LAUREL COURT

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the failed to ensure that its residents are free of any significant medication error for 1 (CR#1) of 5 residents reviewed for medication administration. CR#1 was ordered to receive 600 MG of Gabapentin in the evening for pain on 10/16/25 and 10/17/25 but was administered 300 MG both evenings by MA B. MA B failed to follow physician orders or consult with a nurse for order clarification. These failures could place residents at risks for increased pain, discomfort, and a diminished quality of life. Findings include:Record review of CR#1's face-sheet reviewed 10/21/25, revealed a seventy-six year old woman who was admitted to the facility on [DATE]. Her admitting diagnoses were a Type II Dens fracture (a break in the odontoid process, the peg-like structure that connects the second vertebra (axis) to the first vertebra (atlas) in the cervical spine), elevated white blood cell count, cervicalgia (pain in the neck region), pain, and adult failure to thrive. Record review of CR#1's Pain Management Team Encounter notes dated 10/16/25 stated that she was AAO x2-3. CR#1 had unspecified pain and treatment goals were directly therapeutic and were incorporated to provide improvement and/or prevention of progression of the condition, while providing a reasonable expectation of recovery. Record Review of CR#1's care plan reviewed 10/21/25, displayed a focus on pain management initiated on 10/16/25. Interventions stated to screen for pain on admission and daily. Assess to determine if experiencing pain. If pain was present, conduct, and document pain assessment particularly location, nature, intensity, and duration of pain. Record review of CR#1's orders dated 10/15/25 documented that CR#1 was to receive: 1. Gabapentin Capsule 300 MG Give 1 capsule by mouth three times a day for nerve pain.2. Gabapentin Capsule 300 MG Give 1 capsule by mouth two times a day for nerve pain equals 600mg for AM and PM doses. Record review of CR#1's MAR dated October 2025 revealed the medications were administered as follows: 1- 300MG Gabapentin capsule by mouth two times a day (a.m. and p.m. doses that equaled 600 MG) for nerve pain. * 10/16/25 at 9:00 a.m. dose was marked administered by MA A *10/16/25 at 9:00 p.m. dose was marked administered by MA B. *10/17/25 at 9:00 a.m. dose was marked administered by MA A*10/17/25 at 9:00 p.m. doses was marked administered by MA B.* 10/18/25 at 9:00 a.m., dose was marked administered by the ADON. 1- 300 MG Gabapentin capsule to be given by mouth three times a day for nerve pain. *10/16/25 at 9:00 a.m. dose was marked administered by MA A, *10/16/25 at 3:00 p.m. and the 9:00 p.m. doses were marked administered by MA B. *10/17/25 at 9:00 a.m. dose was marked administered by MA A*10/17/25 at 3:00 p.m. and the 9:00 p.m. doses were marked administered by MA B*10/18/25 at 9:00 a.m., was marked administered by the ADON. In total, 5 Gabapentin 300 MG capsules should be administered to CR#1 daily and a total of 12 capsules should have been administered from 10/16/25 to 10/18/25 at 9:00 a.m. Record review of CR#1's progress notes on 10/18/25 at 11:42 a.m. inputted by ADON stated CR#1 had a change in condition where she was unresponsive. Nursing observation documented: ADON was called to room due to change in condition. NP notified and orders given to send out via 911 to hospital for further evaluation. Resident left with EMS at 11:54 a.m. via stretcher. In an interview and observation on 10/21/25 at 12:14 p.m., MA A, stated she worked at the facility since 2020 and had stepped into the role as a medication aide in March 2025. She worked from 6 a.m. to 2 p.m. and only remembered giving medications to CR#1 twice. She explained when she gave medication, she would verify the orders by checking the resident's name with the picture, asking the resident to verify their first and last name, and making sure the blister pack matched the orders. MA A took the Surveyor to the medication cart and she reviewed CR #1's orders. She stated she saw there was one order to give 1 tab of 300 MG of Gabapentin 3xs a day and another to give 1 tab of 300 MG of Gabapentin 2xs a day. On her shift of 6 a.m. to 2 p.m., she was ordered to give CR#1 2 capsules of Gabapentin. Reviewing the time stamps in the MAR, she administered this medication on 10/16/25 at 10:34 a.m. and on 10/17/25 at 10:22 a.m. She stated although she saw two separate orders in the MAR, she did not feel like it was inputted by accident, and she followed the orders as written. MA A stated she did not notice any adverse effects or any changes in her behavior. She explained that if she suspected there was an overlap in medications or a discrepancy, she would consult with one of the nurses. Inside the medication cart, there was one bottle of Gabapentin 300 MG filled on 10/15/25 for 60 capsules for CR#1. A blister pack was also found for Gabapentin 300 MG filled on 10/16/25 for 70 capsules. MA A recalled that she administered medication from the Gabapentin bottle initially, but she switched over to the blister pack once it was delivered on 10/17/25. MA A counted the amount of medication remaining from both the pack and the bottle that equaled a total of 130 capsules, 8 capsules 300 MG Gabapentin were missing from the count. In an interview with MA B on 10/21/25 at 12:55 p.m., she stated that she had worked at the facility for 1 year and she worked either the 6-2 a.m. shift or the 2-10 p.m. shift. On 10/16/25 and 10/17/25, she worked the 2-10 p.m. shift. She was familiar with CR#1 and after reviewing the MAR, she confirmed that she administered 300 MG of Gabapentin on 10/16/25 at 3:18 p.m. and 9:54 p.m. as well as on 10/17/25 at 3:40 p.m. and 9:02 p.m. She explained that she noticed that there were two orders of 300 MG of Gabapentin, but she figured it was an entry error because she was admitted with the bottle and the blister pack was delivered the next day. She stated that the combined orders of Gabapentin instructed to give CR#1 600 MG in the morning and 600 MG in the evening. She explained that she thought that this was too much and a medication error, so she decided to follow the order that stated to give CR#1 300 MG of Gabapentin 3xs a day and disregard the additional order that instructed this medication also be administered 2xs a day. MA B explained that for CR#1's evening medication passes, she only administered 1 300 MG capsule of Gabapentin and marked that it was given on the other order although she only passed 1 capsule. She stated she did not ask any of the nurses about CR#1's order but she stated that she was supposed to report it to the nurse if there were any kind of suspected medication errors. She stated that the reason she did not report it to a nurse was because she was working both halls and she forgot. In an interview on 10/22/25 at 9:43 a.m. with CR#1 in the hospital, she was in bed wearing her neck brace while she grimaced and moaned in a lot of pain. She stated that while she was in the nursing