**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for 1 (Resident #1) of 13 residents reviewed for comprehensive care plan, in that: LVN A failed to follow the plan of care on 05/01/2024 which required Resident #1 to be monitored and a PCP to be notified if Resident demonstrated a fear of being alone. Resident #1 attempted suicide on 05/02/2024. This failure resulted in the identification of Immediate Jeopardy (IJ) on 05/26/2024 at 06:00 p.m. While the IJ was removed on 05/28/2024, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm because the facility's need to monitor the implementation of the plan of removal. This failure could result in residents not receiving the necessary care to prevent a decline in health due to failure to follow a resident's care plan. Findings included: Record review of Resident #1's admission Record, dated 05/24/2024 revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included dementia (a general term for impaired ability to remember, think, or make decisions), depression, and anxiety (a condition in which a person has excessive worry and feelings of fear, dread, and uneasiness) disorder. Resident #1 was noted as discharged on 05/02/2024 to an acute care hospital. Record review of Resident #1's State Optional MDS, dated [DATE], revealed the resident had a BIMS score of 8, which indicated the resident was mildly cognitively impaired for daily decision-making skills. Record review of Resident #1's MDS PHQ9 (Resident Mood Interview), dated 03/12/2024, revealed the resident had a score of 18, which indicated the resident had moderate severe depression. Further review revealed the SW wrote under explanation, He said that he is hearing voices and forgetting things that he does not want to live. He is open to getting psych services. Record review of Resident #1's care plan revealed: - A focus, initiated on 03/13/2024, revealed Resident #1 had impaired cognitive function/dementia or impaired thought processes related to dementia, difficulty making decisions with intervention, date initiated 03/13/2024, Monitor/document/report to MD any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status. - A focus, initiated on 03/15/2024 and revised on 04/30/2024, revealed Resident #1 used anti-histamine medications related to anxiety/agitation with interventions, date initiated 03/15/2024, [Resident #1] is taking Anti-anxiety meds which are associated with an increased risk of confusion, amnesia .Monitor for safety and Monitor/record occurrence of for target behavior symptoms and document per facility protocol. - A focus, initiated on 03/19/2024, revealed Resident #1 used antidepressant medication related to depression with interventions, date initiated 03/19/2024, Give antidepressant medications ordered by physician. Monitor/document side effects and effectiveness ., and Monitor/document/report to MD prn ongoing s/sx of depression unaltered by antidepressant meds: sad, .suicidal ideations, .fear of being alone or with others .anxiety . - A focus, initiated on 03/19/2024, revealed Resident #1 had a potential psychosocial well-being problem related to depression, anxiety, inability to problem solve, ineffective coping, and lack of acceptance to current condition with intervention, date initiated 03/19/2024, Consult with: Pastoral care, Social services, Psych services. Record review of Resident #1's MAR/TAR for April and May 2024 did not reveal behavior was being monitored according to the care plan. Record review of Resident #1's Psychiatry Follow-Up note, dated 04/29/2024 revealed a note by Psych NP that stated He was recently in an altercation and he was not the aggressor .No increased depression. He is sleeping and eating well. He is nervous about the aggressors hurting him again. He is having some anxiety regarding the situation. Further review revealed Resident #1 was noted as not currently a danger to self/others, not a risk factor for self-harm, and not a risk factor for suicidal ideation. Under assessment and plan, increased anxiety due to altercation was noted. Record review of Resident #1's progress note, dated 05/01/2024 did not reveal an entry by LVN A and did not reveal a notation regarding Resident #1 displaying increased fear or a request for a staff member to stay with him. Record review of Resident #1's progress note, dated 05/02/2024 revealed a note by LVN A that stated he asked me the previous evening to stay in the room with him because he was scared. He did not clarify what he was scared of, only that he was afraid and wanted me to stay with. The note revealed Further review revealed Resident #1 attempted suicide on 05/02/2024 by tying a shirt, fashioned to look like a rope, around his neck in a noose fashion and pulling hard on the shirt to make it tighten enough to cut off his airflow. Attempted interview of LVN A on 05/22/2024 at 10:01 p.m., on 05/23/2024 at 08:07 a.m., and on 05/25/2024 at 10:59 p.m. and 11:03 p.m. was unsuccessful. LVN A worked night shift (10:00 p.m. to 6:00 a.m.). Interview with Psych NP on 05/23/2024 at 04:33 p.m., revealed the Psych NP stated she had assessed Resident #1 on 04/29/2024 and found that he had been okay. The Psych NP stated Resident #1 had initially been very anxious and impulse upon admission to the facility but with medication therapy he had been fine and no longer had depression. The Psych NP stated she thought Resident #1 was anxious after the altercation on 04/28/2024 and he did not want to be alone with anyone with aggression. The Psych NP stated Resident #1 did not have any indication of being at risk for self-harm. The Psych NP stated she never observed, and no one ever reported to her that Resident #1 was at risk for self-harm or suicidal. The Psych NP stated that the facility had standard orders for behavioral monitoring for residents on psychotropics. The Psych NP stated the facility staff was really good at notifying her of any issues when she was in the facility, at least weekly, or calling her. The Psych NP stated the nurses could contact the psych care team twenty-four hours, seven days a week by calling the call center. Interview with MD E on 05/25/2024 at 12:52 p.m., MD E stated she had received notification by a facility nurse on 05/02/2024 that Resident #1 had been sent out to the hospital. MD E stated she had not seen Resident #1 but that he was being seen by the Psych NP, who last saw the resident on 04/29/2024. MD E stated the facility nurses reported incidents or changes of conditions to the medical team's call center. MD E stated the reported information would disseminate to the entire care team, including the psychiatric services team. MD E stated she deferred to the psychiatric services team for behavioral issues or concerns. MD E stated the facility nurses' process of charting in the facility EHR and reporting to the care team or medical call center any changes was adequate for behavioral monitoring. Interview with LVN B on 05/26/2024 at 04:15 p.m., LVN B stated she reviewed resident care plans when she had a question about the resident's care but would only review the specific parts of care plan that she needed information on. Interview with ADON C on 05/26/2024 at 04:58 p.m., ADON C stated her expectation was that direct care staff were to follow the care plan. Interview with MD E on 05/28/2024 at 12:33 p.m., MD E stated she did not recall being notified of Resident #1 ever saying that he did not want to live, per his 03/12/2024 PHQ9 Assessment, or received a report the resident was afraid on the night of 05/01/2024. MD E stated she would have to check her notes. A return call was not received by [Investigator I] prior to the investigation exit, 05/28/2024 at 06:00 p.m. Interview with the Psych NP on 05/28/2024 at 01:44 p.m., the Psych NP stated she did not recall Resident #1 ever saying that he did not want to live. The Psych NP stated Resident #1 was referred to psych services on 03/14/2024 by a facility nurse and could not recall a staff member reporting to her that during his PHQ9 Assessment, Resident #1 said he did not want to live. The Psych NP stated she had a hard time seeing Resident #1 making that statement and stated that she felt the screening assessments could sometimes lead to a response or misunderstanding due to the wording of the questions. The Psych NP stated she did not feel that people with dementia could complete those screeners appropriately. Record review of facility's policy titled, Care Plans, Comprehensive Person-Centered, revised March 2022, revealed. A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .7. The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including .(3) which professional services are responsible for each element of care; . This was determined to be an Immediate Jeopardy (IJ) and the ADMIN was provided with the IJ template on 05/26/2024 at 6:00 p.m. The plan of removal was accepted on 05/27/2024 at 1:18 p.m. and read as follows: Summary of details which leads to outcomes. On 5/17/24 an investigation on a facility reported incident was initiated at [the facility]. On 5/26/2023 at 6:00pm, [Investigator I] provided an IJ Template notification that the Survey Agency has determined that the conditions at the center constitute immediate jeopardy to resident health. The Immediate Jeopardy findings were identified in the following areas: F656: The facility failed to implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for Resident #1. Immediate Corrective Actions for Removal of Immediate Jeopardy: On May 25, 2024, at approximately 12:00 [p.m.] the following actions were initiated upon facility identification of concern: - Ad hoc QAPI meeting held with Administrator, Regional Director of Clinical Operations, ADONs and MD to review process for psychosocial management to include monitoring orders for side effects and effectiveness of medications, and psychosocial assessments. - All resident charts were audited to ensure that care plans include measurable objective and timeframes to meet a resident's medical, nursing, mental and psychosocial needs. - All residents who are currently prescribed psychotropic medication were audited to ensure side effect monitoring and effectiveness of medication monitoring were in place and care planned. - All residents who did not currently have side effects and medication effectiveness monitoring were assessed for adverse effects to psychosocial wellbeing related to monitoring orders not being in place. All residents remained at base line with no adverse effects noted. - Education was initiated immediately with licensed nursing staff, on side effect monitoring and medication effectiveness and reporting psychosocial changes to provider with a completion date of 05/26/2024. - Education initiated to nursing staff on comprehensive care planning and identification of psychosocial interventions with a completion date of 05/26/2024 Identification of Other Affected: All residents who are diagnosed with a mental disorder or psychosocial adjustment have the potential to be affected. Systemic Changes and/or Measures: - Education provided to all nursing staff on May 26, 2024, on Behavioral monitoring, including the requirement to monitor resident for altered mood, behavior, and function and alert the physician via phone with any observations noted, with a completion date of 05/27/2024. - Education provided to all nursing staff on May 26, 2024, on Comprehensive, person-centered care planning, and requirement that nursing staff is aware of residents' plan of care when providing resident care. Education also included that care plans include measurable, person-centered, objectives and timetables to assure residents highest functional, and psychosocial well-being are attained, with a completion date of 05/24/2024. - Ad hoc QAPI meeting held with IDT team and MD to review findings of immediate jeopardy, and to review Plan of Removal/response to Immediate Jeopardy Citation on 5/26/24 @ 8:00 p.m. Tracking and Monitoring: - Assistant Director of Nursing, or designee, will monitor daily through daily clinical meeting and review, Monday through Friday, all new admissions, and new orders, for any psychotropic medications, to validate all residents on psychotropics, have behavior monitoring, monitoring for adverse side effects, and care plan is person-centered and addresses specific behaviors being monitored. Any identified concerns will be addressed immediately, and physician will be notified via phone with any observations noted. - Assistant Director of Nursing, or designee, will review 24 hours report in EHR, to identify any new, acute, mental, or psychosocial concerns from previous day, to validate they were addressed and follow up with provider/physician was completed as indicated. Physician will be notified via phone with any observations noted. The 24 hours report shall include indication of monitoring orders in place and verification of observations noted. Any identified concerns will be addressed immediately. The facility's POR verification was as follows: Interview with the ADMIN on 05/27/2024 at 03:00 p.m., the ADON stated all the nursing staff had received education on behavioral monitoring and care plans. The Administrator stated that the facility had a QAPI meeting on 05/26/2024 and discussed the findings of the deficient practice and the plan of removal. The Administrator stated MD E was the facility medical director. Record review of facility POR Binder on 05/27/2024 at 03:00 p.m. revealed: 1. A copy of the two Ad hoc QAPI Meetings: - The first Ad hoc QAPI document was dated 05/24/2024 and noted with an agenda: Psychotropic Medications, Monitoring and Observations Orders, Auditing, and Psych. Services auditing. Attendees were noted as: the ADMIN, MD E, ADON C, ADON D, and the RDCS. - The second Ad Hoc QAPI document was dated 05/26/2024 and noted with agenda: Immediate Jeopardy Citations- F656, F742, and Plan of Removal. Attendees were noted as: the ADMIN, MD E, ADON C, ADON D, and the RDCS. The binder contained a list of 19 licensed nursing staff. 2. An In-service document, dated 05/26/2024 and titled All nurses must monitor residents for psych issues such as withdrawn behaviors, signs/symptoms or verbalization of fear, depression, anxiety, anger/aggressive behavior, self-harm or attempted self-harm, suicidal ideation or statements and must else report it to nurse managers, administrator, doctor/nurse practitioner, and responsible party. The in-service document included a note *orders for monitoring psych diagnosis and psych meds must be added on admission or new orders. MD must be notified if behaviors observed and included 19 (9 LVN and 10 RN) licensed nurses noted as had received the training. 