Based on staff interviews, clinical record review, and facility document review, the facility staff failed to assess, monitor, and treat bilateral hand contractures resulting in skin breakdown with maggot infestation for (1) one of (7) seven sampled residents, Resident #2. The findings include: For Resident #2, the facility staff failed to follow the medical provider orders for a wound consult on 9/12/24 and failed to follow the comprehensive care plan to monitor and notify therapy of a decline in bilateral hand contractures resulting in increased pain, skin breakdown to both hands, maggot infestation in the right hand, and transfer to an acute care hospital for further treatment. This was a closed record review. Resident #2's diagnosis list indicated diagnoses that included, but were not limited to, Depression, Chronic Kidney Disease-Stage 3 (three), Anxiety Disorder, Type 2 (two) Diabetes Mellitus, Dementia, Mood Affective Disorder, Transient Ischemic Attack (TIA), and Cerebral Infarction. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 10/16/24, assigned the resident a brief interview for mental status (BIMS) summary score of 0 out of 15 for cognitive abilities, indicating the resident was severely impaired in cognition. Section GG (functional abilities) was coded to indicate the resident had impairment on both sides of her upper extremity (shoulder, elbow, wrist, hand). Section O (special treatments, procedures, and programs) A. Range of motion (passive) was coded as 0 (zero) indicating PROM (passive range of motion) was none or less than 15 (fifteen) minutes daily and C. Splint or brace assistance was coded as 0 indicating splint and/or brace assistance was not completed. A review of Resident #2's comprehensive care plan revealed a Focus area that read in part, .Limited Mobility .The resident is at risk for .contractures . With Interventions that read in part, .Monitor/document/report PRN (as needed) any s/sx (signs and/or symptoms) of immobility: contractures forming or worsening .skin breakdown .PT (physical therapy), OT (occupational therapy) referrals as ordered, PRN . Review of Resident #2's clinical record revealed the following documentation: A nurse's note dated 09/12/2024, read in part, .This nurse called to Resident's room d/t (due to) scant amount of blood noted to bedding near right hand. Right hand remains contracted with blood noted to lateral side (thumb side). Unable to assess palm of hand d/t contracture and pain with manipulating fingers. Notified [name omitted] NP (nurse practitioner) and no new orders at this time. NP states for wound care to assess in the AM (morning) . A medical provider's progress note dated, 9/12/24, read in part, .Patient appears to be having pain related to her hand contractures .She has previously taken Tramadol for this but the PRN (as needed) order ran out. Patient has contraction of the hands and very stiff extremities from continued bedbound status .New orders written to renew Tramadol order for Tramadol 25 mg (milligrams) BID (twice a day) PRN. Will follow up as required, sooner if needed . A Therapy Screen dated 9/16/24, read in part, .Patient has documented contracture that occurred prior to admission .Patient was seen by occupational therapy services due to bilateral hand contractures, and was discharged .Patient is currently being seen by wound care due to skin breakdown in bilateral hands {sic}At this time, recommend a carrot hand splint (a device used to gently position a severely contracted hand for easier caregiving and patient comfort. The splint is shaped like a tapered carrot and comes with a plastic wand that allows the user to painlessly insert and draw the splint into place. The splint can be gradually inflated to reduce contractures), 2 (two) hours on {sic} 2 (two) hours off, and on at rest. Recommend positioning of upper extremities and hands, gentle passive range of motion, and edema management techniques to facilitate continued healing. Please monitor patient for any worsening contractures and skin irritation, redness, swelling, or pain associated with the contracture, and inform therapy services . A medical provider's progress note dated, 9/18/24, read in part, .Patient seen for acute visit. Nursing reported that patient has a lot of pain when messing with her hands. Her hands are contracted .New orders written to increase Tramadol from 25 mg BID to 25 mg TID (three times per day). Will follow up as required, sooner if needed . A nurse's note dated 10/08/2024, read in part, .Residents guest came up to this nurse and said her (resident's) hand was hurting . A nurse's note dated 10/22/2024, read in part, .This nurse called to residents room by Nurse [name omitted] and Wound Care Nurse [name omitted] to look at her (resident's) right hand for bloody thick drainage with maggots noted. This nurse, (doctor) Dr. [name omitted], Dr. [name omitted], and both above nurses went to residents room. Dr. [name omitted] looked at hand and noted maggots present. Dr. [name omitted] and Dr. [name omitted] called Dr. [name omitted] has agreed to see resident if admitted to hospital by hospitalist for further evaluation .ER (emergency room at hospital) called by this nurse and explained Dr. [name omitted] has agreed to see resident if admitted . DON (director of nursing) [name omitted] RN (registered nurse) notified. She has contacted [name omitted] APS (adult protective services) and notified her of situation . A medical providers order with a start date of 9/12/24 and an end date of 9/18/24 read in part, .Tramadol .25 mg .every 12 hours as needed for Pain . The September MAR (medication administration record revealed resident received the Tramadol seven times with pain levels documented as five out of ten on six instances and four out of ten on one instance from 9/12/24 through 9/18/24. A medical providers order with a start date of 9/18/24 read in part, .Tramadol .25 mg .every 8 hours as needed for pain . The September 2024 MAR and October 2024 MAR revealed resident received Tramadol from 9/18/24 through 10/19/24 thirty-five times with pain levels documented as two out of ten once, three out of ten six times, four out of ten twelve times, five out of ten fifteen times, and nine out of ten one time for the doses received. Surveyor reviewed Resident #2's current medical provider orders and was unable to locate orders for the care and/or monitoring of the resident's bilateral hand contractures. Review of the September 2024 and October 2024 TARs (treatment administration records) did not reveal any indicated treatments for Resident #2's bilateral hand contractures or skin breakdown on the resident's hands. Surveyor requested evidence of carrots being utilized and evidence of passive range of motion being performed for Resident #2, facility staff were unable to provide any evidence for these recommended treatments. A review of the Skin Assessments for September 2024 and October 2024 did not reveal Resident #2's bilateral hand contractures being acknowledged, did not recognize any form of monitoring/measuring for decline in the contractures or the skin surrounding/beneath the contractures and did not mention Resident #2's hands worsening, having any skin irritation, redness, swelling, or any other issues. Surveyor requested and received an ED (emergency department at the hospital) Provider Notes dated 10/22/24, that read in part, .patient presents to the ED .for wound check .reports that he found maggots in a wound on her right hand and states there is also a wound in palm of her left hand .Right hand: Deformity present. Decreased range of motion. Left hand: Deformity present. Decreased range of motion .Hands are contracted bilaterally .Photos taken by me of the right hand which there is maggots inside the curled up fingers .On exam .Her hands are contracted bilaterally with her fingers fixed into the palms of her hands. There are maggots visualized in the wound on her right and {sic}. There is purulent drainage with foul odor coming from both hands. Nursing flushed the right hand with sterile saline however there are still maggots coming from wound .Dr. [name omitted] was consulted and he presented at bedside to see patient. We are unable to fully visualize the wounds on her hands due to bilateral contractures of her hands. Imaging was obtained. Hand wounds were cleaned with hydrogen peroxide, maggots are still visualized in the right palm .Patient's family request patient be admitted for placement to a different facility. Patient is admitted to the hospitalist service .Problems addressed: Contracture of hand joint, right: complicated acute illness or injury. Maggot infestation: complicated acute illness or injury . On 11/18/24 at 2:45 PM, surveyor contacted Ombudsman via phone conversation. Ombudsman recalled Resident #2 and the maggots in her right hand. She stated resident's fingernails were long and embedded in her hands. She believed there was an order for wound care to put carrot in left hand 2 hours on and 2 hours off. Ombudsman stated she did not observe Resident #2's hands while she was a resident at the facility, but did observe them after resident went to another facility. She stated that APS had the hospital records and the report read that the hands smelled and maggots were executed from the right hand when the hospital irrigated it. She stated the hospital had to use a bucket to catch all the maggots. On 11/18/24 at 3:00 PM, surveyor discussed the allegation in this complaint during a meeting with the administrator in training (AIT), regional director of clinical services, director of nursing (DON), and an administrator from a sister-facility. On 11/18/24 at 3:12 PM, surveyor interviewed licensed practical nurse #1 (LPN#1) and she stated she was called to Resident #2's room (on 10/22/24) related to movement from larva. She stated she got the medical director and they could not see down under the resident's fingers because her hands were so contracted. She stated there was no room for a splint on the right hand and there were no orders for a splint, she did believe at one point that Resident #2 did have a carrot. Prior to the incident (10/22/24), she was not aware of any issues with the resident's hands and she was not aware of any wound care addressing the resident's contractures. On 11/19/24 at 8:17 AM, surveyor interviewed occupational therapist-other staff #2 (OS#2) and she stated she initially did bilateral carrots for Resident #2's hands and she was on therapy caseload in July 2024 and she was able to get the carrots in both hands at that time. It was difficult to get the carrot in the right hand, but they were able to. She stated during her screening in September (9/16/24) that she observed the resident's fingernails to be long and recalled the fingernails had been like that on both hands. OS#2 stated she recommended and gave the carrots for Resident #2 after the screen and she never asked staff to not use the carrots and they were to be worn 2 hours on, 2 hours off, and on at bedtime. She stated no one ever told her they could not get the carrots in the resident's hands. On 11/19/24 at 8:23 AM, surveyor interviewed CNAs (certified nursing assistant's) who gave the showers at the facility, CNA#1 and CNA#2. CNA#2 recalled Resident #2's hands being very contracted. CNA#1 stated they could not get her hands opened to wash them with soap, so they would wash the outside of the hand with soap and use the shower hose to try to rinse out the hand and clean under the contracture. CNA#1 and CNA#2 both agreed the resident would scream out in pain if they attempted to open her hands. CNA#1 stated therapy gave her a carrot. They could wash one of her hands and could get a washcloth down through that hand, but the other one they could not, she could not recall which hand. Both CNAs agreed they could not visualize Resident #2's fingernails on either hand. CNA#1 stated the resident would scream out in pain if you touched her hands because they hurt so much, and she (Resident #2) would tell them she would never try to break their fingers. On 11/19/24 at 9:11 AM, surveyor interviewed registered nurse#1 (RN#1) via phone conversation and reviewed the nurse's note she had written on 9/12/24. RN#1 stated she was not sure if the NP (nurse practitioner) followed-up with acquiring a wound consult for Resident #2 concerning her hands. RN#1 did recall resident having a couple of carrots and stated the caregiver would take them out. She also recalled resident having a white gauze type of thing for her left hand and the right hand used the carrot. She recalled resident's right hand being really contracted