facility she was given a lot of medication, but she did not remember what it was. She stated she did not feel any pain while she was there, and the nurses were nice to her but was not feeling well enough to answer additional questions. In an interview on 10/22/25 at 4:43 p.m. with the NP, she stated the last time she saw CR#1 was on 10/17/25 and she was demented but alert and oriented x2. She explained she consulted with the facility's pain management team regarding her pain medications. She stated she saw there were two orders of 300 MG of Gabapentin orders in the system where one was to be given 3xs a day and the others was to be given 2xs a day. She stated for both morning and evening administration, CR#1 was to receive 600 MG of Gabapentin. Two orders were documented into the system for the medication because sometimes the system made them input each order in separately for it to populate when to administer it in the MAR. She stated these doses of Gabapentin were normal doses and could still be increased if needed. NP stated that she was unaware that CR#1 had not gotten her doses as she had ordered and she did not receive any questions from facility nurses or staff regarding confusion with the two 300 MG Gabapentin orders. She stated that nurses always contacted her if they were confused and no one should ever administer medication unless they have full understanding of the orders. In an interview with the DON on 10/23/25 at 10:55 a.m. she was informed that MA B had not given CR#1 her 300 MG of Gabapentin medication as ordered. She explained if an aide had confusion with the orders, they should have reached out to a nurse for clarification. If the nurse had a question, they should reach out to the physician. All orders were to be followed as documented in the computer. She explained the harm in CR#1 not receiving her medication as ordered would be increased pain for CR#1. Record review of MA B's employee file documented that she was hired at the facility on 08/19/24 as a certified medication aide. Her essential functions in this role were to administer medications as ordered by a physician under the supervision of a licensed nurse in accordance with any state and federal regulations and consistent with facility policy, record the administration of medications appropriately, and demonstrate knowledge of the five rights (right patient, right drug, right dose, right route, and right time). Record review of the facility's policy titled Adverse Consequences and Medication Errors revised April 2014 stated: A medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services.Examples of medications errors include:a. Omission - a drug is ordered but not administered;b. Unauthorized drug - a drug is administered without a physician's order;c. Wrong dose (e.g., Dilantin 12 mL ordered, Dilantin 2 mL given);d. Wrong route of administration (e.g., ear drops given in eye);e. Wrong dosage form (e.g., liquid ordered, capsule given);f. Wrong drug (e.g., vibramycin ordered, vancomycin given);g. Wrong time; and/orh. Failure to follow manufacturer instructions and/or accepted professional standards (e.g., failure to shake medication that is labeled shake well, crushing a medication on the do not crush list without an order).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the failed to ensure that its residents are free of any significant medication error for 1 (CR#1) of 5 residents reviewed for medication administration. CR#1 was ordered to receive 600 MG of Gabapentin in the evening for pain on 10/16/25 and 10/17/25 but was administered 300 MG both evenings by MA B. MA B failed to follow physician orders or consult with a nurse for order clarification. These failures could place residents at risks for increased pain, discomfort, and a diminished quality of life. Findings include:Record review of CR#1's face-sheet reviewed 10/21/25, revealed a seventy-six year old woman who was admitted to the facility on [DATE]. Her admitting diagnoses were a Type II Dens fracture (a break in the odontoid process, the peg-like structure that connects the second vertebra (axis) to the first vertebra (atlas) in the cervical spine), elevated white blood cell count, cervicalgia (pain in the neck region), pain, and adult failure to thrive. Record review of CR#1's Pain Management Team Encounter notes dated 10/16/25 stated that she was AAO x2-3. CR#1 had unspecified pain and treatment goals were directly therapeutic and were incorporated to provide improvement and/or prevention of progression of the condition, while providing a reasonable expectation of recovery. Record Review of CR#1's care plan reviewed 10/21/25, displayed a focus on pain management initiated on 10/16/25. Interventions stated to screen for pain on admission and daily. Assess to determine if experiencing pain. If pain was present, conduct, and document pain assessment particularly location, nature, intensity, and duration of pain. Record review of CR#1's orders dated 10/15/25 documented that CR#1 was to receive: 1. Gabapentin Capsule 300 MG Give 1 capsule by mouth three times a day for nerve pain.2. Gabapentin Capsule 300 MG Give 1 capsule by mouth two times a day for nerve pain equals 600mg for AM and PM doses. Record review of CR#1's MAR dated October 2025 revealed the medications were administered as follows: 1- 300MG Gabapentin capsule by mouth two times a day (a.m. and p.m. doses that equaled 600 MG) for nerve pain. * 10/16/25 at 9:00 a.m. dose was marked administered by MA A *10/16/25 at 9:00 p.m. dose was marked administered by MA B. *10/17/25 at 9:00 a.m. dose was marked administered by MA A*10/17/25 at 9:00 p.m. doses was marked administered by MA B.* 10/18/25 at 9:00 a.m., dose was marked administered by the ADON. 1- 300 MG Gabapentin capsule to be given by mouth three times a day for nerve pain. *10/16/25 at 9:00 a.m. dose was marked administered by MA A, *10/16/25 at 3:00 p.m. and the 9:00 p.m. doses were marked administered by MA B. *10/17/25 at 9:00 a.m. dose was marked administered by MA A*10/17/25 at 3:00 p.m. and the 9:00 p.m. doses were marked administered by MA B*10/18/25 at 9:00 a.m., was marked administered by the ADON. In total, 5 Gabapentin 300 MG capsules should be administered to CR#1 daily and a total of 12 capsules should have been administered from 10/16/25 to 10/18/25 at 9:00 a.m. Record review of CR#1's progress notes on 10/18/25 at 11:42 a.m. inputted by ADON stated CR#1 had a change in condition where she was unresponsive. Nursing observation documented: ADON was called to room due to change in condition. NP notified and orders given to send out via 911 to hospital for further evaluation. Resident left with EMS at 11:54 a.m. via stretcher. In an interview and observation on 10/21/25 at 12:14 p.m., MA A, stated she worked at the facility since 2020 and had stepped into the role as a medication aide in March 2025. She worked from 6 a.m. to 2 p.m. and only remembered giving medications to CR#1 twice. She explained when she gave medication, she would verify