**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 4 residents (Resident #17) reviewed for accidents and supervision. The facility failed to ensure the locking mechanism on Resident #17's bed was operating properly, which caused her to fall and hit her head and resulted in a head injury, laceration over her right eye, and need for emergency medical attention. An IJ was identified on 6/12/2025. The IJ template was provided to the facility on 6/12/2025 at 2:33 pm. While the IJ was removed on 6/13/2025, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm that is not immediate jeopardy due to the facility ' s need to evaluate the effectiveness of the corrective systems. This failure placed all residents who have wheel locks on their beds at risk for falls, decline in health, serious injury, and hospitalization from poor maintenance of the bed rails. Findings include: Resident #17 Record review of Resident #17 ' s face sheet dated June 11, 2025 revealed an [AGE] year old female initially admitted to the facility on [DATE] and re-admitted on [DATE] with a diagnoses of cerebral infarction (stroke-blood flow to the brain is blocked), dysphagia (difficulty swallowing), hypertension (high blood pressure), osteoarthritis, rheumatoid arthritis, chronic kidney disease, atrial fibrillation (irregular heart rate), anticoagulants (medication that prevents blood clots), repeated falls, symbolic dysfunction, and pain. Record review of Resident #17 ' s Quarterly MDS (Minimum Data Set) dated 3/29/2025 revealed memory problems with moderate impaired cognitive skills for decision making. Resident #17 had upper and lower impairments of extremities and was ambulated with a wheelchair. Resident #17 required partial/moderate assistance where the helper does less than half the effort for toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear, and personal hygiene. She required set up or clean-up assistance for rolling left and right, and partial/moderate assistance where the helper does less than half the effort for sit to lying, lying to sitting on side of bed, sit to stand, chair/bed-to-chair transfer, toilet transfer, and tub/shower transfers. Walking 10 feet was not attempted due to medical conditions or safety concerns. Record review of Resident #17 ' s Care Plan last reviewed on 04/17/2025 revealed Resident #17 required assistance to perform functional abilities in self-care and mobility AEB poor quality in functional range of motion r/t stroke with intervention to provide self-care assistance: .toilet hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear and personal hygiene, chair/bed-to-chair transfer, and toilet transfer were all partial assistance. Resident #17 was at risk for falls and increased falls and injury r/t psychoactive drug use with interventions to anticipate needs, provide prompt assistance with ADLs and other special needs, assess for psych services, be sure the resident ' s call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance, call MD of any falls, ensure that resident is wearing appropriate footwear or nonskid socks when ambulating or when up in wheelchair for mobility, fall risk assessments per facility protocol and rehab screen/evaluate and treat as indicated for therapeutic exercises and safety measures. Record Review of Provider Investigation Report dated 9/10/2024 written by former Administrator revealed Resident #17 Fell out of the bed and hit her head receiving a hematoma and laceration to the right eye, and skin tear on forearm 911 was contacted and the patient was transferred to the hospital for further evaluation and treatment. Patient was returned to the facility few hours later with four sutures and laceration above her right eye. Resident is prescribed Eloquis 2x daily. Record review of Resident #17 ' s Order Summary Report revealed acetaminophen tablet 325 mg for pain, apixaban tablet 2.5 mg for anticoagulants, and Lexapro oral tablet 5 mg for generalized anxiety disorder. In an observation and attempted Interview on 05/20/25 at 1:30 Pm Resident #17, was observed to be nonverbal and was non interview able. At the time of the attempted interview and observation, Resident #17 had no marks or bruises. Resident #17 ' s bed was observed, and locks were not working at the time of the observation of her room. Interview on 05/20/2025 at 2:40 PM with CNA E she stated she was no longer employed by the facility. CNA E stated that on 9/10/24 at 9PM she was helping Resident #17 get out of the bed due to resident having bowel movement in the bed. The resident has to be physically lifted out of bed. While CNA E was assisting with lifting the resident, she somewhat swung her arms out, falling off the bed and hitting her head. She stated that the wheel on the bed was not working and therefore not secured on the floor, causing the bed to move at the time the accident occurred. Interview on 05/20/2025 at 2:40 PM with the Former Interim DON, she stated that she was very familiar with Resident #17. She stated that because Resident #17 was non-verbal, she may at times swing her arms and or jerk away when being bathed or moved or aided in getting dressed. She stated that she has never witnessed her being abused. Observation on 05/21/2025 at 2:00 PM of the bed for Resident#43 and Resident # 17 revealed both beds to not have slip resistant pads to avoid movement that would lead to injury to the residents. Both beds had movement with locks on at the time of observation. This