and it was painful for the resident to try to put the carrot in the hand, but she was always able to get the carrot in her hand, just not all the way. RN#1 stated she had tried to trim Resident #2's fingernails but was unable to get her fingers out and assumed resident was on wound care and they (wound care) were taking care of them (fingernails). On 11/19/24 at 9:41 AM, surveyor called RN#1 back and asked who she informed about the incident of Resident #2's right hand bleeding on 9/12/24 and she stated she informed registered nurse#2 (RN#2) [wound care nurse] about the resident's hand bleeding and stated there would be no documentation of that. On 11/19/24 at 9:25 AM, surveyor interviewed RN#2 and she stated she never received any referrals for Resident #2's hands. On 11/19/24 at 10:57 AM, surveyor interviewed nurse practitioner (NP) and she recalled being informed of the blood noted on Resident #2's right hand on 9/12/24 and stated she did visit the resident. She stated for any new skin issues, the nurse would put in as an order for wound care to look at. The NP recalled speaking with the wound care nurse at some point and stated the wound care nurse stated they were addressing cleaning Resident #2's hands. The NP recalls there was no drainage, but the hand did appear to have yeast when she looked at it. The NP did not recall carrots being used in Resident #2's hands but did recall wash cloths in both hands. The NP agreed her intent from the 9/12/24 note was for nursing to put in an order from her to have wound care look at Resident #2's hands and this was a verbal order, as she (the NP) had left for the day. On 11/19/24 at 12:16 PM, at the pre-exit meeting, surveyor reviewed the complaint with the director of nursing, administrator in training, regional director of clinical services, and the administrator from a sister-facility, and reported there was no documented evidence to support utilization of carrots, no documented evidence of passive range of motion, no evidence to support the comprehensive care plan was followed in regards to the contractures of Resident #2's hands, and no evidence the provider order was followed for a wound consult on 9/12/24. Surveyor requested and received a facility policy titled, Abuse, Neglect and Exploitation Prevention and Reporting that read in part, .Each resident has the right to be free from .neglect .8. Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress .Identification of .Neglect .h. Failure to provide care needs . No further information was provided to the survey team prior to exit on 11/19/24.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to ensure residents receive treatment and care in accordance with the comprehensive care plan and medical provider orders for (2) two of (7) seven sampled residents, Resident #2 and Resident #7. The findings include: 1. For Resident #2, the facility staff failed to provide treatment and care in accordance with the comprehensive care plan to monitor and treat bilateral hand contractures and failed to follow the medical provider orders for a wound consult resulting in skin breakdown in both hands, maggot infestation of the right hand, and transfer to an acute care hospital for further treatment. This was a closed record review. Resident #2's diagnosis list indicated diagnoses that included, but were not limited to, Depression, Chronic Kidney Disease-Stage 3 (three), Anxiety Disorder, Type 2 (two) Diabetes Mellitus, Dementia, Mood Affective Disorder, Transient Ischemic Attack (TIA), and Cerebral Infarction. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 10/16/24, assigned the resident a brief interview for mental status (BIMS) summary score of 0 out of 15 for cognitive abilities, indicating the resident was severely impaired in cognition. Section GG (functional abilities) was coded to indicate the resident had impairment on both sides of her upper extremity (shoulder, elbow, wrist, hand). Section O (special treatments, procedures, and programs) A. Range of motion (passive) was coded as 0 (zero) indicating PROM (passive range of motion) was none or less than 15 (fifteen) minutes daily and C. Splint or brace assistance was coded as 0 indicating splint and/or brace assistance was not completed. A review of Resident #2's comprehensive care plan revealed a Focus area that read in part, .Limited Mobility .The resident is at risk for .contractures . With Interventions that read in part, .Monitor/document/report PRN (as needed) any s/sx (signs and/or symptoms) of immobility: contractures forming or worsening .skin breakdown .PT (physical therapy), OT (occupational therapy) referrals as ordered, PRN . A review of the clinical record revealed a Therapy Screen dated 9/16/24, that read in part, .Patient has documented contracture that occurred prior to admission .Patient was seen by occupational therapy services due to bilateral hand contractures, and was discharged .Patient is currently being seen by wound care due to skin breakdown in bilateral hands {sic}At this time, recommend a carrot hand splint (a device used to gently position a severely contracted hand for easier caregiving and patient comfort. The splint is shaped like a tapered carrot and comes with a plastic wand that allows the user to painlessly insert and draw the splint into place. The splint can be gradually inflated to reduce contractures), 2 (two) hours on {sic} 2 (two) hours off, and on at rest. Recommend positioning of upper extremities and hands, gentle passive range of motion, and edema management techniques to facilitate continued healing. Please monitor patient for any worsening contractures and skin irritation, redness, swelling, or pain associated with the contracture, and inform therapy services . Surveyor reviewed Resident #2's current medical provider orders and was unable to locate orders for the care and/or monitoring of the resident's bilateral hand contractures. Review of the September 2024 and October 2024 TARs (treatment administration records) did not reveal any indicated treatments for Resident #2's bilateral hand contractures or skin breakdown on the resident's hands. Surveyor requested documented evidence of carrots being utilized and documented evidence of passive range of motion being performed for Resident #2, facility staff were unable to provide any documented evidence for these recommended treatments. Further review of Resident #2's clinical record revealed the following progress notes: A nurse's note dated 9/12/24 read in part, .This nurse called to Resident's room d/t (due to) scant amount of blood noted to bedding near right hand. Right hand remains contracted with blood noted to lateral side (thumb side). Unable to assess palm of hand d/t contracture and pain with manipulating fingers. Notified [name omitted] NP (nurse practitioner) and no new orders at this time. NP states for wound care to assess in the AM (morning) . A nurse's noted dated 10/22/2024, read in part, .This nurse called to residents room by Nurse [name omitted] and Wound Care Nurse [name omitted] to look at her (resident's) right hand for bloody thick drainage with maggots noted. This nurse, (doctor) Dr. [name omitted], Dr. [name omitted], and both above nurses went to residents room. Dr. [name omitted] looked at hand and noted maggots present. Dr. [name omitted] and Dr. [name omitted] called Dr. [name omitted] has agreed to see resident if admitted to hospital by hospitalist for further evaluation .ER (emergency room at hospital) called by this nurse and explained Dr. [name omitted] has agreed to see resident if admitted . DON (director of nursing) [name omitted] RN (registered nurse) notified. She has contacted [name omitted] APS (adult protective services) and notified her of situation . A review of the Skin Assessments for September 2024 and October 2024 did not reveal Resident #2's bilateral hand contractures being acknowledged, did not recognize any form of monitoring/measuring for decline in the contractures or the skin surrounding/beneath the contractures and did not mention Resident #2's hands worsening, having any skin irritation, redness, swelling, or any other issues. Surveyor was unable to locate any doucmented evidence in the clinical record that a wound consult was obtained for the resident as per the NP's verbal order on 9/12/24 and the facility staff was unable to provide any documented evidence of a wound consult. On 11/18/24 at 3:12 PM, surveyor interviewed licensed practical nurse #1 (LPN#1) and she stated she was called to Resident #2's room (on 10/22/24) related to movement from larva. She stated she got the medical director, and they could not see down under the resident's fingers because her hands were so contracted. She stated there was no room for a splint on the right hand and there were no orders for a splint, she did believe at one point that Resident #2 did have a carrot, but her care companion would take it out because the resident stated it hurt. Prior to the incident (10/22/24), she was not aware of any issues with the resident's hands, and she was not aware of any wound care addressing the resident's contractures. On 11/19/24 at 8:17 AM, surveyor interviewed occupational therapist-other staff #2 (OS#2) and she stated she initially did bilateral carrots for Resident #2's hands and she was on therapy caseload in July 2024, and she was able to get the carrots in both hands at that time. It was difficult to get the carrot in the right hand, but they were able to. She stated during her screening in September (9/16/24) that she observed the resident's fingernails to be long and recalled the fingernails had been like that on both hands. OS#2 stated she recommended and gave the carrots for Resident #2 after the screen and she never asked staff to not use the carrots and they were to be worn 2 hours on, 2 hours off, and on at bedtime. She stated no one ever told her they could not get the carrots in the resident's hands. On 11/19/24 at 8:23 AM, surveyor interviewed CNAs (certified nursing assistant's) who gave the showers at the facility, CNA#1 and CNA#2. CNA#2 recalled Resident #2's hands being very contracted. CNA#1 stated they could not get her hands opened to wash them with soap, so they would wash the outside of the hand with soap and use the shower hose to try to rinse out the hand and clean under the contracture. CNA#1 and CNA#2 both agreed the resident would scream out in pain if they attempted to open her hands. CNA#1 stated therapy gave her a carrot. They could wash one of her hands and could get a washcloth down through that hand, but the other one they could not, she could not recall which hand. Both CNAs agreed they could not visualize Resident #2's fingernails on either hand. CNA#1 stated the resident would scream out in pain if you touched her hands because they hurt so much, and she would tell them she would never try to break their fingers. On 11/19/24 at 9:11 AM, surveyor interviewed registered nurse#1 (RN#1) via phone conversation and reviewed the nurse's note she had written on 9/12/24. RN#1 stated she was not sure if the NP (nurse practitioner) followed-up with acquiring a wound consult for Resident #2 concerning her hands. RN#1 did recall resident having a couple of carrots at one point and stated the caregiver would take them out. She also recalled resident having a white gauze type of thing for her left hand and the right hand used the carrot. She recalled resident's right hand being really contracted and it was painful for the resident to try to put the carrot in the hand, but she was always able to get the carrot in her hand, just not very far. RN#1 stated she had tried to trim Resident #2's fingernails but was unable to get her fingers out and assumed resident was receiving wound care and that they were taking care of them (fingernails). On 11/19/24 at 9:41AM, surveyor called RN#1 back and asked who she informed about the incident of Resident #2's right hand bleeding on 9/12/24 and she stated she informed registered nurse#2 (RN#2) [wound care nurse] about the resident's hand bleeding and stated there would be no documentation of that. On 11/19/24 at 9:25 AM, surveyor interviewed RN#2, and she stated she never received any referrals for Resident #2's hands. On 11/19/24 at 10:57 AM, surveyor interviewed nurse practitioner (NP), and she recalled being informed of the blood noted on Resident #2's right hand on 9/12/24 and stated she did visit the resident. She stated for any new skin issues, the nurse would put in as an order for wound care to look at. The NP did not recall carrots being in Resident #2's hands but did recall wash cloths in both hands. The NP