the orders by checking the resident's name with the picture, asking the resident to verify their first and last name, and making sure the blister pack matched the orders. MA A took the Surveyor to the medication cart and she reviewed CR #1's orders. She stated she saw there was one order to give 1 tab of 300 MG of Gabapentin 3xs a day and another to give 1 tab of 300 MG of Gabapentin 2xs a day. On her shift of 6 a.m. to 2 p.m., she was ordered to give CR#1 2 capsules of Gabapentin. Reviewing the time stamps in the MAR, she administered this medication on 10/16/25 at 10:34 a.m. and on 10/17/25 at 10:22 a.m. She stated although she saw two separate orders in the MAR, she did not feel like it was inputted by accident, and she followed the orders as written. MA A stated she did not notice any adverse effects or any changes in her behavior. She explained that if she suspected there was an overlap in medications or a discrepancy, she would consult with one of the nurses. Inside the medication cart, there was one bottle of Gabapentin 300 MG filled on 10/15/25 for 60 capsules for CR#1. A blister pack was also found for Gabapentin 300 MG filled on 10/16/25 for 70 capsules. MA A recalled that she administered medication from the Gabapentin bottle initially, but she switched over to the blister pack once it was delivered on 10/17/25. MA A counted the amount of medication remaining from both the pack and the bottle that equaled a total of 130 capsules, 8 capsules 300 MG Gabapentin were missing from the count. In an interview with MA B on 10/21/25 at 12:55 p.m., she stated that she had worked at the facility for 1 year and she worked either the 6-2 a.m. shift or the 2-10 p.m. shift. On 10/16/25 and 10/17/25, she worked the 2-10 p.m. shift. She was familiar with CR#1 and after reviewing the MAR, she confirmed that she administered 300 MG of Gabapentin on 10/16/25 at 3:18 p.m. and 9:54 p.m. as well as on 10/17/25 at 3:40 p.m. and 9:02 p.m. She explained that she noticed that there were two orders of 300 MG of Gabapentin, but she figured it was an entry error because she was admitted with the bottle and the blister pack was delivered the next day. She stated that the combined orders of Gabapentin instructed to give CR#1 600 MG in the morning and 600 MG in the evening. She explained that she thought that this was too much and a medication error, so she decided to follow the order that stated to give CR#1 300 MG of Gabapentin 3xs a day and disregard the additional order that instructed this medication also be administered 2xs a day. MA B explained that for CR#1's evening medication passes, she only administered 1 300 MG capsule of Gabapentin and marked that it was given on the other order although she only passed 1 capsule. She stated she did not ask any of the nurses about CR#1's order but she stated that she was supposed to report it to the nurse if there were any kind of suspected medication errors. She stated that the reason she did not report it to a nurse was because she was working both halls and she forgot. In an interview on 10/22/25 at 9:43 a.m. with CR#1 in the hospital, she was in bed wearing her neck brace while she grimaced and moaned in a lot of pain. She stated that while she was in the nursing facility she was given a lot of medication, but she did not remember what it was. She stated she did not feel any pain while she was there, and the nurses were nice to her but was not feeling well enough to answer additional questions. In an interview on 10/22/25 at 4:43 p.m. with the NP, she stated the last time she saw CR#1 was on 10/17/25 and she was demented but alert and oriented x2. She explained she consulted with the facility's pain management team regarding her pain medications. She stated she saw there were two orders of 300 MG of Gabapentin orders in the system where one was to be given 3xs a day and the others was to be given 2xs a day. She stated for both morning and evening administration, CR#1 was to receive 600 MG of Gabapentin. Two orders were documented into the system for the medication because sometimes the system made them input each order in separately for it to populate when to administer it in the MAR. She stated these doses of Gabapentin were normal doses and could still be increased if needed. NP stated that she was unaware that CR#1 had not gotten her doses as she had ordered and she did not receive any questions from facility nurses or staff regarding confusion with the two 300 MG Gabapentin orders. She stated that nurses always contacted her if they were confused and no one should ever administer medication unless they have full understanding of the orders. In an interview with the DON on 10/23/25 at 10:55 a.m. she was informed that MA B had not given CR#1 her 300 MG of Gabapentin medication as ordered. She explained if an aide had confusion with the orders, they should have reached out to a nurse for clarification. If the nurse had a question, they should reach out to the physician. All orders were to be followed as documented in the computer. She explained the harm in CR#1 not receiving her medication as ordered would be increased pain for CR#1. Record review of MA B's employee file documented that she was hired at the facility on 08/19/24 as a certified medication aide. Her essential functions in this role were to administer medications as ordered by a physician under the supervision of a licensed nurse in accordance with any state and federal regulations and consistent with facility policy, record the administration of medications appropriately, and demonstrate knowledge of the five rights (right patient, right drug, right dose, right route, and right time). Record review of the facility's policy titled Adverse Consequences and Medication Errors revised April 2014 stated: A medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services.Examples of medications errors include:a. Omission - a drug is ordered but not administered;b. Unauthorized drug - a drug is administered without a physician's order;c. Wrong dose (e.g., Dilantin 12 mL ordered, Dilantin 2 mL given);d. Wrong route of administration (e.g., ear drops given in eye);e. Wrong dosage form (e.g., liquid ordered, capsule given);f. Wrong drug (e.g., vibramycin ordered, vancomycin given);g. Wrong time; and/orh. Failure to follow manufacturer instructions and/or accepted professional standards (e.g., failure to shake medication that is labeled shake well, crushing a medication on the do not crush list without an order).