failure resulted in the identification of an Immediate Jeopardy (IJ) on 6/12/2025. The Administrator was informed and provided the IJ template on 6/12/2025 at 2:33 PM. The Plan of Removal (POR) was requested. The following Plan of Removal was submitted by the facility and was accepted on 6/12/2025 at 8:37 PM: PLAN OF REMOVAL F689- Accidents/supervision Problem: - The facility failed to act after Resident #17, #43 and #44 injuries and possible injury occurred. -The facility failed to take prompt action after Resident #17 fell and hit her head on a cabinet after bed wheels would not lock in place to hold bed movement. Immediate action: 6/12/25 Residents #17, #43 and #44 remain in the facility in stable condition. Their beds wheels have been assessed for safety, and all wheels are working properly and have working bed locks and/or stoppers that secure the bed. Completed 6/12/25 All beds wheels observed are in working order. 6/12/25 The facility maintenance director/Designee initiated bed safety screenings on all the beds to ensure their wheels break/stoppers are working and that beds are not moving unnecessarily during resident ADL care. Wheels stopper pads have been placed on all bed wheels noted moving during ADL care. Patient beds not in use have working breaks or bed stoppers in place, unless designated as out of order with a posted sign and flagged for no use by admissions. Completed 6/12/25 Interventions: On 6/12/25 the Administrator and DON along with the corporate nurse re-review the facility Accidents and Supervision Policy and the Incident and Accidents Policy to ensure understanding of policies and expectations to always sustain compliance. No modifications or changes needed to either policy. Completed 6/12/25 On 6/12/25 the facility Adm/DON/corporate nurse initiated an in-service with all staff on the facility Accidents and Supervision Policy and the Incident and Accidents Policy to ensure understanding. Completed 6/12/25 On 6/12/25 The Corporate Maintenance Director conducted an in-service with the facility Administrator and Maintenance Director on the TELS System and how to run reports to ensure all work orders are promptly addressed. Completed 6/12/25 On 6/12/25 the facility DON/Designee initiated an in-service with all facilities in regard to the TELS system focusing on immediately reporting beds that are not secure or noted moving. A work order is entered into the EMR. Staff members are to apply wheel stoppers with spare stoppers provided to them in order to secure the beds. In the event the staff are unable to secure the wheels, the bed will be taken out of service until the Maintenance Director is able to correct. The Maintenance Director receives TELS work order and corrects the bed reported issues as soon as possible with a goal of the same business day. Defective equipment will not be in use. Completion on 6/12/25 On 6/12/25 The Adm/designee conducted an in-service with all nursing staff and all therapy staff on incident and accident prevention focusing on bed safety, interventions they are to initiate if resident bed wheel/breaks are noted moving during ADL care. This includes reporting it to TELS and immediately placing stopper pads onto the unsecure beds. Failure to comply will result in disciplinary action and up to termination of employment. Completed 6/12/25. Ongoing Projected Completion 6/13/25 Any staff member who is not present in the service will not be allowed to assume their duties until in-service. Ongoing In-service will be completed by DON/ADON/WC NURSE/or weekend nurse supervisor, until all staff, weekend, prn, and agency staff complete. Monitoring On 6/13/25 The DON/designee began administering a quiz to validate the effectiveness of the training for each member of the staff. Immediate re-education will be completed by the DNS/designee if any staff are unable to answer appropriately the questions on the quiz. Staff will not be allowed to work until after completion of the quiz. Projected completion 6/13/25 Starting on 6/12/25, the facility Administrator/Designee will review TELS work order report daily to ensure completion. Administrator/ Designee will also review the incidents and accidents to promptly identify possible accidents caused by unsafe beds. Any issues identified will be addressed at that time. An impromptu QAPI meeting was conducted with the facility's Medical Director, on 6/12/25, to notify of the potential for non-compliance and the action plan implemented for approval. Plan approved on 6/12/25 Monitoring of the Plan of Removal included the following: Observation on 6/13/25 at 11:00 AM of four beds in the facility showed that slip pads had been put in place and beds were currently stable without added movement. Record Review of Skilled services in-service dated 6/12/2025 revealed an in-service in which staff are to report if the wheel locks on the bed move, they should report to the maintenance man and have TEL stoppers placed on the bed. Record review on 06/13/2025 of in-service signature sheet, revealed in service completed with staff to ensure that they know when and how to report issues with residents' beds. Record Review on 06/13/2025 QAPI minutes and recommendation reviewed, and ad-hoc minutes and documentation reviewed. Facility and staff are aware of issues with bed locks. All locks have been secured with slip pads. Interview with the Administrator on 06/13/2025 at 9:45 AM, the Administrator presented signature sheet for staff in-service