agreed her intent from the 9/12/24 incident was for nursing to put in an order from her to have wound care look at Resident #2's hands and this was a verbal order, as she (the NP) had left for the day. On 11/18/24 at 3:00 PM, during a meeting with the administrator in training (AIT), regional director of clinical services, director of nursing (DON), and an administrator from a sister-facility this surveyor discussed the concerns of Resident #2 having no documented evidence of receiving carrots for bilateral hand contractures, no documented evidence passive range of motion was performed on the resident's hands and no evidence the medical providers verbal order for a wound consult on 9/12/24 was addressed. Surveyor requested and received an ED (emergency department at the hospital) Provider Notes dated 10/22/24, that read in part, .patient presents to the ED .for wound check .reports that he found maggots in a wound on her right hand and states there is also a wound in palm of her left hand .Right hand: Deformity present. Decreased range of motion. Left hand: Deformity present. Decreased range of motion .Hands are contracted bilaterally .Photos taken by me of the right hand which there is maggots inside the curled up fingers .On exam .Her hands are contracted bilaterally with her fingers fixed into the palms of her hands. There are maggots visualized in the wound on her right and {sic}. There is purulent drainage with foul odor coming from both hands. Nursing flushed the right hand with sterile saline however there are still maggots coming from wound .Dr. [name omitted] was consulted and he presented at bedside to see patient. We are unable to fully visualize the wounds on her hands due to bilateral contractures of her hands. Imaging was obtained. Hand wounds were cleaned with hydrogen peroxide, maggots are still visualized in the right palm .Patient's family request patient be admitted for placement to a different facility. Patient is admitted to the hospitalist service .Problems addressed: Contracture of hand joint, right: complicated acute illness or injury. Maggot infestation: complicated acute illness or injury . No further information regarding this concern was presented to the survey team prior to the exit conference on 11/19/24. 2. For Resident #5, the facility staff failed to administer the oral medication Lactulose as ordered by the provider. Lactulose is used to treat constipation and may also be used to reduce ammonia levels in the blood due to liver disease. Resident #5's diagnosis list indicated diagnoses, which included, but not limited to Hepatic Failure, Schizophrenia, Bipolar Disorder, and Adult Failure to Thrive. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 10/24/24 assigned the resident a Brief Interview for Mental Status (BIMS) summary score of 0 out of 15 indicating the resident was severely cognitively impaired. Resident #5's current comprehensive person-centered care plan included a focus area stating Resident #5 was in the facility for long term care due to current healthcare needs and medication management with an intervention for continued care by facility staff per primary care physician and physician orders. On 11/19/24 at 8:55 AM during a medication pass and pour observation, surveyor observed Licensed Practical Nurse (LPN) #4 prepare and administer Resident #5's morning medications. A review of Resident #5's current provider orders included a current order for Lactulose Oral Solution 10 gm/15 ml administer 15 ml by mouth two times a day for elevated ammonia level. According to the resident's November 2024 Medication Administration Record (MAR), Lactulose was scheduled to be administered at 9:00 AM. Surveyor did not observed LPN #4 administer Lactulose to Resident #5 during the medication pass and pour observation on 11/19/24. On 11/19/24 at 10:01 AM, surveyor returned and spoke with LPN #4 who stated she did not administer the Lactulose but would give it to him now. On 11/19/24 at 12:15 PM, the survey team met with the Administrator in Training, Director of Nursing, Regional Nurse Consultant, and an Administrator from a sister facility and discussed the concern of LPN #4 failing to administer Resident #5's Lactulose. No further information regarding this concern was presented to the survey team prior to the exit conference on 11/19/24.

Based on resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to ensure residents were free of significant medication errors for 1 of 7 sampled residents (Resident #1). Resident #1 received eight (8) separate medications in error placing the resident's health and safety in jeopardy resulting in transfer to a higher level of care. The findings included: For Resident #1, the facility staff failed to administer medications as ordered by the medical provider. On 10/21/24, Resident #1 ingested eight (8) separate medications including six (6) psychotropics that were ordered for another resident resulting in transfer to the emergency department where they were subjected to invasive medical procedures including intravenous fluids and blood work. According to The Centers for Medicare and Medicaid (CMS), a psychotropic drug is defined in the regulations at §483.45(c)(3), as any drug that affects brain activities associated with mental processes and behavior. Psychotropic drugs include, but are not limited to the following categories: anti-psychotics, anti-depressants, anti-anxiety, and hypnotics. Resident #1's diagnosis list indicated diagnoses, which included, but not limited to Chronic Cholecystitis, Chronic Obstructive Pulmonary Disease, Atrial Fibrillation, and Essential Hypertension. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 8/27/24 assigned the resident a brief interview for mental status (BIMS) summary score of 13 out of 15 indicating the resident was cognitively intact. Resident #1 was coded as being independent in personal hygiene, toileting hygiene, and upper/lower body dressing. A review of Resident #1's clinical record revealed a nursing progress note dated 10/21/24 at 8:48 PM which read Resident was sitting at cart talking to this nurse while I stop what I was doing and started pre-pairing [sic] his medications. He ask 'hey where my medication' I stated on top of the cart. I bent over to get his nose sprays out of the bottom drew [sic] of cart. looking over I realized he had swallowed another resident medication. I RAN!! to call Dr. [name omitted] MD to explain situation: was notified per Dr. [name omitted] MD to notify resident and send to ER for eval. Called 911, told resident, Notified [director of nursing], Called [hospital name], called family. Vitals 111/69 [blood pressure] 98.3 [temperature] 89 [heart rate] 18 [respirations] 96% [oxygen saturation] WNL [within normal limits]. A nursing progress note dated 10/22/24 at 3:49 AM read Resident arrived back to facility from [hospital]. NO distress noted. Awake alert and pleasant mood. No new orders given. Surveyor requested and received the emergency room provider notes dated 10/21/24 which read in part .Nursing staff accidentally gave him the wrong medications at 9:00 p.m. tonight. They gave him Ativan, Zyprexa and lithium and called 911 to have him evaluated in the emergency department. Patient has no complaints . [Resident #1] is not in acute distress .Cardiovascular .Normal rate. Rhythm irregular .No respiratory distress .No focal deficit present .alert and oriented to person, place, and time .Mood normal .Behavior normal .ECG [electrocardiogram] unchanged from 8/01/2024 .The patient was stable in the emergency department. He was asymptomatic while in the department. Labs were unremarkable. Case discussed with poison control who initially recommended 8 hour observation. 01:29 Poison control was contacted again and noting that the patient was asymptomatic they stated that if the patient was still asymptomatic at 2 am, he would be medically cleared to return to the nursing home. 02:00 Patient was asymptomatic and is medically cleared to return to the nursing home . According to the ER provider notes, while at the hospital, Resident #1 received an ECG, blood work including a Comprehensive Metabolic Panel, Salicylate Level, Acetaminophen Level and a Complete Blood Count, and 500 ml of Sodium Chloride solution. Resident #1 was seen the following morning, 10/22/24, by the facility physician. The progress note read in part .Last night, patient accidentally took medications intended for another patient. There was a miscommunication due to patient's hearing loss and while his nurse turned to grab part of his medications, patient misunderstood her and took a different resident's medications. He ingested Ativan, Zyprexa, and lithium. Patient became weak and hard to respond and subsequently was sent to the emergency room, where he was observed for several hours without further worsening of symptoms. He was discharged and returned here. This morning, he is complaining that his legs still feel a litter [sic] weak and his stomach is hurting some .weakness in legs this morning worse than patient's baseline .Plan: PT [physical therapy] for focal leg weakness. Continue to monitor closely . On 11/18/24 at 1:10 PM surveyor spoke with Resident #1 in his room and asked if he had been out to the emergency room recently. Resident #1 stated a nurse had given him someone else's medicine and he had to go to the hospital. Resident #1 stated the nurse came into his room during the evening around 9 or 10 pm and gave him medicine, left the room and then she came back real fast and they rushed me out of here. Resident #1 said the nurse almost killed me stating his chest hurt and he was short of breath and could not breathe. The resident further stated, that stuff was dangerous, and it took him 10 to 11 days to get over it. Resident #1 stated when he returned from the hospital, the nurse spoke to him and cried about the situation. The resident stated this nurse continues to administer his medications. When asked how he felt about that, he stated, I'm okay if she gives me the right ones and I don't think she meant to kill me. Resident #1 stated he now looks at all his medicine before taking it. At 3:58 PM, surveyor again spoke with Resident #1 who stated he was lying in his bed when the nurse gave him his medications that evening. On 11/18/24 at 3:59 PM, with the verbal consent of Resident #1, surveyor spoke with Resident #1's roommate (Resident #7) and asked him about the incident on 10/21/24. Resident #7 stated the nurse brought the carriage around with the medicine and that night she gave him his medicine and then brought Resident #1's medicine to him and then came back into the room real quick. According to Resident #7's clinical record, his 9/11/24 MDS documented a BIMS score of 14 out of 15 indicating he was cognitively intact. On 11/18/24 at 2:49 PM, surveyor spoke with the local Long-Term Care (LTC) Ombudsman who stated Resident #1, and their roommate were adamant that the nurse brought the wrong medication into his room but the facility stated Resident #1 took the medication from the cart. On 11/19/24 at 1:28 AM, surveyor spoke with Licensed Practical Nurse (LPN) #5 (the writer of the 10/21/24 8:48 PM nursing progress note) and asked her to describe the incident on 10/21/24. LPN #5 immediately stated it's my fault and I panicked. LPN #5 stated the med cart was in the hall in front of Resident #1's room and he was sitting in his wheelchair in his doorway. LPN #5 stated she saw another resident in the hall, Resident #8, and decided to administer his medications while he was near and placed his oral medications in a cup and turned to give them and he was already gone so she sat Resident #8's medicine cup aside on the top of the cart. At that time LPN #5 began preparing Resident #1's medications and while talking to Resident #1, she bent over into the med cart to get nasal spray and Resident #1 reached onto the med cart and picked up Resident #8's medication cup and took everything inside of the cup which was all of Resident #8's oral medication. LPN #5 stated she knew what had happened as soon as he took them, and she ran and called the doctor and sent him to the ER. LPN #5 stated she had received proper training and been a nurse for a long time and understood the scolding she received and thought she would lose her job over it. LPN #5 stated she understood that she needed to own her mistake. A review of Resident #1's October 2024 Medication Administration Record (MAR) indicated Resident #1 was to receive the following medications on 10/21/24 from 9:00 to 10:00 PM: Eliquis 5 mg, Cardizem 15 mg, Digoxin 125 mcg, Midodrine 5 mg, Atorvastatin 