**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure residents environment remained as free of accident hazards as possible and each resident received adequate supervision and assistance devices to prevent accidents for 4 of 8 residents (Resident #38, Resident #17, Resident #110, and Resident #35) reviewed for accidents and supervision. 1.The facility failed to put interventions in place to keep Resident #38 from all harmful items. *On 02/18/24, LVN E documented Resident #38 was on the floor, face down with the call light cord wrapped around her neck x4. No harmful items were removed after the incident, from Resident #38's room to ensure her safety. *On 03/09/24, CNA S reported Resident #38 was stabbing herself in the abdomen with scissors. CNA S removed the scissors from Resident #38 put no other actions were initiated until later. The facility failed to put interventions in place to keep Resident #38 from harming herself after reported self-harming behaviors. *The facility did not immediately initiate 1:1 monitoring after self-harming incident on 03/09/24. The facility classified Resident #38's incident on 02/18/24 as a fall and shortened her call light and placed a fall mat bedside her bed. *The facility did not ensure Resident #38 was seen after a counseling evaluation and treatment ordered was placed on 02/15/24 and a psych evaluation referral was signed by Resident #38 on 03/04/24. The facility failed to follow their Suicide Threat policy after incidents on 02/18/24 and 03/09/24. Resident #38 was left alone after self-harmful behaviors was witnessed and reported. The facility failed to in-service staff of Suicide Prevention after Resident #38's reported self-harming behavior on 03/09/24. LVN R was the only staff member documented on in-service roster. 2. The facility failed to transfer Resident #17 in safe manner by her care planned needs. Resident #17 was transferred by CNA A without a gait belt which resulted in fall causing back pain requiring x-rays. 3. CNA A transferred Resident #110 without a gait belt resulting in laceration to the back of his head. 4. CNA B transferred Resident #35 with a Hoyer lift by herself resulting in a bruise to her left forearm. An Immediate Jeopardy (IJ) situation was identified on 03/28/24 at 3:45 p.m. While the IJ was removed on 3/29/24 at 12:41 p.m. p.m., the facility remained out of compliance at a scope of a pattern with a potential for with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. These deficient practices could place residents at risk to physical harm and could lead to additional pain and suffering. Findings include: Record review of Resident #38's face sheet printed 03/25/24 indicated Resident #38 was a [AGE] year-old, female and admitted on [DATE] with diagnoses including transient cerebral ischemic attack (is a temporary blockage of blood flow to the brain), hemiplegia (paralysis of one side of the body) and hemiparesis (is a mild or partial weakness or loss of strength on one side of the body) following cerebral infarction (also known as an ischemic stroke, is the pathologic process that results in an area of necrotic tissue in the brain) affecting left non-dominant side, anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and depression (is a mood disorder that causes a persistent feeling of sadness and loss of interest). Record review of Resident #38's quarterly MDS assessment dated [DATE] indicated Resident #38 was understood and understood others. The MDS indicated Resident #38 had adequate hearing, clear speech, and adequate vision. The MDS indicated Resident #38 had a BIMS score of 13 which indicated intact cognition. The MDS indicated Resident #38 did not have behaviors such as psychosis or physical or verbal behavioral symptoms. The MDS indicated Resident #38 rated going outside to get fresh air when the weather was good as not very important. The MDS indicated Resident #38 upper extremity limitation in range of motion on one side of the body. The MDS indicated Resident #38 admission performance requirement was maximal assistance for putting on footwear, lower body dressing, and toilet hygiene and moderate assistance for oral hygiene, shower/bathe self, upper body dressing, and personal hygiene. The MDS indicated Resident #38 received antianxiety and antidepressant medication during the last 7 days of the assessment period. Record review of Resident #38's care plan dated 03/09/24, edited on 03/11/24 indicated CNA stated that Resident #38 expressed thoughts of harming self: Resident #38 was in her room with a pair of scissors, and it appears that she was trying to stab herself. Resident #38 stated that she had never thought of anything like that. And she was upset that the CNA even thought that. Interventions created on 03/11/24 included: *Nurse assessed residents' abdomen, and there are no signs of resident trying to stab herself such as redness, discoloration, and marks. *Telemed visit conducted with NP GG- Local Counseling Provider and recommendation made to discontinue 1:1 supervision and suicide precaution on 03/11/24. *Notify MD/RP of suicidal ideations. *Nurse to assess mood and behaviors every shift and document findings. *Provide 1:1 supervision to resident, document every 15 minutes checks during 1:1, Resident to remain on 1:1 until psych provider clears suicidal ideations, discontinued 3/11/24 post psych consult with Local Counseling Provider *Remove all sharp items from room, call light cord, curtains, blinds, phone charger, etc. Provide bell/alternate call light system to resident. Hang sheet over window for privacy. *Resident engages in audiobooks and enjoys listening to Bible app. She enjoys playing on her cell phone and enjoys television. Denies need for activity supplies in room. States she has plenty to do. *Resident #38 was interviewed by the nurse and Resident stated that she would never harm herself that she does not know why the CNA would even say anything like that. Resident #38 was Ax3-4 with a BIMS 15. *Social services to assess mood and behavior and document findings. Record Review of Resident #38's care plan dated 02/14/24, edited on 03/18/24 indicated Resident #38 was at risk for falls due to Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. Falls: 02/17/24: Resident #38 had an unwitnessed fall from her bed with no injury. Intervention edited on 03/18/24 included therapy screen, maintenance to shorten call light string, staff to ensure call light is untangled and within reach. Monitor for delayed injuries, may have fall mat at beside while in bed. Record review of Resident #38's progress notes by LVN L dated 02/15/24 at 1:45 p.m., indicated .received psych orders to eval and treat from NP HH . Record review of Resident #38's progress notes by LVN E dated 02/18/24 at 6:29 a.m., indicated .sn [LVN E] noted resident in floor face down in right side of bed with call light wrapped around neck 4 times .sn [LVN E] asked resident what happened resident stated she trying to get call light undone and kept wrapping it around and somehow fell .no injuries noted .no abnormalities/deformities noted .sn [LVN E] and cna assisted resident back to bed via Hoyer lift .prn pain pill administered po .residents son notified .don notified .NP notified by fax .neuros initiated .edited by: LVN E on 02/19/24 10:04 AM Reason: Incorrect data . Record review of Resident #38's progress notes by LVN E dated 02/18/24 at 6:29 a.m., indicated .sn [LVN E] noted resident in floor face down in right side of bed tangled in call light .sn [LVN E] asked resident what happened resident stated she trying to get call light undone and kept wrapping it around and somehow fell .no injuries noted .no abnormalities/deformities noted .sn [LVN E] and cna assisted resident back to bed via Hoyer lift .prn pain pill administered po .residents son notified .don notified .NP notified by fax .neuros initiated . Record review of Resident #38's progress notes by SW dated 03/04/24 at 12:07 p.m., .Resident #38 stated she is having a hard time with her new discharge plan of long-term care but has not desire to leave the facility .SW discussed a referral to local counseling provider .Resident #38 agreed to the referral . Record review of Resident #38's progress notes by DOCR dated 03/09/24 at 9:20 a.m., indicated .this nurse was told by CNA [CNA S] that she caught this resident with a pair of scissors, and that she wanted to commit suicide .this nurse went right away to ask the resident about the scissors .resident stated I [Resident #38] found them in the drawer, and the aide walked in and said you will not commit suicide in this room! .And I [Resident #38] told her why would I ever do something like that, I wouldn't even think about killing myself .I [Resident #38] found these in the drawer and I don't know where they came from .they could have been here before they moved me in this room .the aide took them but I don't what she did with them . Record review of Resident #38's progress notes by Interim DON dated 03/09/24 at 3:20 p.m., indicated .during rounds visited with resident, resident pleasant and no complaints .mentioned she had an issue this morning .she reported that CNA [CNA S] took her scissors and she didn't know why .CNA [CNA S] told resident [Resident #38] that she had a recent suicide in her family and that is why her awareness is heightened .resident reported that she is going to go to the long term care side of the building soon and its going to be an adjustment for her . Record review of Resident #38's progress notes by LVN R dated 03/09/24 at 11:38 a.m., indicated .8:30 am .CNA [CNA S] reported to this nurse [LVN R] that found Resident [Resident #38] in her room with a pair of scissors and it appeared that she was trying to stab herself .CNA [CNA S] stated that she grabbed the scissors from the Resident and asked what are you doing? .and Resident [#38] stated I [Resident #38] was trying to kill myself .CNA [CNA S] gave the pair of scissors to this nurse [LVN R] .the nurse went into Residents [#38] room to interview her to get her side of the story .resident [#38] stated she did not try to stab herself, and that she would never try to kill herself and that she does not have the guts to do that .DOCR went in to get a statement from resident and resident told her the same thing, that she would not ever try to kill herself . Record review of Resident #38's progress notes by LVN R dated 03/10/24 at 9:12 a.m., indicated .no suicidal remarks or attempts made or reported this shift .Resident [Resident #38] appears to be in pleasant mood this shift . Record review of Resident #38's progress notes by LVN JJ dated 03/10/24 at 10:30 p.m., indicated .resident [Resident #38] placed on 1:1 per Interim DON due to self-harm behaviors on 03/10/24 .sitter has been present to ensure resident safety .at this time patient denies any current thoughts or urges to self-harm . Record review of CNA S written statement dated 03/09/24 at 7:56 a.m., indicated .I went in room [ROOM NUMBER] to pick up her [Resident #38] breakfast tray and the resident was stabbing at her stomach with some scissors .I called her name and she threw them in the drawer and put her foot up to it so I couldn't get them, I told her I had to take them because we can't have them up here .she [Resident #38] stated well if it was a knife I could have cut my throat .I said I have to let the nurse know you're talking like this . she stated well if you tell on me I'm going to say you are mean to me .I told her I can't let her hurt herself and I got the scissors out the drawer .took them to the nurse and let her know what happened . Record review of an undated and untimed statement by the Interim DON (provided after entry on 03/27/24) indicated, .On 03/09/24 during rounds visited with resident [Resident #38], resident pleasant and no complaints .mentioned she had an issue this morning .she reported CNA [CNA S] took scissors and she [Resident #38] did not know why . on Sunday 03/10/24 afternoon, I [Interim DON] read in Matrix nurse notes that agency nurse [LVN R] documented that resident attempted suicide with scissors . Record review of Resident #38's local counseling service provider prepared by SW, dated 03/04/24 indicated .reason for referral: depressive symptoms and anxiety .referral/treatment consent form and doctor's order need to be completed PRIOR TO provision of services and COPY OF EACH FAXED to .Corporate Office .along with a current face sheet .please assure there is an order reads similar to: Please refer to .Evaluation and Treatment . During an interview and observation on 03/25/24 at 10:55 a.m. Resident #38's room was dark and quiet. Resident #38 said she had no complaints about the facility, and nothing had happened in her bathroom recently. No fall mat at bedside. During an interview and observation on 03/26/24 at 11:04 a.m., Resident #38's room was dark and quiet. Fall mat noted on left side of the bed. Resident #38 said the facility added it yesterday because she had a little incident and fell out of the bed. She said the fall mat was something soft in case she fell out of the bed again. She said it had been a bad morning that day. She said CNA S had found her in the wheelchair headed out the room not properly dressed. She said she did not attempt suicide with scissors. She said she was reaching for her hairbrush in the nightstand drawer and picked up the scissors instead. She said CNA S asked why she had the scissors and she told her she found them in the drawer. She said she did suffer depression and anxiety but was on medication for it. She said she really missed her dog. She said her dog was a certified support dog and wanted to have at the facility full time. During an interview on 03/26/24 at 4:45 p.m., CNA S said she was picking up lunch trays and looked in Resident #38's room and saw her stabbing at her stomach with scissors. She said she asked her what she was doing, and she threw the scissors in the drawer. She said Resident #38 said If it was a knife, I would have been able to cut my throat with it! She said Resident #38 put her foot up against the drawer so she could not get the scissors. She said she told Resident #38 she had to get the scissors and had to let the nurse know what was going on. She said Resident #38 said If you tell on me, I will say you hurt me! She said Resident #38's foot slipped from the drawer enough for her to get the scissors. She said she took the scissors to LVN R. She said LVN R said she would take care of it. She said she went to finish picking up trays and heard Resident #38 with probably her son telling him I rammed her knee in the bathroom. She said she went back to the nurse's station to ask LVN R to go to Resident 338's room and talk to her. She said LVN R said she would. She said she took the trays to the dining room and wrote her statement about the incident. She said she saw the DOCR and told her about Resident #38 having the scissors. She said the DOCR asked her if someone was sitting 1:1 with Resident #38 and I told her, No. She said the DOCR went to LVN R and asked her why Resident #38 was alone. She said LVN R told the DOCR, she had spoken with Resident #38 and denied trying to stab herself with scissors. She said Resident #38 was probably left alone for 20-30 minutes because she gave a bath and got linen before she saw the DOCR and told her about the scissors. She said Resident #38 had made other comments about hurting herself before. She said on 03/09/24, Resident #38 did not have 1:1 supervision but staff members were going in and checking on her. She said Resident #38 probably should not have been left alone in case she really tried to harm herself. She said she told LVN R so she felt like she should have start everything like 1:1 monitoring immediately. During an interview on 03/27/24 at 10:04 a.m., a family member of Resident #38 said he had been informed of his family members voiced suicide attempts. He said when Resident #38 got out the back door on 03/03/24 without permission, she later texted him saying she wanted to walk into traffic. He said he thought he told the case worker Resident #38 made that statement. He said Resident #38 did not have a history of suicidal ideations. He said his family member wanted to come home, but he could not care for her anymore. During an interview on 03/27/24 at 11:27 a.m., the DOCR said CNA S saw her in the hallway and told her after breakfast, Resident #38 had scissors and would be mad she reported to her what happened. She said she went into Resident #38's room and she denied allegation of harming herself and having scissors. She said LVN R was at the LVN R was at the nurse's station when she got on the hall to talk to Resident #38. She said when she headed towards Resident #38's room, LVN R followed her. She said Resident #38 was alone when she went into her room to talk to her. She said after she finished talking to Resident #38 about the incident with CNA S, she left for the day, called the Interim DON and she showed. She said she did not know the exact time the Interim DON arrived at the facility. She said the Interim DON lived about 3 hours away from the facility. During an interview on 03/27/24 at 11:39 a.m., the SW said Resident #38 was anxious and depressed when she first admitted to the facility. She said she was initial supposed to go back home but changed plan and she was staying for long term care. She said Resident #38 had some adjustment issues but was on medication and psych services. She said Resident #38's family member never reported to her about her texting him she wanted to walk into traffic. She said Resident #38's family had reported attention seeking behaviors like constantly calling and how she had ruined relationships with her