addressing resident beds and how to recognize issues with beds and how to report it. Interview with Staff A on 06/13/2025 at 11:02 AM revealed that the facility since 6/12/25 has completed training and in-service for all staff about bed safety and methods to ensure they are safe and how to report. The staff member was able to describe all steps of reporting and items to use for a bed with any function issues. Interview with Staff B on 06/13/2025 at 10:30 AM revealed that staff member was in service today prior to clocking in and start of shift. Staff B was able to discuss the procedure of reporting and how to determine if the bed needed adaptive hardware for the resident's safety. Interview with the maintenance director on 06/13/2025 at 12:34 PM revealed that the maintenance staff has checked every bed in the facility, along with tagging all non-occupied beds for future use. The maintenance director stated that he participated and will continue to participate in the in-service for new and future employees. Interview with Staff C on 06/13/2025 at 12:52 PM revealed that the staff member was in service on the beds and wheels. Staff stated that she was in service on how to report on maintenance and record work order in the system. Face to Face Staffing with Administrator on 06/13/2025 1:55 PM The Investigator currently has lowered the IJ. The facility has completed the necessary training and completed the necessary maintenance to all beds in the facility to ensure the safety and well-being of each resident. The facility was informed that the immediacy was removed on 06/13/2025 at 1:55 PM. The facility remained out of compliance at a scope of isolated and severity level of no actual harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure each resident received and the facility provided the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for 2 of 5 residents (Resident #49 and Resident #77) reviewed for behavioral services. - The facility failed to assess Resident #49 and provide behavioral health services from [DATE] to [DATE] after she reported that she wanted to die. - The facility failed to immediately assess Resident #77 after he reported that he wanted to die. These failures could place residents at risk of mental and psychosocial harm, injury, and suicidal ideation. An Immediate Jeopardy (IJ) that started on [DATE] was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 04:45 PM. While the immediacy was removed on [DATE] at 01:55PM, the facility remained out of compliance at a scope of pattern and severity level of no actual harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems. Findings include: Resident #49 Record review of Resident #49's Face Sheet dated [DATE] revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnosis which included: bone cancer, shortness of breath, anal cancer, cognitive communication deficit, difficulty swallowing and pressure ulcer on her sacrum (triangular bone at the base of the spine). Record review of Resident #49's undated Care Plan revealed, focus: pneumonia; intervention: monitor/document/report to MD as needed for the following symptoms of pneumonia: fever, chills, cough, fast breathing, low oxygen. Focus: receiving nebulizer breathing treatments; interventions- monitor O2 saturation (levels) as needed or per orders, administer breathing treatments as ordered by MD. Focus: Hospice services due to terminal illness of anal cancer; intervention- assist with ADLs and provide comfort measures as needed, monitor for signs and symptoms of increased pain, discomfort-give medications/treatments monitor for relief. There was no focus area for oxygen administration. Record review of Resident #49's Quarterly MDS dated [DATE] revealed, intact cognition as indicated by a BIMS score of 14 out of 15 and use of O2 was not indicated. The resident reported no symptoms of being down/depressed/hopeless, little interest or pleasure in doing things, and feelings of social isolation. Record review of Resident #49's Change of Condition MDS dated [DATE] revealed, intact cognition as indicated by a BIMS score of 14 out of 15 and use of O2 was not indicated. The resident was on hospice, Pain was present with rare impact on sleep, rare interference with therapy activity and occasional interference with day-to-day activities. Record review of Resident #49's Hospice RN Comprehensive Visit dated [DATE] revealed, Resident #49 was experiencing pain. was uncomfortable due to her pain and her pain was located on her rectum. Mental status: disoriented, withdrawn, forgetful, unable to report anxiety/depression due to not responding. Resident #77 was co-operative, indifferent, and showed abnormal behavior/mood and effect because she was withdrawn. Record review of Resident #49's Order Summary Report dated [DATE] revealed, Admit to Hospice. Hospice Care effective [DATE]; diagnosis: anal cancer and other conditions of cancer spread to the bone. Oxycodone w/ Acetaminophen 5-325 mg- give 1 tablet every 12 hours for pain management. Oxycodone w/ Acetaminophen 5-325 mg- give 1 tablet every 6 hours as needed for pain level 7-10. Morphine 20 mg/ml- give 0.25 ml by mouth every 6 hours for severe pain. Morphine 20 mg/ml- give 0.25 ml by mouth every 4 hours as needed for pain and shortness of breath. The record indicated that Oxycodone was discontinued when the resident was started her Morphine Sulfate on [DATE]. Record review of Resident #49's [DATE] MAR revealed, all doses of PRN pain