10 mg, Flonase, Azelastine Nasal Spray, Colace 200 mg, Miralax 17 gm, and Debrox. However, Resident #1 received the following medications in error: Zyprexa 10 mg, Lithium 300 mg, Risperdal 1 mg, Oxcarbazepine 150 mg, Ativan 0.5 mg, Trazodone 50 mg, Bactrim DS 800-160 mg, and Simethicone 180 mg. Zyprexa and Risperdal are antipsychotic medications used to treat conditions such as Bipolar Disorder and Schizophrenia. Lithium is a mood stabilizing drug used to treat manic episodes associated with Bipolar Disorder. Ativan is a benzodiazepine used to treat anxiety and insomnia. Trazodone is an antidepressant used to treat depression. Oxcarbazepine is an anticonvulsant used to manage seizures. Bactrim is an antibiotic used to treat infection. Lastly, Simethicone is a medication used to relieve gas in the stomach and intestines. According to documents included in LPN #5's employee file, she was initially licensed as an LPN in 2007 and had a current license expiration date of 6/30/25. LPN #5 began working at the facility in September 2023. A RN/LPN Initial Nurse Orientation checklist indicated LPN #5 received training titled Safely Administer Meds/Med Error Process on 9/21/23. On 11/19/24 at 12:15 PM, the survey team met with the Administrator in Training (AIT), Regional Nurse Consultant (RNC), Director of Nursing (DON), and Administrator from a sister facility and discussed Resident #1's medication error. When discussing the discrepancies between Resident #1, Resident #7, and LPN #5's version of events, the DON stated this was the first she had heard of the resident stating LPN #5 brought the medications to him. Surveyor was unable to verify if the error occurred from the nurse handing the wrong medications to Resident #1 or from the nurse leaving Resident #8's medications unsecured on the top of the med cart resulting in Resident #1 picking up the wrong cup of medications and ingesting them. No further information regarding this concern was presented to the survey team prior to the exit conference on 11/19/24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, resident interview, clinical record review, and facility document review, the facility staff failed to provide adequate supervision to prevent accidents for 4 of 7 Residents (Resident #3, Resident #6, Resident #4, Resident #5). Resident #3 was found in the floor of the Alzheimer's unit with head wounds. Resident #3 was transferred to a local hospital. A CT (Cat Scan) was performed and showed a right occipitoparietal calvarial fracture, subdural hematoma, hemorrhagic parenchymal contusion in the right cerebellar hemisphere, and multifocal subarachnoid hemorrhage. Resident #3 was placed on comfort care and expired. This is harm. The findings included: Resident #3, was found in the floor of the Alzheimer's unit with head wounds, and was transferred to a local hospital. Resident #3 was placed on comfort care due to their injuries, and subsequently expired. Resident #2 reportedly hit Resident #3, resulting in a head wound. Resident #3's diagnoses included, but were not limited to, diabetes, peripheral vascular disease, and difficulty in walking. On [DATE], an entrance conference was conducted with the Director of Nursing. The DON stated that Resident #3 had passed away from their injuries. The DON further stated that the incident was not observed by staff, and the other resident involved, Resident #2 did not have any injuries and no memory of the incident. On [DATE], a review was conducted of Resident #3's clinical record. Resident #3's quarterly Minimum Data Set assessment with an assessment reference date of [DATE] included a brief interview for mental status summary score of 3 out of a possible 15 points, indicating severe cognitive impairment. Resident #3 required supervision of one person for bed mobility, transfers, walk in room/corridor, and locomotion on and off the unit. Resident #3 was not coded as having any limitations in range of motion in the upper and/or lower extremities or as using any mobility devices. Resident #3's comprehensive care plan (CCP) included the following: Requires supervision, assist with all activities of daily living (ADL's). Falls/Injuries: Requires assist with ADL's, ambulates with supervision. Has an unsteady gait, is unsteady with transitions, and receives psychotropic medication, diagnoses diabetes, peripheral vascular disease, repeated falls, dementia, and osteoporosis. Cognitive/Delirium/Communication/Visual: Is alert and verbal with confusion noted. Communicates verbally with clear speech. Understood and understands. Resides in a locked memory care unit. The Director of Nursing (DON) provided the surveyor with a physician order list indicating Resident #3 was receiving medications at the time of the incident on [DATE]. It included Isosorbide Mononitrate, Namenda, Escitalopram, and Seroquel. A review was conducted of the clinical record. It read: [DATE] 1:40 p.m., Certified Nursing Assistant [C.N.A. #1] stated they were at the nurses station with C.N.A. #2, and the Licensed Practical nurse [LPN #1]. We heard yelling, we ran down the hallway and we saw Resident #2 standing in the doorway of another residents room (Resident #6). C.N.A. #2 assisted Resident #2 to the desk. I saw Resident #3 in the floor, tried to wake them up, Resident #3 threw up, and they turned them onto their side. LPN #1 asked me to obtain vital signs, LPN #1 called 911 and we stayed with the resident until the ambulance arrived. C.N.A. #1 stated Resident #6 said they saw it all, and Resident #2 had hit Resident #3 in the face. [DATE] 8:26 p.m., LPN #1 documented, The cna's were standing at the nursing station when they heard yelling from the hall. When the nurses and aides got back there, that is where we saw another resident in the floor lying unconscious. The aides got The resident (Resident #2), who hit the other resident out of the room. Resident #2 is now sitting in a chair up at the nursing station. Resident is being sent out for psych evaluation. On [DATE] 3:55 p.m., an interview was conducted with Resident #6 (BIMS score 15) who stated they were in their room, Resident #3 had come in to talk with them,( Resident #2) came in here and smacked (Resident #3) in the head, who fell down to the floor in my room, and started bleeding. Resident #6 stated, When they turned (Resident #3) to the side (Resident #3) began puking. Regarding Resident #2, Resident #6 stated, [Resident #2] hit me too, but I only got a bruise on my arm. Due to prior altercations with other residents, Resident #2 was supposed to be closely supervised. On [DATE] at 12:28 p.m., the DON stated the incident happened on a Friday at approximately 6:00 p.m. and the activity person had gone, they had tried to find placement to supervise Resident #2, but were not having any luck. The following Facility Reported Incidents were reviewed: 1. [DATE]. Resident to Resident altercation. Resident #2 wandered into another Residents room (Resident #5). Residents are in different rooms but shared a bathroom with a connecting door. Resident #5 attempted to help Resident #2 out of the room and Resident #2 hit Resident #5, Resident #5 then hit Resident #2. No injuries to Resident #5, Resident #2 had 2 red areas on their face. Every 15 minutes checks X 72 hours initiated on both residents. Resident #2 was assessed by the NP [Nurse Practitioner] -patient stable at baseline requiring redirection due to dementia. A follow-up visit was completed on [DATE] NP-Stable. 2. [DATE]. Resident to Resident altercation involving Resident #2 and Resident #4. Resident #2 observed by staff hitting Resident #4 on the head with two shoes. Residents redirected; Resident #2 was moved to a different room. Every 15 minutes checks X 72 hours. No injuries. No further episodes. 3. [DATE], Resident to Resident altercation. Resident #6 told Resident #2 to get away from them. Resident #2 then slapped Resident #6 on the hand and back of head. Every 15 minutes checks continued for another 72 hours. No injuries. Residents separated. Resident #2 was assessed by the NP on [DATE]-stable. On the day of the incident, 2 police officers came to the facility. On [DATE] at approximately 4:25 p.m., an interview was conducted via telephone with both of them. Police Officer #1 stated that one of the workers at the nursing home had taken out an ECO (Emergency Custody Order) on Resident #2. They had taken Resident #2 to the hospital, they were violent, confused, couldn't remember what had happened, did not know where they were. Mental health made the decision to release the Resident back to the facility and they are still allowing the resident to roam free. The Resident was not charged due to their mental capacity but there is still a possibility they may be charged. [DATE] 9:10 a.m., Police Officer #2 stated when they got to the facility, the scene was chaotic on the Alzheimer's wing. We filtered through the issues and emotions and a resident named (Resident #6) had witnessed the assault. Staff stated a resident had hurt a resident. Resident was still in the floor and had vomit and blood in their hair, and the rescue squad personnel got them out pretty quick. Staff kept making statements that Resident #2 was violent, assaulting staff and other residents. Resident #2 was seated in front of the nurses station, staff present. Resident #2 was talking about past issues, fragments. We got word that Resident #3 was bleeding so severe they were placed on comfort care, and they had since passed away from their wounds. Police officer #2 stated Resident #2 was not violent in their presence (but stated they were not the first officer on the scene), they were seated, they had no clue of the incident. Police officer #2 stated Resident #3's autopsy was completed yesterday but they did not have any results of yet. ECO was done by staff, and the facility tried to refuse to take them back, the hospital had to release the resident. Police Officer #1 had spoken with the director or someone and they let Resident #2 come back. Police officer #2 stated they were unsure if Resident #2 was competent to stand trial. On [DATE] at 1:55 p.m., an observation of Resident #2 was made. Resident #2 was resting in bed, with his eyes open, and responding when spoken to. He stated he loved it back here. No mention of any incidents were made by resident. The DON provided the surveyor with copies of hospital records for Resident #3's admission to the hospital on [DATE]. An excerpt read: Emergency Department (ED) Provider Notes, date of service [DATE] 8:37 p.m. past medical history of dementia, hypertension, MI (myocardial infarction) . Patient was either pushed or struck by another patient. It was reported (Resident #3) fell to the ground hitting back of head had loss of consciousness. Physical Exam: Laceration to posterior scalp. Talked with daughter stated she wants patient changed from full code to Do Not Resuscitate [DNR]. I discussed case with palliative care nurse. Patient is given IV Zofran and Compazine for nausea will give Morphine IV. History and Physical, date of service [DATE] 9:35 p.m. admission date [DATE]. History of hypertension, dementia, with repeated falls presented to the emergency room (ER) from . (nursing home) reported by nursing home staff after they were shoved by another resident and lost consciousness approximately several minutes. When arrived in ER, patient was vomiting uncontrollably as soon (Resident #3) arrived via EMS. In the ER, patient's CT showed traumatic brain injury with subdural and subarachnoid hemorrhage. Patient is an assault and trauma patient. Daughter who is a trauma nurse is at bedside and wants (Resident #3) to be comfortable knowing their poor prognosis and likelihood of (Resident #3) coming out of this injury. (Resident #3) is hypoxic and already aspirated which would cause (Resident #3) to develop worsening respiratory distress. Palliative consulted and agreed to see the patient in consult. Will admit to (hospital) for comfort care. CT scan of the brain completed [DATE]. Impression: BRAIN: 1. Right occipitoparietal calvarial fracture. 2. Subdural hematoma involving the cerebellar tentorium bilaterally, greater on the right, with extension on the right inferiorly in the posterior fossa. There is mild mass effect exerted upon the right cerebellar hemisphere. 3. Hemorrhagic parenchymal contusion in the right cerebellar hemisphere. 