3. A document titled F656 Develop/Implement Comprehensive Care Plans revealed care plans were audited on 05/26/2025, the corrected care plans were noted on the order listing report, and the reviewer was the ADON and MDS staff. The document noted the care plans were audited on 05/27/2024 and found to be up to date by the ADON and MDS staff. A facility report, Daily Census, dated 05/26/2024 was included with the audit document with each resident name checked off. 4. A document titled F742 Treatment/Services for Mental/Psychosocial Concerns revealed psychosocial monitoring orders were audited on 05/25/2025, 05/26/2024, and 05/27/2024. For 05/25/2024 and 05/26/2024, the audit form indicated the need for psychosocial assessments. A facility report, Order Listing Report, dated 05/24/2024 - 05/25/2024 was included with the audit document with 36 resident names highlighted and checked off and 14 residents were noted as having a current monitoring order. Interviews with 17 of 19 licensed nursing staff from different shifts was completed on 05/27/2024 and 05/28/2024 which consisted of 2 of 3 licensed nursing staff from morning shift (6:00 a.m. to 2:00 p.m.), 5 of 5 licensed nursing staff from afternoon shift (2:00 p.m. to 10:00 p.m.), 1 of 2 licensed nursing staff from night shift (10:00 p.m. to 6:00 a.m.), 4 of 4 PRN licensed nursing staff, 2 of 2 weekend licensed nursing staff, and 3 of 3 administrative (MDS, ADON C, ADON D) licensed nursing staff. All 17 staff members reported they received education and were trained on behavioral monitoring, notifying the physician of behaviors, and reviewing and updating the residents' care plan. Attempted interview of RN G on 05/27/2024 at 06:19 p.m. and LVN A on 05/27/2024 at 7:11 p.m. to confirm training was unsuccessful. RN G worked morning shift (6:00 a.m. to 2:00 p.m.) and LVN A worked night shift (10:00 p.m. to 6:00 a.m.). Interview with ADON D on 05/28/2024 at 10:48 a.m., ADON D stated she received training from the RDCS regarding behavioral monitoring and care planning, and she provided the training to ADON C and facility licensed nursing staff. ADON D stated the ADONs will be monitoring the psychosocial medications by reviewing the facility 24-hour, 72-hour, and Order Listing reports to identify if there were any new psychosocial mediations, reported behaviors, new treatment orders, new antibiotic medications, new monitoring orders, and any reported behaviors. The report on incidents would also be reviewed. ADON D stated the reports would be reviewed in the morning clinical meeting with the floor nurses and ADON C, to discuss if any changes or incidents occurred the prior day and/or over the weekend. ADON D revealed that by reviewing the Order Listing report and 24-hour or 72-hour report, the ADONs were able to audit that if a new medication order was entered, a progress note for that new medication was entered and verify that additional orders for monitoring the side effects, behaviors, and efficacy were entered. ADON D stated that by reviewing the Order Listing report and 24-hour or 72-hour report, the ADONs were able to review that when a PRN psychosocial medication was provided, a monitor for the behavior and efficacy was entered, and if needed, a progress note indicating that the physician was notified and description of the behavior or reason for providing the PRN medication was documented. ADON D stated that after the IJs were called, each residents' chart was audited for monitoring orders. ADON D stated that for some residents' charts, behavior monitoring, or side effect monitoring was found but not both, and for those residents the other monitor was added. ADON D revealed that the Psych NP was asked to also complete an audit, checking her records and notes to verify that all the monitoring orders were in. She revealed for the care plan audit, she and the MDS nurse reviewed the care plans for every resident and ensured that the interventions in the care plans were also in the orders. ADON D stated they only identified Resident #1 as having the type of monitoring language for sadness and fear of being alone in his care plan. ADON D stated that it was discussed with the Psych NP on how the facility would going forward word their monitor and interventions to reflect the facility's resident's needs and behaviors more accurately. Interview with the RDCS on 05/28/2024 at 06:08 p.m., the RDCS stated she had attended Ad hoc QAPI Meetings on 05/25/2024 and 05/26/2024. The RDCS stated she provided training to ADON D on behavioral monitoring and care planning so ADON D could train the licensed nursing staff. Interview with the MD E on 05/28/2024 at 12:36 p.m., MD E stated she had attended Ad hoc QAPI Meetings on 05/25/2024 and 05/26/2024. MD E stated she was informed of the IJ and the plans for removal. Interview with the Psych NP on 05/28/2024 at 01:44 p.m., the Psych NP stated she was notified of the IJ at the facility and was contacted by her supervisor regarding a request that she provide follow up assessments on specific residents to review current behaviors and monitoring orders. Interview with the ADMIN and record review of facility report Order Summary Report on 05/28/2024 at 04:50 p.m. revealed the facility staff did not create a tracking log of resident orders that were entered as a part of their plan of correction but stated the Order Summary Report start date 05/25/2024 with active orders as of 05/25/2024 captured the new orders created per the order audit. The report noted five (5) residents (Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6) with new orders ordered on 05/24/2024 or 05/25/2024 with start dates 05/25/2024. New orders included observation for anti-depressant medication, observation for anti-anxiety medication, monitor for depression, monitor for anxiety, and monitor for side effects of sedative/hypnotics. The ADMIN revealed a new psychosocial assessment was completed on the five (5) identified residents. 1. Record review of Resident #2's admission Record, dated 05/24/2024, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included dementia (a general term for impaired ability to remember, think, or make decisions), depression, and post-traumatic stress disorder (a condition characterized by intrusive thoughts about the incident, recurrent distress/anxiety, flashback and avoidance of similar situations). Record review of Resident #2's State Optional MDS, dated [DATE], revealed Resident #2 had a BIMS score of 99, which indicated the resident was severely cognitively impaired for daily decision-making skills and/or unable to complete the interview. Record review of Resident #2's MDS PHQ9 (Resident Mood Interview), dated 04/11/2024, revealed Resident #2 had a score of NA. Record review of Resident #2's care plan revealed: - A focus, initiated on 04/15/2024, revealed Resident #2 used antidepressant medication related to depression with interventions, date initiated 04/15/2024, Give antidepressant medications ordered by physician. Monitor/document side effects and effectiveness ., and Monitor/document/report to MD prn ongoing s/sx of depression unaltered by antidepressant meds: sad, .suicidal ideations, .fear of being alone or with others .anxiety . - A focus, initiated on 04/15/2024, revealed Resident #2 had impaired cognitive function/dementia or impaired thought processes related to dementia, difficulty making decisions, impaired decision making, long term memory loss, psychotropic drug use, short term memory loss with interventions, date initiated 04/15/2024, Administer meds as ordered and Review medications and record possible causes of cognitive deficit .adverse drug reactions, drug toxicity. - A focus, initiated on 04/17/2024 and revised on 04/23/2024, revealed Resident #2 used anti-anxiety medications and anti-convulsant medications related to anxiety disorder with interventions, date initiated 04/17/2024, [Resident #2] is taking Anti-anxiety meds which are associated with an increased risk of confusion, amnesia .Monitor for safety, Give anti-anxiety medications ordered by physician. Monitor/document side effects and effectiveness .Paradoxical side effects: mania, hostility and rage, aggressive or impulsive behavior, hallucinations, and Monitor/record occurrence of for target behavior symptoms and document per facility protocol. -A focus, initiated 04/15/2024, revealed Resident #2 had potential mood problems related to PTSD and dementia with intervention, date initiated 04/15/2024, Monitor/record/report to MD prn acute episode feelings or sadness . Record review of facility report Order Summary Report, start date on 05/25/2024 and active orders as of 05/25/2024, revealed two (2) orders for Resident #2, ordered on 05/24/2024 to start on 05/25/2024. The first order was: Observation: AntiDepressant Medication- Observe for behavior WITHDRAWN/ AGITATION. Observe for side effects .every shift. The second order was: Observation: Antianxiety Medication- Observe for behavior AGITATION. Observe for side effects .every shift. Record review of Psychosocial Assessment, dated 05/25/2024, revealed Resident #2 was unable to participate in assessment due to severe cognitive impairment directly related to admitting diagnosis of dementia. Resident remained at baseline. No adverse psychosocial effects noted. Plan of Care revealed continue with current care plan and psych services involvement. Provide quiet space if resident appears to become overstimulated. Monitor for adverse effects to psychosocial well being. 2. Record review of Resident #3's admission Record, dated 05/24/2024, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included anxiety (a condition in which a person has excessive worry and feelings of fear, dread, and uneasiness) disorder, depression, and mild cognitive impairment (difficulty with language, memory, and thinking). Record review of Resident #3's State Optional MDS, dated [DATE], revealed Resident #3 had a BIMS score of 15, which indicated the resident was cognitively intact for daily decision-making skills. Record review of Resident #3's MDS PHQ9 (Resident Mood Interview), dated 01/03/2024, revealed Resident #3 had a score of 4, which indicated the resident was minimally depressed. Record review of Resident #3's care plan revealed: - A focus, initiated on 11/13/2023 and revised 05/07/2024, revealed Resident #3 had impaired cognitive function/ impaired thought processes related to difficulty making decisions, impaired decision making, mild cognitive impairment caused by history of alcoholic intoxication with interventions, date initiated 11/13/2023, Administer meds as ordered, Monitor/document/report to MD any changes in cognitive function ., and Review medications and record possible causes of cognitive deficit: .adverse drug reactions, drug toxicity. -A focus, initiated on 11/16/2023, revealed Resident #3 had potential psychosocial well-being problem related to illness/disease Process, disease process with intervention, date initiated 11/16/2023, Consult with .Psych services, Other. - A focus, initiated on 12/11/2023, revealed Resident #3 used antidepressant medication related to depression with interventions, date initiated 12/11/2023, Give antidepressant medications ordered by physician. Monitor/document side effects and effectiveness ., and Monitor/document/report to MD prn ongoing s/sx of depression unaltered by antidepressant meds: sad, .suicidal ideations, .fear of being alone or with others .anxiety . Record review of facility report Order Summary Report, start date on 05/25/2024 and active orders as of 05/25/2024, revealed two (2) orders for Resident #3, ordered on 05/24/2024 to start on 05/25/2024. The first order was: Depression: Monitor for depressive symptomology .every shift Enter progress note describing behaviors observed if applicable. The second order was: Observation: AntiDepressant Medication- Observe for side effects .every shift. Record review of Psychosocial Assessment, dated 05/25/2024, revealed Resident #3 remained at baseline for psychosocial well-being with no adverse effects noted. Plan of Care revealed continue with current care plan. 3. Record review of Resident #4's admission Record, dated 05/24/2024, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included dementia (a general term for impaired ability to remember, think, or make decisions), insomnia (trouble falling and/or staying asleep), major depressive disorder(a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety (a condition in which a person has excessive worry and feelings of fear, dread, and uneasiness) disorder, and suicide attempt, noted as initial encounter and dated 02/28/2024. Record review of Resident #4's State Optional MDS, dated [DATE], revealed Resident #4 had a BIMS score of 1, which indicated the resident was moderately cognitively impaired for daily decision-making skills. Record review of Resident #4's MDS PHQ9 (Resident Mood Interview), dated 04/08/2024, revealed Resident #4 had a score of 4, which indicated the resident was minimally depressed. Record review of Resident #4's care plan revealed: - A focus, initiated on 02/28/2024 and revised on 05/18/2024, Resident #4 needed pain management and monitoring related depression with intervention, date initiated 02/28/2024, Observe for potential medication side effects. - A focus, initiated on 02/29/2024, revealed Resident #4 had impaired cognitive function/dementia or impaired thought processes related to dementia, difficulty making decisions, impaired decision making, psychotropic drug use, short term memory loss with interventions, date initiated 02/29/2024, Administer meds as ordered, Monitor/document/report to MD any changes in cognitive function ., and Review medications and record possible causes of cognitive deficit: .adverse drug reactions, drug toxicity. - A focus, initiated on 03/04/2024 and revised on 04/18/2024, revealed Resident #4 used anti-histamine medications related to adjustment issues and anxiety disorder with interventions, date initiated 03/04/2024, Give anti-anxiety medications ordered by physician. Monitor/documents side effects and effectiveness ., Monitor/record occurrence of for target behavior symptoms and document per facility protocol, and [Resident #4] is taking Anti-anxiety meds which are associated with an increased risk of confusion, amnesia .Monitor for safety. - A focus, initiated on 03/06/2024, revealed Resident #4 used antidepressant and antiseizure medication related to depression and poor adjustment to admission with interventions, date initiated 03/06/2024, Give antidepressant medications ordered by physician. Monitor/document side effects and effectiveness ., and Monitor/document/report to MD prn ongoing s/sx of depression unaltered by antidepressant meds: sad, .suicidal ideations, .fear of being alone or with others .anxiety . - A focus, initiated 03/13/2024, revealed Resident #4 was at risk for psychosocial well-being problems related to dependent behavior, lack of acceptance to current condition, recent admission, dementia, and depression with intervention, date initiated 03/13/2024, Consult with .Psych services. - A focus, initiated 02/29/2024, revealed Resident #4 had potential mood problems related to dementia with behaviors and history or suicidal behaviors with interventions, date initiated 02/29/2024, Monitor/record/report to MD prn acute episode feelings or sadness ., Monitor/record/repo[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to ensure a resident who displayed or was diagnosed with a mental disorder or psychosocial adjustment difficulty received appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being for 1 (Resident #1) of 13 residents reviewed for psychosocial concerns. LVN A failed to put interventions in place or promptly arrange for psychiatric services for Resident #1 after he displayed increased signs of fear on 05/01/2024. Resident #1 attempted suicide on 05/02/2024. This failure resulted in the identification of Immediate Jeopardy (IJ) on 05/26/2024 at 06:00 p.m. While the IJ was removed on 05/28/2024, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm because the facility's need to monitor the implementation of the plan of removal. This failure to ensure interventions were implemented or psychiatric services were promptly arranged can result in the individual not receiving the necessary care to prevent a decline in health. Findings included: Record review of Resident #1's admission Record, dated 05/24/2024 revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included dementia (a general term for impaired ability to remember, think, or make decisions), depression, and anxiety (a condition in which a person has excessive worry and feelings of fear, dread, and uneasiness) disorder. Resident #1 was noted as discharged on 05/02/2024 to an acute care hospital. Record review of Resident #1's State Optional MDS, dated [DATE], revealed the resident had a BIMS score of 8, which indicated the resident was mildly cognitively impaired for daily decision-making skills. Record review of Resident #1's MDS PHQ9 (Resident Mood Interview), dated 03/12/2024, revealed the resident had a score of 18, which indicated he had moderately severe depression. Further review revealed the SW wrote under explanation, He said that he is hearing voices and forgetting things that he does not want to live. He is open to getting psych services. Record review of Resident #1's care plan revealed: - A focus, initiated on 03/13/2024, revealed Resident #1 had impaired cognitive function/dementia or impaired thought processes related to dementia, difficulty making decisions with intervention, date initiated 03/13/2024, Monitor/document/report to MD any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status. - A focus, initiated on 03/15/2024 and revised on 04/30/2024, revealed Resident #1 used anti-histamine medications related to anxiety/agitation with interventions, date initiated 03/15/2024, [Resident #1] is taking anti-anxiety meds which are associated with an increased risk of confusion, amnesia .Monitor for safety and Monitor/record occurrence of for target behavior symptoms and document per facility protocol. - A focus, initiated on 