medication were documented as effective on follow up pain assessments. Record review of Resident #49's Progress Notes from admission ([DATE] to [DATE]) and saved on [DATE] at 02:23 PM revealed: - [DATE] at 11:07- Resident repositioned multiple times to relieve sacral pain - [DATE] at 04:02 PM- Resident resident in bed, no shortness of breath, no complaints of pain. - [DATE] at 10:27 PM- Resident participated in PT and OT while remaining in pain. Resident denied pain or discomfort - [DATE]: IDT met with family at this time. Family asked about DNR and hospice. Family stated they are ready to move. forward with the process. At this time, we gave Family the DNR form, and they filled out his part and a referral were sent to a hospice company. No other concerns were voiced at this time. - [DATE] at 09:27 PM- Resident refused breathing treatment, she said she was breathing fine. Resident denied pain or discomfort. - [DATE] at 09:23 PM- Resident denies pain or discomfort. Resident observed calm and pleasant in bed with eyes closed. - [DATE]: Resident #49 refused care, treatment, and meal in the morning. She shouted No, let me die, leave me alone! Hospice RN made aware, and RP stated Resident #49 had been making statements of this nature to her guests. There was no other documentation to show Resident #49's MD was notified, Resident #49 received psychiatric evaluation/consultation, Resident #49 was evaluated by social services or any other nursing facility staff about her mental state/psychosocial condition. - [DATE] at 06:53 AM- Resident continues with routine pain medication and comfort measures as needed. All needs met, vitals stable - [DATE] at 02:54 PM- Resident states he wants to die. This started on [DATE]. The following makes this condition WORSE: resident being in pain. - [DATE]: Patient psychosocial goals are to adjust to the facility. Patient social services need to provide home health and DME. No ancillary services. There have not been any changes in the RES's family status over this past quarter. The res does get along with res and staff. The res does have family contact and involvement in help with D/C Record review of Resident #49's Clinical Assessments on [DATE] at 12:36 PM revealed, Resident #49 did not have any clinical assessments, SBARs or social services assessments completed after her statement of wanting to die made on [DATE]. Record review of Resident #49's EMR on [DATE] at 04:12 PM revealed, Resident #49 had no documented psychologist, psychiatry visits after stating she wanted to die on [DATE]. An observation on [DATE] at 09:33 AM revealed, Resident #49 received oxygen via nasal canula between 3.5-4 L/min. The resident was dressed in a hospital gown, appeared well fed and in no immediate distress. Resident #49 woke up and said she had no current issues or concerns, and she would talk to the surveyor at a different time. An observation on [DATE] at 02:45 PM revealed, Resident #49 in bed grimacing from pain. The resident said she could not think because of her pain and the pain was due to an ulcer on her bottom. She said the pain was so severe that she could not sleep, and she pressed the call light, but no one answered. The resident and the surveyor both pressed the call light and the light that indicated a call did not work. At 02:55 PM, the Administrator entered Resident #49's room after the surveyor notified her of the malfunctioning call light. She first pressed the call light to verify it was not working, then she unplugged the call light and plugged it back in, and at that time the call light became functional. The resident did not communicate any other form of distress beyond the pain from her sacral ulcer; she would not elaborate further on her mental state or feelings. An observation and Interview on [DATE] at 03:24 PM revealed, Resident #49 received wound care with the Wound Care Nurse and CNA F. The resident was on her right side with support from CNA F and wound care was completed with good technique. Resident #49 said her pain medication had been working and her pain medications were received regularly. In an interview on [DATE] at 12:15 PM, the DON said when a resident experienced a change of mood the nursing staff must immediately notify the administrator and DON, then the social worker interviews the resident and finally a referral for psych services should be made. She said the assessment must be immediate/ the same day. The DON said if a resident said they want to die; the statements need to be investigated immediately to find out more information like why. She said additional interventions like increased observation of the resident, and every staff member providing care for the resident should be aware of the resident's change of mood. The surveyor notified the DON that Resident #49 stated that she wanted to die on [DATE] and the DON said she was not aware of the president's statement. The DON said the facility should have taken immediate action to address Resident #49's statement that she wanted to die faster, they should have immediately notified the social worker to ensure the resident was safe and not a danger to herself or others. She said the facility had not taken any action to address Resident #49's change of mood. In an interview on [DATE] at 01:00 PM, the DON said Resident #49 was seen by her hospice nurse on [DATE] but they did not notify the facility of any concerns regarding the resident's statements of wanting to die. She said after learning