4. Multifocal subarachnoid hemorrhage. History and Physical date of service [DATE] 5:03 p.m., Patient was admitted to the floor for intracranial hemorrhage due to injury, started on Phenobarbital for possible seizures, placed on comfort care and was ordered Dilaudid 0.5 every 2 hours as needed for pain. Hospice was consulted and hospice saw patient today and was admitted to inpatient hospice care. Discharge summary signed by the provider at the hospital on [DATE] at 3:54 p.m. admission Date [DATE]. Date of Discharge [DATE]. Discharge Diagnoses: Principal Problem: Intracranial hemorrhage following injury. Active Problems: Subarachnoid hemorrhage, subdural hemorrhage, closed fracture of occipital bone with routine healing, assault, scalp contusion, acute respiratory failure with hypoxia, and aspiration pneumonia of both lower lobes due to vomit. Resident #2's diagnoses included, but were not limited to, unspecified dementia unspecified severity with other behavioral disturbances, unspecified dementia severe with agitation, brief psychotic disorder, and bipolar disorder. Resident #2's quarterly MDS assessment with an ARD of [DATE] coded this resident as having problems with long- and short-term memory, and was severely impaired in cognitive skills for daily decision making. Resident #2 was not coded as using a mobility device. An excerpt from Resident #2's CCP read: Requires assist with some ADL's. Ambulates AD LIB {At Liberty} with supervision. Interventions included, assist with ADL's as needed. Alert and oriented to person. Limited mental abilities due to dementia, confusion, and agitation noted. Interventions included, allow rest breaks between activities, assist to get to preferred activities, provide diversional activities. Alert with confusion noted, communicates verbally with clear speech, usually understood and usually understands, no hearing problems, vision is adequate. Has a diagnosis of psychotic disorder, dementia, bipolar disorder. Resides in a locked memory care unit and is known to pace at times. Interventions included, Social Worker to visit as needed, meds/labs as ordered, pharmacy reviews, explain procedures prior to giving care, approach in a calm manner, reorient with care and as needed, if becomes agitated allow time to calm down before continuing/giving care, and provide a calm environment. Resident #2 was receiving the following medications at the time of the incident, [DATE]. Donepezil, and Rosuvastatin. Resident #2 was evaluated and medically cleared at a local hospital and returned to the facility. Resident #2 was placed on 1:1 upon their return. Resident #2 was assessed by the FNP on [DATE] and was placed on Seroquel 12.5 mg at bedtime. On [DATE] the provider discontinued the residents Gabapentin, added Depakote, increased the Seroquel to 25 mg every 12 hours for psychosis, and ordered Alprazolam twice a day as needed for agitation after speaking with the residents spouse. On [DATE] the provider discontinued Resident #2's 1:1 beginning [DATE] and started every 15-minute checks for 72 hours then every 2-hour checks for 72 hours. On [DATE] at 10:45 a.m., a meeting was conducted with the DON, Administrator, Nurse Consultant, and ADON. The DON stated that this unit had 35 residents and was staffed with 1 LPN and 3 C.N.A.'s at the time of the incident. The nurse and 2 C.N.A.'s were at the nurses station charting. The third C.N.A. was at the other end of the hall away from the room where the residents were found. There were no staff actively monitoring Resident #2, or the the other residents in the vicinity of the incident. No further information regarding the incident was presented prior to the exit conference.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, clinical record review, and during the course of a complaint investigation, facility staff failed to ensure the resident environment remained as free of accident hazards related to call light cord availability for 1 of 27 residents, Resident #121 and failed to include investigation of an elopement with identifying how the resident was able to exit the building for one (1) of 27 sampled current residents (Resident #64). The findings included: 1. For Resident #121, the facility staff failed to remove the resident's call light cord following three separate incidents in which the resident had the call light cord wrapped around their neck. Two incidents resulted in transfer to a higher level of care following incidents occurring on 2/04/21 and 4/11/21. In the 5/1/21 attempt, the resident was found in room laying in bed with eyes closed with call light tied tightly around neck. The resident was turning blue and when released and untied call light cord, resident stated (he/she) wished to die. This is harm. Resident #121's diagnosis list indicated diagnoses, which included, but not limited to Mood Disorder due to Known Physiological Condition, Schizoaffective Disorder Unspecified, Major Depressive Disorder Recurrent Unspecified, Unspecified Dementia with Behavioral Disturbance, Dysphagia following Unspecified Cerebrovascular Disease, Vitamin B12 Deficiency Anemia Unspecified, and Type 2 Diabetes Mellitus with Diabetic Neuropathy Unspecified. The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 4/02/21 assigned the resident a BIMS (brief interview for mental status) score of 3 out of 15 in section C, Cognitive Patterns. Resident #121 was coded as requiring supervision only for eating, extensive assistance with bed mobility, dressing, personal hygiene, and being totally dependent in transfers. On 5/04/21 at approximately 2:45 pm surveyor observed Resident #121 sitting up in a reclining chair in the common area with other residents watching television. Surveyor introduced self and asked the resident how they were doing, Resident #121 immediately responded depressed. The resident further stated I'd rather be dead and I pray every day that I will die. The resident had a hand-held looped strap with jingle bells attached within reach, surveyor asked what the bells were for and resident stated to get the nurses when I need them. On 5/04/21 at 6:34 pm, surveyor again spoke with the resident in the presence of Surveyor #2 and asked the resident if this surveyor could look at their neck. Resident #121 stated what's wrong with my neck, oh I tried to choke myself and resident further stated (he/she) turned it loose when it started to hurt. Resident then became tearful and stated they were tired of living. A nursing progress note dated 2/04/21 8:48 pm states this nurse was notified by cna (certified nursing assistant) when (he/she) went in to answer call bell call bell was pulled out of the wall and was laying behind and across res (resident) neck when asked about this res stated (he/she) didn't know it was that way. A subsequent nursing progress note dated 2/04/21 9:06 pm states this nurse went in to talk to res about (him/her) going to ER where (he/she) had call bell around neck res stated (he/she) didn't want to hurt (himself/herself) that (he/she) didn't know it was that way I explained to res were [sp] (he/she) had previously said (he/she) wanted to hurt (himself/herself) that (he/she) needs to go to ER res stated (he/she) didn't even remember saying that that I'm libel to say anything just because I say it doesn't mean I need it. Resident #121 was transported to the local ER and admitted on [DATE]. The (hospital name omitted) Discharge summary dated [DATE] states in part, [AGE] year-old (male/female) brought in for suspected suicidal intent. The nursing home reports that they found (him/her) with (his/her) nurse call light cord wrapped around (his/her) neck. The patient states that (he/she) does not remember this nor does (he/she) remember any intent to hurt (himself/herself). (He/she) admits to being depressed but states (he/she) has no intention of harming (himself/herself). In the ER (he/she) was found to have acute blood loss anemia with AKI (acute kidney injury) with UTI (urinary tract infection). (He/she) was admitted to the ICU with one-to-one; Crisis was consulted and initially recommended (he/she) go back to (facility name omitted) that can consult psychiatry NP (nurse practitioner), but (facility name omitted) declined. Today (he/she) was coordinate [sp] a bed with (facility name omitted) for inpatient psych, but require [sp] COVID 19 was positive today, after being negative (antigen and 4plex 2/05/21). Nursing home was notified and stated that patient had previously been COVID positive November 6th. Because of new COVID positive status patient was transferred to (facility name omitted). Patient is not able to make (his/her) own medical decisions with (his/her) confused status, continued suicidal ideations/depression/dementia. Resident #121's Physician Discharge Summary from (facility name omitted) dated 2/11/21 states in part, Patient was also seen by psychiatry. (He/she) is still actively suicidal/homicidal. (He/she) should continue full psych precautions; Patient is now medically stable for discharge. I have discussed with hospitalist at (facility name omitted) who agrees to accept patient in transfer and will assist in getting patient to (facility name omitted) inpatient psych as previously planned. Resident #121 was admitted to (facility name omitted) for inpatient psych care on 2/13/21 and discharged on 2/27/21. Surveyor requested the resident's clinical records on 5/10/21, however, as of 5/18/21 the records had not been received. Resident #121 was readmitted to the facility on [DATE] following inpatient psychiatric care at (facility name omitted). A nursing progress note dated 4/11/21 7:46 pm states this nurse was setting at desk was told by cna that res roommate had told (him/her) that res had put call bell around (his/her) neck when this nurse spoke with res (he/she) stated (he/she) was trying to kill herself but (he/she) stopped when it started to hurt. Addendum dated 4/11/21 9:44 pm states Upon assessment of res o [sp] injuries noted by this nurse. Resident #121 was transported to the local ER at 7:58 pm. The After Visit Summary from (facility name omitted) Emergency Department dated 4/11/21 states in part, Follow-up with behavioral medicine on an outpatient basis. Maintain suicidal precautions. Surveyor requested the resident's clinical records from (facility name omitted) emergency department on 5/05/21, however, as of 5/18/21 the records had not been received. A nursing progress note dated 4/11/21 11:58 pm states res back from (facility name omitted) ER on ly order is verbal order from hospital to follow up with (name omitted) on 4/12/21 res in bed with eyes closed. Resident #121 was seen by the psychiatric NP (nurse practitioner) the following day on 4/12/21, the progress note states in part, Per nursing patient had made a suicide attempt by wrapping call bell around (his/her) neck and was sent out to E.R. r/t suicide attempt and was returned back to the facility from (facility name omitted) with a diagnosis of memory problem. Subjective: Lying in bed (patient currently constant observation by CNA). Discussed with patient (his/her) attempt at suicide yesterday. Pt verbalized, 'I don't remember that, I'm glad I don't.' Denies thoughts of self harm/suicidal ideations. Endorses depressed; denies anxiety. Recommendations include continue constant observation. Resident #121 was seen by the licensed psychologist via telehealth on 4/14/21, progress note from the visit states in part, Approached Resident with progress note report of 4/11/21, 7:46 pm, finding Resident with call bell cord around (his/her) neck. However, no evidence of intent or plan or strength to tighten cord. When confronted, Resident said (he/she) had no recall of doing that (He/she) said (he/she) still wanted to die but denied intent or plan It is requested that with each shift change, a staff person be appointed, who would spend 10 mins. for a one on one with Resident for positive attention and support. Incident of 4/11 appears to be a suicide gesture w/o intent or plan to carry out. Resident #121 was seen by the licensed psychologist on 4/28/21 via telehealth and progress note states in part, Staff consult prior to session indicated that Resident keeps saying 'I don't want to live' . at end of session (he/she) started to cry saying (he/she) could not do it and (he/she) did not want to live. Resident has expressed in prior session (he/she) has no plan and no way or strength to do it. What Resident is expressing is not suicidal ideation but no will to live. Current risk factor for suicidal/self injury was documented as none. On 5/06/21 at 6:58 am, surveyor spoke with LPN (licensed practical nurse) #1 who was caring for Resident #121 on 2/04/21 and 4/11/21 during the aforementioned incidents with the call bell cord. LPN #1 stated that in February, the CNA found the resident with the call light cord looped around their neck and originally the resident