03/19/2024, revealed Resident #1 used antidepressant medication related to depression with interventions, date initiated 03/19/2024, Give antidepressant medications ordered by physician. Monitor/document side effects and effectiveness ., and Monitor/document/report to MD prn ongoing s/sx of depression unaltered by antidepressant meds: sad .suicidal ideations .fear of being alone or with others .anxiety . - A focus, initiated on 03/19/2024, revealed Resident #1 had a potential psychosocial well-being problem related to depression, anxiety, inability to problem solve, ineffective coping, and lack of acceptance to current condition with intervention, date initiated 03/19/2024, Consult with: Pastoral care, Social services, Psych services. Record review of Resident #1's MAR/TAR for April and May 2024 did not reveal behavior was being monitored according to the care plan. Record review of Resident #1's Psychiatry Follow-Up note, dated 04/29/2024 revealed a note by Psych NP that stated He was recently in an altercation, and he was not the aggressor .No increased depression. He is sleeping and eating well. He is nervous about the aggressors hurting him again. He is having some anxiety regarding the situation. Further review revealed Resident #1 was noted as not currently a danger to self/others, not a risk factor for self-harm, and not a risk factor for suicidal ideation. Under assessment and plan, increased anxiety due to altercation was noted. Record review of Resident #1's progress note, dated 05/01/2024 did not reveal an entry by LVN A and did not reveal a notation regarding Resident #1 displaying increased fear or a request for a staff member to stay with him. Record review of Resident #1's progress note, dated 05/02/2024 revealed a note by LVN A that stated he asked me the previous evening to stay in the room with him because he was scared. He did not clarify what he was scared of, only that he was afraid and wanted me to stay with. Further review revealed Resident #1 attempted suicide on 05/02/2024 by tying a shirt, fashioned to look like a rope, around his neck in a noose fashion, and pulling hard on the shirt to make it tighten enough to cut off his airflow. Attempted interview of LVN A on 05/22/2024 at 10:01 p.m., on 05/23/2024 at 08:07 a.m., and on 05/25/2024 at 10:59 p.m. and 11:03 p.m. was unsuccessful. LVN A worked night shift (10:00 p.m. to 6:00 a.m.). In an interview with Psych NP on 05/23/2024 at 04:33 p.m., revealed the Psych NP stated she had assessed Resident #1 on 04/29/2024 and found that he had been okay. The Psych NP stated Resident #1 had initially been very anxious and impulse upon admission to the facility but with medication therapy he had been fine and no longer had depression. The Psych NP stated she thought Resident #1 was anxious after the altercation on 04/28/2024 and he did not want to be alone with anyone with aggression. The Psych NP stated Resident #1 did not have any indication of being at risk for self-harm. The Psych NP stated she never observed, and no one ever reported to her that Resident #1 was at risk for self-harm or suicidal. The Psych NP stated that the facility had standard orders for behavioral monitoring for residents on psychotropics. The Psych NP stated the facility staff were really good at notifying her of any issues when she was in the facility, at least weekly, or calling her. The Psych NP stated the nurses could contact the psych care team twenty-four hours, seven days a week by calling the call center. In an interview with MD E on 05/25/2024 at 12:52 p.m., MD E stated she had received notification by a facility nurse on 05/02/2024 that Resident #1 had been sent out to the hospital. MD E stated she had not seen Resident #1 but that he was being seen by the Psych NP, who last saw the resident on 04/29/2024. MD E stated the facility nurses reported incidents or changes of conditions to the medical team's call center. MD E stated the reported information would disseminate to the entire care team, including the psychiatric services team. MD E stated she deferred to the psychiatric services team for behavioral issues or concerns. MD E stated the facility nurses' process of charting in the facility EHR and reporting to the care team or medical call center any changes was adequate for behavioral monitoring. In an interview with LVN B on 05/26/2024 at 04:15 p.m., LVN B stated she reviewed resident care plans when she had a question about the resident's care but would only review the specific parts of the care plan that she needed information on. In an interview with ADON C on 05/26/2024 at 04:58 p.m., ADON C stated her expectation was that direct care staff were to follow the care plan. In an interview with MD E on 05/28/2024 at 12:33 p.m., MD E stated she did not recall being notified of Resident #1 ever saying that he did not want to live, per his 03/12/2024 PHQ9 Assessment, or received a report the resident was afraid on the night of 05/01/2024. MD E stated she would have to check her notes. A return call was not received by [Investigator I] prior to the investigation exit, 05/28/2024 at 06:00 p.m. In an interview with the Psych NP on 05/28/2024 at 01:44 p.m., the Psych NP stated she did not recall Resident #1 ever saying that he did not want to live. The Psych NP stated Resident #1 was referred to psych services on 03/14/2024 by a facility nurse and could not recall a staff member reporting to her that during his PHQ9 Assessment, Resident #1 said he did not want to live. The Psych NP stated she had a hard time seeing Resident #1 making that statement and stated that she felt the screening assessments could sometimes lead to a response or misunderstanding due to the wording of the questions. The Psych NP stated she did not feel that people with dementia could complete those screeners appropriately. Record review of facility's policy titled, Care Plans, Comprehensive Person-Centered, revised March 2022, revealed A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident .7. The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including (3) which professional services are responsible for each element of care . This was determined to be an Immediate Jeopardy (IJ) and the ADMIN was provided with the IJ template on 05/26/2024 at 6:00 p.m. The plan of removal was accepted on 05/27/2024 at 1:18 p.m. and read as follows: Summary of details which lead to outcomes. On 5/17/24 an investigation on a facility reported incident was initiated at [the facility]. On 5/26/2023 at 6:00pm, [Investigator I] provided an IJ Template notification that the Survey Agency has determined that the conditions at the center constitute immediate jeopardy to resident health. The Immediate Jeopardy findings were identified in the following areas: 0742: The facility failed to ensure a resident who displayed or was diagnosed with a mental disorder or psychosocial adjustment difficulty received appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being for Resident #1. Immediate Corrective Actions for Removal of Immediate Jeopardy: On May 25, 2024, at approximately 12:00 [p.m.] the following actions were initiated upon facility identification of concern: - Ad hoc QAPI meeting held with Administrator, Regional Director of Clinical Operations, ADONs and MD to review process for psychosocial management to include monitoring orders for side effects and effectiveness of medications, and psychosocial assessments. - All resident charts were audited to ensure that care plans include measurable objective and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs. - All residents who are currently prescribed psychotropic medication were audited to ensure side effect monitoring and effectiveness of medication monitoring were in place and care planned. - All residents who did not currently have side effects and medication effectiveness monitoring were assessed for adverse effects to psychosocial wellbeing related to monitoring orders not being in place. All residents remained at base line with no adverse effects noted. - Education was initiated immediately with licensed nursing staff, on side effect monitoring and medication effectiveness, and reporting psychosocial changes to provider with a completion date of 5/26/2024. - Education initiated to nursing staff on comprehensive care planning and identification of psychosocial interventions with a completion date of 5/26/2024. Identification of other affected: All residents who are diagnosed with a mental disorder or psychosocial adjustment have the potential to be affected. Systemic Changes and/or Measures: - Education provided to all nursing staff on May 26, 2024, on behavioral monitoring, including the requirement to monitor resident for altered mood, behavior, and function and alert the physician via phone with any observations noted with a completion date of 5/27/2024. - Education provided to all nursing staff on May 26, 2024, on Comprehensive, person-centered care planning, and requirement that nursing staff is aware of residents' plan of care when providing resident care. Education also included that care plans include measurable, person-centered, objectives, and timetables to assure residents highest functional, and psychosocial well-being are attained with a completion date of 5/27/2024. - Ad hoc QAPI meeting held with IDT team and MD to review findings of immediate jeopardy, and to review Plan of removal/response to Immediate Jeopardy Citation on 5/26/24 @ 8:00 pm Tracking and Monitoring: - Assistant Director of Nursing, or designee, will monitor daily through daily clinical meeting and review, Monday through Friday, all new admissions, and new orders, for any psychotropic medications, to validate all residents on psychotropics, have behavior monitoring, monitoring for adverse side effects, and care plan is person-centered and addresses specific behaviors being monitored. Any identified concerns will be addressed immediately and physician will be notified via phone with any observations noted. - Assistant Director of Nursing, or designee, will review 24 hours report in EHR, daily Monday through Friday, to identify any new, acute, mental, or psychosocial concerns from previous day, and validate they were addressed to include follow up with provider/physician was completed as indicated. The 24 hours report shall include indication of monitoring orders in place and verification of observations noted. Any identified concerns will be addressed immediately and physician will be notified via phone with any observations noted. The facility's POR Verification was as follows: Interview with the ADMIN on 05/27/2024 at 03:00 p.m., the ADON stated all the nursing staff had received education on behavioral monitoring and care plans. The Administrator stated that the facility had a QAPI meeting on 05/26/2024 and discussed the findings of the deficient practice and the plan of removal. The Administrator stated MD E was the facility medical director. Record review of facility POR Binder on 05/27/2024 at 03:00 p.m. revealed: 1. A copy of the two Ad hoc QAPI Meetings: - The first Ad hoc QAPI document was dated 05/24/2024 and noted with an agenda: Psychotropic Medications, Monitoring and Observations Orders, Auditing, and Psych. Services auditing. Attendees were noted as: the ADMIN, MD E, ADON C, ADON D, and the RDCS. - The second Ad Hoc QAPI document was dated 05/26/2024 and noted with agenda: Immediate Jeopardy Citations- F656, F742, and Plan of Removal. Attendees were noted as: the ADMIN, MD E, ADON C, ADON D, and the RDCS. The binder contained a list of 19 licensed nursing staff. 2. An In-service document, dated 05/26/2024 and titled All nurses must monitor residents for psych issues such as withdrawn behaviors, signs/symptoms or verbalization of fear, depression, anxiety, anger/aggressive behavior, self-harm or attempted self-harm, suicidal ideation or statements and must else report it to nurse managers, administrator, doctor/nurse practitioner, and responsible party. The in-service document included a note *orders for monitoring psych diagnosis and psych meds must be added on admission or new orders. MD must be notified if behaviors observed and included 19 (9 LVN and 10 RN) licensed nurses noted as had received the training. 3. A document titled F656 Develop/Implement Comprehensive Care Plans revealed care plans were audited on 05/26/2025, the corrected care plans were noted on the order listing report, and the reviewer was the ADON and MDS staff. The document noted the care plans were audited on 05/27/2024 and found to be up to date by the ADON and MDS staff. A facility report, Daily Census, dated 05/26/2024 was included with the audit document with each resident name checked off. 4. A document titled F742 Treatment/Services for Mental/Psychosocial Concerns revealed psychosocial monitoring orders were audited on 05/25/2025, 05/26/2024, and 05/27/2024. For 05/25/2024 and 05/26/2024, the audit form indicated the need for psychosocial assessments. A facility report, Order Listing Report, dated 05/24/2024 - 05/25/2024 was included with the audit document with 36 resident names highlighted and checked off and 14 residents were noted as having a current monitoring orders. Interviews with 17 of 19 licensed nursing staff from different shifts were completed on 05/27/2024 and 05/28/2024 which consisted of 2 of 3 licensed nursing staff from morning shift (6:00 a.m. to 2:00 p.m.), 5 of 5 licensed nursing staff from afternoon shift (2:00 p.m. to 10:00 p.m.), 1 of 2 licensed nursing staff from night shift (10:00 p.m. to 6:00 a.m.), 4 of 4 PRN licensed nursing staff, 2 of 2 weekend licensed nursing staff, and 3 of 3 administrative (MDS, ADON C, ADON D) licensed nursing staff. All 17 staff members reported they received education and were trained on behavioral monitoring, notifying the physician of behaviors, and reviewing and updating the residents' care plan. Attempted interview of RN G on 05/27/2024 at 06:19 p.m. and LVN A on 05/27/2024 at 7:11 p.m. to confirm training was unsuccessful. RN G worked morning shift (6:00 a.m. to 2:00 p.m.) and LVN A worked night shift (10:00 p.m. to 6:00 a.m.). In an interview with ADON D on 05/28/2024 at 10:48 a.m., ADON D stated she received training from the RDCS regarding behavioral monitoring and care planning, and she provided the training to ADON C and facility licensed nursing staff. ADON D stated the ADONs will be monitoring the psychosocial medications by reviewing the facility 24-hour, 72-hour, and Order Listing reports to identify if there were any new psychosocial medications, reported behaviors, new treatment orders, new antibiotic medications, new monitoring orders, and any reported behaviors. The report on incidents would also be reviewed. ADON D stated the reports would be reviewed in the morning clinical meeting with the floor nurses and ADON C, to discuss if any changes or incidents occurred the prior day and/or over the weekend. ADON D revealed that by reviewing the Order Listing report and 24-hour or 72-hour report, the ADONs were able to audit that if a new medication order was entered, a progress note for that new medication was entered, and verify that additional orders for monitoring the side effects, behaviors, and efficacy were entered. ADON D stated that by reviewing the Order Listing report and 24-hour or 72-hour report, the ADONs were able to review that when a PRN psychosocial medication was provided, a monitor for the behavior and efficacy was entered, and if needed, a progress note indicating that the physician was notified and description of the behavior or reason for providing the PRN medication was documented. ADON D stated that after the IJs were called, each residents' chart was audited for monitoring orders. ADON D stated that for some residents' charts, behavior monitoring, or side effect monitoring was found but not both, and for those residents the other monitor was added. ADON D revealed that the Psych NP was asked to also complete an audit, checking her records, and notes to verify that all the monitoring orders were in. She revealed for the care plan audit, she and the MDS nurse reviewed the care plans for every resident and ensured that the interventions in the care plans were also in the orders. ADON D stated they only identified Resident #1 as having the type of monitoring language for sadness and fear of being alone in his care plan. ADON D stated that it was discussed with the Psych NP on how the facility would going forward with their monitoring and interventions to reflect the facility's resident's needs and behaviors more accurately. In an interview with the RDCS on 05/28/2024 at 06:08 p.m., the RDCS stated she had attended Ad hoc QAPI Meetings on 05/25/2024 and 05/26/2024. The RDCS stated she provided training to ADON D on behavioral monitoring and care planning so ADON D could train the licensed nursing staff. In an interview with the MD E on 05/28/2024 at 12:36 p.m., MD E stated she had attended the Ad hoc QAPI Meetings on 05/25/2024 and 05/26/2024. MD E stated she was informed of the IJ and the plans for removal. In an interview with the Psych NP on 05/28/2024 at 01:44 p.m., the Psych NP stated she was notified of the IJ at the facility and was contacted by her supervisor regarding a request that she provide follow up assessments on specific residents to review current behaviors and monitoring orders. Interview with the ADMIN and record review of facility report Order Summary Report on 05/28/2024 at 04:50 p.m. revealed the facility staff did not create a tracking log of resident orders that were entered as a part of their plan of correction but stated the Order Summary Report dated start date 05/25/2024 with active orders as of 05/25/2024 captured the new orders created per the order audit. The report noted five (5) residents (Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6) with new orders on 05/24/2024 or 05/25/2024 with start dates 05/25/2024. New orders included observation for anti-depressant medication, observation for anti-anxiety medication, monitor for depression, monitor for anxiety, and monitor for side effects of sedative/hypnotics. The ADMIN revealed a new psychosocial assessment was completed on the five (5) identified residents. 