about the resident's statements from the surveyor, she just completed a stat psych referral, and social services would visit the resident. The DON said the facility had not performed a mood or behavioral assessment of Resident #49 or put any interventions in place since she made the statement of wanting to die on [DATE] but she said it's going to be happening. The DON said when a resident made a statement that they want to die, the facility was expected to report and discuss the situation in their 24-hr. report, communicate the incident with all staff and follow up initiated with the resident. She said not having timely response to mood or behavioral changes could place residents in mental distress. In an interview on [DATE] at 02:58 PM, Psychiatric NP A said previously she was not following Resident #49, but she received a psychiatric consultation request today ([DATE]) at 02:18 PM. She said she received a STAT referral from the facility to evaluate the resident, which meant she would see Resident #49 by the next working day. Psychiatric NP A said since Monday was a holiday she would see Resident #49 on Tuesday [DATE], and the interventions in place prior to her visit with the patient was facility dependent/specific. In an interview on [DATE] at 03:03 PM, the MD said a resident stating they wanted to die was a mood change and she expected to receive notification within hours and the social worker should be informed. The MD said she was actively having conversations with Resident #49 about end of life and was discussing her choices of comfort care and eventually Resident #49 was placed on hospice. She said she was not notified of Resident #49's statement that she wanted to die on [DATE], but she was told by staff that she was saying that during the week ([DATE] to [DATE]). She said she never heard or discussed it with the resident but she heard rumors from staff. The MD said she expected staff to immediately assess and document a resident's change of mood and immediately notify the MD of MD on call. In an interview on [DATE] at 04:35 PM, the Social Worker said she last saw the resident on [DATE], but the resident did not feel well at the time. She said she was not aware that Resident #49 said she wanted to die on [DATE] and she had not performed a mood or behavioral assessment of Resident #49's. The Social Worker said when a resident reports a change in mood, staff were expected to initiate an assessment, notify the ADON/DON of the resident's change in mood, and document it as a change of condition. She said failure to assess and take immediate action after a resident experienced a change in mood could place residents at risk of psychosocial discomfort, depression, and psychosocial distress. In an interview on [DATE] at 03:45 PM, LVN C said Resident #49 was actively dying when she made the statement that she wanted to die so she took it as the resident verbalizing her feelings. She said in the morning of [DATE] she woke Resident #49 up to have breakfast and she looked at her tray and shouted she wanted to be left alone and wanted to die. LVN C said she reported the incident to ADON A, the residents family member son, the hospice service but she did not remember if she notified the doctor. She said Resident #77 had accepted her condition (terminal illness) and did not want to continue. LVN C said Resident #49 was in pain sometimes, but her pain was well controlled. She said the facility was repositioning the resident every 1-1/2 hours, she had an air mattress, wedges in place and received wound care as ordered. LVN C said she was not sure if Resident #49 received any behavioral interventions or monitoring after she verbalized, she wanted to die. She said she did not know the procedure to handle residents who voiced suicide but if the resident was not on hospice, she would have called for a psych consult and placed the resident on 1on1 observation. LVN C said she did not take Resident #49's statements as suicidal ideation because the resident was actively dying/received hospice. Resident #77 Record review of Resident #77's Face Sheet dated [DATE] revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included: diabetes, colostomy (is a surgical procedure that creates an opening in the abdominal wall to allow stool to exit the body), and anxiety disorder. Record review of Resident #77's admission MDS dated [DATE] revealed, intact cognition as indicated by a BIMS score of 15 out of 15, little interest or pleasure in doing things, resident did not report feeling down, depressed, or hopeless, no social isolation or behavioral symptoms. Record review of Resident #77's Care Plan completed [DATE], focus- risk for altered mood state related to depression; interventions- administer medications per MD order, document staff interventions in the clinical record, listen when resident is upset and try to resolve the issue, psych referral as needed. Focus- uses antidepressant medications; interventions- monitor/report as needed adverse reactions to antidepressant medications: change in behavior/mood/condition . social isolation, suicidal thoughts, and withdrawal. Record review of Resident #77's SBAR with effective [DATE] at 02:54 PM revealed, before calling MD/NP/PA a- evaluate the resident, c- review record: recent progress notes, labs, orders. The change in condition, symptoms, or signs I am calling about is/are resident states he wants to die. This started on [DATE]; things that make the condition/symptoms