said (he/she) wanted to hurt (himself/herself) but then said (he/she) did not say that. LPN #1 stated that the second time (he/she) put the call light cord around (his/her) neck the roommate told the CNA and the CNA came and got them. LPN #1 stated the resident had already taken the cord off and said it started to hurt and (he/she) took it off. Surveyor asked LPN #1 what was done each time to prevent it from happening again and LPN #1 responded CNAs came in both times and did one on one care I think for a couple days. A nursing progress note dated 5/01/21 12:33 am states in part Late note for 2158 (9:58 pm): Resident was found in room laying in bed with eyes closed with call light tied tightly around neck. Resident was turning blue and when released and untied call light cord, resident stated (he/she) wished to die and that I had not found (him/her) so soon. Vitals were taken B/P 118/76, Pulse 84, O2 96, Resp 18, Temp 98.4. Placed aide 1 on 1 while calling transport and notifying doctor and family. Subsequent progress note dated 5/01/21 12:39 am states in part late note for 2232 (10:32 pm) transport arrived .As resident was leaving (he/she) stated (he/she) didn't remember tying call light cord around (his/her) neck and (he/she) didn't know why (he/she) would do something like that. The After Visit Summary from (facility name omitted) Emergency Department dated 4/30/21 states in part, Patient is not truly 'suicidal' due to the severity of (his/her) dementia. ((He/she) can't really decide to commit suicide). And (he/she) is so disabled (bed bound) that (he/she) is not able to act on a suicidal impulse even if (he/she) did have one. There is no known treatment for (his/her) acting out and having another psych evaluation and treatment would not do (him/her) any good. (He/she) does not need protective custody at a psych facility to prevent suicide. There is just no value in this. Please remove the call cord from (his/her) reach. (Facility name omitted) is a safe and good place for (him/her) to stay. Surveyor requested the resident's clinical records from (facility name omitted) emergency department on 5/05/21, however, as of 5/18/21 the records had not been received. Nursing progress note dated 5/01/21 9:11 am states in part Resident back from ER for EVAL with no new orders noted. Resident denies suicidal ideations at this time. Placed on 1:1 observation and given hand bell to ring when needing assistance. Educated on use of hand bell and Resident states 'I'm not too far gone to understand how to use a bell'. On 5/10/21 at 1:54 pm, surveyor spoke with RN #3 who was Resident #121's nurse on 4/30/21. RN #3 stated Resident #121's call light was on and they went to answer it and found resident with the call light cord wrapped around (his/her) neck 2 to 3 times and had to get help to remove it. RN #3 stated the resident's neck had a reddish bruise place where the call light clip was in their neck and neck appeared like if you wear a rubber band on your wrist. RN #3 stated the call light cord became unplugged from the wall and caused the light to come on. RN #3 stated that after the fact I was told (he/she) had done it before. Resident #121's current care plan includes the problem area stating in part has hx (history) of suicidal ideations, care plan approaches include in part, monitor safety needs, 1 on 1 monitoring/sitter with res during times of crisis, hand call bell, In room visits 2x day by staff. On 5/05/21 at approximately 3:30 pm, surveyor spoke with the MDS nurse who stated they were the manager on Saturday, 5/01/21, and they gave the resident the hand bells that day and added it to the care plan. On 5/04/21 at approximately 6:40 pm, this surveyor and Surveyor #2 observed Resident #121's room, the resident's bed was positioned with the left side against the wall with the bed's electrical cord plugged into an outlet on the left side of the bed approximately two feet above the mattress. If the resident were in the bed, the electrical cord and outlet would be within arm's reach. Surveyor did not observe the resident in the bed on 5/04/21 during the first day of the survey. Both call light cords were plugged into the call light port on the wall and cords were lying on the other empty bed in the resident's room. The resident's over bed light had a string attached to turn the light on and off. At 6:55 pm Surveyor #2 discussed the room observations with the administrator, assistant administrator, DON (director of nursing), and nurse consultant #1. The following morning, on 5/05/21 at approximately 8:00 am, surveyor entered the resident's room and observed a maintenance staff member in the room. Maintenance worker stated they were moving the bed outlet and removing the call light from the room because the resident was suicidal and they needed to get all the cords out. Resident #121 was not in the room during this time. At 1:06 pm, surveyor observed the resident's room and noted the outlet on the left side of the bed had been replaced with a solid plate covering it and the bed was now plugged into an outlet to the right side of the bed's headboard with a cord cover covering over the cord going down the wall. The call light cords were removed and the call light plug in ports were covered with a solid plate. The string attached to the over bed light had been removed. On 5/06/21 at 1:50 pm, surveyor spoke with the administrator, DON, and the social worker and discussed precautions that were taken following each incident with the call bell cord. The DON stated that there were no recommendations from (facility name omitted) for suicide precautions when Resident #121 was readmitted to the facility. The administrator stated after the second incident, the resident was sent to the ER and the ER decided that (he/she) did not need evaluation and the facility put (him/her) on one to one checks until (he/she) was seen by (name omitted) psych nurse practitioner and (name omitted) psych services. The administrator stated the one to one checks were continued until the nurse practitioner and psych services decided to discontinue. The administrator further stated that after the third time (he/she) was sent to the ER and sent back, the call bell cord was taken away. The administrator stated that yesterday they took the outlet, put on a blank cover and wire molded the bed's electrical cord to the wall and removed the cord from the resident's radio and replaced it with batteries. On 5/10/21 at 1:45 pm, surveyor spoke with the administrator and DON and asked why Resident #121's call light cord was not removed prior to the third incident. The DON stated that following the second incident it was something that was missed and I didn't see it based on what the ER was saying. Surveyor requested and received the facility policy and procedure entitled, Suicidal Precautions which states in part: Policy The resident who requires closer observation because of possible suicide are: b. Depressed residents e. Confused residents f. Those with a history of previous suicide attempts g. Those who have expressed a wish to die From a nursing standpoint, suicide must always be kept in mind when caring for the resident with organic brain syndrome. Any attempt at suicide, any talk of death, uselessness of life or attempts (regardless of how minor), are considered serious and must be reported and written on the resident's chart. Procedures 2. Maintain safe environment by removing sharp objects, cleaning solutions etc. 3. Careful documentation of subjective/objective assessment in Clinical Record. On 5/12/21 at 12:30 pm during a meeting with the administrator, DON, nurse consultant #1, and nurse consultant #2 surveyor discussed the concern of Resident #121's call bell cord not being removed following two separate incidents of the resident wrapping the call light cord around their neck. No further information regarding this issue was presented to the survey team prior to the exit conference on 5/12/21. This is a complaint deficiency. 2. The facility's response to Resident #64's elopement failed to include documentation of an investigation into how the resident was able to exit the building without facility staff being aware. Resident #64's minimum data set (MDS) assessment, with an assessment reference date (ARD) of 3/1/21, had the resident assessed as being able to make self understood and as being able to understand others. Resident #64's brief interview for mental status (BIMS) summary score was documented as six (6) out of 15. Resident #64 was documented as requiring limited assistance with bed mobility, transfers, toilet use, and personal hygiene. Resident #64 was diagnosed with traumatic brain injury (TBI). Resident #64's clinical documentation included a nursing note dated 4/24/21 at 12:55 a.m. that appeared to be a late entry for 4/23/21 at 10:45 p.m. This note included the following information: A nurse from North Side Hall called this nurse asked if I had all my patients on the floor, I checked on all my patients everyone was present and accounted for with the exception of this (patient). The nurse stated (local ambulance service name omitted) seen a male wearing a hat and jacket walking down the hill past the (hospital) thought (the patient) might be a patient here (at) this facility. Two nurses drove down the road together picked (patient) up (at) (local church name omitted) (patient) transported back to this facility no acute distress noted. Documentation indicated Resident #64 was immediately placed on a secure unit in the facility and was also placed on 'every 15 minute' checks. On 5/11/21 at 10:22 a.m., the facility's Administrator, Director of Nursing (DON), and Nurse Consultant #2 was asked about the availability of recordings from facility security cameras. It was reported the facility does not have security cameras. On 5/11/21 at 4:25 p.m., the facility's Acting Maintenance Director (AMD) was interviewed about the facility's door alarms. The AMD reported that all doors exiting the building, with the exception of the front doors, had an alarm that when triggered would sound until someone turned the alarm off. The AMD explained that there was a door, prior to residents accessing the front doors, that when triggered would sound until someone turned the alarm off. On 5/12/21 at 11:13, the Assistant Administrator provided the survey team with staff members' written statements obtained in response to Resident #64's aforementioned elopement. No information was provided to indicate the facility's doors were checked after the elopement to evaluate the functioning of the door alarms. The survey team was provided documentation that showed the routine door checks were completed on 4/23/21 and 4/26/21; this documentation did not include the times of when the facility's doors were checked. No evaluation of the door alarm system was documented as part of the investigation into this event. The written statements provided by facility staff working at the time Resident #64 eloped on 4/23/21 addressed the discovery of the resident missing and the return of the resident. The written statements did not address an investigation into how Resident #64 was able to exit the building without staff being aware. The facility policy titled Wandering and Elopement (with a revision date of March 2019) included the following information: The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. This policy focused on the resident specific prevention of and response to an elopement; this policy did not address the investigation of facility factors that could have contributed to an elopement. The facility policy titled INCIDENT AND ACCIDENT REPORT (no date was found on this document) included the following information: - The Incident and Accident Report is completed for all unexplained bruises or abrasions, all accidents or incidents where there is injury, allegations of theft and abuse registered by residents, visitors or family members and resident altercations and associates. - Incident is defined as any happening, not consistent with the routine operation of the facility that does not result in bodily injury or property damage. - An investigation must be initiated immediately and the incident must be reported within 24 hours of the discovery to the OLC and APS within 5 days. The survey team had a meeting with the facility's Administrator, Director of Nursing, Nurse Consultant #1, and Nurse Consultant #2, on 5/12/21 at 12:27 p.m. During this meeting, the failure of facility staff's investigation, of this event, to attempt to address how the resident was able to exit the building without facility staff knowledge was discussed. No additional information related to this issue was provided to the survey team.