1. Record review of Resident #2's admission Record, dated 05/24/2024, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included dementia (a general term for impaired ability to remember, think, or make decisions), depression, and post-traumatic stress disorder (a condition characterized by intrusive thoughts about the incident, recurrent distress/anxiety, flashback and avoidance of similar situations). Record review of Resident #2's State Optional MDS, dated [DATE], revealed Resident #2 had a BIMS score of 99, which indicated the resident was severely cognitively impaired for daily decision-making skills and/or unable to complete the interview. Record review of Resident #2's MDS PHQ9 (Resident Mood Interview), dated 04/11/2024, revealed Resident #2 had a score of NA. Record review of Resident #2's care plan revealed: - A focus, initiated on 04/15/2024, revealed Resident #2 used antidepressant medication related to depression with interventions, date initiated 04/15/2024, Give antidepressant medications ordered by physician. Monitor/document side effects and effectiveness ., and Monitor/document/report to MD prn ongoing s/sx of depression unaltered by antidepressant meds: Sad .suicidal ideations .fear of being alone or with others .anxiety . - A focus, initiated on 04/15/2024, revealed Resident #2 had impaired cognitive function/dementia or impaired thought processes related to dementia, difficulty making decisions, impaired decision-making, long-term memory loss, psychotropic drug use, short term memory loss with interventions, date initiated 04/15/2024, Administer meds as ordered and Review medications and record possible causes of cognitive deficit .adverse drug reactions, drug toxicity. - A focus, initiated on 04/17/2024 and revised on 04/23/2024, revealed Resident #2 used anti-anxiety medications and anti-convulsant medications related to anxiety disorder with interventions, date initiated 04/17/2024, [Resident #2] is taking anti-anxiety meds which are associated with an increased risk of confusion, amnesia .Monitor for safety, Give anti-anxiety medications ordered by physician. Monitor/document side effects and effectiveness .Paradoxical side effects: mania, hostility, and rage, aggressive or impulsive behavior, hallucinations, and Monitor/record occurrence of for target behavior symptoms and document per facility protocol. -A focus, initiated 04/15/2024, revealed Resident #2 had potential mood problems related to PTSD and dementia with intervention, date initiated 04/15/2024, Monitor/record/report to MD prn acute episode feelings or sadness . Record review of facility report Order Summary Report, start date on 05/25/2024 and active orders as of 05/25/2024, revealed two (2) orders for Resident #2, ordered on 05/24/2024 to start on 05/25/2024. The first order was: Observation: antidepressant medication- observe for behavior WITHDRAWN/ AGITATION. Observe for side effects .every shift. The second order was: Observation: antianxiety medication- observe for behavior AGITATION. Observe for side effects .every shift. Record review of Psychosocial Assessment, dated 05/25/2024, revealed Resident #2 was unable to participate in assessment due to severe cognitive impairment directly related to admitting diagnosis of dementia. Resident remained at baseline. No adverse psychosocial effects noted. Plan of Care revealed continue with current care plan and psych services involvement. Provide quiet space if resident appears to become overstimulated. Monitor for adverse effects to psychosocial well-being. 2. Record review of Resident #3's admission Record, dated 05/24/2024, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included anxiety (a condition in which a person has excessive worry and feelings of fear, dread, and uneasiness) disorder, depression, and mild cognitive impairment (difficulty with language, memory, and thinking). Record review of Resident #3's State Optional MDS, dated [DATE], revealed Resident #3 had a BIMS score of 15, which indicated the resident was cognitively intact for daily decision-making skills. Record review of Resident #3's MDS PHQ9 (Resident Mood Interview), dated 01/03/2024, revealed Resident #3 had a score of 4, which indicated the resident was minimally depressed. Record review of Resident #3's care plan revealed: - A focus, initiated on 11/13/2023 and revised 05/07/2024, revealed Resident #3 had impaired cognitive function/ impaired thought processes related to difficulty making decisions, impaired decision making, mild cognitive impairment caused by history of alcoholic intoxication with interventions, date initiated 11/13/2023, Administer meds as ordered, Monitor/document/report to MD any changes in cognitive function ., and Review medications and record possible causes of cognitive deficit .adverse drug reactions, drug toxicity. -A focus, initiated on 11/16/2023, revealed Resident #3 had potential psychosocial well-being problem related to illness/disease process, disease process with intervention, date initiated 11/16/2023, Consult with .Psych services, Other. - A focus, initiated on 12/11/2023, revealed Resident #3 used antidepressant medication related to depression with interventions, date initiated 12/11/2023, Give antidepressant medications ordered by physician. Monitor/document side effects and effectiveness ., and Monitor/document/report to MD prn ongoing s/sx of depression unaltered by antidepressant meds: Sad .suicidal ideations .fear of being alone or with others .anxiety . Record review of facility report Order Summary Report, start date on 05/25/2024 and active orders as of 05/25/2024, revealed two (2) orders for Resident #3, ordered on 05/24/2024 to start on 05/25/2024. The first order was: Depression: Monitor for depressive symptomology .every shift enter progress note describing behaviors observed if applicable. The second order was: Observation: antidepressant medication- observe for side effects .every shift. Record review of Psychosocial Assessment, dated 05/25/2024, revealed Resident #3 remained at baseline for psychosocial well-being with no adverse effects noted. Plan of Care revealed continue with current care plan. 3. Record review of Resident #4's admission Record, dated 05/24/2024, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included dementia (a general term for impaired ability to remember, think, or make decisions), insomnia (trouble falling and/or staying asleep), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety (a condition in which a person has excessive worry and feelings of fear, dread, and uneasiness) disorder, and suicide attempt, noted as initial encounter and dated 02/28/2024. Record review of Resident #4's State Optional MDS, dated [DATE], revealed Resident #4 had a BIMS score of 1, which indicated the resident was moderately cognitively impaired for daily decision-making skills. Record review of Resident #4's MDS PHQ9 (Resident Mood Interview), dated 04/08/2024, revealed Resident #4 had a score of 4, which indicated the resident was minimally depressed. Record review of Resident #4's care plan revealed: - A focus, initiated on 02/28/2024 and revised on 05/18/2024, Resident #4 needed pain management and monitoring related depression with intervention, date initiated 02/28/2024, Observe for potential medication side effects. - A focus, initiated on 02/29/2024, revealed Resident #4 had impaired cognitive function/dementia or impaired thought processes related to dementia, difficulty making decisions, impaired decision making, psychotropic drug use, short term memory loss with interventions, date initiated 02/29/2024, Administer meds as ordered, Monitor/document/report to MD any changes in cognitive function ., and Review medications and record possible causes of cognitive deficit: .adverse drug reactions, drug toxicity. - A focus, initiated on 03/04/2024 and revised on 04/18/2024, revealed Resident #4 used anti-histamine medications related to adjustment issues and anxiety disorder with interventions, date initiated 03/04/2024, Give anti-anxiety medications ordered by physician. Monitor/documents side effects and effectiveness ., Monitor/record occurrence of for target behavior symptoms and document per facility protocol, and [Resident #4] is taking anti-anxiety meds which are associated with an increased risk of confusion, amnesia .Monitor for safety. - A focus, initiated on 03/06/2024, revealed Resident #4 used antidepressant and antiseizure medication related to depression and poor adjustment to admission with interventions, date initiated 03/06/2024, Give antidepressant medications ordered by physician. Monitor/document side effects and effectiveness ., and Monitor/document/report to MD prn ongoing s/sx of depression unaltered by antidepressant meds: Sad .suicidal ideations .fear of being alone or with others .anxiety . - A focus, initiated 03/13/2024, revealed Resident #4 was at risk for psychosocial well-being problems related to dependent behavior, lack of acceptance to current condition, recent admission, dementia, and depression with intervention, date initiated 03/13/2024, Consult with .Psych services. - A focus, initiated 02/29/2024, revealed Resident #4 had potential mood proble[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide and document sufficient preparation and orientation to residents to ensure safe and orderly discharge from the facility for 1 of 5 residents (Resident #1) reviewed for discharge rights, in that: The facility failed to ensure Resident #1 was safely discharged to a homeless shelter on 8/15/23. Resident #1's whereabouts remained unknown until 8/18/23, when he was found at a local park. These failures resulted in the identification of an Immediate Jeopardy (IJ) on 8/18/23 at 6:32 p.m. While the IJ was removed on 8/19/23, the facility remained out of compliance at a level of no actual harm with potential for more than minimal harm with a scope identified as a isolated until interventions were put in place to ensure residents were discharged safely. These failures could place residents at risk of being discharged without preparation, causing a disruption in their care and services and denying them a voice regarding their treatment plan. The findings were: Record review of Resident #1's face sheet, dated 8/17/23, revealed Resident #1 was admitted to the facility on [DATE] with diagnoses of metabolic encephalopathy [a chemical imbalance in the blood that causes problems in the brain], thrombocytopenia [a low amount of platelets, which are blood cells that cause clotting, in the blood], unspecified, essential (primary) hypertension, muscle weakness (generalized), and dysphagia [difficulty swallowing], oral phase. Further record review of this document revealed Resident #1 did not have a responsible party or a guardian. Further record review of this face sheet revealed Resident #1 was discharged on 8/15/23 and his length of stay was 20 days. Record review of Resident #1's entry MDS, dated [DATE], revealed Resident #1 had a BIMS score of 8, signifying moderate cognitive impairment. Record review of this same document, revealed the following items: - Section G, Item G0110. Activities of Daily Living (ADL) Assistance. Review of this item revealed Resident #1 required one-person physical assist with the following activities of daily living: bed mobility, transfer, walking in room, walking in corridor, dressing, eating, toilet use, and personal hygiene. - Item Q0300A. Resident's Overall Expectation: Select one for resident's overall goal established during assessment process. The answer to this item was: Unknown or uncertain. The other options which were not selected for item Q0300 were: Expects to be discharged to the community, expects to remain in this facility, and expects to be discharged to another facility/institution. - Item Q0300B. Indicate information source for Q0300A. The answer to this item was: Resident. - Item Q0400A. Discharge Plan: Is active discharge planning already occurring for the resident to return to the community? The answer to this item was: No. - Items Q0500B. Return to the community: Ask the resident . 'Do you want to talk to someone about the possibility of leaving this facility and returning to live and receive services in the community?' The answer to this item was Unknown or uncertain. Record review of Resident #1's MoCA assessment [which is a test used to detect mild cognitive decline and early signs of issues with the ability to remember, think, or make decisions], dated 8/9/23, revealed Resident #1 had a MoCA score of 6 out of 30, signifying severe cognitive deficits. Record review of Resident #1's care plan, dated 8/15/23, revealed the following Focus area initiated on 8/8/23: Resident will be assessed for discharge needs, included in the discharge planning process, and educated appropriately to ensure a successful discharge. This Focus area was associated with the following intervention initiated on 8/8/23: Resident's discharge plan will be discussed with physician and orders will be obtained if needed. Record review of Resident #1's Discharge Planning and Summary, dated 8/15/23 at 11:27 a.m., revealed an incomplete and unsigned Discharge Planning and Summary form. There was no documentation regarding a discharge location or coordination of care to the local homeless shelter. Record review of Care Conference Summary, dated 8/16/23 at 11:01 a.m., revealed the DOR documented the following in the section titled: Summary of Therapy and/or Restorative: Resident was on therapy and was D/C on 8/11/23; Resident was on OT ST and PT; Resident is not a safe DC secondary to the Montreal Cognitive Assessment (MOCA) which the resident scored 6/30 which is severe cognitive deficits. Per IDT; it was determined that the resident was not a safe DC. There was no documentation on this Care Conference regarding a future discharge location or coordination of care for a safe discharge. Record review of Resident #1's orders, obtained on 8/17/23, revealed no physician order for Resident #1's discharge. Further record review of this document revealed Resident #1 had the following medications: - AmLODIPine Besylate Tablet 5 M [G [a medication used to lower blood pressure] Give 1 tablet by mouth one time a day for hypertention hold if bp below. Ordered on 7/27/23. - Bisacodyl Suppository [a medication used to relieve constipation] 10 MG Insert 1 suppository rectally every 24 hours as needed for constipation Bowel Protocol #3: Give if constipation unrelieved by oral laxative; If ineffective after 4 hours then do assessment. Ordered on 7/26/23. - cloNIDine [a medication used to treat hypertension] Transdermal Patch Weekly 0.1 MG/24HR (Clonidine) Apply 1 patch transdermally one time a day every Mon for hypertension notify provider if BP less than 110/60, pulse less thab 60 and remove per schedule. Ordered on 8/4/23. - Fleet Oil Enema (Mineral Oil) [a medication used to treat constipation] Insert 1 application rectally every 24 hours as needed for constipation Bowel Protocol #4: Give if constipation unrelieved by suppository: If ineffective, call provider. Ordered on 7/26/23. - Lactulose Oral Solution 10 GM/15ML (Lactulose) [a medication used to treat constipation] Give 30 ml by mouth one time a day for elevated ammonia. Ordered on 7/27/23. - Milk of Magnesia Concentrate Suspension (Magnesium Hydroxide) [a medication used to treat constipation] Give 30 ml by mouth every 12 hours as needed for constipation Bowel Protocol #2: Give if no BM in last 3 days. Ordered on 7/26/23. - Multi-Vitamin/Iron Tablet (Multiple Vitamins-Iron) Give 1 tablet by mouth one time a day for supplement. Ordered on 7/27/23. - Thiamine HCl Oral Tablet 100 MG (Thiamine HCl) [a type of vitamin] Give 1 tablet by mouth two times a day for Supplement. Ordered on 7/27/23. Record review of ST Progress Report, dated 8/8/23 and written by ST K, revealed the following: Remaining Impairments: Patient Demonstrates with severe cognitive deficits . Due to the documented physical impairments and associated functional deficits, without skilled therapeutic intervention, the patient is at risk for: decreased ability to return to prior level of supervision/assistance, decrease leisure task participation and decreased participation with functional tasks. Record review of Speech Therapy Discharge summary, dated [DATE] and written by ST K, revealed the following: How often does patient demonstrate adequate cog/com skills to complete age-appropriate complex living tasks?