behavior. She said Resident #38 family member said Resident #38 would not harm herself, it was just attention seeking and she would not do it. She said she was not notified of the incident on 03/09/24 until Monday, 03/11/24, when she returned for work. She said she assessed Resident #38 on 03/11/24 and she did not make any comments of self-harm. During an interview on 03/27/24 at 12:00 p.m., the Interim DON said she did not know where the 1:1 monitoring documentation paperwork was. During an interview on 03/27/24 at 12:59 p.m., LVN R said she was agency staff but had worked with Resident #38 often. She said Resident #38 had never told her she was depressed. LVN R said she went to speak to Resident #38 after CNA S brought her the scissors and told her Resident #38 tried to harm herself with them. She said CNA S told her she took the scissors from Resident #38 and asked her what she was doing. She said the first time, CNA S said Resident #38 said I don't know or I'm not doing anything. She said she went to speak with Resident #38, and she said CNA S was mad at her because she did not want to assist her to the restroom. She said Resident #38 said she would never harm herself or have the guts to do it. She said she assessed Resident #38's stomach and there were no marks or anything. She said Resident #38 tried to call her family member. She said she tried to call Resident #38's family member also. She said later, her and DOCR went to talk to Resident #38. She said Resident #38 said CNA S may have been frustrated when she took her to the bathroom and did not ram her knees on purpose. She said the Interim DOB showed up and spoke with Resident #38. She said the Interim DON told CNA S to apologize to Resident #38. She said Resident #38 was left alone after the incident, but she was checked on frequently. She said she worked until 6pm on 03/09/24. She said 1:1 monitoring for Resident #38 was started on 03/10/24. During an interview on 03/27/24 at 1:34 p.m., the Interim DON said she went to Resident #38's room on 03/09/24 and she said CNA S took her scissors and accidently bumped her knee. She said she did speak with LVN R, but LVN R never mentioned to her Resident #38's self-harming incident. She said the DOCR did not call her on 03/09/24. During an interview on 03/28/24 at 8:40 a.m., LVN E said on 02/18/24, Resident #38 fell out of her bed. She said Resident #38 said she was trying to get the call light cord and rolled out of the bed. She said Resident #38 did have the cord wrapped around her neck four times when she found her. She said there were no marks on Resident #38 neck after the fall. She said she did not modify her nursing note to state tangled instead of wrapped around neck. She said she believed what Resident #38 said because she was confused, and her room was dark when she arrived. She said she did not think Resident #38 was trying to harm herself. She said she did not know what interventions were put in place after that incident on 02/18/24 because she was agency staff then. She said it was ruled a fall so nothing was taken from her room or 1:1 monitoring done. During an observation on 03/28/24 at 9:00 a.m., Resident #38 was lying down in a dark room asleep. During an interview on 03/28/24 at 4:30 p.m., the SW said the psych treat and evaluation order placed on 02/15/24 was done without a discussion between the morning meeting. She said normally referrals were discussed between her and NP HH. She said then the referral was sent by fax or email to the local counseling provider. She said she preferred doing it by email. She said on 03/04/24, she did a well check and got consent for an evaluation. She said the local counseling provider normally took less than 3 weeks to see residents for services. She said telehealth could be used if needed for some residents. She said medication management was normally done by NP GG. And a Psychologist normally did the evaluations. She said the facility had a licensed counselor that served the facility. She said she did not believe the delay in psych service contributed to Resident #38's self-harming incidents. She said Resident #38 just wants to go home. On 03/29/24 at 9:46 a.m., attempted to contact NP HH by phone and text message. No response before or after exit. During an interview on 03/29/24 at 12:19 p.m., the interim DON said she was not aware of Resident #38's incident on 02/18/24. She said it looked like they tried to cover it up. She said she was also not aware of Resident #38 telling her son she wanted to walk into traffic. She said the Suicide policies should have been followed for Resident #38's incidents. She said the Suicide policies were not new and staff had been re in serviced. She said harmful items should have been removed from Resident #38's room until she was assessed. She said she expected nurses to document every 4 hours and CNAs every 15 mins when the resident is being monitored. She said Resident #38 was able to be seen on Telemed by NP GG who determined she could come off 1:1 monitoring. She said the psych referral process had always been the same and the SW was terminated for not completing them social service duties. She said it was important to take all reports of threats seriously and addressed right way to prevent something from happening. During an interview on 03/29/24 at 12:21 p.m., the Interim ADM said all suicide threats should be taken seriously. He said he expected staff to address the suicide threat or attempt immediately and follow the facility's policies. He said harmful items should be removed from the resident's room and monitoring done. He said it was to keep the resident safe. Record review of an undated facility's in-service Suicide Prevention Program revealed LVN R signature. Record review of a facility's Suicide Threats policy revised 12/07 indicated .resident suicide threats shall be taken seriously and addressed appropriately .staff shall report any resident threats of suicide immediately to the nurse supervisor/charge nurse .the nurse supervisor/charge nurse shall immediately assess the situation and shall notify the Charge nurse/Supervisor and/or Director of Nursing Services of such threats .all staff member shall remain with the resident until the nurse supervisor/charge nurse arrives to evaluate the resident . Record review of a facility's Mandatory Notifications policy revised 02/25/23 indicated .employees must immediately notify the facility Administrator and DON if any of the following events occur .resident with suicidal ideations, suicide attempts . Record review of an undated facility's Suicidal Precaution Management policy indicated .if a resident, who is voicing suicidal thoughts or attempts suicide, is a danger to self or others .physician, psychiatrist/counselor/psychologist, and family are notified immediately .referral is made at this time .suicide precautions are implemented immediately if resident is deemed to be threat to themselves or others .suicide precautions will be implemented immediately for any resident that presents with a significant level of depression or suicidal preoccupation and will be used to address the risk factors .suicide precautions include .one on one supervision .call light removed .if available, a wander device is placed on the patient's wrist or ankle .a licensed nurse will assess the resident at least every four hours and document the assessment .record that the resident as checked every fifteen minutes . Record review of an undated facility's Processing Psych Referrals policy indicated .nurse receives order for psych referral and enters matrix order .nursing to notify social services of needed referral and discuss in daily C.A.R.E meeting to ensure need for referral is communicated .social services will complete referral form/consents as required for psych referral and submit to psych provider in a timely manner .social services to follow up on resident until psych provider visit is made . 2. Record review of Resident #17's face sheet printed 03/25/24 indicated Resident #17 was [AGE] year-old, female and admitted on [DATE] with diagnosis including wedge compression fracture of first lumbar vertebra (this fracture usually occurs in the front of the vertebra, collapsing the bone in the front of the spine and leaving the back of the same bone unchanged, which results in the vertebra taking on a wedge shape). Record review of Resident #17's admission MDS assessment dated [DATE] indicated Resident #17 was understood and understood others. The MDS indicated Resident #17 had a BIMS score of 12 indicated moderate cognitive impairment. The MDS indicated Resident #17 was dependent for putting on footwear, lower body dressing, and toilet hygiene, maximal assistance for shower/bathe self, moderate assistance for oral hygiene and upper body dressing, and supervision for personal hygiene. The MDS indicated Resident #17 was dependent for toilet transfer, chair/bed-to-chair transfer, and sit to stand. Record review of Resident #17's care plan dated 01/31/24, edited on 03/19/24 indicated ADLs Functional Status/Rehabilitation Potential: About Me, My name is [Resident #17], I speak only Spanish and I can understand some English. I require two people to help me transfer. Intervention included Resident #17 needed assist with all transfers related to my diagnosis. Record review of Resident #17's care plan dated 07/28/23, edited on 03/18/24 indicated Falls: 03/11/24: Resident #17 had a fall during transfer. Intervention included in-service CNA [CNA A] to always use a gait belt during transfer and lock the wheelchair prior to transferring the resident. Record review of Resident #17's progress notes by LVN J on 03/11/24 at 8:36 a.m., indicated .patient [Resident #17] fell during transfer from bed to chair with assistance of one when wheelchair moved and patient fell .CNA [CNA A] called this SN to assess patient .on SN arrival patient lying on back on the floor trying to get up .this SN assessed patient, no injury noted .patient motioned that she had hit the back of her head, no bumps or bruising noted .patient also c/o moderate pain to lumbar region .no increased pain on palpation .spoke with admin .and instructed me to have x-rays done here .call to x-ray and paperwork sent for thoracic and lumbar x-ray to be done . Record review of Resident #17's progress notes by LVN J on 03/11/24 at 10:45 a.m., indicated .left shoulder x-ray ordered as well due to pian since fall . Record review of Resident #17's progress notes by LVN J on 03/11/24 at 3:42 p.m., indicated .all x-rays WNL, doctor notified as well as NP . Record review of Resident #17's Safety Event-Fall by LVN J, dated 03/11/24 indicated .fall location was in the resident room .transferring with assistance of 1 .witnessed fall .lumbar back pain .no injury noted .x-rays ordered to rule out back injury . During an interview on 03/29/24 at 11:01 a.m., CNA A said she started at the facility in mid-January 2024. She said CNAs did not receive gait belts until 3 weeks ago. She said the last week the ADON went to PT to figure out if Resident #17 was a 1- or 2-person transfer. She said the charge nurses were never on the same page about the amount of assistance Resident #17 required for transfer. She said the week before last was the first time a gait belt was used on Resident #17. She said when she originally hired on it was somewhere else. She said she was transferred to the floor with 1 week of shadowing another CNA. She said she felt like there was no training on how to properly do things. She said she did not know what resident needed what type of assistance for cares. She said the facility did provide in-services and trainings on transfers and things, but it was verbal and never demonstrated. She said it was important to use a gait belt to transfer for the safety of the resident. She said the resident could fall if transfers were done without gait or right amount of assistance. During an interview on 03/29/24 at 11:45 a.m., LVN J said she assessed Resident #17 after the fall on 03/11/24. She said CNA S transferred Resident #17 alone and with no gait belt. She said after the fall Resident #17 complained of pain and x-ray was done which was all fine. She said Resident #17 was a 2 person transfer assist. She said gait belts were needed to stabilize the resident and a secured hold in case she started to fall. During an interview on 03/29/24 at 12:19 p.m., the Interim DON said she expected staff to use gait belts for one and two person transfers. She said she expected the right amount of assistance to be provided to the resident according to their care plan. She said the gait belt was used for the safety of the resident. 3.Record review of the undated face sheet revealed Resident #110 was a [AGE] year-old male, admitted on [DATE] and discharged [DATE]. Resident #110 had diagnoses that included: wedge compression fracture of the fourth lumbar vertebra with routine healing (the spine weakens and crumbles, loss of bone mass), depression (loss of interest in activities causing significant impairment in daily life), atrial fibrillation (irregular impulses in the heart), and congestive heart failure (accumulation of fluids in the body). Record review of the admission MDS dated [DATE] revealed Resident #110 had a BIMS score of 11 indicating moderate cognitive impairment. The MDS indicated he had no impairment for his upper[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure each resident received necessary behavioral health care services to maintain the highest practicable mental and psychosocial wellbeing for 1 of 3 residents (Resident #38) reviewed for behavioral services. The facility did not ensure Resident #38 was seen after a counseling evaluation and treatment order was placed on 02/15/24 and a psych evaluation referral was signed by Resident #38 on 03/04/24. The facility failed to comprehensively address Resident #38's behaviors and mental distress. The facility failed to update Resident #38's care plan to reflect her increased anxiety medication needs and behaviors. An IJ was identified on 03/28/2024 at 3:45 p.m. While the IJ was removed on 03/29/2024 at 12:41 p.m., the facility remained out of compliance at a scope of a pattern with a potential for with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk for the lack of behavioral health services with the potential for emotion trauma, mental distress, and adjustment issues. Findings include: Record review of Resident #38's face sheet printed 03/25/24 indicated Resident #38 was a [AGE] year-old, female and admitted on [DATE] with diagnoses including transient cerebral ischemic attack (is a temporary blockage of blood flow to the brain), hemiplegia (paralysis of one side of the body) and hemiparesis (is a mild or partial weakness or loss of strength on one side of the body) following cerebral infarction (also known as an ischemic stroke, is the pathologic process that results in an area of necrotic tissue in the brain) affecting left non-dominant side, anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and depression (is a mood disorder that causes a persistent feeling of sadness and loss of interest). Record review of Resident #38's quarterly MDS assessment dated [DATE] indicated Resident #38 was understood and understood others. The MDS indicated Resident #38 had adequate hearing, clear speech, and adequate vision. The MDS indicated Resident #38 had a BIMS score of 13 which indicated intact cognition. The MDS indicated Resident #38 did not have behaviors such as psychosis or physical or verbal behavioral symptoms. The MDS indicated Resident #38 rated going outside to get fresh air when the weather was good as not very important. The MDS indicated Resident #38 upper extremity limitation in range of motion on one side of the body. The MDS indicated Resident #38 admission performance requirement was maximal assistance for putting on footwear, lower body dressing, and toilet hygiene and moderate assistance for oral hygiene, shower/bathe self, upper body dressing, and personal hygiene. The MDS indicated Resident #38 received antianxiety and antidepressant medication during the last 7 days of the assessment period. Record review of Resident #38's care plan dated 03/09/24, edited on 03/11/24 indicated CNA stated that Resident #38 expressed thoughts of harming self: Resident #38 was in her room with a pair of scissors, and it appears that she was trying to stab herself. Resident #38 stated that she had never thought of anything like that. And she was upset that the CNA even thought that. Interventions created on 03/11/24 included: *Nurse to assess mood and behaviors every shift and document findings. *Social services to assess mood and behavior and document findings. Record review of Resident #38's care plan dated 03/03/24, edited on 03/05/24 indicated Resident #38 had the potential for elopement. Intervention included: *Move room closer to nurse's station redirect resident to courtyard area if wanting to go outside. *Attempt to make resident feel secure/safe within facility. Record review of Resident #38's care plan dated 02/14/24, edited on 03/18/24 indicated: *Resident #38 received antidepressant medication for depression. Resident expresses feeling of depression due to long term care transition. Intervention included SW met with resident and referred to Carousel counseling (03/04/24). *Resident #38 received Ativan (antianxiety) for anxiety. On 02/21/24, Resident #38 received Buspirone (antianxiety) tablet for anxiety. The care plan did not indicate several dose changes to the Buspar due to increased anxiety. The care plan did not mention Resident #38's call to 911 due to anxiety. Record review of Resident #38's progress notes by LVN L dated 02/15/24 at 1:45 