worse are resident being in pain; this condition, symptom, or sign has occurred before: No. Record review of Resident #77's Psychiatric Subsequent assessment dated [DATE] revealed, medical necessity for visit- per facility request for crisis. Resident reported chronic anxiety, depressive symptoms related to medical issues and endorses recent end of life statement. Assessment (RN) or Appearance (LPN), LPN- the resident appears: upset but safe. Request- other new orders: psych eval, reported to NP. Record review of Resident #77's Progress Notes printed [DATE] revealed, [DATE] at 03:34 PM- per therapy staff resident states he wants to die, maybe upset about room change. Resident in bed at time in safe position call light in reach. The writer asked the resident why he was upset resident states do not talk to me social worker notified NP and [family member] made aware. Record review of Resident #77's Trauma Screening Assessment effective [DATE] at 02:09 PM revealed, the assessment was blank. No assessment was documented. Record review of Resident #77's Order Summary dated [DATE] at 02:31 AM revealed, Hydrocodone w/ Acetaminophen 5-325 mg- Give 1 table by mouth every 6 hours as needed for pain, initiated [DATE]. Hydrocodone w/ Acetaminophen 05-325 mg- Give 2 tablet by mouth every 6 hours as needed for pain, initiated [DATE]. Fentanyl 25 mcg/hr. patch- apply 1 patch one time a day every 3 days, initiated on [DATE]. Record review of Resident #77's [DATE] MAR revealed, all PRN administration of Hydrocodone was effective on follow up pain assessment. An observation and interview on [DATE] at 10:05 AM revealed, Resident #77 in bed, resident appeared to be sleeping and said he was all right when surveyor tried to talk to him. The resident would not further interact with the surveyor. An observation and interview on [DATE] at 11:07 APM revealed, MD and LVN X talking to each other as they came out of a resident's room. When the surveyor entered the room, Resident #77 was observed in a new room in bed. Resident #77 said he was in pain and could not talk. He said the facility moved his room because something was not working in the room. The resident looked away and would not further interact with the surveyor. Record review of Resident #77's MD Progress note dated [DATE] revealed, Patient seen lying down with head of bead elevated. The resident complained of pain to his back and to his stomach with no report of cramps. Breathing was stable with no wheezing noted. The MD discussed adding a fentanyl patch and increasing his hydrocodone to 2 tablets every 6 hours for pain until fentanyl is placed and then it will continue as needed. In an interview on [DATE] at 01:04 PM, LVN X said Resident #77 had cancer and returned from the hospital with a colostomy after colitis. She said she was working with the resident since he was on the other hall. LVN X said the resident received therapy and reported pain for the last 2 weeks since his colostomy and he was being treated with PRN medications. She said she had not observed any changes in Resident #77's behaviors and the resident did what he wanted. LVN X said Resident #77 had not complained about wanting to die and had not heard about any such complaints or complaints about suicide. She said if she was notified that a resident wanted to die, she would expect the social worker to be notified and the DON as well. LVN X said so far, the resident has not had any additional behavioral monitoring, and management had not communicated any interventions such as behavioral monitoring or increased supervision. In an interview on [DATE] at 01:45 PM, ADON A and the Interim DON said the IDT discussed residents daily in their stand-up meeting when they go over progress notes that appeared on the 24-hour report. They said they had only discussed his room change in the standup meeting because he was changed from the 100 to 500 hall. The Interim DON said they had not heard about the resident wanting to die, or anything like that. ADON A said she may have heard that the resident said he wanted to die because she did a psych consult for him on [DATE]. ADON A and Interim DON said when a resident made a statement like they wanted to die, they should be immediately assessed and placed on observation. The Interim DON would not state what the facility's expectation of staff or interventions required when a resident stated they wanted to die, she said it depended on the assessment. The Interim DON said at the moment she did not see any form of documentation that an assessment was completed for Resident #77 after he said he wanted to die. In an interview on [DATE] at 01:55 PM, the Social Worker said the first time she talked to Resident #77 about his statement that he wanted to die was today, [DATE] at approximately 12:00 PM but she had not had the opportunity to document her visit. She said when she met with the resident, he said he was fine, but she did not ask the resident specifically if he wanted to die but asked all the questions in the PH-Q9 (depression assessment). The social worker said she asked Resident #77 what was going on and he said there were a lot of people going in and out of his room and would not further elaborate. She said her coworker told her Resident #77 said he wanted to die at around 09:00 AM and she saw him at 12:00 PM. The Social Worker said she had seen Resident #77 once and will see him again because she was new to her position and the first time a resident saw a