would be better off dead, or of hurting yourself in some way? -0 - not at all -1 - Several days -2 - More than half the days -3 - Nearly every day -Adjustments were made as needed, and care plans were updated accordingly. -Resident #1 received a PHQ-9 assessment, a room safety search, and a virtual psychiatric visit, all completed by 9:00 PM on 5/7/2025. Staff In-Service - 5/7/2025 - Completed by Admin or designee -All facility staff, including nursing, therapy, dietary, housekeeping, and administration, completed training on suicide prevention, including immediate reporting of suicidal ideation to the charge nurse and social worker, immediate notification of the resident's physician, and immediately initiating 1:1 supervision of the resident when suicidal ideation is expressed, provided by the Director of Nursing or designee, completed by 10:00 p.m. on 5/7/2025. -A post-training exam with a required 100% passing score was administered. Staff unable to attend the in-service will not be permitted to work until training is completed. Ongoing Monitoring - Effective 5/7/2025 -The Director of Nursing or designee will conduct weekly audits of residents identified as high risk for suicidal ideations or health needs to ensure that proper supervision, documentation, updated resident-centered care plans and interventions are maintained. -Any discrepancies will be addressed immediately and reviewed during weekly clinical stand-ups and monthly QAPI meetings. Monitoring: Record review and interviews of completed: Observation on 05/08/25 from 3:00 p.m. through 4:45 p.m. of 10 resident rooms indicated no hazardous items noted. Record review of the facility wide resident safety review dated 05/07/25 indicated there were no additional residents identified and high risk for suicide of unmet behavioral health needs. Record review of Resident #1's PHQ-9 assessment, a room safety search, and a virtual psychiatric visit, indicated all were completed by 9:00 PM on 05/07/25. There were no concerns identified. Record review of Resident #1's care plan dated 05/07/25 indicated Resident #1 had diagnoses of major depressive disorder, insomnia, and history of suicidal thoughts/self harm. Interventions included administer medications as ordered, conduct depression questionnaire on 05/07/25. Monitor/document/report PRN any risk for harm to self: suicidal plan, past attempt at suicide, risky actions, intentionally harming or tried to harm self, refusing to eat or drink, refusing med or therapies, sense of hopelessness or helplessness, impaired judgment or safety awareness. Monitor/record/report to MD PRN risk for harming others: increased anger, labile mood or agitation, feels threatened by others or thoughts of harming someone, possession of weapons or objects that could be used as weapons. Observe/report PRN any s/sx of depression, including: hopelessness, anxiety, sadness, insomnia, anorexia, verbalizing, negative statements, repetitive anxious or health-related complaints, tearfulness. If the resident expresses suicidal thoughts or ideas, staff will be assigned one-on-one care, and the Primary Physician and Abuse Coordinator will be notified immediately for further intervention(s) and guidance. If the resident expresses suicidal thoughts or ideas, staff will inspect the immediate area/room for items that could be used for self-harm and remove such items if found upon inspection. Record review of staff in-service dated 05/07/25 indicated facility staff, including nursing, therapy, dietary, housekeeping, and administration, completed training on suicide prevention, including immediate reporting of suicidal ideation to the charge nurse and social worker, immediate notification of the resident's physician, immediately initiating 1:1 supervision of the resident when suicidal ideation is expressed, and immediate search for hazards and hazardous items. Record review of staff post-training exams indicated all staff passed with a required 100% passing score. Staff unable to attend the in-service would not be permitted to work until training and testing was completed. During an interview on 05/08/25 at 1:51 p.m., Administrator L said the facility would conduct weekly audits of residents identified as high risk for suicidal ideations or health needs to ensure that proper supervision, documentation, updated resident-centered care plans and interventions are maintained. Any discrepancies would be be addressed immediately and reviewed during weekly clinical stand-ups and monthly QAPI meetings. She said residents were at risk of self-harm, injury or death without adequate supervision following suicide ideation or attempts. During an interview on 05/08/25 at 4:22 p.m., the DON said she would conduct weekly audits of residents identified as high risk for suicidal ideations or health needs to ensure that proper supervision, documentation, updated resident-centered care plans and interventions are maintained. Any discrepancies would be be addressed immediately and reviewed during weekly clinical stand-ups and monthly QAPI meetings. Interviews conducted on 05/08/25 from 2:55 p.m. through 4:54 p.m. with staff (Administrator L, DON, ADON, SW, LVN E OTR N, Receptionist O, LVN P, Dietary Director Q, LS R, BOA S, CMA T, Medical Records U, MDS/LVN V, ST W, CNA X, CNA AA, CMA BB, CNA DD, CNA EE), who represented all shifts on all days of the week (6:00 a.m.-6:00 p.m., 6:00 p.m.-6:00 a.m., 6:00 a.m.-2:00 p.m., 2:00 p.m. -10:00 p.m., and 10:00 p.m.-6:00 a.m., 8:00 a.m.-4:00/5:00 p.m., and 3:00 p.m. -11:00 p.m.) indicated they were aware of the facility's policy and protocols for suicide prevention that included immediate reporting of suicidal ideation to the charge nurse and social worker, immediate notification of the resident's physician, immediately initiating 1:1 supervision of the resident when suicidal ideation is expressed, and immediate search for hazards and hazardous items. The Administrator and DON were informed the Immediate Jeopardy was removed on 05/08/25 at 4:55 p.m. the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy and a scope of isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.