p.m., indicated .received psych orders to eval and treat from NP HH .increased Buspar (Buspirone) 10 MG BID . Record review of Resident #38's progress notes by LVN L dated 02/15/24 at 2:54 p.m., indicated .Resident #38 called 911 for herself and stated she wanted to go to the ER .Resident #38 has severe anxiety and has complaints of UTI .Notified NP HH and stated patient can go at her request .EMS arrive at 1500 . Record review of Resident #38's progress notes by LVN E dated 02/18/24 at 6:29 a.m., indicated .sn [LVN E] noted resident in floor face down in right side of bed with call light wrapped around neck 4 times .sn[LVN E] asked resident what happened resident stated she trying to get call light undone and kept wrapping it around and somehow fell .no injuries noted .no abnormalities/deformities noted .sn [LVN E] and cna assisted resident back to bed via Hoyer lift .prn pain pill administered po .residents family member notified .DON notified .NP notified by fax .neuros initiated .edited by: LVN E on 02/19/24 10:04 AM Reason: Incorrect data . Record review of Resident #38's progress notes by LVN E dated 02/18/24 at 6:29 a.m., indicated .sn [LVN E] noted resident in floor face down in right side of bed tangled in call light .sn [LVN E] asked resident what happened resident stated she trying to get call light undone and kept wrapping it around and somehow fell .no injuries noted .no abnormalities/deformities noted .sn[LVN E] and cna assisted resident back to bed via Hoyer lift .prn pain pill administered po .residents son notified .don notified .NP notified by fax .neuros initiated . Record review of Resident #38's progress notes by LVN L dated 02/19/24 at 12:02 p.m., .received new orders to increase Buspar to 10 mg 1 PO TID related to increased depression, RP notified, and orders updated . Record review of Resident #38 progress notes by LVN L dated 02/21/24 at 12:03 p.m., .Resident #38 complained of increased anxiety .notified NP HH .received new order for 1 x dose Ativan 0.5mg now for agitation . Record review of Resident #38's progress notes by LVN KK dated 02/23/24 at 3:35 p.m., indicated .Resident #38 had a crying episode and stated it was because she had an upsetting phone call with her son being mean to her . Record review of Resident #38 progress notes by LVN U dated 03/03/24 at 7:25 p.m., indicated .Resident #38 up in wheelchair, sitting inside building at the back door on the long hall .This nurse [LVN U] encouraged resident to stay inside and to notify staff if she wanted to go out .Resident #38 verbalized understanding .Approx 20 mins later, CNAs notified this nurse that they opened the door for a group of family members and noticed Resident #38 sitting outside in the driveway .Resident #38 questioned why she went outside, she stated, well, I just wanted to get a little fresh air. I wasn't going anywhere . Record review of Resident #38's progress notes by SW dated 03/04/24 at 12:07 p.m., .Resident #38 stated she is having a hard time with her new discharge plan of long-term care but has not desire to leave the facility .SW discussed a referral to local counseling provider .Resident #38 agreed to the referral . Record review of Resident #38's progress notes by LVN R dated 03/09/24 at 11:38 a.m., indicated .8:30 am .CNA [CNA S] reported to this nurse [LVN R] that found Resident [Resident #38] in her room with a pair of scissors and it appeared that she was trying to stab herself .CNA[CNA S] stated that she grabbed the scissors from the Resident and asked what are you doing? .and Resident [#38] stated I was trying to kill myself .CNA [CNA S] gave the pair of scissors to this nurse [LVN R] .the nurse went into Residents [#38] room to interview her to get her side of the story .resident [#38] stated she did not try to stab herself, and that she would never try to kill herself and that she does not have the guts to do that .DOCR went in to get a statement from resident and resident told her the same thing, that she would not ever try to kill herself . Record review of Resident #38's progress notes by the SW dated 03/19/24 at 4:55 p.m., indicated .Resident #38 discussed her difficulty with transitioning to long term care .stated she [Resident #38] didn't have anything to live for now that she is here in the facility .stated that she [Resident #38] had no plan to harm herself .she expressed her sadness about being away from her home and dog .she[Resident #38] said that the only thing she has to look forward to is the food . Record review of Resident #38's local counseling service provider prepared by SW, dated 03/04/24 indicated .reason for referral: depressive symptoms and anxiety .referral/treatment consent form and doctor's order need to be completed PRIOR TO provision of services and COPY OF EACH FAXED to .Corporate Office .along with a current face sheet .please assure there is an order reads similar to: Please refer to .Evaluation and Treatment . Record review of Resident #38's General Order dated 03/11/24 at 7:45 p.m., by the Interim DON indicated .Refer to local counseling service provider for evaluation and treatment . Record review of a local counseling service provider NP medication review for Resident #38 dated 03/11/24 at 8:00 p.m., indicated .staff requesting patient [Resident #38] to be seen for services due scissors and statement about death .telemed .anxiety level 5 (1-low 10-high) .mood level (1-poor 10-good) .thought process: other .motor activity: other .affect: other .suicidality: none .insights: fair .impulse control: fair .judgement: fair .discontinue one on one .patient [Resident #38] not suicidal .will monitor any changes . No recommendation chosen (medication change or therapy). Record review of Resident #38's local counseling psychological evaluation dated 03/13/24 indicated .the resident was referred for mental health services due to depressive symptoms and anxiety .mood: depressed mood/apathy, anxiety, loss of interest/withdrawal, helplessness, loss of energy/motivation, hopelessness .affect: restricted .recommend therapy (16-60 min 1x per/wk) . During an interview and observation on 03/25/24 at 10:55 a.m. Resident #38's room was dark and quiet. Resident #38 said she had no complaints about the facility, and nothing had happened in her bathroom recently. No fall mat was at her bedside. During an interview and observation on 03/26/24 at 11:04 a.m., Resident #38's room was dark and quiet. Fall mat noted on left side of the bed. Resident #38 said the facility added it yesterday because she had a little incident and fell out of the bed. She said the fall mat was something soft in case she fell out of the bed again. She said it had been a bad morning that day. She said CNA S had found her the wheelchair headed out the room not properly dressed. She said she did not attempt suicide with scissors. She said she was reaching for her hairbrush in the nightstand drawer and picked up the scissors instead. She said CNA S asked why she had the scissors and she told her she found them in the drawer. She said she did suffer depression and anxiety but was on medication for it. She said she really missed her dog. She said her was a certified support dog and wanted to have at the facility full time. During an interview on 03/26/24 at 4:45 p.m., CNA S said she was picking up lunch trays and looked in Resident #38's room and saw her stabbing at her stomach with scissors. She said she asked her what she was doing, and she threw the scissors in the drawer. She said Resident #38 said If it was a knife, I would have been able to cut my throat with it! She said Resident #38 put her foot up against the drawer so she could not get the scissors. She said she told Resident #38 she had to get the scissors and had to let the nurse know what was going on. She said Resident #38 said If you tell on me, I will say you hurt me! She said Resident #38's foot slipped from the drawer enough for her to get the scissors. She said she took the scissors to LVN R. She said LVN R said she would take care of it. She said Resident #38 had made other comments about hurting herself before. During an interview on 03/27/24 at 10:04 a.m., a family member of Resident #38 said he had been informed of his family members voiced suicide attempts. He said when Resident #38 got out the back door on 03/03/24 without permission, she later texted him saying she wanted to walk into traffic. He said he thought he told the case worker Resident #38 made that statement. He said Resident #38 did not have a history of suicidal ideations. He said his family member wanted to come home, but he could not care for her anymore. During an interview on 03/27/24 at 11:39 a.m., the SW said Resident #38 was anxious and depressed when she first admitted to the facility. She said she was initial supposed to go back home but changed plan and she was staying for long term care. She said Resident #38 had some adjustment issues but was on medication and psych services. She said Resident #38's family member never reported to her about her texting him she wanted to walk into traffic. She said Resident #38's family had reported attention seeking behaviors like constantly calling and how she had ruined relationships with her behavior. She said Resident #38 family member said Resident #38 would not harm herself, it was just attention seeking and she would not do it. She said she was not notified of the incident on 03/09/24 until Monday, 03/11/24, when she returned for work. She said she assessed Resident #38 on 03/11/24 and she did not make any comments of self-harm. During an interview on 03/27/24 at 12:59 p.m., LVN R said she was agency staff but had worked with Resident #38 often. She said Resident #38 had never told her she was depressed. LVN R said she went to speak to Resident #38 after CNA S brought her the scissors and told her Resident #38 tried to harm herself with them. She said CNA S told her she took the scissors from Resident #38 and asked her what she was doing. She said the first time, CNA S said Resident #38 said I don't know or I'm not doing anything. She said she went to speak with Resident #38, and she said CNA S was mad at her because she did not want to assist her to the restroom. She said Resident #38 said she would never harm herself or have the guts to do it. She said she assessed Resident #38's stomach and there were no marks or anything. During an interview on 03/28/24 at 8:40 a.m., LVN E said on 02/18/24, Resident #38 fell out of her bed. She said Resident #38 said she was trying to get the call light cord and rolled out of the bed. She said Resident #38 did have the cord wrapped around her neck four times when she found her. She said there were no marks on Resident #38 neck after the fall. She said she did not modify her nursing note to state tangled instead of wrapped around neck. She said she believed what Resident #38 said because she was confused, and her room was dark when she arrived. She said she did not think Resident #38 was trying to harm herself. She said she did not know what interventions were put in place after that incident on 02/18/24 because she was agency staff then. During an observation on 03/28/24 at 9:00 a.m., Resident #38 was lying down in a dark room asleep. During an interview on 03/28/24 at 9:15 a.m., LVN L said she had taken care of Resident #38. She said when Resident #38 was first admitted , her anxiety and depression seemed to progressively get worse every time she worked. She said she had to contact NP HH several time about Resident #38 anxiety. She said Resident #38 wanted to go to the hospital because her anxiety was so bad. She said Resident #38 was having a hard transition from being at home with her son to now in a nursing home. She said she did stay in her room a lot but was normally in pleasant mood. She said she tried to assess Resident #38 mood and address what may be causing the issue. She said Resident #38's care plan should mention her recent medication changes and behavioral issues. She said the care plan would show what had worked and if Resident #38 was improving or not. During an interview on 03/28/24 at 4:30 p.m., the SW said the psych treat and evaluation order placed on 02/15/24 was done without a discussion between the morning meeting. She said normally referrals were discussed between her and NP HH. She said then the referral was sent by fax or email to the local counseling provider. She said she preferred doing it by email. She said on 03/04/24, she did a well check and got consent for an evaluation. She said the local counseling provider normally took less than 3 weeks to see residents for services. She said telehealth could be used if needed for some residents. She said medication management was normally done by NP GG. And a Psychologist normally did the evaluations. She said the facility had a licensed counselor that served the facility. She said she did not believe the delay in psych service contributed to Resident #38's self-harming incidents. She said Resident #38 just wants to go home. On 03/29/24 at 9:46 a.m., attempted to contact NP HH by phone and text message. No response before or after exit. During an interview on 03/29/24 at 12:19 p.m., the interim DON said she was not aware of Resident #38's incident on 02/18/24. She said it looked like they tried to cover it up. She said she was also not aware of Resident #38 telling her son she wanted to walk into traffic. She said the Suicide policies should have been followed for Resident #38's incidents. She said the Suicide policies were not new and staff had been re in serviced. She said Resident #38 was able to be seen on Telemed by NP GG who determined she could come off 1:1 monitoring. She said the psych referral process had always been the same and the SW was terminated for not completing them social service duties. She said it was important to take all reports of threats seriously and addressed right way to prevent something from happening. Record review of an undated facility's Behavioral Assessment, Intervention and Monitoring policy indicated .behavioral symptoms will be identified using facility-approved behavioral screening tools and the comprehensive assessment .the nurse staff will identify, document, and inform the physician about specifics details .new onset or change in behavior will be documented regardless of the degree of risk to the resident .cause identification .emotional. Psychiatric and/or psychological stressors .functional, social or environmental factors .management .the care plan will incorporate findings from the comprehensive assessment .monitoring . Record review of an undated facility's Processing Psych Referrals policy indicated .nurse receives order for psych referral and enters matrix order .nursing to notify social services of needed referral and discuss in daily C.A.R.E meeting to ensure need for referral is communicated .social services will complete referral form/consents as required for psych referral and submit to psych provider in a timely manner .social services to follow up on resident until psych provider visit is made . The Interim ADM and Interim DON was notified this was determined to be an Immediate Jeopardy (IJ) on 03/28/24 at 3:45 p.m The Interim ADM was provided with the IJ template on 03/28/24 at 3:45 p.m. The POR was accepted on 03/29/24 at 11:07 a.m., and indicated the following: Plan of Removal F740 Immediate Actions: The Medical Director was notified of the immediate jeopardy on 3/28/2024. The resident #38 was seen on 3/09/2024 by Carousal Counseling. An emotional support visit was completed on 3/28/2024 with resident #38 and the resident was assessed for continuing thoughts of self-harm. This visit was completed by the corporate social worker. Abuse Coordinator contact information and Mandatory Notification requirements were confirmed posted at each nursing station for staff use on 3/28/2024. Resident #38's record was reviewed. The care plan was updated for the events on 2/18/24 and 3/3/24. The resident continues on weekly psychotherapy with a licensed psychologist. The provider was notified of these two events by the corporate social worker. Residents, including resident #38, were assessed to ensure no other residents were having suicidal ideations/mental distress on 3/28/2024 and 3/29/2024 by members of the corporate team, including regional nurse consultant, acting administrator and regional reimbursement director. An audit was completed to ensure all orders for psych referrals were completed. Orders for the past 60 days were reviewed. This audit was completed on 3/28/2024 by the corporate social worker. The social worker was terminated on 3/28/2024. The administrator was terminated on 3/26/2024. The previous DON was terminated on 3/08/2024 related to issues leading up to the survey. Education Provided: Direct care staff were educated on Mandatory Notifications to the facility abuse coordinator. Mandatory Notifications include Resident, Environmental and Other extraordinary events that pose a risk to resident safety, among other things. Suicidal Ideations / Attempts are included in this in-service. Direct care staff were educated on Suicide Prevention Management Policy and Procedure, which includes an overview of the steps the facility should enact in the event of suicidal ideations / attempts. These include required notifications, immediate protections and other actions required. Nursing management and social services were in-serviced on the process for managing, communicating, and completing psych referrals timely, including during the daily CARE Meeting. The social worker is responsible for ensuring psych evals are completed timely. The CARE meeting is performed by nurse management and is a review of the previous day(s) activity, including