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure that each resident who was incontinent of bowel/bladder and each resident with an indwelling catheter received appropriate treatment and services to prevent urinary tract infections, for 1 of 6 residents (Resident #95) reviewed for incontinent care and for indwelling urinary catheters. The facility failed to ensure Resident #95's indwelling catheter (a tube into the bladder to drain urine) securement device used to stabilize the catheter was in place. This failure could place the residents at risk for pain, dislodgement, or infection. Findings included:Record review Resident #95's (undated) face sheet revealed a [AGE] year-old female readmitted to the facility on [DATE]. Her diagnoses included chronic kidney disease, acute kidney failure, and neuromuscular dysfunction of bladder disorder (condition that affects the muscles and nerves that controls the bladder). Record review of Resident #95's quarterly MDS assessment dated [DATE] revealed a BIMS was scored as 11, which indicted moderately impaired cognition. Resident #95's self-care assessment revealed she required substantial/maximal assistance with toileting, showering, lower body dressing, and putting on/taking off footwear. She was also noted to be incontinent to both bowel and bladder. Record review of Resident #95's care plan revealed she had a Foley catheter related to neuromuscular dysfunction of the bladder with a goal to remain free from catheter related trauma. Resident #95's interventions included positioning the catheter bag and tubing below the level of the bladder and away from the entrance room door, checking tubing for kinks each shift, monitoring and documenting pain/discomfort due to catheter, and monitoring/recording/reporting s/sx of UTI to MD. Record review of Resident #95's physician orders dated 07/11/25 indicated to change Foley catheter anchor every night shift starting on the 15th and ending on the 15th every month. During an observation on 07/16/2025 at 9:31 AM Resident #95 did not have a strap or device to secure the catheter tube to the resident's thigh. Resident #95 was alert and oriented, and said she never had a Foley securement device. During an interview on 07/16/2025, at 9:35 AM, CMA K, who was at Resident #95's bedside, said residents are supposed to wear a leg strap to secure their catheter. She said she did not know why the resident did not have a leg strap and referred the surveyor to Resident #95's nurse. During an interview on 07/16/2025 at 10:13 AM, LVN V said Resident #95's catheter should have been secured in place with a leg strap. She said the nurses and CNAs were responsible for ensuring the catheter was properly secured. LVN V said the risk of the catheter tubing not being secured was the tube could be pulled out and cause injury to the resident's urethra. During an interview on 07/17/2025 at 1:10 PM, the DON stated LVN V informed her that Resident #95 did not have a strap to secure the tubing. The DON said Resident #95's catheter strap should be on her thigh, per physician's orders. The DON said the risk of not having the strap was the tubing could cause injury/trauma and/or infection . During an interview on 07/18/2025 at 1:03 PM, the Administrator said she expected all residents with catheters to have leg straps or a securing device to prevent the catheter tube from pulling. The administrator said the risk could cause injury, pain, and/or lead to an infection. Record review of the facility policy titled Catheter Care, Urinary, revised September 2014 read in part: . Steps in the Procedure 18. Secure catheter utilizing a leg band .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 6 residents (Resident #6) reviewed for infection control practices. 1. The facility failed to ensure CNA J applied enhanced barrier precautions while providing incontinent/catheter care to Resident # 6. 2. The facility failed to ensure that CNA J sanitized their hands when providing incontinent/catheter care to Resident #6. These failures could place residents at risk of cross-contamination and infections leading to illness. Findings included: Record review of Resident #6's undated face sheet indicated the resident was a 66-year- old male who was readmitted to the facility on [DATE] with diagnoses of hemiplegia and hemiparesis affecting right dominant side (paralysis or severe weakness on one side of the body), Benign prostatic hyperplasia (prostate gland enlargement that can cause urinary difficulty), and Neuromuscular Dysfunction of Bladder (condition that affects the muscles and nerves that controls the bladder). Record review of Resident #6's MDS assessment, dated 4/07/2025, revealed a BIMS summary score of 12, indicating cognitively intact. The MDS also indicated Resident #6 required maximal/substantial assistance with showering, lower body dressing, personal hygiene, and removing lower body dressing. Record review of Resident #1's care plan initiated on 4/04/2025, indicated Resident #6 had a catheter. The goal was for Resident #6 to show no s/sx of urinary infection. Interventions included checking for kinks, monitoring and documenting for pain/discomfort due to catheter, and monitoring/recording/reporting too MD for s/sx of a UTI. Record review of physician's orders dated 06/11/25 revealed Resident #6 was also on enhanced barrier precautions (infection control interventions designed to reduce transmission of multidrug-resistant organism). During an observation on 7/17/2025 at 9:43 AM, enhanced barrier precautions signage was posted on the outside door, and PPE was noted outside the room. CNA J was observed performing incontinent/Catheter Care on Resident #6 without wearing proper personal protective equipment (gown). The resident was lying on his right side, and she was observed cleaning stool on the resident's buttocks using the same soiled gloves that held the dirty wipes to reenter the multi-wipe package. She continued to use the soiled gloves and applied a new brief to the resident. She doffed her gloves and left the room to retrieve soap, water, and new linen for catheter care, without sanitizing her hands. She returned to the resident's room, sanitized her hands, applied new gloves, and proceeded to start catheter care. She cleaned the resident's penis per policy and began wiping the catheter tubing from the urethra opening downward per policy; however, she did not doff gloves, sanitize hands and don new gloves after handling the soiled towels. She used the same soiled gloves and applied a new brief. She doffed her gloves and sanitized her hands after applying the new brief and adjusting Resident #6's linen and bed. She was observed using the same gloves throughout the entire Cath care procedure. During an interview on 7/17/2025 at 10:04 AM, CNA J said she forgot to put on her protective personal equipment (PPE) before performing incontinent/catheter care. The CNA said she was aware that she was supposed to wear PPE when performing incontinent care for Resident #6, based on previous infection control in-services/training and the signage posted on the door. CNA J also said she should have changed her gloves after discarding the dirty brief. She said she should have sanitized her hands and donned new gloves before applying the new brief or touching his linen and bed remote. She said the risk of not wearing PPE or not performing hand hygiene could spread germs and lead to infection. During an interview on 7/17/2025 at 10:04 AM, LVN V said all staff had been in-serviced on enhanced barrier