=26-49% of the time; How often does patient function safely without additional assistance/supervision due to cognitive deficits?=26-49% of the time. Memory= Impaired. Record review of OT Therapy Progress Note, dated 8/8/23 and signed by OT H, revealed: Patient characteristics that may Impact Treatment=Lacks capacity for chronic disease management, lacks insight into condition and risk factors. Record review of Resident #1's Occupational Therapy Treatment Encounter Note, dated 8/10/23 and written by COTA I, revealed: Pnt confused, disoriented to time and place, easily distracted, needs constant redirection, verbal and visual cues to follow one-step instructins [sic], sequencing of task. Record review of Resident #1's OT Discharge summary, dated [DATE] and signed by OT H, revealed the following documentation in regards to Resident #1's ability to perform ADLs: - Lower body dressing: supervision or touching assistance. - Shower/bathe self: supervision or touching assistance. - Discharge Recommendations: 24 hour care. Record review of Physical Therapy Treatment Encounter Note(s), dated 8/11/23 and written by PTA J, revealed the following: Precautions: Confusion and Fall Risk. Record review of Resident #1's PT Discharge summary, dated [DATE] and signed by PT A, revealed the following: -12 steps [referring to the patient's ability to safely go up and down twelve steps]: Partial/moderate assistance [which the resident does 50% of the work the rehabilitation therapist is doing 50% of the exercise or activity.] - Patient will exhibit improved dynamic activity/ambulation tolerance as evidenced by increase in distance on the Six Minute Walk Test to 1590 feet . Pt unable to follow test instructions on DC. - Assessment and summary of Skilled Services .Pt requires S/U - SUP for functional mobility due to cognitive deficits. - Discharge Recommendation and Status . Discharge Recommendations: Assistance with IADLs and 24 hour care. Record review of Resident #1's progress notes from 7/26/23 to 8/17/23, revealed the following progress notes: - Nursing Progress Note dated 8/15/23 at 4:17 p.m. and written by LVN G: This nurse was informed that pt was d/c to [local homeless shelter.] - Nursing Progress Note dated 8/15/23 at 11:29 a.m. and written by the DON: This nurse with the IDT agreed that this was an unsafe DC. - Discharge Plan Update Note dated 8/14/23 at 3:29 p.m. and written by the SW: In anticipation of upcoming discharge of resident, the following agencies were contacted for possible housing for resident: [8 local agencies were listed here, including the local homeless shelter Resident #1 was ultimately discharged to.] SW was informed by agencies ID is required or other forms of identification and would have to register, and resident had no form of ID. Administrator was informed of requirements for housing and that resident had none. SW told Adm. this is an unsafe discharge Adm. responded [Resident #1] had no payor source and would have to be discharged today. Adm. stated he should have been out yesterday because we are not getting paid. SW will continue to follow closely. Further record review of these progress notes ranging from 7/26/23 to 8/17/23 revealed no documentation that written records were provided to Resident #1's discharge location: the local homeless shelter. During an interview on 8/17/23 at 2:51 p.m., PT A stated Resident #1 had problems with sequencing . If you handed him a list of instructions, I don't think he would sequence things like that. Like pick this up, bring it over here, bring it back to me. PT A stated Resident #1 required queuing. PT A stated Resident #1 was on physical therapy for generalized weakness . just seeing if he had deficits and balance deficits. PT A stated Resident #1 had physical therapy from 7/27/23 until 8/11/23. PT A stated Resident #1 was discharged from physical therapy because per physician or case manager. They just discharged from the facility. I don't have a whole lot to do on that end. During an interview on 8/17/23 at 2:59 p.m., COTA B stated Resident #1 had occupational therapy from 7/27/23 to 8/11/23 and he had several goals such as increasing his ability to maintain balance, increase ability to perform lower body dressing, and bathe himself with the use of a bath bench. COTA B stated Resident #1 was discharged from the facility because he achieved his highest practicable level. During an interview on 8/17/23 at 3:15 p.m., the DOR stated, in the morning it's usually [the Administrator] . myself, the BOM, the SW, who attended that meeting because we talk about discharges, where they're [the residents are] at, and what's the plan. Well, that day [8/15/23] . we talked about [Resident #1] and that it's an unsafe discharge and [Resident #1] needs help with feeding in terms of verbal queues and he's at risk for failure to thrive. And I said that his last day for us would be at 8/11/23, and he'd need to be a long-term . We talked about him being long-term and the money. No one knew nothing about it [Resident #1's discharge.] [Resident #1] was gone before we ever walked out of the room. During an interview on 8/17/23 at 3:36 p.m., the Driver stated he transported Resident #1 to the local homeless shelter on 8/15/23 between 2:00 - 3:00 p.m. The Driver stated that his direct supervisor, the Maintenance Director, said he [the Driver] needed to transport Resident #1 to [the local homeless shelter]. The Driver stated he transported Resident #1's to the local homeless shelter's intake area, but did not see if Resident #1 entered the premises before leaving the area. The Driver stated he did not know why Resident #1 was discharged and stated Resident #1 only had the clothes he [Resident #1] was wearing when Resident #1 left the facility. The Driver sated he did not see Resident #1's nurse provide him with medications. During an interview on 8/17/23 at 4:01 p.m., CNA C stated she helped Resident #1 with changing his clothes, but did not assist him with eating. CNA C stated on 8/15/23 she was asked to pack Resident #1's belongings. CNA C stated, we were in the room and I was like, 'this man don't have any belongings. He don't have no clothes.' .So he didn't leave with any belongings.So we were like, 'where's he going?' And they said he was going to the homeless shelter. And then I went back to working. CNA C stated she did not see if Resident #1's nurse provided him with medications when he left. During a confidential interview on 8/17/23 on 4:38 p.m., the confidential interviewee stated they worked on 8/15/23. The interviewee stated, if we know the patient is discharged , then we have to do the necessary documentation, like the discharge papers and anything, prepare all of those that needs to be done, like the medications and everything, if they will go with their medications . [The DON or ADON] will inform us beforehand so we can prepare the necessary materials and the documentations that go with that and we can give report to the facility where they're going, but in that case [of Resident #1] nobody said nothing. Usually we have this discharge paper form that we need to fill out-all the departments, the nursing, everything-so we have to consolidate that discharge paper form. But at that point, I was surprised and I wasn't able to prepare anything for [Resident #1.] The interviewee stated Resident #1 was alert and oriented by 1 . He can answer his name and simple questions, he can answer that. But he has a Wanderguard [a monitoring bracelet worn by a resident that alerts staff when a resident attempts to leave a safe area] on. And most of the time he wants in my hallway and back and forth. And we can just redirect him and he will follow. But he always forget easily . He doesn't take that much medications . but I know he's taking blood pressure pills . He could still manage to put on his clothes, but there should be somebody because he might put it on upside down or something like that.He can do it, but someone has to supervise him. Just for him to know what he needs to do . He could eat by himself . maybe he could [bathe] himself, but there has to be somebody to queue him. During he his stay he is polite. He is a happy person. Every time he always smiles. I feel so sorry that he's gone because he's easy to be with. He didn't give you any problems at all. The interviewee stated on 8/15/23, she was assisting someone with their lunch meal and thought Resident #1 went to therapy. The interviewee stated, I didn't know he was discharged until someone told me. And I said 'discharged ? Where?' And it was the med aide who told me he was discharged . So I said, 'to where?' And she goes, 'I don't know but he was discharged . So when I looked back and checked the orders, there was no order from the doctor to discharge. The interviewee stated she did not prepare Resident #1 for discharge. The interviewee stated she did not know who prepared Resident #1 for discharge. During an interview on 8/17/23 at 5:05 p.m., the SW stated the discharge planning process started at time of admission. The SW stated, I ask what their [the resident's] plans are once they meet their goals. Well, I follow up with the family and see what the family says and sometimes we have to wait until they [the resident] finish their therapy and see how they're doing if they're going to stay for long term. When asked when a resident is able to discharge, the SW stated, If they [the residents] come in for therapy, once they've met their goals on therapy, and this population, the psychiatric ones, they're long-term. Meaning they'll stay here unless the family wants them to go to another facility. When asked what was the facility's policy on facility-initiated discharges, the SW stated, Well, like in 30 days, behaviors, non-payment, once they met their needs, and if we're not able to meet their needs. I issue [the 30 day discharge.] I present it to the resident. And then I tell him this is the 30-day discharge and I tell him the reason and I tell him I will assist them in finding alternative placement. When asked if a resident was able to appeal a discharge notice, the SW stated, Yes. When asked how a resident would appeal a discharge, the SW stated I don't know, but if they [the residents] tell me they want to appeal, I'm going to find out real fast. Continuing the interview with the SW on 8/17/23 at 5:05 p.m., when asked if Resident #1 required 24-hour care, the SW stated, I'm going to say no, because he is a street person. He can survive by himself. When asked if Resident #1 met criteria for long-term care, the SW stated, Well, this is my conundrum: he could do everything, but his-he was confused. Yet, he could function. When asked if Resident #1 had medically necessity to stay, the SW stated, I personally don't think so. Just because you're confused and a street person, why does that give you medical necessity? Now I may be wrong. When asked what were Resident #1's discharged goals, the SW stated, He wanted to leave . Back to the community. When asked why Resident #1 was discharged , the SW stated, Because he had already used up his Medicare days and he had no funding and there was no family member to help him get his financial Medicaid. I would have said that he has the right to leave. You may want him on Medicaid or think that he's better her, but the man has a right to leave. We can't tell him what's best for him and the way to live. That's my opinion. The SW stated, Medicare pays for 100% for the first day until the 20th day and 80% from the 21st day to the 100th day. When asked who initiated Resident #1's discharge, the SW stated, I guess I did. I was told [by the Administrator] that 'it's time for him to go and do what you need to do.' When asked how the Administrator made the determination to discharge Resident #1, the SW stated, when he [Resident #1] ran out of his Medicare. When asked how Resident #1 was involved in his discharge, the SW stated, He couldn't say he just-he just wanted to go And he made that clear throughout his stay . he said that he's a drifter and lives out in the streets. Continuing the interview with the SW on 8/17/23 at 5:05 p.m., when asked how she ensured Resident #1 had a safe discharge, the SW stated, I told the Administrator it was not a safe discharge. Over and over, multiple times. Not only me, but the Director of Nurses, the ADON, the IDT kept saying it's not a safe discharge. [The Administrator] just said he had to go. He had to be discharged because of the money. The SW stated Resident #1 went to the local homeless shelter. The SW stated she started reaching out to multiple agencies on 8/14/23, the day before Resident #1 was discharged . The SW stated, I called multiple places but they required an ID, or some sort of ID which he didn't have, or some type of money, so he ended up having to go [the local homeless shelter.] When asked about what she knew about the day Resident #1 was discharged , the SW stated, All I know is that our van was going to take him to [the local homeless shelter.] When asked how the local homeless shelter could address Resident #1's needs, the SW stated, he would at least get a place to sleep. It was the best place that I was able to locate for him, period. All these agencies require ID. They have all these requirements that he didn't have it. That was the very best that I could do for him. When asked if Resident #1 had medications or medical records when he was discharged , the SW stated, No. During an interview on 8/18/23 at 8:50 a.m., the Maintenance Director stated he worked on 8/15/23. The Maintenance Director stated, when I got to the meeting on Tuesday morning [8/15/23] . I guess [the SW] raised questions of what we're going to do with [Resident #1.] And I think [the Administrator] stated [the local homeless shelter.] Then they went on and went on . So at the end of the meeting . I said, 'what do you want me to do for [Resident #1?] Do you want me to take him to [the local homeless shelter?] And [the Administrator] basically said 'yes.' .He looked at me and nodded, like yes. And so then I proceeded by leaving the meeting. I went to the second floor, I found [the Driver], I said, 'you need to go [Resident #1's room] and find [Resident #1] to take him to [the local homeless shelter]' and [the Driver] brought [Resident #1] down in the hallway. [Resident #1] was at the elevator, I cut the bracelet [the Wanderguard] off his arm and that was the end of it.And [Resident #1] was a flight risk, and that stuff on his arm [the Wanderguard], he didn't like it. He said, 'I need to leave, I want to leave,' even the day before that. Because he left previously before that. And