a review of nurse's notes, new orders, any events and the 24-hour report during the period reviewed. Items that require follow-up are noted and tracked until completion, including any ordered psych referrals. The ADONs, with oversight from the corporate social worker, will oversee this process in absence of a social worker. These in-services will be given by the Director of Nursing or designee starting on 3/28/2024 at 5:00PM and completed on 3/29/2024 by 12:00PM. Any staff who haven't been educated by that time will not be allowed to work until education is completed. The DON was educated by the acting administrator and corporate social worker on 3/28/2024. Policies reviewed include the Suicide Management Precaution Policy and Procedure and Abuse Prevention Program. The Psych Referral Process was updated on 3/28/2024. On 03/29/24, Five surveyors confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: Record review of Resident #38's Carousel Counseling note. Resident #38 was seen on 03/11/24, 03/13/24, 03/19/24, and 03/26/24 (Resident #38 cancelled her session due to pain). Record review of Resident #38's Corporate SW note dated 03/28/24. Resident #38 denied feelings of depression or anxiety at the time. Corporate SW spoke with NP GG this evening to request a follow up visit with resident. Record review of Resident #38 care plan dated 03/09/24, edited on 03/29/24 indicated added information of incidents on 02/15/24 (call 911 wanting to go for anxiety), 02/18/24 (Resident noted in floor with call light around neck), and 03/03/24 (found outside in parking lot). Interventions also updated to reflect Carousel Counseling visit and increase Buspar on 02/15/24. Record review of an audit of 60 residents Mood Assessments. Six resident expressed mental distress or depression. Facility has follow up in place for residents. Record review of an audit of 60 resident assessing Carousel Services in place. No issues noted. Record review of the previous SW termination letter dated 03/28/24. Termination of employment due to failed to perform social services duties by failure to complete psych reports as required. Record review of the previous ADM termination letter dated 03/27/24. discharged due to failure to perform Administrator duties. Record review of the previous DON termination letter dated 03/08/24. discharged due to failure to perform Director of Nursing duties. Record review of an In-Service Form indicated for direct care staff dated 03/28/24-03/29/24. The in-service was presented by the [NAME] President of Clinical Operation. The Topics was Abuse Prevention Program. The policy included the seven components: prevention, screening, identification, training, protection, reporting/responding, and investigation. Record review of an In-Service Form indicated for direct care staff dated 03/28/24-03/29/24. The in-service was presented by the [NAME] President of Clinical Operation. The Topics was Suicide Precaution Policy and Procedure. The policy included intervention to start, who to contact, and what to chart. Record review of an In-Service Form indicated for direct care staff dated 03/28/24-03/29/24. The in-service was presented by the [NAME] President of Clinical Operation. The Topics was Mandatory Notifications. The policy included when to notify the facility administrator and DON and what events to report. Record review of an In-Service Form indicated for direct care staff dated 03/28/24-03/29/24. The in-service was presented by the [NAME] President of Clinical Operation. The Topics was Psych Referral Process. This policy included how to initiate a psych referral, step by step process, who was responsible, and the provider the facility used with phone number. During an observation 03/29/24 at 11:22 a.m., posted Abuse Coordinator signs at nurse's station. Abuse Coordinator was the Interim ADM. During interviews conducted on 02/29/24 beginning at 11:20 a.m. through 12:25 p.m., 40 of 69 direct care in-serviced (including staff across all shifts that were upper management, AD, Treatment Nurse, MDS Coordinator, and Maintenance) were interviewed. All staff said they received education on the Abuse Prevention Program, Mandatory Notifications, Suicide Precaution Policy and Procedure, and Psych Referrals (Nurses). All staff said they received education on resident environmental and other extraordinary events that pose a risk to residents' safety, among other things, suicidal ideations/attempts, steps the facility should enact in the event of suicidal ideations/attempts, required notifications, immediate protections and other actions required, processing for managing, communicating, and completing psych referrals timely. All staff reported they would report all reports of suicidal ideation to the charge nurse, DON, and ADM. All staff reported they would not leave the resident alone until another staff member arrived. All staff reported they would remove all harmful items from the resident's room. Nursing staff reported they would document every 4 hours while the resident was on 1:1 monitoring, and the CNA staff said they documented every 15 mins. Nursing staff said when a counseling service order was placed, they would follow the psych referral process. During an interview on 03/29/24 at 12:21 p.m., the Interim DON said she was in-serviced by the Interim ADM on the Abuse Prevention Program. She said the facility was required to report to the State within 2 hours for abuse allegation. She said the facility's policy should be followed to protect the residents. She said suicide policy and procedure should be followed. She said mandatory events should be reported to the facility ADM and DON such as abuse allegation and suicide attempts. She said psych referrals will be followed through and discussed in the C.A.R.E. meetings. She said the facility performed mood assessments on all the residents and would address any signs of mental distress. The Interim ADM, DOCR, Corporate SW, and Regional Nurse were informed the Immediate Jeopardy was removed on 03/29/24 at 12:41 p.m., the facility remained out of compliance at a scope of a pattern with a potential for with a 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 observation, interview and record review the facility failed to ensure residents were free from abuse, neglect, misappropriation of resident property, and exploitation for 3 of 7 residents (Resident #2, Resident #5, and Resident #6) reviewed for abuse and neglect. The facility neglected to oversee the implementation of resident care policies and staff responsibilities. Resident #6 was transferred using a bearhug method by a sitter on 12/2/23 and an RN heard a pop during the transfer. Resident #6 had a left hip fracture. Sitters were providing care to residents that had not been trained, facility staff were aware the sitters were providing care and allowed the practice to continue. The facility failed to have a policy and procedure in place for private sitters outlining the care they could provide. The facility failed to ensure sitters were aware of what their duties were and did not perform care to residents to prevent harm. The facility failed to ensure staff did not allow sitters to preform ADL care for their residents. Resident #2 was transferred by a sitter on 2/8/24 and had a fall during the transfer. There were no interventions put into place at that time. Resident #2 had a sitter and on 2/13/24 the sitter said she performed all of Resident #2's care to include, transfers, incontinent care, and assistance with eating. Resident #2 was a 2 person transfer and the resident and the sitter said the sitter transferred her to the chair or bed unassisted. Facility staff were aware sitters were providing care to Resident #2 and Resident #5 and neglected to intervene to prevent possible harm. An Immediate Jeopardy (IJ) situation was identified on 2/14/24 at 4:40 p.m. While the IJ was removed on 2/15/24 at 5:49 p.m., the facility remained out of compliance at a scope of a pattern with the potential for with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. These deficient practices could place residents at risk of physical harm and could lead to additional pain and suffering. Findings include: 1. Record review of Resident # 6's, undated, face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #6 had diagnoses which included high blood pressure, anxiety disorder, rheumatoid arthritis, and cognitive communication deficit. Record review of Resident #6's hospice visit note, dated 11/26/23, reflected Resident #6 required a total lift or Hoyer for transfer. Record review of Resident #6's significant change MDS, dated [DATE], reflected the resident had moderate cognitive impairment. She required substantial to maximal assist with sit to stand, to move from chair to bed and toilet transfer. She used a manual wheelchair for ambulation. Record review of Resident #6 nursing note dated 12/2/23 at 1:33 p.m. indicated she was transferred from the recliner to the bed using the bear hug transfer technique by Sitter ZZ. As Resident #6 was turned to be repositioned on the bed. A loud noise was heard by the nurse and the sitter. Sitter ZZ carefully seated, the patient on the bed, and Resident #6 was assessed for pain. Resident #6's left knee had no redness, swelling or bruising. The patient expressed that her left knee was hurting, and Tylenol was given for pain. Record review of a provider investigation report dated 12/3/23 indicated on 12/2/23. The weekend RN documented she observed Sitter ZZ transfer Resident #6 from the bed to the recliner using a bear hug transfer technique. As the resident was turned the weekend RN stated she and the sitter heard a noise. Sitter ZZ carefully seated the Resident #6 on the bed. The weekend RN assessed the resident. There was no pain noted. On 12/3/23 at 8:08 p.m. the resident complained of pain in her left knee and hip. The nurse assessed the pain level at a 7 the physician was notified and ordered stat x-ray. The x-ray results indicated left femur fracture. Record review of the Provider Report with an attachment of an in serviced dated 12/3/23 that indicated nursing staff who have sitters are only allowed to sit with the residents. Ensure that our staff ( CNA, Nurses, Therapy) only provide the care and transfers to any resident who has a sitter. Another in service titled transferring indicated Resident #6 was to be transferred via to persons with a Hoyer. If a family refused the Hoyer lift the resident was to be left in bed. Resident #6 had a sitter for companionship and would not provide any care. Another in service indicated Mandatory Notifications that indicated employees must immediately notify the Administrator or DON of events that occur with the Resident or environment that could possibly be abuse, to include injury of unknown origin, fractures, and bruises. Record review of the Provider Report with an attachment dated 12/2/23 attached to the Provider Report indicated on 12/2/23 Resident #6 was transferred by the Sitter ZZ using a bear hug transfer technique to move Resident #6 from the recliner to the bed. The Sitter said she did not require assistance, as she transferred Resident #6 regularly. During the transfer an audible sound was heard. Following this the sitter carefully sat Resident #6 on the bed. Resident #6 said her left knee was hurting and requested a Tylenol. 2. Record review of Resident #2's face sheet with no date indicated she was a [AGE] year-old female admitted to the facility on [DATE]. Some of her diagnoses were high blood pressure, vascular dementia, mood disturbance, anxiety, and Parkinson's. Record review of Resident #2's admission MDS assessment dated [DATE] indicated she had severe cognitive impairment. Resident #2 required substantial to maximum assistance from lying to sit on the side of the bed. She was totally dependent for sit to stand, chair to bed mobility, and transfer to the toilet. Record review of Resident #2's care plan dated 1/18/24 indicated an acute care plan with the resident experiencing self-care deficit related to requiring assist with feeding, bathing, toileting, and self-care. Some of the approaches were staff would assist or supervise with eating at each meal. Staff would assist with transfers, sitting up, transferring to chair, and location in the room and hallways. The resident had a problem of at risk for falls due to weakness to the bilateral lower extremities and safety awareness due to a diagnosis of dementia. Record review of an event report dated 2/8/24 at 8: 00 a.m. indicated Resident #2 had a witness fall. There were no injuries noted. The event indicated, assisted sitter with transfer of resident, advised sitter not to transfer alone, and instructed sitter on proper use of the gate belt. Record review of resident #2 Nurses notes dated 2/8/24 indicated the nurse was called to the room. Upon entrance to the room the resident was noticed sitting on the floor in front of her recliner with a sitter standing at the side. The sitter stated she witnessed the resident slide to the floor. The resident denied pain and discomfort. No injuries were noted at this time. Once level of safety was determined, this nurse and the residence sitter assisted the resident back in the chair. During an observation and interview on 2/13/24 Resident #2 was sitting up in the recliner with covers pulled up to her neck. There were so heel protector boots on the nightstand. She appeared some what confused at that time. During an interview on 2/13/24 at 9:57 a.m. CNA B an agency aide said she worked yesterday. She said Resident#2 was very confused. She said Resident #2 had a sitter from 8:00 a.m. to 5:00 p.m. CNA B said she did not know anything about the boots on the nightstand. She said the sitter was the one that got the resident up and she did not know what the boots were for. CNA B said the sitter was the one that took care of the resident. She said that the sitter got Resident #2 up to the wheelchair for therapy. During an interview on 2/13/24 at 10:05 a.m. LVN G said she was the nurse for Resident # 2. She said Resident #2 had a sitter in the morning and the sitter did everything for the Resident #2. LVN B said sometimes they have different sitters, and some would ask for help when they needed help. During an interview on 2/13/24 at 10:05 a.m. CNA D said she was a full-time staff and did not have any residents with sitter. She said knew some of the sitters provided more care to residents and some did not. During an interview and observation on 2/13/24 at 1:25 p.m. Resident #2 was noted with Sitter BB assisting the resident with eating her lunch. The resident was accepting spoons filled with food when they were presented to her mouth. Sitter BB said she was in the facility it was her job to change, feed, and transfer the resident. She said Resident #2 was her responsibility. Sitter BB said this was her third day working with the resident. She said it was in her job description from the company that she worked for that she was supposed to bath, dress, transfer, feed, and provide incontinent care. She said the resident had been sitting in the chair all day and likely needed to be changed. Sitter BB said she was going to transfer the resident from the recliner to the bed and change her. Resident #2 said she could not bear any weight. The Investigator asked Sitter BB if she got assistance from the staff and she said no, they were too slow. She said by the time they got there she could have the resident changed. She said it was not right for the resident to be left wet so long and the staff did not provide care. Sitter BB was determined about transferring the resident unassisted and the Investigator suggested she wait until staff could be located to assist her. During an interview and observation on 2/13/24 at 1:29 p.m. Corporate RN came to Resident #2's room. She told Sitter BB that Resident #2 was a two person transfer and required two people to safely transfer. The Corporate RN told Sitter BB she should not be transferring Resident #2 alone. The Corporate RN told the sitter the aide and a PTA were coming to transfer Resident #2. During interview and observation on 2/13/24 at 1:31 p.m. CNA B said Resident #2 was a two-person transfer. She said she had used the sit to stand lift to get the resident up and change her about 11:30 a.m. to 11:45 a.m. The CNA said she and CNA D had gotten the resident up. CNA B said and then she brought the food tray to Resident #2. When asked how the regular sitter for Resident #2 changed Resident #2. CNA B said she did not know how she changed her all she knew was that she put the dirty things outside the door to be picked up. During an observation and interview on 2/13/24 at 1:40 p.m. the sitter said she was upset because it was taking the staff so long to come and transfer the resident. She was making comments about transferring Resident #2 herself. The investigator asked her to please wait for the safety of the resident. CNA B brought a sit to sand lift into the room. The sitter said she had not seen one of those in the room and did not know how to use it. She said she was not a CNA, and no one had instructed her on how to transfer or care for Resident #2 Observation at 1:45 p.m. PTA and the CNA B using the sit to stand lift to raise the resident out of her chair. The pulled down her pants and dropped the brief which was saturated and heavy. Her pants and the chair appeared dry. The resident said, y'all are going to stand me up and change me. As if that was new to her. During an interview on 2/13/24 at 1:47 p.m. the PTA said usually when she arrived in the room the morning sitter already had Resident #2 sitting in the wheelchair. She said it should be two people to transfer Resident #2 the resident