precautions (EBP). She said PPE should be worn when providing direct care by wearing gowns and gloves. She said all staff should change gloves and sanitize their hands before, during, and after incontinent/catheter care. LVN V said the risk of not following EBP and not sanitizing hands could cause a cross-contamination and lead to a UTI. During an interview on 7/17/2025 at 1:10 PM, the DON said the facility had frequently in-serviced staff on enhanced barrier precautions (EBP) and infection control. The DON said she expected her staff to wear proper PPE when providing care, as per protocol. She also said her expectation was for staff to wash their hands before, during and after incontinent/Cath care. She said the risk was cross contamination and infection. During an interview on 7/18/2025 at 1:03 PM, the Administrator said she expected the nurses and staff to adhere to the enhanced barrier precautions/infection control policy. The Administrator said the risk of not following the infection control policy puts staff and residents at risk of spreading infection, which could lead to a decline in a resident's health. Record review of a policy titled Enhanced Barrier precautions dated August 2024, read in part . Policy: EBP are used as an infection prevention and control intervention to reduce the spread of multi-drug-resistant organisms to residents. 3. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: dressing, bathing/showering transferring providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc., and wound care any skin opening requiring a dressing .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure individuals with mental health disorders were provided an accurate Preadmission Screening and Resident Review (PASRR) Screening for 1 (Resident #81) of 4 residents reviewed for resident assessments.<BR/>The facility failed to ensure Resident #81 had a PASRR on file for his bipolar and depression diagnoses.<BR/>This failure could place residents with mental disorders and developmental disabilities at risk of not receiving specialized PASRR services which could contribute to a decline in physical, mental, psychosocial well-being and quality of life.<BR/>Findings included: <BR/>Record review of Resident #81's face sheet revealed a [AGE] year-old male admitted on [DATE]. His diagnoses were bipolar disorder (A serious mental illness characterized by extreme mood swings), and depression. <BR/>Record review of Resident #81's Quarterly MDS assessment dated [DATE] noted Resident #81 had a BIMS score of 5 out of 15 which indicated he was cognitively severely impaired. Section, Active Diagnoses noted the resident with bipolar disorder and depression. Section, Antipsychotic medications noted the resident was on antipsychotic medication.<BR/>Record review of Resident #81's care plan dated 03/11/24 reflected Resident #81 had not been care planned for his bipolar disorder.<BR/>Record review of Resident #81's medical record revealed one PASRR Level 1 Screening dated 03/11/24 with negative results for mental illness. There was no evidence a new screening was performed when Rresident #81 was admitted with a diagnosis of bipolar disorder.<BR/>During an interview on 06/05/24 at 11:18 AM with the MDS Coordinator, he said he had been in his position for a little over a year. He said he was responsible for reviewing and completing the PASRRs and ensuring that all residents with a mental illness diagnoses were referred for PASRR evaluation for services. He said he must have overlooked this Rresident #81's mental illness diagnosis. He said the risk of not having and accurate PASRR Screening and evaluation was the resident was not receiving service such as and community services that they qualify for.<BR/>Interview with the DON on 06/06/24 at 12:20 PM, she said the Resident #81's PASRR was completed upon admission on [DATE]. She reported she was unaware an additional PASRR needed to be completed. She reported the MDS Coordinator was responsible for PASRR's. She said she was unaware of risk or negative effects of not completing the correct PASRR screening or PASRR evaluation.<BR/>Interview on 6/6/2024 at 12:26 PM with the Administrator, she said PASRR screening was completed prior to admission to the facility. She reported they followed the Texas Health and Human Services guidelines for PASRR screenings. She said the risk to the resident of not having an accurate PASRR screening and assessment would be that the resident would not receive mental health services to which they are entitled.<BR/>Record review of Record review of the facility's Detailed Item by Item guide for referring entities to complete the PASRR Level 1 Screening policy dated 6/2023 read in part . Purpose. The PL1 screening form is designed to identify individuals who are suspected of having a mental illness (MI), intellectual disability (ID), or developmental disability((DD). All people who are confirmed as having MI ID RTD's are identified as PASRR positive. Administering the PE helps to ensure that PASRR positive individuals are placed in the most integrated residential setting of their choice, where they can receive the specialized services needed to improve and maintain the best level of functioning .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure each resident was free from neglect for 1 of 11 residents (CR #1) reviewed for neglect. <BR/>The facility failed to initiate safety interventions/monitoring or provide psychiatric services for CR #1, who had a documented history of depression and suicidal ideations. The physician ordered an urgent psychiatric consultation (05/21/2023) after he expressed suicidal ideations and attempted to elope from the facility several times, which resulted in an actual suicide attempt on 05/27/2023. <BR/>The facility failed to refer CR #1 for psychiatric services as recommended when he was discharged from an acute care hospital on [DATE]. <BR/>LVN A failed to notify the DON and Administrator when CR #1 initially expressed suicidal ideations on 05/21/2023 and inform them that CR #1's physician ordered an urgent psychiatric consultation.<BR/>The facility failed to notify CR #1's physician when he expressed suicidal ideations a second time on 05/26/2023. <BR/>An Immediate Jeopardy (IJ) situation was identified on 06/02/2023 at 1:25 p.m. While the IJ was removed on 06/07/2023, the facility remained out of compliance at the severity level of actual harm with a scope identified as pattern due to the facility's need to evaluate the effectiveness of the corrective systems.<BR/>These failures placed residents with a history of depression or suicidal ideations at risk of experiencing emotional distress, psychiatric episodes, and possible death from not receiving adequate care, interventions, and psychiatric services.