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, and clinical record review, the facility staff failed to coordinate necessary behavioral health care services to attain the highest practicable physical, mental, and psychological well-being for 1 of 27 residents, Resident #121. The finding included: For Resident #121, facility staff failed coordinate behavioral health care services between the resident's guardian, facility staff, physician, and behavioral health care services following suicidal ideations resulting in three separate suicide attempts. In one of the attempts, The resident was found in room laying in bed with eyes closed with call light tied tightly around neck. The resident was turning blue and when released and untied call light cord, resident stated (he/she) wished to die. This is harm. Resident #121's diagnosis list indicated diagnoses, which included, but not limited to Mood Disorder due to Known Physiological Condition, Schizoaffective Disorder Unspecified, Major Depressive Disorder Recurrent Unspecified, Unspecified Dementia with Behavioral Disturbance, Dysphagia following Unspecified Cerebrovascular Disease, Vitamin B12 Deficiency Anemia Unspecified, and Type 2 Diabetes Mellitus with Diabetic Neuropathy Unspecified. The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 4/02/21 assigned the resident a BIMS (brief interview for mental status) score of 3 out of 15 in section C, Cognitive Patterns. Resident #121 was coded as requiring supervision only for eating, extensive assistance with bed mobility, dressing, personal hygiene, and being totally dependent in transfers. In section I, Active Diagnoses, Resident #121 was coded for the diagnoses of anxiety disorder, depression, schizophrenia, and schizoaffective disorder unspecified. On 5/04/21 at approximately 2:45 pm surveyor observed Resident #121 sitting up in a reclining chair in the common area with other residents watching television. Surveyor introduced self and asked the resident how they were doing, Resident #121 immediately responded depressed. The resident further stated I'd rather be dead and I pray every day that I will die. The resident had a hand-held looped strap with jingle bells attached within reach, surveyor asked what the bells were for and resident stated to get the nurses when I need them. On 5/04/21 at 6:34 pm, surveyor again spoke with the resident in the presence of Surveyor #2 and asked the resident if this surveyor could look at their neck. Resident #121 stated what's wrong with my neck, oh I tried to choke myself and resident further stated (he/she) turned it loose when it started to hurt. Resident then became tearful and stated they were tired of living. A nursing progress note dated 2/04/21 8:48 pm states this nurse was notified by cna (certified nursing assistant) when (he/she) went in to answer call bell call bell was pulled out of the wall and was laying behind and across res (resident) neck when asked about this res stated (he/she) didn't know it was that way. A subsequent nursing progress note dated 2/04/21 9:06 pm states this nurse went in to talk to res about (him/her) going to ER where (he/she) had call bell around neck res stated (he/she) didn't want to hurt (himself/herself) that (he/she) didn't know it was that way I explained to res were [sp] (he/she) had previously said (he/she) wanted to hurt (himself/herself) that (he/she) needs to go to ER res stated (he/she) didn't even remember saying that that I'm libel to say anything just because I say it doesn't mean I need it. Resident #121 was transported to the local ER and admitted on [DATE]. The (hospital name omitted) Discharge summary dated [DATE] states in part, [AGE] year-old (male/female) brought in for suspected suicidal intent. The nursing home reports that they found (him/her) with (his/her) nurse call light cord wrapped around (his/her) neck. The patient states that (he/she) does not remember this nor does (he/she) remember any intent to hurt (himself/herself). (He/she) admits to being depressed but states (he/she) has no intention of harming (himself/herself). In the ER (he/she) was found to have acute blood loss anemia with AKI (acute kidney injury) with UTI (urinary tract infection). (He/she) was admitted to the ICU with one-to-one; Crisis was consulted and initially recommended (he/she) go back to (facility name omitted) that can consult psychiatry NP (nurse practitioner), but (facility name omitted) declined. Today (he/she) was coordinate [sp] a bed with (facility name omitted) for inpatient psych, but require [sp] COVID 19 was positive today, after being negative (antigen and 4plex 2/05/21). Nursing home was notified and stated that patient had previously been COVID positive November 6th. Because of new COVID positive status patient was transferred to (facility name omitted). Patient is not able to make (his/her) own medical decisions with (his/her) confused status, continued suicidal ideations/depression/dementia. Resident #121's Physician Discharge Summary from (facility name omitted) dated 2/11/21 states in part, Patient was also seen by psychiatry. (He/she) is still actively suicidal/homicidal. (He/she) should continue full psych precautions; Patient is now medically stable for discharge. I have discussed with hospitalist at (facility name omitted) who agrees to accept patient in transfer and will assist in getting patient to (facility name omitted) inpatient psych as previously planned. Resident #121 was admitted to (facility name omitted) for inpatient psych care on 2/13/21 and discharged on 2/27/21. Surveyor requested the resident's clinical records on 5/10/21, however, as of 5/18/21 the records had not been received. Resident #121 was readmitted to the facility on [DATE] following inpatient psychiatric care at (facility name omitted). A nursing progress note dated 4/11/21 7:46 pm states this nurse was setting at desk was told by cna that res roommate had told (him/her) that res had put call bell around (his/her) neck when this nurse spoke with res (he/she) stated (he/she) was trying to kill herself but (he/she) stopped when it started to hurt. Addendum dated 4/11/21 9:44 pm states Upon assessment of res o [sp] injuries noted by this nurse. Resident #121 was transported to the local ER at 7:58 pm. The After Visit Summary from (facility name omitted) Emergency Department dated 4/11/21 states in part, Follow-up with behavioral medicine on an outpatient basis. Maintain suicidal precautions. Surveyor requested the resident's clinical records from (facility name omitted) emergency department on 5/05/21, however, as of 5/18/21 the records had not been received. A nursing progress note dated 4/11/21 11:58 pm states res back from (facility name omitted) ER on ly order is verbal order from hospital to follow up with (name omitted) on 4/12/21 res in bed with eyes closed. Resident #121 was seen by the psychiatric NP the following day on 4/12/21, the progress note states in part, Per nursing patient had made a suicide attempt by wrapping call bell around (his/her) neck and was sent out to E.R. r/t suicide attempt and was returned back to the facility from (facility name omitted) with a diagnosis of memory problem. Subjective: Lying in bed (patient currently constant observation by CNA). Discussed with patient (his/her) attempt at suicide yesterday. Pt verbalized, 'I don't remember that, I'm glad I don't.' Denies thoughts of self harm/suicidal ideations. Endorses depressed; denies anxiety. Recommendations include continue constant observation. On 5/06/21 at 1:50 pm, surveyor spoke with the administrator, DON (director of nursing), and the social worker and asked how long did the psychiatric NP want Resident #121 to remain under constant observation, the DON stated (he/she) didn't specify. Surveyor attempted to contact the psychiatric NP on 5/05/21, 5/06/21, and 5/10/21; however, the voice mailbox was full each time and surveyor was unable to leave a message. Resident #121 was seen by the licensed psychologist via telehealth on 4/14/21, progress note from the visit states in part, Approached Resident with progress note report of 4/11/21, 7:46 pm, finding Resident with call bell cord around (his/her) neck. However, no evidence of intent or plan or strength to tighten cord. When confronted, Resident said (he/she) had no recall of doing that (He/she) said (he/she) still wanted to die but denied intent or plan It is requested that with each shift change, a staff person be appointed, who would spend 10 mins. for a one on one with Resident for positive attention and support. Incident of 4/11 appears to be a suicide gesture w/o intent or plan to carry out. Resident #121 was seen by the licensed psychologist on 4/28/21 via telehealth and progress note states in part, Staff consult prior to session indicated that Resident keeps saying 'I don't want to live' . at end of session (he/she) started to cry saying (he/she) could not do it and (he/she) did not want to live. Resident has expressed in prior session (he/she) has no plan and no way or strength to do it. What Resident is expressing is not suicidal ideation but no will to live. Current risk factor for suicidal/self injury was documented as none. On 5/06/21 at 6:58 am, surveyor spoke with LPN (licensed practical nurse) #1 who was caring for Resident #121 on 2/04/21 and 4/11/21 during the aforementioned incidents with the call bell cord. LPN #1 stated that in February, the CNA found the resident with the call light cord looped around their neck and originally the resident said (he/she) wanted to hurt (himself/herself) but then said (he/she) did not say that. LPN #1 stated that the second time (he/she) put the call light cord around (his/her) neck the roommate told the CNA and the CNA came and got them. LPN #1 stated the resident had already taken the cord off and said it started to hurt and (he/she) took it off. Surveyor asked LPN #1 what was done each time to prevent it from happening again and LPN #1 responded CNAs came in both times and did one on one care I think for a couple days. A nursing progress note dated 5/01/21 12:33 am states in part Late note for 2158 (9:58 pm): Resident was found in room laying in bed with eyes closed with call light tied tightly around neck. Resident was turning blue and when released and untied call light cord, resident stated (he/she) wished to die and that I had not found (him/her) so soon. Vitals were taken B/P 118/76, Pulse 84, O2 96, Resp 18, Temp 98.4. Placed aide 1 on 1 while calling transport and notifying doctor and family. Subsequent progress note dated 5/01/21 12:39 am states in part late note for 2232 (10:32 pm) transport arrived .As resident was leaving (he/she) stated (he/she) didn't remember tying call light cord around (his/her) neck and (he/she) didn't know why (he/she) would do something like that. The After Visit Summary from (facility name omitted) Emergency Department dated 4/30/21 states in part, Patient is not truly 'suicidal' due to the severity of (his/her) dementia. ((He/she) can't really decide to commit suicide). And (he/she) is so disabled (bed bound) that (he/she) is not able to act on a suicidal impulse even if (he/she) did have one. There is no known treatment for (his/her) acting out and having another psych evaluation and treatment would not do (him/her) any good. (He/she) does not need protective custody at a psych facility to prevent suicide. There is just no value in this. Please remove the call cord from (his/her) reach. (Facility name omitted) is a safe and good place for (him/her) to stay. Surveyor requested the resident's clinical records from (facility name omitted) emergency department on 5/05/21, however, as of 5/18/21 the records had not been received. Nursing progress note dated 5/01/21 9:11 am states in part Resident back from ER for EVAL with no new orders noted. Resident denies suicidal ideations at this time. Placed on 1:1 observation and given hand bell to ring when needing assistance. Educated on use of hand bell and Resident states 'I'm not too far gone to understand how to use a bell'. On 5/10/21 at 1:54 pm, surveyor spoke with RN #3 who was Resident #121's nurse on 4/30/21. RN #3 stated Resident #121's call light was on and they went to answer it and found resident with the call light cord wrapped around (his/her) neck 2 to 3 times and had to get help to remove it. RN #3 stated the resident's neck had a reddish bruise place where the call light clip was in their neck and neck appeared like if you wear a rubber band on your wrist. RN #3 stated the call light cord became unplugged from the wall and caused the light to come on. RN #3 stated that after the fact I was told (he/she) had done it before. Resident #121's current care plan includes the problem area stating in part has hx of suicidal ideations, care plan approaches include in part, monitor safety needs, 1 on 1 monitoring/sitter with res during times of crisis, hand call bell, In room visits 2x day by staff. On 5/05/21 at approximately 3:30 pm, surveyor spoke with the MDS nurse who stated they were the manager on Saturday, 5/01/21, and they gave the resident the hand bells that day and added it to the care plan. Resident #121 was seen for their weekly telehealth visit with the licensed psychologist on 5/05/21, the progress note states in part, (He/she) added 'I'm depressed out of my mind. I don't want to live' .