did bear any weight. During an interview on 2/13/24 at 1:50 p.m. CNA D said she did see the CNA B with the lift but she did not assist her with changing Resident #2 She said she had not been Resident #2's room today. The CNA B confronted CNA D about helping her change Resident #2. CNA D still Resident #2 room and she did not assist with a transfer or her care. During an interview on 2/13/24 at 2:30 p.m. Corporate RN said they did not have a sitter policy and they had two residents with sitters. Resident #2 and Resident #5. During an interview on 2/13/24 at 5:20 p.m. Administrator said they had not taken the sitter issue to QA with the sitter transferring the resident and her falling in December 2023. She said they let the sitters know they were not supposed to be providing care and did an in service with the sitter at that time. Resident #6 had since transferred. The Administrator said she did not know Resident #2 had fallen while a sitter was trying to transfer her. She said they had met with the families in December 2023 when the incident occurred with Resident #6. She said had met with all the families at that time and told them no ADL care was allowed by sitters. The Administrator said she was not aware the sitters had continued to provide care to the Residents. During interview on 2/13/24 at 5:24 p.m. the Corporate RN said staff are supposed to notify the DON and they were [NAME] serviced on today that sitters are for companionship only they are not to provide care. She said the Visitation policy they have said the sitters were for companionship only. The Corporate RN said , they have called the family to let them know the sitters are only for companionship. During interview on 2/14 /24 at 3:31 p.m. DON said no one had notified her that sitters were providing care. She said she had told families before sitters were for companionship only. She said they had conducted an Inservice in December 2023 about sitters. During an interview on 2/14/24 at 3:40 p.m. LVN J said the sitter had been providing care to Resident #2. She said she was very pleasant and appeared to think that it was her job to provide care because the family wanted Resident #2 back at the assisted living. She said on today the sitter had a hard time understanding why she could no longer provide care. During an interview on 2/14/24 at 3:45 p.m. PTA said the sitter was the one that transferred Resident #2 and she knew that she did it by herself because she had told her so. PTA said all the staff knew she was transferring the resident unassisted. She said she had glanced in the room once and saw her transferring the resident. The resident was sitting on the side of the bed and had the gait belt around her. There was no one else in the room the sitter kind of hugged her and placed her in the chair. She said the family said that one person could transfer her safety. She said she told the staff at the assisted living that was not how they transfer, and they required two people for a safe transfer. During an interview on 2/15/24 at 3:00 p.m. Sitter CC said prior to yesterday, she did everything for Resident #5. She said Resident #5 no longer got out of bed, but she felt Resident #5 was her total responsibility. She said now she had been told not to touch her at all. She was to pull the call light if the resident required assistance. She said she got her this morning at 8:30 a.m. and the resident was wet. She pulled the call light at 9:43 a.m. the girl came in and told her she had a shower, and the resident was not changed until 10:48 a.m. She said she had read the policy and signed the form, but it was hard to not do anything for the resident. During an interview on 2/15/24 at 3:31 p.m. DON said she was not aware the sitters were providing care to residents. She said had a conversation with Resident #2 family member. He appeared to encourage the sitters to provide care to Resident #2 he wanted her to go back to the assisted living facility. She had talked to him in the past and talked to him again on yesterday and he agreed the sitter was companionship only. She said they had in service staff, any new staff that comes on that sitters are only here for companionship and not to do any ADL care. The sitters have a siter agreement that they must sign in agreement, and they all work for same company. The company said they are not supposed to provide care, but Resident #2's family had a problem they wanted them to provide care. She said she told the staff that that was a form of neglect, if they did not provide the care the residents required . During an interview on 2/15/24 at 3:59 p.m. CNA E said on yesterday Sitter CC was upset because she said she normally did everything for Resident #5 and she was not allowed to provide care. During an interview on 2/15/24 at 4:30 p.m. LVN J said- said she had two residents with sitters on her hall Resident #2 and Resident #5. She said Resident# 5 was relatively new and was admitted this week. She said Resident #5 had sitters 24 hours a day per the family. She said Resident #2's sitters wanted to take care of her and tried their best to do so. She said one of the sitters had let Resident #2 fall during a transfer about a week ago. Apparently, she put a gait belt on the resident not tight enough and Resident#2 slid out to the floor. Record review of the facility Visitation police dated 4/22/22 indicated the facility permits, residents to receive visitors subject to the residents wishes and the protections of the rights of other residents in the facility. Sitters (no care duties allowed) approved by resident and or family. Record Review of a Safe Lifting and Movement of Residents policy dated 8/17/23 indicated protect the safety and wellbeing of staff and residents and to promote quality of care, this policy is to identify appropriate techniques and devices to live and move residents. Resident safety, dignity, comfort, and medical condition will be incorporated into the goals and decisions regarding the safe lifting and moving of residents. Manual lifting of resident's shell be eliminated when feasible. Staff responsible for direct resident care will be trained in the use of manual (gait/transfers belts, lateral boards) and mechanical lifting devices. Mechanical lifting devices shall be used for heavy lifting, including lifting, and moving residents when necessary. Staff will be observed for competency in using mechanical lifts, and observed periodically for adherence to polices, and procedures regarding the use of equipment and safe lifting techniques. Record review of the Abuse and Neglect Clinical Protocol, dated 4/8/21, reflected Neglect is defined as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The Administrator or designee and staff will help identify potential or actual abuse or neglect with the facility for example, problematic family issues, problems related to staff knowledge, skill or performance that might affect how the residents are being cared for. Recurrent failure to provide incontinent care. Upon receiving an allegation of abuse committed against a resident staff must ensure the safety of the resident immediately and notify the supervisor. This was determined to be an Immediate Jeopardy (IJ) on 2/14/24 at 4:40 p.m. The Administrator, Regional Nurse Consultant, VP of Clinical Services and Regional Director of Marketing were notified. The Administrator was provided with the IJ template on 2/14/24 at 4:40 p.m The following Plan of Removal submitted by the facility was accepted on 02/15/24 at 3:29 p.m. Plan of Removal F600 Neglect Failures: o Provide oversight to prevent untrained private sitters from providing ADL care to facility residents. o Oversee the implementation of resident care policies and staff responsibilities. Plan of Removal 1. Immediate actions o Instructed existing sitters (2) on 2/13/24 at 1:30 PM that they are not allowed to provide ADL care. o May not administer Direct Care to the resident. Direct Care includes, but is not limited to, transferring the resident, providing incontinent care, providing assistance with feeding, repositioning, toileting, bathing and dressing, wound care and administering medications, (including over-the-counter medications and supplements). o May monitor patient needs, report issues, ensure patient comfort (e.g., changing bedding, filling water jugs and positioning items within reach) and provide companionship. o Will assist facility to maintain, create and provide a safe environment for the patient. o Must report to the Nurse Supervisor/Charge Nurse when coming on and going off duty. o Must report changes in a resident's condition to the Nurse Supervisor/Charge Nurse immediately. o All residents with sitters (2) were assessed head to toe for any injuries on 2/13/24 at 1:30pm o Notified RP of residents with sitters in place of Facility Sitter Policy. o Family responsible to notify facility of private duty sitter. o Residents/responsible party desiring the use of private duty sitters must first obtain written approval Facility by reviewing and signing the Facility Sitter Agreement. o Private Duty Sitters are required to sign in at nurses station prior to start of shift. Binder at nurses station with sign in sheet for private duty sitters. Charge nurses in-serviced on process of private duty sitters' requirement to sign in and provided Private Duty Sitter Acknowledgement forms to be completed. o Facility staff to monitor private duty sitters as they are rounding to ensure no private duty sitters are providing ADL care. o The Medical Director was notified by the Director of Nursing on 02/14/2024 at 5:00 PM. 2. Education (Administrator/Regional Nurse) o Personal and private sitters in-serviced on Facility Sitter Policy on 2/13/24. Education provided on following: o May not administer Direct Care to the resident. Direct Care includes, but is not limited to, transferring the resident, providing incontinent care, providing assistance with feeding, repositioning, toileting, bathing and dressing, wound care and administering medications, (including over-the-counter medications and supplements). o May monitor patient needs, report issues, ensure patient comfort (e.g., changing bedding, filling water jugs and positioning items within reach) and provide companionship. o Will assist facility to maintain, create and provide a safe environment for the patient. o Must report to the Nurse Supervisor/Charge Nurse when coming on and going off duty. o Must report changes in a resident's condition to the Nurse Supervisor/Charge Nurse immediately. o Nurse Administrative Staff/Direct Care Staff educated on Facility Sitter Policy on 2/13/24. Agency Provider Companies to be notified on 2/14/24 of need for all agency staff to review Private Duty Sitter Policy prior to start of shift at Summer Meadows. To be completed by 2/14/24 at 5:00 PM. All future facility staff will be in-serviced upon hire. o Private Duty Sitter Acknowledgement to be signed for residents with current sitters by 2/14/24 and reviewed with future sitters as they are assigned to residents. o Facility Administrative Staff/Nurses/CNA/Agency staff were in-serviced on 2/13/24 by ADON and Regional Nurse on their job duties related to residents with private duty sitters present on providing all ADL care by (facility) staff only, private duty sitter policy and agreement o All facility staff in-serviced by Administrator/DON/ADON's on Abuse and Neglect, covering prevention, screening, identification, training, protection, reporting/responding and investigation, including all ADL care to be provided by (facility) staff regardless of sitter on 2/14/24 at 5:00 PM. Staff who are out on vacation, FMLA, or PRN will be in-serviced prior to next scheduled work shift. 3. Medical Director - The Medical Director has been notified of the Immediate Jeopardy. 4. QAPI Committee Review - An interim QAPI committee meeting was completed on 02/14/2024. 5. Plan of removal date: 02/14/2024] Monitoring of the POR on 02/15/24 included the following: Record review of the Private Duty Sitter Agreement with no date indicated: by signing below we agree to the following. The sitter is an employee of the family, failure to meet the guidelines or interference in the care of other patients could result I the sitter not being allowed to work in the facility. The sitter will be required to adhere to the responsibilities listed below. Th sitter May Not administer direct care to the resident. Direct care includes, transferring, providing incontinent care, assistance with eating, reposition, toileting, bathing and dressing, wound care administering medications including over the counter. They must report when coming on and going off duty, monitor the patient needs and report issues. Record review of Resident #5's nursing notes dated 2/13/24 at 2;50 p.m. p.m. indicated the RN spoke with the POA. He as reminded sitters for Resident #2 need to always call for assistance when performing any care for the resident. He was informed he needed to alert the sitters that sit with her daily. Record review of Resident #2's nursing notes dated 2/13/24 at 6:31 p.m. indicated the RN spoke with the POA. He as reminded sitters for Resident #2 need to always call for assistance when performing any care for the resident. He was informed he needed to alert the sitters that sit with her daily. Interviews with facility staff: At 3:35 p.m. LVN A- agency work all shifts At 3:59 p.m. CNA E said she worked all shifts At 4:10 p.m. CNA F worked 2p to 10 p At 4:15 p.m. CNA H worked 6a to 6p and sometimes 6p to 10 p. At 4:22 LVN I worked 6a to 6p At 4:30 p.m. LVN J worked 6a to 6p At 4:40 p.m. CNA K worked 2p to 10 p At 4:49 p.m. CNA L agency worked 6a to 6p and all shifts At 4:45 p.m. CNA M worked 6a to 6p At 5:01 p.m. MA worked 6:30 a.m. to 6:30 p.m. Interviews with staff indicated they were knowledgeable about the in-services provided. They were able to voice their knowledge of the sitter policy, the sitter books located at the nurse's station. They voiced if they saw a sitter providing ADL care to a resident, they would intervene to ensure the resident safety. Then they would inform the charge nurse, and or DON. They also indicated staff not providing care to residents could be a form of neglect, and allowing sitter to perform care they were not trained to provide could be neglect. During an interview on 2/15/24 at 5:05 p.m. the family member of Resident #5 said they were informed that sitters were no longer to provide personal care to the residents. The family member said she understood but was concerned Resident #6 would not receive timely care. During an interview on 2/15/24 at 5:10 p.m. Sitter DD the evening sitter f for Resident #5 said she was made aware today that she could no longer provide care to the resident. She said this was her first day back this week. The sitter said in the past she had provided ADL care to Resident #5 but would comply with the new rules. During an interview on 2/15/24 at 5:15 p.m. the DON said she had been out sick and not aware they had a new resident, Resident #6. She said she had just gotten back from sick leave yesterday and was not aware the new admissions. The census indicated the resident was admitted on Monday. The DON said she was not aware there was an incident on 2/8/24 when the sitter was transferring Resident #2 fall and she fell. She said they had the sitter books at the nurse's station and sitters were to sign in and out so they knew who was in the building. The DON said if the sitter was new the Charge nurse would have them read and sign the sitter policy. If there were any problems the staff were aware they could contact her for assistance. The aides and nurses were also aware if they saw any sitter breaking the policy by providing care they were to intervene and let the charge nurse, and DON know. During an interview on 2/15/24 at 5:20 p.m. Sitter EE said she was providing care to Resident #2 before and did not understand why she could not continue. She said had been a CNA for 5 years. She had provided all care, assistance with eating, transfers, and incontinent care the staff were aware and just left them alone. She said on yesterday, LVN J and the DON explained to her she was not supposed to provide any care and she signed the form stating she understood. During an interview on 2/15/24 at 5:25 p.m. the two sitters with Resident #6 Sitter GG said she was going home, and Sitter HH said she was coming on. They said they were aware they were not to provide any care Resident #6 they were there for companionship only. They said they understood their duties and had not proved care to the resident while she was at the facility. They were informed by the facility staff and had signed the form. During an observation on 2/15/24 at 5:30 p.m. of the north wing nurses' station had a sitter book with the sitter policy, and the signatures of the sitters and a sign in and out sheet. During an observation on 2/15/24 at 5:32 p.m. of the East wing nurses' station had a sitter book with the sitter policy, and the signatures of the sitters and a sign in and out sheet. During an interview on 2/15/24 at 5:35 p.m. the Administrator said they had met with the Director of the company all the sitters worked for today and told them they did not want the sitters providing ADL care to the residents. The Director of the sitter company had agreed. They had spoken to the families via telephone and one family in person and they said they understood. She said they had taken the concerns with sitters and neglect to the QA meeting. The Medical Director was involved via phone. The administrator said they had placed the sitter books at the nurse's station and all sitters were to sign in and out. if it was a new sitter the charge nurse would go over the policy with them and have them to sign. The Administrator said that staff were aware they were to notify the DON or Administrator if they noticed any sitter breaking the policy. She said staff were aware that not providing care to residents could be a form of neglect. The Administrator, DON, Regional Nurse Consultant and VP of Clinical Services were informed the Immediate Jeopardy was removed on 2/15/24 at 5:49 p.m. The facility remained out of compliance at a severity level of potential harm with a scope of a pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure residents environment remained as free of accident hazards as possible and each resident received adequate supervision and assistance devices to prevent accidents for 3 of 7 residents ( Resident #2, Resident #5 and Resident #6) and 5 of 7 sitters (Sitters BB, CC, EE, DD and ZZ ) reviewed for accidents and supervision. 