<BR/>Findings include:<BR/>Record review of CR #1's face sheet dated 06/01/2023 revealed he was an [AGE] year-old male who was admitted to the facility on [DATE]. His admitting diagnoses included with Parkinson's Disease (a disease of the central nervous system that affects movement, often including tremors), rhabdomyolysis (a breakdown of muscle tissue that releases a damaging protein into the blood), acute kidney failure (a condition in which the kidneys suddenly cannot filter waste from the blood), weakness, repeated falls, depression (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and dementia (a condition characterized by progressive or persistent loss of intellectual functioning). CR #1 was also diagnosed with suicidal ideations (often called suicidal thoughts or ideas, is a broad term used to describe a range of contemplations, wishes, and preoccupations with death and suicide). CR #1 was transferred to a local acute care hospital on [DATE]. <BR/>Record review of CR #1's MDS dated [DATE] revealed he had a BIMS score of 7 (severe cognitive impairment); he felt down, depressed, or hopeless between 7-11 days; he did not experience hallucinations or delusions; he rejected care daily; he wandered daily which placed him at significant risk of getting to potentially dangerous places; he required supervision with no physical assistance for bed mobility, transfers, walking, dressing, and bathing; he required supervision with setup assistance with eating and personal hygiene; he ambulated independently with a walker; he was always continent of bowel and bladder; he experienced coughing or choking during meals or when swallowing medications; and he was prescribed antidepressant medication.<BR/>Record review of CR #1's care plan updated 05/27/2023 revealed the following:<BR/>-CR #1 had potential for elopement as evidenced by exit seeking behavior (05/23/2023 exited out the front door). Goals included: Maintain the least restrictive environment while providing safety. Interventions included: Have activities involved with favorite past times. Music. Exercise. Photo in Elopement risk book. All staff to be made aware of CR #1's risk status via staff sign-in book and verbal reports. If possible, have family or volunteers visit on a regular basis. Keep doctor and family informed. SW to make regular visits. Reorient/Redirect as needed. Reassess as needed. SW to obtain detailed prior routine of CR #1. <BR/>-CR #1 was taking psychotropic medications for Depression (Sertraline). Goals included: CR #1 will not experience adverse side effects. Interventions included: Monitor and record any displayed behavior or mood problems. Encourage appropriate behavior, discourage inappropriate behavior. Monitor effectiveness of psychotropic medications. Monitor for involuntary movements and repetitive behaviors and report to doctor. Review medications every three months for possible dose reduction. Allow CR #1 to express feelings. Protect CR #1 from self-harm or harm to others. Monitor for weight loss. Psych consult as needed. <BR/>-CR #1 had behavioral symptoms not directed toward others (05/27/2023- CR #1 attempted to harm himself by wrapping a phone cord around his neck- 911 was called- will re-evaluate interventions upon return. Goals included: Incidents of self-harm will be decreased. Interventions included: Gently remind CR #1 that behavior is not appropriate. Provide medication as ordered. Record behaviors on Behavior Tracking form. Monitor pattern of behavior (time of day, precipitating factors, specific staff, or situations). Head to toe assessment completed to check for any injuries (no injuries noted). 1 on 1 monitoring until EMS arrived. <BR/>-CR #1 exhibited wandering behaviors. Goals included: Current level of mobility will be maintained. Interventions included: Assess potential causes for wandering (need for toilet, water, food, pain relief). Provide diversional activities. Record behaviors on Behavior Tracking form. Redirect CR #1's behavior/activity when wandering is observed. <BR/>-CR #1 had other behavioral symptoms not directed toward others (refusal of care, threatening to break windows. Goals included: Incident will be decreased. Interventions included: Gently remind CR #1 that behavior is not appropriate. Provide medication as ordered. Record behaviors on Behavior Tracking form. Remove from situation; allow time to calm down. <BR/>-CR #1 was at risk for falls as evidenced by cognitive impairment, fall history, weakness, unsteady gait, and rhabdomyolysis. Goals included: Dignity will be maintained. CR #1 will not experience falls or injuries from falls. Interventions included: Encourage CR #1 to ask for assistance of staff. Ensure call light is in reach, answer promptly. Therapy to evaluate and treat per orders. Anticipate needs, provide prompt assistance. Assure lighting is adequate and areas are free of clutter. <BR/>Observation and interview of CR #1 at a psychiatric hospital on [DATE] at 9:00 a.m. revealed he was alert, oriented and ambulated independently with a walker. CR #1 said they went by the rules at the facility. He said he sneaked out the front door and tried to go to Whataburger. He said he did not like living there because there was no place to go, and he was the type of guy who liked to go places. He said they (he did not say who they were) would not let him go sit outside because he had a fall outside. He said he wanted to get some fresh air, but the nurses caught him. CR #1 said he did not do anything but sit at the facility because there were no activities he liked. He said two of the nurses stood at the door and would not let him out. He said he was going to get out one way or the other, either they would let him walk out, or kill himself and let the undertaker carry him out. He said the cops picked him up from the facility when he tried to kill himself. CR #1 said he wrapped a telephone cord around his neck. He said he had not been home in a very long time, and he wanted to go home. He said they gave him more medication and he felt better now. He said he did not want to kill himself anymore, he wanted to go home. <BR/>Record review of CR #1's hospital records dated 05/16/2023 revealed he was admitted to a local acute care hospital via the emergency room on [DATE] after he fell in his home and was on the floor several hours. The document read in part, . Patient states, 'You're wasting your time- I want to die . I don't have any family- They should have left me on the floor' . Precautions: Falls, Depressed state/ reports, 'I want to die' . Discharge Recommendations: Continue Rehab, Psych Consult. Precautions: Fall, Anxiety/Depression - Recommend Psych Consult . Home Medications: . Sertraline (Zoloft) 50 MG tablets daily . <BR/>Record review of CR #1's hospital records dated 06/02/2023 revealed he was transported to the emergency room by EMS on 05/27/2023. The records read in part, . presenting with EMS after possible strangulation attempt, patient was reported to have been found with a telephone cord around his neck, cyanotic (bluish or grayish color of the skin) appearing face, removed telephone cord and transported to hospital hemodynamically (how your blood flows through your arteries and veins and the forces that affect