I thought, 'well, it's an agreement they made with [Resident #1] to take him to [the local homeless shelter.] During an interview on 8/18/23 at 9:43 a.m., a representative from the local homeless shelter, Representative E, stated Resident #1 was not at the local homeless shelter. Representative E stated, we have a discharge process for our intake center since we're not a medical facility. We want to make sure that people who are discharged from a medical facility, we have a form that is submitted. We didn't have any records that the form was submitted [for Resident #1.] And we did search for [Resident #1] . we searched by the date of birth and SSN provided and we didn't have anyone there . And then usually the facility, they will transport by non-emergency vehicle or ambulance and they'll usually pull up in front of our intake center and then walk the individual inside, like a 'warm hand-off.' We don't have a record of anyone bringing him into our intake center and that paperwork . I believe [the facility] should know our process, because [Resident #1] wouldn't have been accepted here, it would have been an inappropriate placement. We do have our [clinic] that will come and look at him, but our ADLs are just different than the standard ADLs. It mainly comes down to how far they can walk on their own and things like that. During an interview on 8/18/23 at 10:56 a.m., the Administrator stated he was currently on suspension due to Resident #1's discharge on [DATE]. The Administrator stated typically discharge planning started even before the resident was admitted to the facility. The Administrator stated, There's a process to it. Sometimes they come in long-term but then they become short-term because of the resident's wishes. We have meetings. We talk about discharging if they're going to be short-term or long-term . The social worker helps with the discharge planning. When asked when a resident was able to be discharged , the Administrator stated, If the resident is expressing they want to leave and they don't want to be there anymore, obviously we can't hold them hostage in the building or keep them there. We have to find a plan and get them to a place they want to be . or if their skilled stay is up. And if it comes down to financial or behavioral, where we can't meet their needs, we've had to issue a 30-day notice. When asked what were the state guidelines for facility-initiated discharges, the Administrator stated, I know there's 30-day notices. If it's an immediate discharge there's a letter you can send out or write up. Continuing the interview with the Administrator on 8/18/23 at 10:56 a.m., when asked if Resident #1 had medical necessity, the Administrator stated, I do believe he met medical necessity. I want to say he was on skilled services. I don't know if he was all three therapies or just one. When asked what were Resident #1's discharge goals, the Administrator stated, I do recall that he wanted to leave. I know we had an elopement at one point with him. He wanted to leave and I know the [resident's] hospital paperwork said Resident #1 worked for [the local homeless shelter] and resided there. That was one of the things he wanted. Personally, I wasn't the one who sat down with him and asked him what were his goals. When asked why Resident #1 was discharged , the Administrated stated, He was a short-term resident. When he first got here we saw that he was going to be potentially a long-term but due to him not having co-insurance and things, we looked at that. But he also verbalized to our social worker and the business office manager that he wanted to leave and I was aware the resident was homeless. And during our PDPM meeting it was discussed that the resident had to be discharged after 20 days. And according to the SW and BOM that he had expressed a desire to leave. The DON and SW, we made that decision to find placement for him. That's when I looked at my SW . for discharge planning and she looked at multiple different facilities and [the local homeless shelter] came up and it seemed like she [the SW] had it under control and taken care of it and I trusted that and that's when we made the decision. When asked if Resident #1 was discharged because he (Resident #1) could not pay for his stay, the Administrator stated, It was part of that yeah . But I took the fact that he wanted to leave into consideration into it, too. When asked when was the decision made to discharge Resident #1, the Administrator stated, Maybe the week before because we had those daily meetings. The Administrator was not sure exactly when the SW began looking for alternative placement for Resident #1. The Administrator stated he was aware Resident #1 was going to the local homeless shelter before Resident #1 was discharged but did not check if arrangements were made for Resident #1 to discharge. The Administrator stated, When my social worker said that [Resident #1] was ready to go to [the local homeless shelter] and we just needed someone to transport him there. Right then and there I was thinking plans had been arranged and we can proceed with this. I didn't question it. When asked how Resident #1 was involved in his discharge, the Administrator stated, I heard that he was ready to go and happy to leave over there. But I'm not sure involved he personally was. Continuing the interview with the Administrator on 8/18/23 at 10:56 a.m., the Administrator stated at 9:00 a.m. during the usual morning meeting, the SW stated Resident #1 was ready to go to [the local homeless shelter] and they just needed someone to pick up Resident #1 and take him to [the local homeless shelter.] The Administrator stated, And that's when the [Maintenance Director] stood up and got someone and they went upstairs to discharge him. The Administrator stated Resident #1 was discharged around the afternoon, but did not recall exactly when Resident #1 discharged . When asked what sort of items went with Resident #1, the Administrator stated, he didn't have anything. He didn't have much to begin with. When asked if Resident #1 went with any medications or medical records, the Administrator stated, I wasn't present at the time of his actual discharge. Continuing the interview with the Administrator on 8/18/23 at 10:56 a.m., when asked how he ensured Resident #1's discharged was safe, the Administrator stated, I look at his past. That he was homeless before and this was his home base . And to me it was like he's been to [the local homeless shelter] before. He's been homeless before. He wants to leave. When asked how the local homeless shelter Resident #1 was discharged to would have been able to address his needs, the Administrator stated, I don't know, I honestly don't know. When [the SW] said he was ready to go to [the local homeless shelter], I trusted it. When asked if he felt Resident #1's discharge location was safe for Resident #1, the Administrator stated, Because I heard that he was a homeless resident before, and that was his baseline, I did, but I knew that-ok, being homeless, regardless, is not safe . I don't know much about [the local homeless shelter], I don't know anything about it. I assumed he was going there and that he'd be taken care of. Instead of just discharging him to a street . The fact that I saw it as a place he could go to, I took that as okay. When asked if anyone protested Resident #1's discharge, the Administrator stated, I know that there was talk of it being an unsafe discharge. But it was just-as an IDT team we have to discuss the pros and cons of things and there were some [the DON and the SW] that discussed and said it was unsafe. But when I spoke to [the SW] to find placement she said she'd be happy to look and see what she can find . That's when she said he's ready to go for [the local homeless shelter.'] That's when I dropped it. I'm sure they all thought regardless this was an unsafe discharge just because he-in our minds he was homeless before . And it seemed after the fact that this was an unsafe discharge. When asked if there was anything he could have changed about Resident #1's discharge, the Administrator stated, Definitely trusting and verifying . micromanaging, diving into every detail. When asked if he would have considered another place to discharge Resident #1 the Administrator stated, I think, sure, yeah, if our sister facilities would have taken him. If he wanted to go . at that point, we were looking for anywhere he wanted to go. During an interview on 8/18/23 at 12:08 p.m., the DON stated the discharge planning process started at the point of admission. When asked when a resident was able to be discharged , the DON stated, they [the residents] can be discharged at their request, but there's safety criteria that we have to meet. When asked what were the state guidelines for facility-initiated discharges, the DON stated, they have to be planned, it has to be a safe discharge, it cannot be not because of funds . It has to be safe. That's why we do PDPM to make sure we're following the plans . You have to give a 30 day [notice] and you have to assist in finding placement. When asked what typically happened when a resident is discharged , the DON stated, we [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible, and each resident received adequate supervision to prevent accidents for 1 of 6 residents (Resident #1) reviewed for wandering, in that: Resident #1 eloped from the facility, traveled approximately 1.5 miles away from the facility and required medical treatment in emergency room for hypokalemia [low potassium] and hypotension [low blood pressure]. An Immediate Jeopardy (IJ) was identified on 08/03/2023 at 4:41 p.m. While the IJ was removed on 08/05/2023 at 6:34 p.m., the facility remained out of compliance at a severity level of actual harm that was not Immediate Jeopardy and a scope of isolated. This deficient practice could place residents at risk of harm, serious injury, or death. The findings were: Record review of Resident #1's face sheet, dated 08/04/2023, revealed the resident was admitted to the facility on [DATE] with diagnoses including: [Metabolic Encephalopathy] occurs when problems with your metabolism cause brain dysfunction, [Thrombocytopenia] a condition that occurs when the platelet count in your blood is too low; [ Metabolic acidosis] a condition in which acids build up in your body. Record review of Resident #1's admission MDS, dated [DATE], revealed the resident had a BIMS of 8, indicating moderately impaired cognition. Further review of the MDS revealed the resident's balance during transfers and walking was not steady, but he was able to stabilize without staff assistance, and he required assistance from others to complete activities such as planning regular tasks (shopping or remembering to take medication). Record review of LN-Elopement/Wandering Evaluation-V2, in Resident #1's clinical record, revealed an admission date of 7/26/2023; The elopement wandering assessment on 7/26/2023 revealed Resident #1 was assessed at a score of 4, at risk for elopement. Record review of orders dated 8/1/2023 did not reveal orders for the wandering guard. Record review of the care plan dated 7/26/23 did not reveal a care plan to address elopement. Record Review of the resident sign-out log for dates 7/26/23 to 8/1/23 found at Receptionist desk', did not reveal any sign-out signatures for Resident #1. Record review of the initial facility report to the State Agency, dated 08/2/2022, revealed, The reporter [Administrator] first learned of the incident on 08/1/2023 at 11:30 a.m. [Resident #1] was last seen on the morning of 08/01/2023. The resident was noted to be missing on 08/01/2023 at 11:30 a.m. It is unknown what time he left the facility since he did not notify anyone .There were no witnesses to the incident. During an interview with the Facility Administrator and DON on 08/02/2023 at 9:45 a.m., the Administrator stated he was notified by facility staff that they were unable to locate Resident #1 on 08/01/2023 at approximately 11:30 am. The Administrator stated he did not know how Resident #1 exited the building. The DON stated the facility knew Resident #1's had been indigent prior to his admission. The DON stated Resident #1 had not voiced his desire to return to the community. The DON stated that Resident #1 had frequently wandered within the facility since his admission but that there had not been any reports of exit-seeking behavior. The DON stated that resident #1 did not have a care plan or wander guard system as he was not considered an elopement risk at admission on [DATE]. Surveyor requested hospital discharge records from elopement on 8/1/2023, and DON stated that since he was not admitted , no discharge paperwork was provided at discharge. During an interview with Local police officer on 8/2/23 at 12:10 pm stated he arrived at Name of Facility on 8/1/2023 at 10:35 am to file a missing person's report. He stated it was unclear on how resident #1 eloped from the facility. The Police Officer stated he had one helicopter and three patrol officers searching the area for Resident #1, when on 8/1/2023, at approximately 11:30 am, an elderly man was found by name of the street, meeting the resident's description was found by emergency department and taken to name of the hospital. Police officer stated that when he arrived at the name of the hospital to confirm the identity of Resident #1, he was welcomed by the name of nursing facility nursing scheduler, who had just located the resident moments prior. During an interview with the Nursing scheduler on 8/2/2023 at 10:05 am revealed she had left the facility to search for Resident #1 at nearby hospitals she stated this was helpful last time an incident like this occurred, and she found Resident #1 at local hospital on 8/1/2023 at approximately 11:35 a.m. and notified the Administrator and DON via text message. During an interview with CNA C on 08/02/2023 at 1:45 p.m., CNA C stated she was assigned to work on the resident hall where Resident #1 resided on 8/1/23. CNA C reported that Resident #1 was not known to exit seek within the facility. CNA C stated she notified the Charge nurse when Resident #1 could not be located at lunchtime. CNA C further reported that the Charge nurse immediately instructed staff members to search the facility and the grounds. During an interview with LVN A on 08/02/2023 at 11:45 a.m., LVN A stated she was the assigned nurse for Resident #1 on 8/1/23. LVN A did not know how Resident #1 eloped as he was in the facility at one minute and not there the next minute other. LVN A stated that Resident #1 did not have a history of attempting to leave the facility. During an interview with Receptionist B on 08/02/2023 at 11:08 a.m., Receptionist B reported she worked from 8 a.m. to 5 p.m. Monday through Friday. Receptionist B stated she was at her workstation by the entrance door, monitoring staff, visitors, and patients that went outside. Receptionist B stated she did not see Resident #1 leave the facility as residents signed themselves out on the Resident's sign-out book. During an interview with the Maintenance Director on 08/02/2023 at 1:50 p.m., the Maintenance Director stated that all doors in the facility opened after 15 seconds of applying pressure on the breaker bar following the elopement incident; Maintenance Director demonstrated to the Surveyor that both door alarms were in working order. Observation on 08/02/2023 at 5:30 p.m. revealed that the alarm on the front door and back door leading to the outside emitted a loud sound when engaged, and two staff members immediately responded to the alarm. Record review of Hospital discharge paperwork dated 08/01/2023 revealed Resident #1 arrived in emergency room triage at approximately 11:35 a.m. via ambulance, and he was discharged on 8/1/2023 at 11:00 p.m. Resident #1 was found on the street by an emergency response team at a time unknown, approximately 1.5 miles from the facility. Resident #1 was found oriented to person only and was treated with epinephrin x 2 via intramuscular route, 1500 ML of intravenous fluids, and taken to the hospital emergency room. Record review of Hospital Medication administration records dated 8/1/23 revealed resident # 1 was administered potassium bicarbonate 40 MEQ orally for hypokalemia and Sodium Chloride 1,000 ML via the intravenous route for hypotension . Record review of the facility policy titled Elopement/Unsafe