1. The facility failed to ensure Resident #6 was appropriately transferred. The resident was transferred using a bearhug method by Sitter ZZ on 12/2/23 and an RN heard a pop during the transfer. Resident #6 had a left hip fracture. 2. The facility failed to have a policy and procedure in place for private sitters outlining the care they could provide. 3. The facility failed to ensure sitters were aware of what their duties were and did not perform care to residents to prevent harm. 4. The facility failed to ensure staff did not allow sitters (Sitters, BB, CC, EE, DD, and ZZ) to preform ADL care for their residents. 5. The facility failed to ensure interventions were put into place after Resident #2 was transferred by a sitter (unknown) on 2/8/24 and had a fall during the transfer. 6. The facility failed to ensure Sitter BB did not perform care to include, transfers, incontinent care, and assistance with eating for Resident #2. 7. The facility failed to ensure Resident #2 was appropriately transferred by a two person transfer. Resident #2 was transferred by the sitter to the chair or bed unassisted. An Immediate Jeopardy (IJ) situation was identified on 2/13/24 at 5:26 p.m. While the IJ was removed on 2/15/24 at 5:49 p.m. p.m., the facility remained out of compliance at a scope of a pattern with a potential for with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. These deficient practices could place residents at risk to physical harm and could lead to additional pain and suffering. Findings include: 1. Record review of Resident # 6's, undated, face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #6 had diagnoses which included high blood pressure, anxiety disorder, rheumatoid arthritis and cognitive communication deficit. Record review of Resident #6's hospice visit note, dated 11/26/23, reflected Resident #6 required total lift or Hoyer for transfer. Record review of Resident #6's significant change MDS, dated [DATE], indicated the resident had moderate cognitive impairment. She required substantial to maximal assist with sit to stand, to move from chair to bed and toilet transfer. She used a manual wheelchair for ambulation. Record review of Resident #6's nursing note, dated 12/2/23 at 1:33 p.m., reflected she was transferred from the recliner to the bed using the bear hug transfer technique by Sitter ZZ. As Resident #6 was turned to be repositioned on the bed. A loud noise was heard by the nurse and the sitter. Sitter ZZ carefully seated, the patient on the bed, and Resident #6 was assessed for pain. Resident #6's left knee had no redness, swelling or bruising. The patient expressed that her left knee was hurting, and Tylenol was given for pain. Record review of a provider investigation report, dated 12/3/23, reflected on 12/2/23 the weekend RN documented she observed Sitter ZZ transfer Resident #6 from the bed to the recliner using a bear hug transfer technique. As the resident was turned the weekend RN stated she and the sitter heard a noise. Sitter ZZ carefully seated Resident #6 on the bed. The weekend RN assessed the resident. There was no pain noted. On 12/3/23 at 8:08 p.m. the resident complained of pain in her left knee and hip. The nurse assessed the pain level at a 7 the physician was notified and ordered stat x-ray. The x-ray results indicated a left femur fracture. Record review of the Provider Report with an attachment of an in-serviced, dated 12/3/23, reflected nursing staff who have sitters are only allowed to sit with the residents. Ensure that our staff (CNA, Nurses, Therapy) only provide the care and transfers to any resident who has a sitter. Another in-service titled transferring indicated Resident #6 was to be transferred via two persons with a Hoyer. If a family refused the Hoyer lift the resident was to be left in bed. Resident #6 had a sitter for companionship and would not provide any care. Another in-service indicated Mandatory Notifications which indicated employees must immediately notify the Administrator or DON of events that occur with the resident or environment that could possibly be abuse, to include injury of unknown origin, fractures, and bruises. Record review of the Provider Report, with an attachment of a statement, written by RN Supervisor, dated 12/2/23, reflected on 12/2/23 Resident #6 was transferred by Sitter ZZ using a bear hug transfer technique to move Resident #6 from the recliner to the bed. The Sitter said she did not require assistance, as she transferred Resident #6 regularly. During the transfer an audible sound was heard. Following this the sitter carefully sat Resident #6 on the bed. Resident #6 said her left knee was hurting and requested a Tylenol. 2. Record review of Resident #2's, undated, face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #2 had diagnoses which included high blood pressure, vascular dementia, mood disturbance, anxiety and Parkinson's. Record review of Resident #2's admission MDS assessment, dated 1/23/24, reflected she had severe cognitive impairment. Resident #2 required substantial to maximum assistance from lying to sit on the side of the bed. She was totally dependent for sit to stand, chair to bed mobility and transfer to the toilet. Record review of Resident #2's care plan, dated 1/18/24, indicated an acute care plan with the resident experiencing self-care deficit related to requiring assist with feeding, bathing, toileting, and self-care. Some of the approaches included staff would assist or supervise with eating at each meal. Staff would assist with transfers, sitting up, transferring to chair, and location in the room and hallways. The resident had a problem of at risk for falls due to weakness to the bilateral lower extremities and safety awareness due to a diagnosis of dementia. Record review of an event report, dated 2/8/24 at 8: 00 a.m., reflected Resident #2 had a witnessed fall. There were no injuries noted. The event indicated, assisted sitter with transfer of resident, advised sitter not to transfer alone, and instructed sitter on proper use of the gait belt. Record review of Resident #2 Nurses notes, dated 2/8/24, reflected the nurse was called to the room. Upon entrance to the room the resident was noticed sitting on the floor in front of her recliner with a sitter standing at the side. The sitter stated she witnessed the resident slide to the floor. The resident denied pain and discomfort. No injuries were noted at this time. Once level of safety was determined, this nurse and the residence sitter assisted the resident back in the chair. During an observation on 2/13/24 revealed Resident #2 was sitting up in the recliner with covers pulled up to her neck. She appeared somewhat confused at that time. During an interview on 2/13/24 at 9:57 a.m., CNA B, an agency aide, said she worked yesterday. She said Resident #2 was very confused. She said Resident #2 had a sitter from 8:00 a.m. to 5:00 p.m. CNA B said she did not know anything about the boots on the nightstand. She said the sitter was the one who got the resident up and she did not know what the boots were for. CNA B said the sitter was the one that took care of the resident. She said the sitter got Resident #2 up to the wheelchair for therapy. During an interview on 2/13/24 at 10:05 a.m., LVN G said she was the nurse for Resident # 2. She said Resident #2 had a sitter in the morning and the sitter did everything for the Resident #2. LVN B said sometimes they had different sitters, and some would ask for help when they needed help. During an interview on 2/13/24 at 10:05 a.m., CNA D said she was a full-time staff and did not have any residents with sitters. She said she knew some of the sitters provided more care to residents and some did not. During an interview and observation on 2/13/24 at 1:25 p.m., Resident #2 was noted with Sitter BB assisting the resident with eating her lunch. The resident was accepting spoons filled with food when they were presented to her mouth. Sitter BB said she was in the facility it was her job to change, feed and transfer the resident. She said Resident #2 was her responsibility. Sitter BB said this was her third day working with the resident. She said it was in her job description from the company that she worked for that she was supposed to bath, dress, transfer, feed and provide incontinent care. She said the resident had been sitting in the chair all day and likely needed to be changed. Sitter BB said she was going to transfer the resident from the recliner to the bed and change her. Resident #2 said she could not bear any weight. Sitter BB stated she didn't receive assistance from the staff and stated they were too slow. She said by the time they got there she could have the resident changed. She said it was not right for the resident to be left wet so long and the staff did not provide care. Sitter BB was determined about transferring the resident unassisted and the State Surveyor suggested she wait until staff could be located to assist her. During an observation on 2/13/24 at 1:29 p.m., the Corporate RN came to Resident #2's room. She told Sitter BB Resident #2 was a two person transfer and required two people to safely transfer. The Corporate RN told Sitter BB she should not be transferring Resident #2 alone. The Corporate RN told the sitter the aide and a PTA were coming to transfer Resident #2. During interview and observation on 2/13/24 at 1:31 p.m., CNA B said Resident #2 was a two-person transfer. She said she used the sit to stand lift to get the resident up and change her about 11:30 a.m. to 11:45 a.m. The CNA said she and CNA D had gotten the resident up. CNA B said then she brought the food tray to Resident #2. When asked how the regular sitter for Resident #2 changed the resident, CNA B said she did not know how she changed her all she knew was she put the dirty things outside the door to be picked up. During an observation and interview on 2/13/24 at 1:40 p.m., the Sitter said she was upset because it was taking the staff too long to come and transfer the resident. She made comments about transferring Resident #2 herself. The State Surveyor asked her to please wait for the safety of the resident. CNA B brought a sit to sand lift into the room. The sitter said she had not seen one of those in the room and did not know how to use it. She said she was not a CNA, and no one had instructed her on how to transfer or care for Resident #2. Observation at 1:45 p.m. revealed the PTA and CNA B used the sit to stand lift to raise the resident out of her chair. They pulled down her pants and dropped the brief which was saturated and heavy. Her pants and the chair appeared dry. The resident said, y'all are going to stand me up and change me? As if that was new to her. During an interview on 2/13/24 at 1:47 p.m., the PTA said usually when she arrived in the room the morning sitter already had Resident #2 sitting in the wheelchair. She said it should be two people transferring Resident #2, the resident did bear any weight. During an interview on 2/13/24 at 1:50 p.m., CNA D said she saw CNA B with the lift, but she did not assist her with changing Resident #2. She said she had not been in Resident #2's room today. CNA B confronted CNA D about helping her change Resident #2. CNA D still Resident #2 room and she did not assist with a transfer or her care. During an interview on 2/13/24 at 2:30 p.m., Corporate RN said they did not have a sitter policy and they had two residents with sitters, Resident #2 and Resident #5. During an interview on 2/13/24 at 5:20 p.m., the Administrator said they had not taken the sitter issue to QA with the sitter transferring the resident and her falling in December 2023. She said they let the sitters know they were not supposed to be providing care and did an in service with the sitter at that time. Resident #6 had since transferred. The Administrator said she did not know Resident #2 had fallen while a sitter was trying to transfer her. She said they had met with the families in December 2023 when the incident occurred with Resident #6. She said she met with all the families at that time and told them no ADL care was allowed by sitters. The Administrator said she was not aware the sitters continued to provide care to the residents. During an interview on 2/13/24 at 5:24 p.m., the Corporate RN said staff were supposed to notify the DON and they were [NAME]-serviced today (02/13/24) that sitters were for companionship only and they were not to provide care. She said the Visitation policy they had said the sitters were for companionship only. The Corporate RN said they called the families to let them know the sitters were only for companionship. During interview on 2/14/24 at 3:31 p.m., the DON said no one notified her that sitters were providing care. She said she told families before sitters were for companionship only. She said they conducted an In-service in December 2023 about sitters. During an interview on 2/14/24 at 3:40 p.m., LVN J said the sitter was providing care to Resident #2. She said she was very pleasant and appeared to think that it was her job to provide care because the family wanted Resident #2 back at the assisted living. She said today the sitter had a hard time understanding why she could no longer provide care. During an interview on 2/14/24 at 3:45 p.m., PTA said the sitter was the one who transferred Resident #2 and she knew she did it by herself because she had told her. PTA said all the staff knew she was transferring the resident unassisted. She said she had glanced in the room once and saw her transferring the resident. The resident was sitting on the side of the bed and had the gait belt around her. There was no one else in the room the sitter kind of hugged her and placed her in the chair. She said the family said one person could transfer her safety. She said she told the staff at the assisted living that was not how they transferred, and they required two people for a safe transfer. During an interview on 2/15/24 at 3:00 p.m. Sitter CC said prior to yesterday, she did everything for Resident #5. She said Resident #5 no longer got out of bed, but she felt Resident #5 was her total responsibility. She said now she was told not to touch her at all. She was to pull the call light if the resident required assistance. She said she got her this morning at 8:30 a.m. and the resident was wet. She pulled the call light at 9:43 a.m. the girl came in and told her she had a shower, and the resident was not changed until 10:48 a.m. She said she read the policy and signed the form, but it was hard to not do anything for the resident. During an interview on 2/15/24 at 3:31 p.m., the DON said she was not aware the sitters were providing care to residents. She said she had a conversation with Resident #2's family member. He appeared to encourage the sitters to provide care to Resident #2 he wanted her to go back to the assisted living facility. She talked to him in the past and talked to him again on yesterday and he agreed the sitter was companionship only. She said they had in-serviced staff, any new staff that came on, that sitters were only there for companionship and not to do any ADL care. The sitters had a sitter agreement that they must sign in agreement, and they all worked for same company. The company said they were not supposed to provide care, but Resident #2's family had a problem they wanted them to provide care. She said she told the staff that was a form of neglect, if they did not provide the care the residents required. During an interview on 2/15/24 at 3:59 p.m., CNA E said yesterday Sitter CC was upset because she said she normally did everything for Resident #5, and she was not allowed to provide care. During an interview on 2/15/24 at 4:30 p.m., LVN J said she had two residents with sitters on her hall Resident #2 and Resident #5. She said Resident #5 was relatively new and was admitted this week. She said Resident #5 had sitters 24 hours a day per the family. She said Resident #2's sitters wanted to take care of her and tried their best to do so. She said one of the sitters had let Resident #2 fall during a transfer about a week ago. LVN J stated the sitter put a gait belt on the resident not tight enough and Resident #2 slid out to the floor. Record review of the facility Visitation policy, dated 4/22/22, reflected the facility permits, residents to receive visitors subject to the residents wishes and the protections of the rights of other residents in the facility. Sitters (no care duties allowed) approved by resident and or family. Record review of a Safe Lifting and Movement of Residents policy, dated 8/17/23, reflected protect the safety and well-being of staff and residents and to promote quality of care, this policy is to identify appropriate techniques and devices to live and move residents. Resident