resident they may not open up. The social worker said she had not gone back after the visit at 12:00 PM to see Resident #77 and she did not read the resident's progress notes that showed the resident was reporting pain and a room change being exacerbating factors for the resident feeling like he wanted to die. The Social Worker said the physical therapist her coworker said the resident was safe, and she asked the resident how he was feeling and did not ask about his pain, or room changes and how they made him feel. She said normally if a resident made a statement that they wanted to die, the nursing team would normally review the resident, make medication changes, and have an impromptu IDT meeting to discuss the statement, but the facility had not had a meeting regarding Resident #77's statements. The surveyor asked the Social Worker to read the time she was notified of Resident #77's statement of wanting to die by her coworker; she checked her phone and said 12:00 PM on Monday ([DATE]). After reading the text and confirming the date, the Social Worker changed her narrative and said she first talked to Resident #77 on Monday [DATE]. In an interview on [DATE] at 02:10 PM, the DON said Resident #77 was seen today, [DATE] and his MD gave an order for Fentanyl because the resident's pain was not well controlled on his medications on [DATE]. She said Resident #77 recently got a colostomy, and that was the cause of his self-esteem issues, and possibly why he was depressed. The DON said she talked to the resident, and he did not verbalize any suicidal ideation. In an interview on [DATE] at 02:15 PM, PT A said as she worked with Resident #77 on [DATE] the resident said, I want to die, I want to die, don't tell anyone I said that. She said she immediately put the resident back in bed and immediately notified the charge nurse, who was not a regular full-time nurse she knew, and the DOR. PT A did not report Resident #77 was in pain during the therapy session. Record review of Resident #77's PT Therapy Progress Report dated [DATE] signed by PT A revealed, there was no documentation of Resident #77 being in pain during the therapy session. In an interview on [DATE] at 04:19 AM, the Psychiatric NP B said she had just interviewed Resident #77, but the interview was short because the resident was not feeling well since he experienced nausea and vomiting. She said Resident #77 reported feeling safe and was already receiving Buspar for his old diagnosis of depression. Psychiatric NP B said Resident #77's Paxil, an antidepressant, was increased recently in response to his behaviors, she said Resident #77 had no intention to harm himself. Psychiatric NP B said she had limited availability to talk to the surveyor because she had emergent issues with other residents, she had to take care of. In an interview on [DATE] at 03:03 PM, the MD said she was not aware when she saw Resident #77 on [DATE] that he wanted to die, she said she talked to him about pain that required an increased in the use of his PRN pain occurred [DATE]. The MD said in response to the reported pain and increased used of PRN medications on [DATE] she changed his medications [DATE]. She said she was not told when she arrived the facility, but it was possible the on-call physician was notified. After reviewing the on-call physician's notes the MD said, the on-call physician was notified of Resident #77's statement and an order for a psych consult was given . The MD said when a resident state they want to die, the facility staff were expected to ensure the resident got a psychological consult and the resident should be interviewed to figure out what happened. The MD said most of Resident #77's issues were regarding pain, and his medication was increased. She said the resident says his pain was better so in her mind his is improving and in a better mood. The MD said Resident #77 said he wanted to die because of the pain, and the facility had put interventions in place since they changed his pain medication/treatment. Record review of the facility policy Behavioral Assessment, Intervention and Monitoring revised 04/2023 revealed, 1.The facility will provide, and residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care. 2. Behavioral symptoms will be identified using facility-approved behavioral screening tools and comprehensive assessment. continues on next page. Management 1.The interdisciplinary team will evaluate behavioral symptoms in residents to determine the degree of severity, distress, and potential safety risk to the resident, and develop a plan of care accordingly. Safety strategies will be implemented immediately if necessary to protect the resident and others from harm. a. atypical behavior will be differentiated from behavior that is dangerous or problematic for the resident(s) or staff, or behavior that signals underlying distress. b. If the behavior is atypical but not problematic or dangerous and the resident does not appear to be in distress, then the IDT will monitor for changes but not necessarily intervene to normalize the behavior. 