Wandering, dated 2001; revised March 2019, revealed, If Identified as a risk for wandering, elopement or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. This was determined to be an Immediate Jeopardy (IJ) on 08/03/2023 at 4:41 p.m. and the Administrator was notified at 4:58 p.m. and was provided with the IJ template on 08/03/2023. The following Plan of Removal (POR) was accepted on 08/04/2023 at 2:23 p.m. and indicated the following: Immediate Corrections Implemented for Removal of Immediate Jeopardy. On August 1, 2023, at approximately 9:00pm Resident #1 returned to the facility from the Emergency Department. Action: Resident #1 is a current resident and was readmitted to second floor on August 1, 2023. The director of nursing reassessed Resident #1 for Elopement risk and wander guard was placed on Left ankle on 8/2/2023 to monitor for resident exiting facility. IDT reviewed and interventions initiated, and care plan updated reflect elopement risk. On August 3, 2023, at approximately 5:30pm the following actions were taken; Action: Education initiated Elopement risk, Abuse/Neglect/Exploitation, Signs to watch for with residents exhibiting potential for elopement, increased wandering, exit seeking, increased behaviors. Education will be completed prior to staff working next scheduled shift, and ongoing with general orientation for all new hires. Start Date: 8/3/2023 Completion Date: 8/4/2023 Responsible: Director of Nursing/designee Action: Administrator validated that exit doors are functioning with wander guard system and alarms placed on exit emergency release doors and placed audio alarm for notification of opening doors. Start Date: 8/3/2023 Completion Date: 8/4/2023 Responsible: Administrator/Designee IDENTIFICATION OF OTHER AFFECTED: All residents have the potential to be affected. Action: Completed Elopement Risk Assessment on all residents and validated all residents at risk of elopement, score of 3 or greater, have appropriate interventions and plan of care in place per risk assessment. Start Date: 8/3/2023 Completion Date: 8/3/2023 Responsible: Director of nursing/designee SYSTEMIC CHANGES AND/OR MEASURES: Action: In-service and education was provided to facility staff and residents regarding the process for safe discharge as well as risks associated with heat exhaustion including signs and symptoms to watch for. Start Date: 8/3/2023 Completion Date: Ongoing until all staff have received education prior to their next scheduled shift. Responsible Party: Director of Nursing/Designee Action: Education was provided to all staff on Elopement policy, Abuse/Neglect/Exploitation. Start Date: 8/3/2023 Completion Date: 8/4/2023 and Ongoing until staff have received training prior to the start of their next shift. Responsible Party: Director of Nursing/Designee Action: Ad hoc QAPI meeting held with IDT team and MD to review policy on Elopement, Abuse and neglect, and Plan of removal/response to Immediate Jeopardy Citation on 8/3/2023 Start Date: 8/3/2023 Completion Date: 8/3/2023 Responsible: Administrator/Designee Tracking and Monitoring * Director of Nursing/Designee will review residents with At Risk for wandering or elopement identified or newly admitted with history of elopements to assure appropriate interventions and plan of care are in place 5 times per week beginning 8/4/2023. * Director of Nursing/Designee will complete audits for those residents who wear a wander guard to ensure electronic monitoring device is functioning every shift for 7 days beginning 8/4/23 then will monitor electronic monitoring devices daily 5 times per week. * Administrator/designee will complete random audit every shift for 7 days, beginning 8/4/2023, for appropriate staff response to wandering or potentially exit seeking residents, immediate education will be provided, if necessary, then will monitor random shifts, 5 times a week. * Administrator/designee will complete audit of exits for proper functioning of doors, alarms and wander guard system for proper functioning every shift for 7 days, beginning 8/4/2023 then will monitor random shifts, 5 times a week. * Any trends or concerns were/will be addressed with Quality Assurance Performance Committee and continue until a lessor frequency deemed appropriate through QAPI review On 08/04/2023 through 08/05/2023 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ after verifying their POR had been initiated and or completed. Verification: Record review of the face sheet with Resident #1's room change to 35B. Reviewed Resident #1's updated care plan and Elopement risk assessment dated [DATE]. Observation and interview on 08/04/2023 at 11:30 a.m. of Resident #1 in his room on the second floor with wander guard in place. Resident #1 stated he liked being at the facility but that he liked to be outside also. An interview with the Corporate Registered Nurse (CRN) on 08/05/2023 at 5:22 p.m. revealed the activity department was available to take a walk around the building or sit in the courtyard with residents who enjoy spending time outdoors. Residents that received therapy services could request to do some of their therapy outside, weather permitting. Smoking times were also an opportunity for any resident to go outdoors regardless of if they chose to smoke. Record review of in-services titled Wandering and Elopements and Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revealed 64 of 93 staff signatures. Of the employees in-serviced in person currently; 31 are nursing/direct care staff, 11 are therapy/activities staff, 6 are administrative staff, and 16 are ancillary staff. In an interview with the Corporate Registered Nurse (CRN) on 08/04/2023 at 3:45 pm revealed all staff training began on 08/03/2023. Employees who have not worked since the incident have been in-serviced via phone however all will be trained in person on a one-to-one basis by the DON/designee before they are allowed to work their next shift. Of the employees in-serviced via telephone currently; 13 are nursing/direct care staff, 2 are therapy/activities staff, 1 is administrative/office staff, and 4 are ancillary staff. There are 9 employees, 2 CNAs, 2 housekeepers, the Marketer, 2 physical therapists, and 2 nurses) that the DON/designee has been unable to reach via telephone at this time. Interviews with 18 employees were conducted on 08/04/2023 by surveyor, all were able to verbalize an understanding of elopement risk and stated they were provided handouts to reference as needed. Of the employees interviewed all shifts were covered, including: (4) 6am - 2pm, (2) 2pm - 10pm, (2) 10pm - 6pm, (1) 6am - 6pm (12-hour shift), (1) 6am - 10pm (doubles), (7) 8am - 5pm/8pm (office staff). An interview with the Administrator on 08/04/2023 at 4:45 pm revealed wander guard system and alarms had been tested and were operational. An interview with the CRN on 08/04/2023 at revealed additional alarms had been purchased to increase the volume and ensure alarm could be heard in all areas of the building. Observations on 08/04/2023 through 08/05/2023 revealed the alarms were being tested frequently. In an interview with the DON on 08/04/2023 at 5:40 pm, the DON revealed all wander guard systems had been tested with the additional alarms installed and there was a noticeable difference in the volume. Observation by surveyor on 08/04/23 at 12:30 pm of the DON testing the wander guard system with a resident near the front entrance revealed the wander guard system was operational. An interview with CRN on 08/04/2023 at 3:45 pm revealed nursing had completed new Elopement Risk Assessments on all residents in the facility on 08/03/2023. Record review of the Resident Listing Report revealed an updated list of each resident's elopement risk status. Record review for all residents identified as high risk revealed care plans had been updated. Record review of in-services titled Transfer or Discharge, Resident-Initiated and Heat Exhaustion, revealed 64 of 93 staff signatures. In an interview with the Corporate Registered Nurse on 08/04/2023 at 4:20 pm, the CRN stated employees were trained on this policy to ensure the employee's ability to educate residents prior to them leaving AMA or signing out on leave/pass since sometimes residents choose to not return. The CRN revealed this staff training began on 08/03/2023 and employees who have not worked since the incident will be trained in person on a one-to-one basis by the DON/designee before they are allowed to work their next shift. Record review of in-services titled Wandering and Elopements and Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revealed 64 of 93 staff signatures. An interview with the Corporate Registered Nurse revealed all staff training began on 08/03/2023. Employees who have not worked since the incident have been in-serviced via phone however all will be trained in person by the DON/designee on a one-to-one basis before they are allowed to work their next shift. Record review of additional in-services initiated on 08/04/2023 titled Use of the door alarm and Responding to all door alarms, targeted for completion by 08/07/2023. In an interview with the CRN on 08/04/2023 at 03:45 pm revealed an Ad hoc QAPI meeting had been held on 08/03/2023 to review the IJ and POR. At that time, the Administrator in-serviced all managers on the wandering and elopement and abuse and neglect policies. Medical Director, attended via phone. Record review completed of the sign-in sheets provided by the Administrator of the Ad hoc QAPI meeting on 08/03/2023. In an interview with CRN on 08/04/2023 at 3:45 pm the CRN stated all residents in the facility had been reviewed to determine At Risk for wandering or elopement on 08/04/2023 to assure appropriate interventions were in place. The CRN provided Resident Listing Report for review. The DON/Designee will continue reviewing residents At Risk 5 times per week. In an interview with the DON on 08/05/2023 at 12:05 pm she stated audits were being completed each shift for residents who wear a wander guard to ensure devices are functioning. She stated most can be tested with a tester that was brought to the resident however one resident becomes agitated if they attempt to interfere with her personal space and layers of clothing she wears so they take her near the door to test her device. Observation on 08/04/23 at 12:30 pm of the DON testing the wander guard system with a resident near the front entrance revealed the wander guard system was operational. Record review on 08/05/2023 of monitoring logs revealed four (2) audits completed by the DON and (2) completed by the treatment nurse, who the Administrator stated has been assigned several administrative duties in recent months, one for each shift beginning with 08/04/2023. In an interview with the Administrator on 08/04/2023 at 5:25 pm he stated he was completing audits of staff response each shift. Record review on 08/05/2023 of a monitoring log revealed four (4) audits completed by the Administrator, one for each shift beginning with 08/04/2023. In an interview with the Administrator on 08/04/2023 at 5:25 pm he stated he had gone through the facility on 08/03/2023 to ensure all wander guard system doors were working properly. The Administrator stated the doors were working however he wanted to improve the overall system and added extra alarms on 08/04/2023. Observation on 08/04/2023 by surveyors revealed the alarms had been purchased, were being tested and operational. Record review on 08/05/2023 of a monitoring log revealed four (4) audits completed by the Administrator, one for each shift beginning with 08/04/2023. The Administrator was informed the Immediate Jeopardy was removed on 08/05/2023 at 6:34 p.m. While the IJ was removed the facility remained out of compliance at a severity level of actual harm that was not an Immediate Jeopardy and a scope of isolated, due to the facility was still monitoring the effectiveness of their Plan of Removal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility personnel failed to provide basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders follow physician orders and the resident's advance directives for 1 of 14 residents (Resident #1) whose records were reviewed for Full code status. The facility failed to ensure nursing staff followed emergency protocol and failed to ensure staff provided Resident #1, who had a Full Code in place, CPR, after the resident was found unresponsive with no pulse or respirations, according to professional standards of practice. An Immediate Jeopardy (IJ) situation was identified on [DATE] at 2:07 p.m. While the IJ was removed on [DATE] at 9:23 p.m., the facility remained out of compliance at a severity level of actual harm that was not Immediate Jeopardy and a scope of isolated. These deficient practices could contribute to a resident's decline in emotional, physical, and psychological health and result in serious injury and or death. Findings include: Record review of Resident #1's face sheet in her electronic medical record, dated [DATE] revealed a 57-year female who was initially admitted to the facility on [DATE] with diagnoses to include senile degeneration of brain (a term used to describe the mental deterioration that is associated with old age.), impulse behavior(an improvised or unpredicted course of action that's not based on logic.), dysphagia(inability to speak), unspecified dementia(general name for a decline in cognitive abilities that impacts a person's ability to do every day activities.), and need for assistance with personal care. Record review of Resident #1's Quarterly MDS assessment dated [DATE] revealed her BIMS score was 0 reflective of severe cognitive impairment and was rarely or never understood. She required extensive assistance by 2 persons for ADL's. The MDS did not reflect code status. Record review of Resident #1's Care Plan, date initiated [DATE], with a revision date of [DATE], revealed Focus: Advanced Directives: Full Code Status, Goal: Resident will maintain their optimal level of comfort, advanced directive will be honored, and resident/family will be advised of Advanced Directive Forms upon admission, annual review, or significant change in status through next review. Interventions: MD and staff to be made aware of code status/treatment decisions. Staff will start CPR should cardiac arrest occurs and/or breathing independently cease, call EMS and transport to hospital as ordered. Staff will maintain all advanced directives in a prominent location in the medical record. Record review of Resident #1's active physician orders for [DATE] revealed she had an order for Full code with original date [DATE]. Record review of Resident #1's Resident admission Agreement, signed by Resident #1 on [DATE],revealed on page 5-6 of 41; section titled: Care Planning, Refusal of Treatment and Issuance of Advance Directive; The Resident may issue an Advance Directive in accordance with state law that describes the Resident's wishes with respect to treatments that may be administered or withheld in the event the Resident becomes unable to make health care decisions for him or herself. Further review of Resident #1's medical record revealed there was no Advance Directive. Record review of Resident #1's progress notes, dated [DATE], at 9:00 a.m. authored by Agency LVN A, read as follows: -Resident #1 was found unresponsive by Nurse Aide F and Nurse Aide G. They both informed charge nurse Agency LVN A immediately of Resident #1 not breathing and cold to touch. Agency LVN A went to Resident #1's room immediately, checked Resident #1 finding Resident #1 in semi-Fowler's, with eyes open and fixed, mouth open, cold and stiff to touch with no spontaneous to rigor mortis setting in, did not initiate CPR. Agency LVN A alerted ADON LVN B and was advised to place call to hospice. Hospice was notified at 10:00 a.m. on [DATE]. During an interview on [DATE] at 1:00 p.m. CNA F revealed he was working during the 6:00 a.m. to 2:00 p.m. shift. He was asked by Agency LVN A to give a bed bath to Resident #1 around 7:30 a.m. as she had an incontinent episode. He stated he provided Resident #1 a bed bath at that time with assistance from CNA G. He further revealed Resident #1 tolerated the bed bath and was resting in bed afterwards. He stated when he returned to check Resident #1 at approximately 9:00 a.m. she was not breathing appeared pale in color and was cool to touch. He stated he immediately told Agency LVN A