safety, dignity, comfort, and medical condition will be incorporated into the goals and decisions regarding the safe lifting and moving of residents. Manual lifting of resident's shall be eliminated when feasible. Staff responsible for direct resident care will be trained in the use of manual (gait/transfers belts, lateral boards) and mechanical lifting devices. Mechanical lifting devices shall be used for heavy lifting, including lifting, and moving residents when necessary. Staff will be observed for competency in using mechanical lifts, and observed periodically for adherence to polices, and procedures regarding the use of equipment and safe lifting techniques. This was determined to be an Immediate Jeopardy (IJ) on 2/13/24 at 5:26 p.m. The Administrator, Regional Nurse Consultant, VP of Clinical Services and Regional Director of Marketing were notified. The Administrator was provided with the IJ template on 2/13/24 at 5:26 p.m. The following Plan of Removal submitted by the facility was accepted on 02/14/24 at 2:45 p.m.: Plan of Removal F689 Supervision to Prevent Accidents Failures: o Ensure Resident #6 received ADL care and was transferred in the correct way by facility staff. o Ensure Resident #2 received ADL care from facility staff. o Ensure the facility had policy and procedures in place for private sitters outlining the care they can provide. o Ensure personal/private sitters were aware of what their duties were and did not perform care to residents to prevent harm. o Ensure facility staff were aware they were to provide care to Resident #2 when the sitters were at the facility. Plan of Removal 1. Immediate actions o Instructed existing sitters (2) on 2/13/24 at 1:30 PM that they are not allowed to provide ADL care. o May not administer Direct Care to the resident. Direct Care includes, but is not limited to, transferring the resident, providing incontinent care, providing assistance with feeding, repositioning, toileting, bathing and dressing, wound care and administering medications, (including over-the-counter medications and supplements). o May monitor patient needs, report issues, ensure patient comfort (e.g., changing bedding, filling water jugs and positioning items within reach) and provide companionship. o Will assist facility to maintain, create and provide a safe environment for the patient. o Must report to the Nurse Supervisor/Charge Nurse when coming on and going off duty. o Must report changes in a resident's condition to the Nurse Supervisor/Charge Nurse immediately. o Notified RP of residents with sitters in place of Facility Sitter Policy. o Family responsible to notify facility of private duty sitter. o Residents/responsible party desiring the use of private duty sitters must first obtain written approval Facility by reviewing and signing the Facility Sitter Agreement. o Private Duty Sitters required to sign in at nurses station prior to start of shift. Binder at nurses station with sign in sheet for private duty sitters. Charge nurses in-serviced on process of private duty sitters requirement to sign in and provided Private Duty Sitter Acknowledgement forms to be completed. o Facility staff to monitor private duty sitters as they are rounding to ensure no private duty sitters are providing ADL care. o The Medical Director was notified by the Director of Nursing on 02/13/2024 at 6:05 PM. o Resident #2 was assessed with head-to-toe assessment on 2/13/24 at 1:30 PM by facility ADON. 2. Education (Administrator/Regional Nurse) o Personal and private sitters in-serviced on Facility Sitter Policy on 2/13/24. Education provided on following: o May not administer Direct Care to the resident. Direct Care includes, but is not limited to, transferring the resident, providing incontinent care, providing assistance with feeding, repositioning, toileting, bathing and dressing, wound care and administering medications, (including over-the-counter medications and supplements). o May monitor patient needs, report issues, ensure patient comfort (e.g., changing bedding, filling water jugs and positioning items within reach) and provide companionship. o Will assist facility to maintain, create and provide a safe environment for the patient. o Must report to the Nurse Supervisor/Charge Nurse when coming on and going off duty. o Must report changes in a resident's condition to the Nurse Supervisor/Charge Nurse immediately. o Nurse Administrative Staff/Direct Care Staff educated on Facility Sitter Policy on 2/13/24. Agency Provider Companies to be notified on 2/14/24 of need for all agency staff to review Private Duty Sitter Policy prior to start of shift at [the facility]. To be completed by 2/14/24 at 5:00 PM. All future facility staff will be in-serviced upon hire. o Private Duty Sitter Acknowledgement to be signed for residents with current sitters by 2/14/24 and reviewed with future sitters as they are assigned to residents. o Facility Nurses/CNA/Agency staff were in-serviced on 2/13/24 by ADON and Regional Nurse on their job duties related to residents with private duty sitters present. 3. Medical Director - The Medical Director has been notified of the Immediate Jeopardy. 4. QAPI Committee Review - An interim QAPI committee meeting was completed on 02/13/2024. 5. Plan of removal date: 02/13/2024 Monitoring of the POR on 02/15/24 included the following: During an observation on 2/15/24 at 5:30 p.m. of the north wing nurses' station revealed a sitter book with the sitter policy, and the signatures of the sitters and a sign in and out sheet. During an observation on 2/15/24 at 5:32 p.m. of the East wing nurses' station revealed a sitter book with the sitter policy, and the signatures of the sitters and a sign in and out sheet. At 3:35 p.m. LVN A- agency work all shifts At 3:59 p.m. CNA E said she worked all shifts At 4:10 p.m. CNA F worked 2p to 10 p At 4:15 p.m. CNA H worked 6a to 6p and sometimes 6p to 10 p. At 4:22 LVN I worked 6a to 6p At 4:30 p.m. LVN J worked 6a to 6p At 4:40 p.m. CNA K worked 2p to 10 p At 4:49 p.m. CNA L agency worked 6a to 6p and all shifts At 4:45 p.m. CNA M worked 6a to 6p At 5:01 p.m. MA worked 6:30 a.m. to 6:30 p.m. Interviews with staff indicated they were knowledgeable about the in-services provided. They were able to voice their knowledge of the sitter policy and the sitter books located at the nurse's station. They voiced if they saw a sitter providing ADL care to a resident, they would intervene to ensure the resident's safety. They would inform the charge nurse and/or the DON. They also indicated staff not providing care to residents could be a form of neglect, and allowing sitters to perform care they were not trained to provide could be neglect. During an interview on 2/15/24 at 5:05 p.m. the family member of Resident #5 said they were informed sitters were no longer to provide personal care to the residents. The family member said she understood but was concerned Resident #6 would not receive timely care. During an interview on 2/15/24 at 5:10 p.m., Sitter DD the evening sitter for Resident #5, said she was made aware today that she could no longer provide care to the resident. She said this was her first day back this week. The sitter said in the past she had provided ADL care to Resident #5 but would comply with the new rules. During an interview on 2/15/24 at 5:15 p.m., the DON said she was out sick and not aware they had a new resident, Resident #6. She said she had just gotten back from sick leave yesterday and was not aware of the new admissions. The census indicated the resident was admitted on Monday. The DON said she was not aware there was an incident on 2/8/24 when the sitter was transferring Resident #2 and she fell. She said they had the sitter books at the nurse's station and sitters were to sign in and out so they knew who was in the building. The DON said if they were new the Charge nurse would have them read and sign the sitter policy. If there were any problems the staff were aware they could contact her for assistance. The aides and nurses were also aware if they saw any sitter breaking the policy by providing care they were to intervene and let the charge nurse and the DON know. During an interview on 2/15/24 at 5:20 p.m., Sitter EE said she was providing care to Resident #2 before and did not understand why she could not continue. She said was a CNA for 5 years. She provided all care, assistance with eating, transfers, and incontinent care the staff were aware and just left them alone. She said yesterday, LVN J and the DON explained to her she was not supposed to provide any care and she signed the form stating she understood. During an interview on 2/15/24 at 5:25 p.m. the two sitters with Resident #6, Sitter GG said she was going home, and Sitter HH said she was coming on. They said they were aware they were not to provide any care for Resident #6 they were there for companionship only. They said they understood their duties and had not provided care to the resident while she was at the facility. They were informed by the facility staff and had signed the form. During an interview on 2/15/24 at 5:35 p.m., the Administrator said they met with the Director of the company and all the sitters worked for today and told them they did not want the sitters providing ADL care to the residents. The Director of the sitter company agreed. They spoke to the families via telephone and one family in person and they said they understood. She said they took the concerns with sitters and neglect to the QA meeting. The Medical Director was involved via phone. The Administrator said they placed the sitter books at the nurse's station and all sitters were to sign in and out. If it was a new sitter, the charge nurse would go over the policy with them and have them sign. The Administrator said staff were aware they were to notify the DON or Administrator if they noticed any sitter breaking the policy. Record review of the, undated, Private Duty Sitter Agreement with reflected: by signing below we agree to the following. The sitter is an employee of the family, failure to meet the guidelines or interference in the care of other patients could result I the sitter not being allowed to work in the facility. The sitter will be required to adhere to the responsibilities listed below. The sitter May Not administer direct care to the resident. Direct care includes, transferring, providing incontinent care, assistance with eating, reposition, toileting, bathing and dressing, wound care administering medications including over the counter. They must report when coming on and going off duty, monitor the patient needs and report issues. Record review of Resident #5's nursing notes, dated 2/13/24 at 2:50 p.m., reflected the RN spoke with the POA. He was reminded sitters for Resident #5 need to always call for assistance when performing any care for the resident. He was informed he needed to alert the sitters that sit with her daily. Record review of Resident #2's nursing notes, dated 2/13/24 at 6:31 p.m., indicated the RN spoke with the POA. He as reminded sitters for Resident #2 need to always call for assistance when performing any care for the resident. He was informed he needed to alert the sitters that sit with her daily. The Administrator, DON, Regional Nurse Consultant and VP of Clinical Services were informed the Immediate Jeopardy was removed on 2/15/24 at 5:49 p.m. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy with a scope of a pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being 1 of 1 residents (Resident #170) reviewed for behavioral health. 1.The facility failed to assess, provide safety intervention and immediate psychological services, per their policy, for Resident #170 who made a verbalization of suicidal ideation to the facilities on 02/09/23. 2. The facility failed to in-service staff on behavioral healthcare and services as a part of the person-centered environment. 3. The facility failed to train on and implement suicidal precautions per policy, (for example: assigned a one-to-one staff member who will remain within 6 feet of resident and maintain visual contact and document the observation every 15 minutes) for Resident #170. 4. The facility failed to have the Nurses document every 4 hours the assessment of the resident in the medical records per policy for Resident #170. 5. The facility failed to revise Resident #170's mood state care plan with interventions for suicidal ideations. 6. The facility failed to inform staff of Resident #170 suicidal ideation. These failures resulted in an Immediate Jeopardy (IJ) situation. The Administrator was notified on 02/13/23 at 3:40 PM. While the IJ was removed on 02/14/23 at 3:49 PM and the Administrator was notified, the facility remained out of compliance at a severity level of no actual harm at a scope of isolated due to the need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures placed residents at risk for a decline in quality of life related to suicidal ideations. Findings include: Record review of Resident #170's electronic face sheet, dated 02/14/23, revealed an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included depression, PVD (a systemic disorder that involves the narrowing of peripheral blood vessels), anxiety (Feelings of being worried, tense, or afraid that are triggered by certain traumatic situations), and high blood pressure. Record review of Resident #170's admission MDS assessment, with an ARD of 02/02/23, revealed under Section B, Hearing, Speech, and Vision, under sections B0300 was coded a 0 indication her speech was clear, under section B0700 was coded as a 0 indicating she understands and was usually understood by others. Section C, Cognitive Patterns, under section C0500 Brief Interview for Mental Status, was scored a 15 indicating she had cognitive intact cognition. Section D, Mood, under section D0200 was coded a15 indicating she was moderately severely depressed. Section E, Behavior, under section E0200 was coded a 0 indicating she had no behaviors. Section G, Function Status, under section G0110 indicated he needed extensive assistance with bathing, personal hygiene, toileting limited assist with dressing, bed mobility, and supervision with eating. Record review of Resident #170's comprehensive person-centered care plan, dated 02/02/23, indicated, Problem: mood state, Resident #170 had signs and symptoms of mood distress as evidence by feeling down and depressed and hopeless. Approach: Administer medication as ordered, encourage resident to verbalize feelings, observe for signs and symptoms of depression, obtain a psychologist consult and work with resident to identify effective coping skills. The care plan was not revised to indicate anything about suicidal ideations. Record review for Resident #170's progress note dated 02/02/23 at 4:23 p.m., revealed, the social worker was in room visiting with Resident #170, when she expressed some feelings of depression. SW sent a referral to Carousel clinical services for counseling. Record review for Resident #170's counseling clinical nurse practitioner (NP) medication review note dated 02/06/23 at 11:27 a.m., revealed, facility requested service. Resident #170's mood was coded a 4. The NP wrote order for Remeron 15mg by mouth every night for mood and to increase appetite. Record review for Resident #170's progress note dated 02/07/23 at 3:00 p.m., revealed, the facility received a new order for Remeron 15 mg, give 1 tablet by mouth every night for mood and to increase appetite. Review of Resident #170's physician's orders dated 02/08/23 indicated: Remeron 15 mg, give 1 by mouth every night for mood and appetite. Record review for Resident #170's MAR (medication administration records) dated 02/01/23 until 02/14/23 revealed Remeron 15 mg was initially given on 02/08/23 at 8:00pm. Record review for Resident #170's progress note dated 02/09/23 at 1:13 p.m., revealed hospice nurse in facility with new orders for Citalopram (Celexa) 10 mg, give 1 tablet by mouth every day for depression. Review of Resident #170's physician's orders dated 02/09/23 indicated: Celexa 10mg, give 1 tablet by mouth daily for depression. Record review for Resident #170's MAR revealed Celexa10mg was initially given on 02/10/23 at 8:00am. Record review for Resident #170's progress note dated 02/09/23 at 2:36 p.m., revealed facility called the resident's family member to talk about new medication when he said a family friend called him and said Resident #170 told the friend she wanted to die, and if she could, she would kill herself. The son said Resident #170 said if she could get ahold of some razors, this was how she would do it. Record review for Resident #170's hospice progress note dated 02/09/23, revealed blood pressure at 174/68, pulse at 101, heart rate at 18, temperature at 98.8 and oxygen saturation at 90%. Resident #170 was tearful with no eye contact, soft spoken voice. No complaints of pain or distress. Resident #170 was moved to room [ROOM NUMBER] and placed on suicidal watch. Record review for Resident #170's progress noted written on 02/10/23 by a licensed psychologist revealed diagnosis of major depression, generalized anxiety, and unspecified neurocognitive disorder. His treatment plan indicated: medication and counseling are the most common treatment for depression. It was recommended that the client see a physician and a counselor for treatment. He indicated the physician often prescribed an antidepressant, and the counselor could monitor for efficiency and compliance. The counselor can also help the client learn effective coping mechanism for this disorder. Resident #170 was unlikely to follow through with suicide attempt. However, counseling and medication were recommended immediately