your blood flow) stable in route. When asked about this, patient reports he was just playing around with cord, had no suicidal intention. Patient would like to leave, does not know why is here, does not want to go back to the facility . patient with history of suicidal ideation . Assessment: Suicidal Attempt . Plan: Admit to floor . Sitter 1:1 . CR #1 was discharged to an inpatient psychiatric hospital on [DATE]. <BR/>Record review of CR #1's physician's orders for May 2023 revealed he was prescribed Sertraline, 50 mg tablets once daily for depression. Start date: 05/18/2023. <BR/>Record review of CR #1's MAR for May 2023 revealed he received Sertraline daily as ordered from 05/19/2023 until 05/26/2023. <BR/>Record review of CR #1's referral for a psychiatry consultation dated 05/21/2023 revealed CR #1's physician gave LVN A verbal orders to refer CR #1 for the consultation on 05/21/2023. The order was electronically signed by LVN A on 05/21/2023 at 8:12 p.m. <BR/>Record review of CR #1's physician progress notes dated 05/22/2023 revealed, . Chief Complaint: New skilled nursing patient seen and examined for admission visit. Patient sitting on side of bed in no apparent distress. Pleasantly confused. States he lives alone. No suicidal ideation today. States he is ready to go home and wants to go home . Physical Exam: . Psychiatric: Judgement/insight: Poor . Summary of Plans: . Consults: Psychiatry to follow . Diagnosis and Assessment: . Dementia - . Has tried to exit seek multiple occasions since admission . Depression - Consult psych. Continue Zoloft 50 mg daily. Per report, suicidal ideation yesterday. None today. Plan: . Urgent consult on psych to evaluate and treat. Recent history of suicidal ideation. None noted today. States he wants to go home and not be in a nursing home .<BR/>Record review of CR #1's physician progress notes dated 05/24/2023 revealed, Chief Complaint: Skilled nursing patient seen and examined in follow-up . Per staff, patient was found outside of the facility walking along the sidewalk stating that he wanted to go home .<BR/>Record review of CR #1's progress notes for May 2023 revealed the following:<BR/>*On 05/21/2023 at 8:05 p.m. (incident occurred at 5:15 p.m.), LVN A wrote, Resident was being evaluated by ST for swallowing issues that were reported. ST was introducing a mechanical soft diet. Resident stated he did not want to change diets. Asked ST 'What for?' He verbalized to ST that he wanted to die instead because he was tired. Will notify MD and refer resident for Psych evaluation.<BR/>*On 05/22/2023 at 12:24 p.m., LVN B wrote, . Resident wanders throughout facility via walker. He attempted to exit x2 despite redirection .<BR/>*On 05/23/2023 at 5:52 a.m., LVN C wrote, During rounds resident was noted to be sitting on the bed and asked this writer to come here. Resident thanked this writer for providing care to him and that he will be leaving today. Asked resident was family coming to get him, he stated no, 'I'm walking. I would walk now but it is dark.' Educated resident on the importance of staying at the facility, resident stated, 'I will think about it .'<BR/>*On 05/23/2023 at 9:54 a.m., LVN B wrote, . This shift, he eloped out of front door and started to walk down the sidewalk. This nurse and other nurses on duty spoke with resident and attempted to provide redirection. After some time, resident agreed to come back inside. Resident still upset, threatening to break windows. Administrator speaking with RP at this time to make a discharge decision. <BR/>*On 05/24/2023 at 3:33 a.m., LVN C wrote, . Resident is in bed resting quietly at this time, sitter is sitting outside of door . <BR/>*On 05/26/2023 at 8:10 p.m., LVN C wrote, Resident is walking around asking staff to help him leave, staff redirects resident. Currently resident is in his room stating that he is leaving as soon as he finds a window to go out of. All staff notified to keep an eye on resident due to him stating he is going to leave.<BR/>*On 05/27/2023 at 2:31 a.m. (incident occurred 05/26/2023 at 8:50 p.m.), LVN C wrote, This writer seen resident going towards the back door. This writer and another began to stand between resident and the door. Resident asked staff if we could move so he could leave. Asked resident where he was going, he stated, home to his bed because he had things to do. This writer explained to resident that I could not let him leave and I was responsible for his wellbeing. Resident stepped closer to staff and asked resident to please step back, he did. Resident continued to stand at the door. Resident then stated that he was going to leave one way or another, resident made a cutting sign (gesture) towards his neck. Asked resident what that was, he stated, 'Could you just let me leave?' Call placed to Administrator, advised resident that he would have to go to his room, or I will call 911, orders given from management. Aide offered popcorn, resident stated he guessed he would go brush his teeth and go to bed. Administrator called and asked if I could interview resident to see if he was a danger to himself. When interviewing resident, he could not recall making a cutting sign at his throat, resident also stated that he will never hurt himself, notified Administrator, resident is currently in bed resting quietly . rounds are made every 2 hours.<BR/>*On 05/27/2023 at 10:12 a.m. (incident occurred at 9:15 a.m.), LVN A wrote, Receptionist was walking towards nursing station when she noted resident sitting in library. When she attempted to approach resident sitting in library, she noted that the resident had the phone cord wrapped around him and attempting to tighten it harder. Receptionist stated that the resident was turning blue when she ran in to intervene and remove the cord from the resident's neck. The Receptionist called for help and LVN E reached out to me on the way to assist resident and Receptionist.<BR/>*On 05/27/2023 at 10:16 a.m., LVN A wrote, . Assessed resident. Resident stabilized after removing cord from neck and having to sit down. Stated wanted to leave. Asked if he was attempting to kill himself and he stated, 'If that's the only way out then, yes?' Called 911 to have resident transferred to hospital for psych evaluation . RN D spoke with family and advised that resident was being sent out to hospital for Psych evaluation due to suicide attempt. Family stated that it was not the first time the resident has attempted suicide .<BR/>Record review of CR #1's, Elopement Risk Assessment dated 05/22/2023 revealed LVN F determined CR #1 was a moderate risk for elopements based on his cognitive impairment and wandering behaviors. Action included, Implement Elopement Risk care plan; Implement Frequent Monitoring Form (form was not completed) to determine elopement risk or until Interdisciplinary Team reviews and makes recommendation.