and she immediately went to Resident #1's room. He stated he did not know the code status of the resident , Agency LVN A left Resident #1's room after checking for pulse respirations. CNA F stated , Agency LVN A stated that Resident #1 did not have any signs of life at that time. He stated she did not do any CPR. When asked if CNA F was CPR certified, he stated yes. When asked if he started CPR on Resident #1, he stated no because he did not know the code status on Resident #1 at the time and he was not directed by Agency LVN A to do any first aide. During an interview on [DATE] at 1:07 p.m. CNA G revealed she was working during the 6:00 a.m. to 2:00 p.m. shift. She was asked by Agency LVN A to assist CNA F in giving a bed bath to Resident #1 around 7:30 a.m. as she had an incontinent episode. She stated she provided Resident #1 a bed bath at that time with assistance from CNA F. She further revealed Resident #1 tolerated the bed bath and was resting in bed afterwards. She stated when she returned to check Resident #1, with CNA F at approximately 9:00 a.m. she was not breathing appeared pale in color and was cool to touch. She stated CNA F immediately told Agency LVN A and she immediately went to Resident #1's room. She stated she did not know the code status of the resident, Agency LVN A left Resident #1's room after checking for pulse respirations. CNA G stated, Agency LVN A stated that Resident #1 did not have any signs of life at that time. He stated she did not do any CPR CNA G stated she was not CPR certified and did not perform first aide on Resident #1 because she was not directed by Agency LVN A to do anything. During an interview on [DATE] at 1:12 p.m. Hospice RN revealed she was informed via telephone call from Agency LVN A that Resident #1 had expired and would need an RN from hospice to pronounce her. Hospice RN stated she arrived at facility and pronounced Resident #1 at 10:16 a.m. on [DATE]. Hospice RN stated Resident #1 was full code. During an interview on [DATE] at 1:21 p.m. Agency LVN A revealed she found Resident #1 in semi-Fowler's position in bed with eyes open and fixed, mouth open, cold and stiff to touch with no spontaneous movement. No respiratory sounds on auscultation, no pulses palpable in carotid or femoral arteries. Agency LVN A stated, due to rigor mortis setting in, she did not initiate CPR even though she was aware that Resident #1 was a Full Code from her medical record. She further revealed she had last seen Resident #1 at 8:30 a.m. and she was in no distress. She stated rigor mortis had set in. When asked if she knew how to determine if rigor mortis is present or how long it would take for rigor mortis to be present, she stated, I just know stiffening occurs with the body, I am not sure how long it actually takes. Agency LVN A stated she then went downstairs to speak with ADON LVN B to ask her for recommendations on what she should do about Resident #1, as she felt that she had expired. She stated ADON LVN B told her to contact hospice, as Resident #1 was under the services of hospice care. During an interview on [DATE] at 3:00 p.m. with ADON-LVN B revealed Agency LVN A did not perform CPR after assessment of Resident #1, when she was found unresponsive by CNA F and CNA G. ADON-LVN B stated she was in the management role of ADON and there was no current DON working at the facility. ADON-LVN B further revealed there was no RN in the building at the time of the incident with Resident #1. During an interview on [DATE] at 3:00 p.m. the facility ADON LVN B revealed, if a resident is found to be unresponsive and is a Full Code, the primary nurse should begin CPR and contact 911. She further revealed staff should follow the protocol of a Full code and receive interventions such as CPR. During an interview on [DATE] at 3:02 p.m. the facility Administrator stated staff should follow the protocol of a Full code and receive interventions such as CPR. Record review of CPR certification status for Agency LVN A revealed she had a current active CPR certification with an issue date of [DATE] and renew by 8/2024 provided by the American Heart Association. Record review of facility policy titled, Emergency Procedure- Cardiopulmonary Resuscitation. Section General Guidelines: 6. If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is CPR certified in CPR/BLS shall initiate CPR unless: a: It is known that a Do Not Resuscitate order that specifically prohibits CPR and/or external defibrillation exists for that individual: or b. There are obvious signs of irreversible death (e.g., rigor mortis). Review of website: https://www.medicinenet.com/what_are_the_stages_of_rigor_mortis/article.htm, revealed the definition of Rigor Mortis to be in stages: Pallor mortis: The main change that occurs is increased paleness because of the suspension of blood circulation. This is the first sign and occurs quickly, within 15-30 minutes of death.Algor mortis: Humans are warm-blooded creatures, which means that we keep a consistent body temperature, regardless of the external environment. The brain is our temperature regulator, and the circulatory framework is the principal heat dissipator. After death, the brain cells stop signaling, and the heart stops pumping blood, which means the body begins to match the external temperature. Our normal body temperature level is 98.6°F (37°C). Assuming the surrounding temperature around the dead body is not exactly the same, it normally takes somewhere in the range of 18-20 hours for the body's temperature to match the external temperature. Rigor mortis: Following death, the body will turn stiff. The muscles become loose and limp, yet the entire body will stiffen after a couple of hours. This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 2:07 p.m. and the Administrator was notified at 2:07 p.m. and was provided with the IJ template on [DATE]. The following Plan of Removal(POR) was accepted on [DATE] at 9:23 p.m. and indicated the following: Immediate corrective actions for removal of immediate jeopardy: On [DATE], at approximately 3:00 p.m. the following actions were taken: Director of Nursing/designee completed immediate education with LVN A, and CNA B who were in attendance on proper response to emergency situation, when to initiate CPR on a resident and including the following steps for emergency response. a. Instruct a staff member to activate the emergency response system (code) and call 911. b. Instruct a staff member to retrieve the automatic external defibrillator. c. Verify or instruct a staff member to verify the DNR or code status of the individual. d. Initiate the basic life support (BLS) sequence of events. e. LVN role in determining when to initiate CPR. o Director of Nursing/designee validated all resident current Code status were up to date and in EHR, including care planned and on direct care [NAME] on [DATE]. o The Corporate Clinical Resource completed education with Assistant Director of nursing regarding requirements on Emergency response, including, following policy titled: Emergency Procedure-Cardiopulmonary Resuscitation on [DATE]. o Administrator/designee completed sweep of all licensed staff to verify CPR certification status is up to date on [DATE]. IDENTIFICATION OF OTHER AFFECTED: All residents have the potential to be affected. o The Director of nursing/designee validated that all residents had up to date code status in EHR, their code is reflected in both care plan and direct care staff [NAME] care record on [DATE]. SYSTEMIC CHANGES AND/OR MEASURES: o The Corporate Registered Nurse/Designee will complete education with all staff to include agency staff on proper procedures to follow in case of Emergency, including initiation of emergency response system, validating resident code status in EHR, appropriate initiation of CPR, and designating staff in emergent situations to these tasks. Education will specify that any staff responsibility in performing CPR will be delegated to certified personnel, with additional staff to aid in support areas, such as initiating 911, validating code status, etc. Education will be initiated on [DATE] to ensure that staff have a clear understanding of how they should respond during an emergency once they have established a resident's code status. This education will be ongoing with all staff to include agency prior to working their next scheduled shift. o The Corporate Registered Nurse/Designee will complete education regarding initiation of CPR/Emergency response based on resident's code status and wishes, emphasis will be placed on staff understanding of following resident code status indicated in EHR. Education will be initiated on [DATE] and be ongoing will all staff prior to working next scheduled shift. o Administrator/Designee will upload policy on Emergency Procedure-Cardiopulmonary resuscitation policy to agency website for new agency staff to review and acknowledge prior to working shift. o Ad hoc QAPI meeting held with IDT team and MD to review policy on Emergency Procedure-Cardiopulmonary resuscitation and Plan of removal/response to Immediate Jeopardy Citation on [DATE] @ 4:00 pm o The Corporate Registered Nurse/Designee will initiate a process to conduct quarterly Mock Code training with clinical staff beginning the week of [DATE]-[DATE]. o The Corporate Registered Nurse/Designee will conduct post code blue debriefing with staff following a code blue events to ensure proper procedures were followed. TRACKING AND MONITORING: o The Corporate Registered Nurse/Designee will, through record review, monitor resident code status in PCC to validate codes are in place and on plan of care, daily x 7 days, then 5 x per week beginning [DATE]. o The Corporate Registered Nurse/Designee will conduct observational rounds and interviews, daily x 7 days, then 5 x per week beginning [DATE], to validate that staff can verbalize understanding of how and where to find resident code status and proper steps for initiating emergency response if needed. Are they keeping a list of staff they have conducted observational rounds and interviews with this is supposed to be post in-service training? o The Administrator/designee will monitor that licensed staff are certified and certifications are up to date, to perform CPR, for all current staff, then weekly for all new hires. o The Administrator/designee will conduct a monthly audit to ensure staff that have CPR certifications that are going to be expiring soon will be set up to take CPR recertification. o Any trends or concerns were/will be addressed with the Quality Assurance Performance Committee and monitoring will continue until a lessor frequency is deemed appropriate. The Administrator will be responsible for ensuring the adequate process regarding Emergency Response, including initiation of CPR are followed per policy. The education on process/system was initiated on [DATE]. Verification: Verified; Record review of in-service titled Emergency Procedures - Cardiopulmonary Resuscitation, staff signatures and interviews with ADON and the Corporate Registered Nurse on [DATE] revealed LVN A and CNA B were trained step by step in the emergency response procedure via phone initially on [DATE] to cover immediacy, by the ADON, the Corporate Registered Nurse and Administrator. Upon returning for their next shift, LVN A on [DATE] and CNA B on [DATE], they were brought into the office, provided a copy of the procedure and were able to verbalize understanding of procedure. See in-service sheets attached. Verified; Record review of resident's code status in EHR however, surveyor discovered that one OOH-DNR was completed incorrectly/invalid. Interview with ADON and Corporate Registered Nurse on [DATE] acknowledged the deficiency, and this deficient practice will be cited. Verified; Record review of an in-service titled Emergency Procedures - Cardiopulmonary Resuscitation, staff signatures and interviews with the Corporate Registered Nurse and ADON on [DATE] revealed the ADON and Treatment Nurse were immediately trained on [DATE] in the emergency response procedures to ensure they were able to train other staff. Verified; Record review of the staff schedule dated [DATE] - [DATE] revealed at least one CPR certified staff was scheduled on each shift. CPR cards for each of these staff members were attached to the schedule as well. Interview with the Corporate Registered Nurse on [DATE] verified that all staff not fully certified at this time are scheduled to attend CPR on [DATE] at 10:30 with [name of company]. Record review of a confirmation text from [name of company] verified CPR is scheduled for [DATE] at 10:30 am at the facility. Verified; Record review of resident's code status in EHR however, surveyor discovered that one OOH-DNR was completed incorrectly/invalid. Interview with ADON and Corporate Registered Nurse on [DATE] acknowledged the deficiency, and this deficient practice will be cited. Verified; Record review of an in-service titled Emergency Procedures - Cardiopulmonary Resuscitation, revealed 44 of 87 staff signatures. Interviews with the Corporate Registered Nurse and ADON on [DATE] revealed all staff training began immediately on [DATE]. The ADON reported she and the Treatment Nurse went to each employee together to instruct in the emergency procedures and make sure they understood the importance of the situation. The ADON added that each staff member had to be able to verbalize understanding of the procedure. Copies of the procedure were provided to each staff member. Staff members who have not worked since the incident have been in-serviced via phone however all will be trained in person on a one-to-one basis before they are allowed to work their next shift. On [DATE], 17 direct care staff members, including RNs, LVNs, CNAs and an Activity Director, to include all shifts at the facility were interviewed and verified they had received inservice training on the facility's Emergency Procedures for CPR. Verified; record review of a printout from the [name of agency] website revealed link that agency staff are required to review and acknowledge Emergency Procedure-Cardiopulmonary resuscitation policy prior to being able to choose a shift on the schedule. Interview with Corporate Registered Nurse on [DATE] revealed all staff that had previously read and accepted the previous version must now read and accept the updated policy prior to working. Verified; record review of the [name of agency] site (agency website) and interview with Corporate Registered Nurse [DATE] revealed agency staff are required to review and acknowledge Emergency Procedure-Cardiopulmonary resuscitation policy prior to being able to choose a shift on the schedule. Verified; Record review of sign-in sheets provided by the Administrator of Ad hoc QAPI meeting on [DATE]. The Administrator in-serviced all managers on emergency procedures for CPR policy and POR for IJ. Medical Director, Physician J attended via phone. Verified; Record review Ad hoc QAPI meeting and interview with Corporate Registered Nurse on [DATE] revealed Mock code scheduled for [DATE] (1st shift), [DATE] (2nd shift) and [DATE] (3rd shift). Verified; Each mock code packet contains a debriefing sheet that staff will complete following code to discuss what occurred and any improvements that could be made. This will be presented at QA. These sheets are also to be used in the event of an actual code. Verified; Interview with Corporate Registered Nurse on [DATE] acknowledged the invalid OOH-DNR and initiated correction of document immediately. Verified; record review of Observational Rounds/Interviews CPR logs for [DATE] (13 staff) and [DATE] (14 staff) revealed ADON (the designee) rounded to ensure staff continued to verbalize understanding of content from previous in-service training on [DATE]. Verified; record review of CPR audit completed on [DATE] and interview with the Corporate Registered Nurse on [DATE] revealed a CPR course is scheduled for [DATE] at 10:30 with [name of company]. On [DATE] the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ after verifying their POR had been initiated and or completed. The Administrator was informed the Immediate Jeopardy was removed on [DATE] at . While the IJ was removed the facility remained out of compliance at a severity level of actual harm that was not an Immediate Jeopardy and a scope of isolated, due to the facility was still monitoring the effectiveness of their Plan of Removal .