to relieve symptoms. Note: It can take weeks or a month for many of the antidepressants to have a significant effect. Resident #170 had started medications already, but he indicated counseling could provide quicker symptoms relief. Counseling can help her adjust to the nursing home as well. Record review for Resident #170's 24-hour report dated 02/09/23 indicated she wanted to kill herself, moved to room [ROOM NUMBER], all sharp objects removed from room and dietary aware to send plastic ware with meals. Record review for Resident #170's 24-hour report dated 02/10/23 did not indicate anything about suicide or ideations. Record review for Resident #170's 15-minute surveillance log dated 02/09/23 indicated facility started monitoring at 2:30pm. Record review for Resident #170's 15-minute surveillance log dated 02/10/23 indicated facility started monitoring at 6:00pm. Record review for Resident #170's 15-minute surveillance log dated 02/11/23 indicated facility started monitoring at 10:15pm. Record review for Resident #170's 15-minute surveillance log dated 02/12/23 indicated facility started monitoring at 6:15 am and completed at 11:45 am. Re-started at 4:30 pm and completed at 6:00 am on 2/13/23. Record review for Resident #170's 15-minute surveillance log dated 02/13/23 indicated facility started monitoring at 6:15 am and completed at 12:00 noon. Record review for Resident #170's MAR (medication administration records) indicated no depressed mood documented under target behavior from 02/02/23 thru 02/13/23. Record review for Resident #170's progress noted written on 02/13/23 by a psychologist indicated mood was a 3. His comment stated: Some previous ideals and verbalization, dealt with in therapy. Resident #170 said she will try to let go of the thought. During an observation and interview on 02/12/23 at 9:59 a.m., Resident #170 was in her bed alert with eyes open. Resident #170 said she was moved to room [ROOM NUMBER] about a week ago because of suicide statement. Resident #170 said she wanted to kill herself because she was depressed. Resident # 170 said she did not feel like harming herself at that time but it was still present in her mind. Resident # 170 became tearful when talking about her suicidal thoughts. Resident # 170 said she felt like she was dumped in the nursing home, had no independence, no friends and did not see the need to live. Resident #170 said she did not have a plan at that time. Resident #170 had her call light attached to her sheets, remote control to her bed and blinds still in room during interview. During an interview on 02/13/23 at 11:32 a.m., the SW said she went to do an assessment on Resident #170 and felt she was depressed based off the PHQ (Quick Depression Assessment) scale score of 15 indicating moderately severely depressed and the way she was answering the questions to her. The SW said she referred Resident #170 to counseling clinical services. During an interview on 02/12/23 at 12:00 p.m., LVN N said Resident #170 was moved to room [ROOM NUMBER] because she said she wanted to kill herself with a razor. LVN N said on Friday (02/10/23) a psychologist doctor came to visit Resident #170 and he let someone in management know upfront she was not a threat to herself or anyone else. LVN N said management staff wanted us to keep her on every 15-minute suicided watch for the next 72 hours. LVN N presented the 15-minute monitoring sheets for Resident #170, but they were incomplete on days for 2/10/23, and 2/11/23. LVN N said she should have filled out the forms on 2/10/23, and 2/11/23 but did not. LVN N said she had not started the 15-minute monitoring sheets for that day but had seen Resident #170 every 15-minutes and would fill out the sheet. During an interview on 02/12/23 at 12:21 p.m., the SW said during a visit and assessment on 02/02/23, Resident #170 made a statement she was ready to die but it was not a suicidal statement. The SW said she talked with a family member about the statement and they both agreed to have counseling to see her. The SW said she made the referral to counseling. The SW said Resident #170 was currently on every 15-minute checks because on 02/09/23, she had a plan to cut her throat, if she was able. The SW said Carousel counseling talked to Resident #170 on Friday 02/10/23 and felt she was not suicidal but gave her a diagnosis of major depression. The SW said she had not typed up her note from Friday's (02/10/23) visit with the psychologist but would. During an interview on 02/12/23 at 1:04 p.m., CNA E said she was the aide providing care to Resident # 170. CNA E said she was not aware of any suicidal threats on Resident #170. CNA E said LVN N gave her report on Resident #170 but failed to mention anything about suicidal thoughts. During an interview on 02/12/23 at 2:28 p.m., LVN O said she had worked since Friday (02/10/23) in the facility but was not aware of any resident with suicidal thought until 02/12/23 when they did an in-service. During an interview on 02/12/23 at 2:31 p.m., LVN Y said she worked Friday (02/10/22), Saturday (02/11/23), and 02/12/23 and was aware a resident said something but was not quite sure what was said or who the resident was. LVN Y said LVN N and LVN G sat at the front nurse's station during the 6am-6pm shift for the last three days but neither voiced anything about suicidal thoughts to her. LVN Y said she sometimes reliefs LVN N for breaks. LVN Y said prior to 02/12/23 they had not had an in-service on suicide. During an interview on 02/12/23 at 2:38 p.m., CNA W said she was the primary aide for Resident #170 since Friday (02/10/23) but was not aware of any residents with suicidal thoughts. CNA W said she thought Resident #170 moved rooms because she was complaining about her mattress. During an interview on 02/12/23 at 2:43 p.m., LVN G said she worked since Friday (02/10/23), but was not aware they had a resident with suicidal ideation and she often walks hall 100 where Resident #170 resides and reliefs LVN N for breaks at times. During an interview on 02/12/23 at 2:51 p.m., LVN N said she was Resident #170 day nurse. LVN N said Resident #170 kept her call light and remote control to her bed during suicidal watch. LVN N said no staff member sat with Resident #170 during her shift. LVN N said they just walked by Resident #170's room and checked on her every 15 minutes. LVN N said Resident #170 required assist x 1 with ADL's and usually sat up in her wheel chair throughout the day. During an interview on 02/13/23 at 8:21 a.m., LVN A said she was Resident #170 primary day nurse. LVN A said she was the nurse who called the family member on 02/09/23 to get consent for Celexa and during the call the family member informed her a friend had stopped by and told him his mother was having suicidal thoughts of killing herself and if she had a razor, she would end it now. The family member stated he called hospice and informed them. LVN A said when she hung up, the hospice nurse called her. LVN A said she informed the ADON, and they searched Resident #170's room and removed some scissors and a fork. LVN A said they moved Resident #170 to room [ROOM NUMBER] and did every 15 minutes checks. This nurse stated the resident kept her call light and bed control. During an interview on 02/13/23 at 9:49 a.m., CNA B said on Thursday (02/09/23) Resident #170 told the hospice nurse she wanted some medicine for depression and the nurse told her she would see what she could do. CNA B said when she came back to work on Saturday (02/11/23) they had moved Resident #170 to room [ROOM NUMBER]. CNA B said she was not aware why Resident #170 was moved and she thought she could not sleep in the other room because her roommate was loud at times. CNA B said she was Resident #170 primary day aide since Saturday and still not aware why she moved rooms. During an interview on 02/12/23 at 12:37 p.m., the DON said on Thursday (02/09/23) Resident # 170 told an unidentified nurse she wanted to kill herself and had a plan. The DON said she was not in the building at the time but was aware they swept Resident #170's room, moved her to another room, notified the family member and was on every 15-minute checks. During an interview on 02/12/23 at 1:12 p.m., the ADON said she was in charge Thursday (02/09/23) when LVN A reported Resident #170's family member called and said Resident #170 was having suicidal thoughts with a plan. The ADON said she notified the SW and they went down to talk to Resident #170. The ADON said they did a sweep of Resident #170's room and moved her to room [ROOM NUMBER]. The ADON said they initiated every 15-minute monitoring of Resident #170. Record review of Suicidal Precautions policy given by DON on 02/13/23 indicated, Management policy: #1. Resident suicide threats shall be taken seriously and addressed appropriately, #2 the facility will provide and or arrange for transfer to the safest, practical living environment for all patients slash residents who voice suicidal thoughts, attempt suicide, or cause self the injury. Procedures: #1 if a resident who was voicing suicidal thoughts or attempts suicide was a danger to self or others. A. additional interventions will be initiated including physician, psychiatrist, counselor, and family are notified immediately. If the patient doesn't have a psychiatrist, then a referral was made at this time, B. suicidal precautions are implemented immediately if a resident was deemed to be a threat to themselves or others to preserve the well-being of patient resident. The physician should be notified immediately of suicide ideations and for further orders, C. if it was determined that the facility cannot provide a safe environment due to suicide ideations of the resident the resident will be transported to an acute care setting for evaluation and treatment. #2 suicide precautions will be implemented immediately for any resident that presents with a significant level of depression or suicidal preoccupation and will be used to address the risk factors presented by the resident. #3 suicidal precautions include the following: A. one-on-one supervision be the resident will eat on the unit without sharp utensils sing until evaluation or transfer current can occur third item such as belts, drawstring pants, shoes with laces, sheets etc. May be prohibited if they present a potential danger for the resident. D. call light cord was removed from residence room. If available a bell or other signal device was given to replace the call light E. medication nurses observe resident swallowing all medications and checks or cavity to ensure resident has swallowed, I. a licensed nurse will assess the resident at least every four hours and document the assessment in the medical record. #4 family member or responsible party will be notified of suicide precautions. # 5 a physician order was required to discontinue suicide precaution. # 7 documentation guidelines: A. when a position order suicide precaution documentation was completed at least every 15 minutes and more often if needed, B. Documentation includes date, time, one-on-one continue, the reason the patient was placed on suicide precautions, resident responses and behaviors, additional safeguard and supervision of resident, the search for and removal of items that may be used in suicide attempts and time family was contacted, C. date, time and reason suicidal precautions were discontinued and signature. #8 record the resident was checked every 15 minutes or suicide precaution. Staff documents this by signing their initials in the column for their shift. This was determined to be an Immediate Jeopardy (IJ) situation on 02/13/23 at 3:43 p.m. The Administrator was notified of the IJ and he needed to send us his plan of removal. The Administrator was provided with the IJ template on 02/13/23 at 3:49 p.m. The following Plan of Removal submitted by the facility was accepted on 02/14/23 at 3:49 p.m. and included the following: Plan of Removal 1. Immediate actions o The Medical Director was notified by the Director of Nursing on 02/13/2023 at 4:25 PM. o Resident #170 care plan was updated immediately on 02/13/2023 at 5:00 PM to include interventions related to suicidal ideation which include Carousel Counseling discontinuing suicidal precautions and continuing psychology services, nurse to monitor for 72 hours after suicide precautions discontinued, social services available as needed, and notification to hospice to provide spiritual and social services. o Resident #170 will continue Psychiatric visits from 02/13/2023 ongoing. The QAPI Team will monitor continued care based on the results of the consult to include potential placing resident in a behavioral health setting. Resident #170 will continue Psychiatric Services to monitor any recurrence of suicidal ideation. 2. Education (provided by DON or ADON) o All staff were in-serviced on behavioral healthcare and services available to include Carousel Counseling should a resident's mood and behavior warrant them. In-patient facilities are available, such as Oceans Behavioral, etc. This in-service will be completed by 02/14/2023 at 10:00 PM. Staff will not be allowed to return to shift without this in-service. This in-service was completed by the Director of Nursing and the Social Services Consultant. o SW/DON/Activity Director/MDS/ADON were in-serviced on implementing person-centered care plans to include interventions for behavioral healthcare and the importance of updating care plan to reflect current interventions related to suicidal ideations, current behaviors, and mood. Care plan to be updated as situation changes, and suicide precautions are discontinued. This in-service will be completed by 2/14/23 at 10:00 PM. Staff will not be allowed to return to work without this in-service. o In-service Social Worker/DON/All Charge Nurses on 2/13/23 at 5:00 PM on need to visit with resident after resident expresses feelings of depression to build coping skills until Carousel Counseling/psychology service arrives. This in-service will be completed on 2/14/23 at 10:00 PM. Staff will not be allowed to return to shift without this in-service. o In-service Social Worker/DON/Charge Nurse on need to notify hospice when resident was experiencing depression/mood changes to have hospice agency send chaplain/social worker for resident visit. This in-service will be completed on 2/14/23 at 10:00 PM. Social Service Consultant to complete in-service, staff will not be allowed to return to shift without this in-service. o All staff were in-serviced on implementing suicidal precautions per current facility policy, resident will be assigned a one-to-one staff member who will remain within 6 feet of resident and maintain visual contact and document the observation every 15 minutes on 02/13/2023. Each staff member will be in-serviced prior to returning to shift. This will be completed by 02/14/2023 at 10:00 PM. Staff will not return to shift without the in-service. This in-service includes the removal of potentially harmful objects. Staff will follow the current policy. In-service completed by Director of Clinical Services and DON. o All staff were informed of [Resident #170's] suicidal ideation on 02/12/2023 at 5:00 PM by the Director of Nursing. o All nurses were in-serviced on documenting every 4 hours the assessment of the resident's mood and behavior in the medical record on 02/12/2023. This in-service will be completed by 02/12/2023 at 10:00 PM. This in-service was completed by the Director of Nursing and the Regional Nurse Consultant. The Director of Nursing will review the 24-hour report as well as the documentation to ensure all staff are documenting appropriately and monitoring for further suicidal ideation during the morning meeting. 3. Medical Director - The Medical Director has been notified of the Immediate Jeopardy. 4. QAPI Committee Review - An interim QAPI committee meeting was completed on 02/13/2023. 5. Plan of removal date: 02/13/2023 Monitoring included: Interviews on 02/14/2022 from 1:30 p.m. until 4:00 p.m., the surveyors confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: Interviews with 4 (6am-6pm) nurses LVN A, LVN G, LVN F, and LVN N,1 (6pm-6am) nurses LVN K who indicated they had received a written in-service regarding suicidal precautions and things they needed to do such as put them on 1 on 1, chart every 15 minutes on form provided, and assess on condition and document in chart every 4 hours. They also indicated they learned how to notify outside services such as carousel counseling or hospice for spiritual services if needed. SW or designee are supposed to chart every day until resident seen by carousel counseling. Interviews with 4 CNAs (6am-2pm) CNA B, CNA C, CNA M, and CNA T, 4 CNAs (2pm-10am) CNA H, CNA W, CNA Z and CNA X and 1 CNA (10-6) CNA R who all indicated they were in-serviced on suicidal precautions and if they heard a resident voice any concerns over killing themselves or even if they are feeling down, they were to stay with the resident and notify the nurse, so they could assess them. Interviews with the MDS nurse, the social worker, the dietary manager, the activity director, the ADON, the DON and the ADM who all indicated they were in serviced on behavior health support, person centered care plans, depression, coordinating spiritual services with hospice, care plans for suicidal residents and residents with mood changes or depression and suicide precautions. They said they all played a part in the residents' overall care. The Administrator was informed the Immediate Jeopardy was removed on 02/14/2023 at 3:49 p.m. The facility remained out of compliance at a severity level of no actual harm that was not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.