(He/she) continues to express low will to live in terms of praying for god to take (him/her), which is differentiated from active suicidal ideation, intent, or plan at this time. The progress note does not include any documentation of the incident on 4/30/21 when the resident wrapped the call bell cord around their neck. Surveyor could not locate documentation that the psychologist was notified of the 4/30/21 incident. Surveyor attempted to contact the licensed psychologist by leaving voice messages on 5/06/21 and 5/10/21, however, as of survey exit on 5/12/21 the calls had not been returned. Surveyor was unable to locate documentation in the resident's clinical record of the psychiatric NP being notified following the 4/30/21 incident. The last documented progress note from the psychiatric NP was dated 4/28/21. On 5/04/21 at approximately 6:40 pm, this surveyor and Surveyor #2 observed Resident #121's room, the resident's bed was positioned with the left side against the wall with the bed's electrical cord plugged into an outlet on the left side of the bed approximately two feet above the mattress. If the resident were in the bed, the electrical cord and outlet would be within arm's reach. Surveyor did not observe the resident in the bed on 5/04/21 during the first day of the survey. Both call light cords were plugged into the call light port on the wall and cords were lying on the other empty bed in the resident's room. The resident's over bed light had a string attached to turn the light on and off. At 6:55 pm Surveyor #2 discussed the room observations with the administrator, assistant administrator, DON, and nurse consultant #1. The following morning, on 5/05/21 at approximately 8:00 am, surveyor entered the resident's room and observed a maintenance staff member in the room. Maintenance worker stated they were moving the bed outlet and removing the call light from the room because the resident was suicidal and they needed to get all the cords out. Resident #121 was not in the room during this time. At 1:06 pm, surveyor observed the resident's room and noted the outlet on the left side of the bed had been replaced with a solid plate covering it and the bed was now plugged into an outlet to the right side of the bed's headboard with a cord cover covering over the cord going down the wall. The call light cords were removed and the call light plug in ports were covered with a solid plate. The string attached to the over bed light had been removed. On 5/06/21 at 1:50 pm, surveyor spoke with the administrator, DON (director of nursing), and the social worker and discussed precautions that were taken following each incident with the call bell cord. The DON stated that there were no recommendations from (facility name omitted) for suicide precautions when Resident #121 was readmitted to the facility. The administrator stated after the second incident, the resident was sent to the ER and the ER decided that (he/she) did not need evaluation and the facility put (him/her) on one to one checks until (he/she) was seen by (name omitted) psych nurse practitioner and (name omitted) psych services. The administrator stated the one to one checks were continued until the nurse practitioner and psych services decided to discontinue. The administrator further stated that after the third time (he/she) was sent to the ER and sent back, the call bell cord was taken away. The administrator stated that yesterday they took the outlet, put on a blank cover and wire molded the bed's electrical cord to the wall and removed the cord from the resident's radio and replaced it with batteries. On 5/10/21 at 1:45 pm, surveyor spoke with the administrator and DON and asked why Resident #121's call light cord was not removed prior to the third incident. The DON stated that following the second incident it was something that was missed and I didn't see it based on what the ER was saying. Surveyor requested and received the facility policy and procedure entitled Suicidal Precautions which states in part: Policy The resident who requires closer observation because of possible suicide are: b. Depressed residents e. Confused residents f. Those with a history of previous suicide attempts g. Those who have expressed a wish to die From a nursing standpoint, suicide must always be kept in mind when caring for the resident with organic brain syndrome. Any attempt at suicide, any talk of death, uselessness of life or attempts (regardless of how minor), are considered serious and must be reported and written on the resident's chart. Procedures 2. Maintain safe environment by removing sharp objects, cleaning solutions etc. 3. Careful documentation of subjective/objective assessment in Clinical Record. On 5/06/21 at 2:59 pm, surveyor spoke with the administrator and asked if the facility had discussed the resident's current situation with the resident's physician or the medical director for assistance, administrator stated maybe the DON has but I haven't. At 3:15 pm, the DON stated they had just spoken with the medical director and they are okay with the resident being here now but if it happens again and the ER will not provide services then discharge (him/her). A progress note written by the DON dated 5/06/21 3:16 pm states This nurse spoke with (name omitted), Medical Director of this facility in regards to resident's multiple discharges to ER d/t resident being found with cord wrapped around resident's neck. (Name omitted) advised that at this time (he/she) is comfortable with resident being in facility, however, if resident is discharged to ER from this facility for this or any other attempt to harm self and ER does not provide crisis services for resident that (name omitted) will request discharge from this facility d/t facility not being able to provide the extra services resident seems to need. Surveyor could not locate documentation of physician notification following the resident's return from the ER on [DATE] without a mental health evaluation. Surveyor could not locate documentation that the resident's physician had assessed (him/her) following the incident on 4/30/21. On 5/10/21 at approximately 3:30 pm, surveyor spoke with Resident #121's physician via telephone. The physician stated they had been in the facility in the last 2 weeks, they stated they were aware of the three suicide attempts by Resident #121. Physician stated they have a problem with the ER and have no control over them. The physician further stated it is almost impossible to get an appointment with a psychiatrist. Surveyor asked the physician if they feel that Resident #121 is safe in the facility and they stated that's a tough one but it is a guarded yes and overall I think it is. On 5/10/21 at 1:20 pm surveyor spoke with the facility medical director concerning Resident #121's history of suicide attempts. The medical director stated that he was not very familiar with Resident #121 as (he/she) is (name omitted) patient but the facility did notify them when the resident was sent out on 5/01/21. The medical director stated that they do not think the ER called in the crisis team for the resident on 5/01/21. The medical director also stated that it is very unlikely that an outpatient psychiatrist would see (him/her). They also stated that the facility could watch (him/her) carefully, remove things out of reach, continue to see the psychiatric nurse practitioner, and set something up with nursing to check on (him/her). On 5/06/21 at 2:32 pm, surveyor spoke with (name omitted) County Social Services APS (adult protective services) worker who stated they were present at the facility on 5/03/21 concerning the resident's suicide attempts, APS further stated that this is still an open investigation. APS worker stated they spoke to the resident's guardian via phone while onsite at the facility and asked about sending the resident out for further evaluation and the guardian stated the facility was not doing what (name omitted) the psychologist ordered and (he/she) did not want the resident sent out. The guardian also wanted the resident moved out to another facility. APS worker stated the area ombudsman was present during the call with the guardian. On 5/05/21 at 4:41 pm surveyor spoke with the facility social worker who stated the guardian does not want the resident sent out to a psych hospital but did not say why. On 5/06/21 at 9:45 am, surveyor spoke with the guardian listed on the resident's face sheet. Guardian #1 stated (name omitted) County DSS (Department of Social Services) has guardianship of Resident #121 and it includes three DSS employees. Guardian #1 stated the resident has had three suicide attempts and the first time they received conflicting stories and the resident said (he/she) did not do it. Guardian #1 stated they have been in contact with (name omitted), the licensed psychologist who recommended 20 minutes of one to one time each day, Resident #121 does not need to be sent out, they need to know someone cares. Guardian #1 states the psychologist believes the resident is doing this for attention. Guardian #1 stated the resident's guardianship is being changed to (name omitted) and it is currently in the court system. On 5/06/21 at 12:10 pm, surveyor meet with Guardian #1 and Guardian #2 onsite at the facility following their visit with Resident #121. On 5/11/21 at 11:30 am, surveyor spoke with Guardian #3 who stated they were present during the phone conversation between Guardian #1 and (name omitted) County APS when further evaluation of Resident #121 was declined. Guardian #3 stated they are in agreement with Guardian #1's decisions and does not see the reason to send the resident out as (he/she) is not suicidal unless (he/she) truly hurts themselves. Guardian #3 stated the resident is seeking attention and they are trying to follow the advice of the psychologist. On 5/06/21 at 1:50 pm, surveyor spoke with the administrator who stated after the third incident, (name omitted) County APS was onsite at the facility and had behavioral health on the phone willing to evaluate the resident and the guardian refused for (name omitted) behavioral health to evaluate (him/her). Surveyor asked if the facility feels the resident is appropriate to stay in the facility at this time and the administrator stated they are potentially looking at a discharge unless the guardian comes around or the new guardian allows evaluation and right now I think (he/she)'s okay. On 5/12/21 at 10:45 am, surveyor spoke with the administrator and asked why the facility did not contact the guardian to further discuss the need for a mental evaluation with the guardian after his/her refusal was voiced to the (name omitted) County APS worker. The administrator stated APS was the direct liaison and (he/she) said (he/she) did not want the resident sent out and did not want (him/her) in this facility. Surveyor also asked if the facility had spoken with either of the two additional guardians and the DON stated the resident's guardianship is with (name omitted) and if guardianship is shared that's news to us. The resident's face sheet lists Guardian #3 as the second contact with the relationship listed as guardian. Surveyor was unable to locate documentation of physician or medical director notification of the guardian's decision to decline the mental evaluation being offered by (name omitted) County DSS APS. On 5/12/21 at 12:30 pm during a meeting with the administrator, DON, nurse consultant #1, and nurse consultant #2 surveyor discussed the concern of facility failing to follow up and coordinate care decisions related to the resident's suicidal ideations with the guardian, physician, psychiatric NP, behavioral psychologist, or the medical director. No further information was presented to the survey team prior to the exit conference on 5/12/21.