7. Interventions will be individualized and part of an overall care environment that supports physical, functional, and psychosocial needs, and strives to understand, prevent or relieve the resident's distress or loss of abilities. An IJ that started on [DATE] was Identified on [DATE]. The Administrator was notified of the IJ, and the template was provided to the facility on [DATE] at 04:45 PM. The following Plan of Removal submitted by the facility was accepted on [DATE] at 04:37 PM. Plan of Removal Name of facility: [Ridgewood At the Woodlands Rehabilitation and Healthcare Center Date: [DATE] F-740. Problem: The facility failed to take action for resident #49 and resident #77 when they expressed to staff that they wanted to die. 1.Resident #49 and resident # 77, no longer a resident in the facility. a. Resident #49 Expired on Hospice Services b. Resident #77 Currently hospitalized , Dx: Sepsis, with intent to return 2. The Administrator and DON received 1:1 in-service on the facility Behavioral Health Policy and procedures along with the company expectation to adhere to it by the Vice-President of Clinical Services. Completion date [DATE] 3. [DATE] the facility corporate nurse/DON/SW/designee conducted resident interviews who were able to participate and answer questions regarding their current mood status, pain needs, and identify any passive and active suicidal thoughts. No residents voiced current suicidal thoughts, intent for self-harm passive suicidal thoughts and/ or uncontrolled pain. Completion date [DATE] 4. The Facility Corporate nurse reviewed the Behavioral Health Services policy and procedure no changes were needed. Staff in-serviced on policy and procedure. Completion [DATE] Interventions 5. [DATE] The facility DON/Designee conducted an in-service with all facility License nurses and the social worker on adhering to the facility Behavioral Health Policy focusing on addressing resident behavioral needs. Completed [DATE] 6. [DATE] the DON/Designee initiated an in-service with the facility nursing staff (C.N.A, LVN's and RN) on Communicating Changes in Condition via the STOP and WATCH tool, including but not limited to changes in resident moods, expressing thoughts of suicide, increased pain, etc. Completed [DATE]. 7. [DATE] the DON/Designee initiated an in-service with the licensed nurses regarding communicating changes in condition including but not limited to changes in mood, suicidal thoughts, uncontrolled pain .etc. via SBAR to the physician to initiate and or change resident treatment, orders, recommendation for psych referral, transfers out to the hospital. Completed [DATE] 8. Staff will not be allowed to work until after completion of in-service. Completed [DATE]. 9. [DATE] the Administrator/ Designee initiated an in-service on Maintaining the Mental and Psychosocial Wellbeing of Hospice Residents with staff. The in-service includes approaches staff can take to address and improve resident's psychosocial wellbeing. Monitoring 10. [DATE] The DON and administrator are immediately notified of residents expressing passive or active suicidal ideation, uncontrolled pain to provide guidance and ensure proper assessment, and interventions are done completed. Issues identified will be immediately addressed through further education, disciplinary action and or termination of employment. Administrator and DON are on call 24/7. 11. [DATE] The DON/designee began a questionnaire to validate the effectiveness of the training. The questionnaire is conducted with all employees. Immediate re-education will be completed by the DNS/designee if any staff is unable to answer appropriately the questions on the questionnaire. Staff will not be allowed to work until after completion of the questionnaire. Completed [DATE]. 12. [DATE] The Nursing management team reviews Stop and Watch Tools and SBAR for changes in residents' behaviors/mood/ pain needs .etc . daily. Any issues identified will be addressed at this time. 13. [DATE] An impromptu QAPI meeting was conducted with the facility's Medical Director to notify of the potential for non-compliance and the action plan implemented for approval. Plan approved [DATE] Monitoring of the POR In an interview on [DATE] 11:35 AM with RN A , she said she was trained on resident behavior changes on [DATE]. She said if a resident experienced a mood change of condition you immediately stop what you are doing, RN A said that the resident will be watched constantly, and any issues and information will be reported to DON or Admin so the individual can receive whatever next step help that is needed. All information should be documented in PCC as change of condition and in the progress notes. The RN stated that staff were expected to treat hospice residents the same way they would treat a regular resident in all areas of care. In an interview on [DATE] at 11:43 AM, the Activity Director said she received an inservice on resident behaviors on [DATE]. She said that any mental health or changes in condition, would be reported to the Admin. The Activity Director said that she if a resident experienced a mood change or verbalized thoughts of suicide, she would call for assistance for someone to monitor the resident and then proceed to report to DON and Admin. She said all staff were responsible for ensuring all issues were reported and that residents received treatment and or assistance. The Activity Director said that hospice residents were are treated in the same manner, when dealing with suicidal ideations or changes in behavior. In an interview on [DATE] at 11:50 AM, the Social Worker said she received an in-service on behavior changes and or suicidal ideations. She said staff were trained on how to report in PCC and to report to the [NAME] and Admin. The Social Worker said hospice residents will go through the same process as all other residents in the