<BR/>Record review of CR #1's, Elopement Risk Assessment dated 05/23/2023 revealed RN G determined CR #1 was an imminent risk for elopements based on his ambulation status, wandering behaviors, and his intentional or unintentional attempts to leave the community. Action included, Implement Elopement Risk care plan; Implement Frequent Monitoring Form (form was not completed) to determine elopement risk or until Interdisciplinary Team reviews and makes recommendation.<BR/>In an interview with the DON and the Regional Director of Clinical Services on 06/01/2023 at 9:45 a.m., the Regional Director of Clinical Services stated the DON was new to the facility and regional staff was not always in the building. The Regional Director of Clinical Services stated, based on what they knew, CR #1 had no previous suicidal ideations. The Regional Director of Clinical Services said CR #1's wife passed away in the facility many years prior and he had no other family other than a neighbor who helped him out prior to admission. The Regional Director of Clinical Services said CR #1's neighbor stated he (CR #1) previously talked about wanting to die. The DON stated to their (administration) knowledge, CR #1 spoke with the ST and referenced dying. The DON said CR #1's physician was notified and ordered an urgent referral for psychiatric services, but psych services was not able to see CR #1 before the suicide attempt. The Regional Director of Clinical Services stated CR #1's physician spoke with LVN A and that is where it ended. The Regional Director of Clinical Services stated LVN A was educated because something like that (suicidal ideations) should be escalated to the top (DON and Administrator). The Regional Director of Clinical Services said LVN A did not let anybody else know about the conversation between CR #1 and the ST. The Regional Director of Clinical Services said CR #1's physician documented his suicidal ideations and that she wanted an urgent psych consult. The Regional Director of Clinical Services said the incident was not communicated to the top (administration), so they did not have an opportunity to follow-up on the referral. The facility's elopement policy was requested, but the wandering policy was provided. <BR/>In an interview with the VP of Clinical Operations on 06/01/2023 at 11:00 a.m., she stated the facility did an emergency QAPI on 05/27/2023, after CR #1 attempted suicide. She said all staff involved were counseled and in-serviced. She said nursing staff talked to each resident who could speak and used a special psychiatric tool given to them by a psych provider to interview about depression and suicide. She said the residents who could not talk were assessed head to toe to insure nothing was out of the ordinary for them. She said the Administrator was suspended because their investigation found he may have known about CR #1's prior history of depression.<BR/>In a telephone interview with the Administrator on 06/01/2023 at 11:45 a.m., he stated he knew CR #1 kept saying he wanted to go home because he wanted to shampoo his carpet at home. He said it was not out of the ordinary for residents to express desires to go home. The Administrator said CR #1 had previously been admitted to the facility for rehab and he (CR #1) wanted attention, that was it. The Administrator said CR #1 was not depressed and he just wanted to go home and do chores. The Administrator said CR #1's depression, suicidal ideations, or behaviors were never brought to his attention prior to admission, and he never spoke to CR #1's family before or after his admission. The Administrator said the night before the suicide attempt (05/26/2023), LVN C called him around 10:00 p.m. He said he thought LVN C texted him, or he missed her call and then she texted saying CR #1 was trying to leave the building and that he wanted to kill himself. The Administrator said he sent LVN C a text to call 911, but she sent a text or called him, saying CR #1 was doing fine after they gave him popcorn. The Administrator said he called the LVN C back and she said CR #1 was fine and brushing his teeth. The Administrator said he told LVN C he needed to know what CR #1's state of mind was. He said LVN C said CR #1 could not even recall what he said earlier. He said he told LVN C to put CR #1 on monitoring (no monitoring was documented) and notify him if anything changed. He said he did not receive any more calls that night until incident on Saturday, 05/27/2023 when LVN A called and said CR #1 tried to hurt himself. <BR/>In a telephone interview with LVN A on 06/01/2023 at 11:59 a.m., he stated he was a charge nurse and he only worked weekends. He said on 05/21/2023, the ST approached him and said CR #1 had difficulty swallowing and she wanted to down grade his diet (to a mechanical soft diet). He said the ST told him CR #1 refused the food she used to assess him and said he (CR #1) was tired and wanted to die. LVN A said he went to follow-up with CR #1 in his room and asked about his diet. LVN A said he wanted CR #1 to say in his own words how he felt, but he did not express a desire to die to him. LVN A said he did not ask CR #1 about what he said to the ST. LVN A said he called CR #1's doctor and got an order for a psych consultation and he documented the situation. LVN A said the order was not an urgent order. He said orders for psychiatric services were usually turned in to the SW. LVN A said he slipped the referral under the SW's door on Sunday, 05/21/2023, and he did not hear anything else about CR #1's referral after that. He said he did not relay this information to the DON, the Administrator, or anybody else. He said he did not know the SW was on vacation, but had he known, he would have taken the referral order to someone else. He said no special monitoring or intervention was initiated for CR #1. LVN A said that next weekend, 05/27/2023, CR #1 said he wanted to go home, but that was nothing out of ordinary from his usual agitation. He said on 05/27/2023, he heard another nurse call his name and he ran to the library room and saw CR #1 there with the Receptionist. He said by the time he got to the library, other staff had removed the phone cord from CR #1's neck and he (CR #1) was just shaking. He said he got someone to stay with CR #1 while he called his doctor for an order to send him out and he called CR #1's family and the Administrator. LVN A said the police arrived while he was assessing CR #1 and CR #1 told the officer, Oh, I tried to kill myself, but it was nothing big. LVN A said the officer asked CR #1 again if he wanted to kill himself and CR #1 said yes. LVN A said he did not assign CR #1 a sitter the previous weekend when he initially expressing suicidal ideations. He said RN D called CR #1's family (after the suicide attempt) who said CR #1 had a history of suicidal ideations and had done this (attempted suicide) before. He said CR #1's family never mentioned prior to him having the cord around his neck that he had a history of suicide attempts. LVN A said after he was in-serviced (after CR #1's suicide attempt), he realized he should have expedited the information about the suicidal ideations and referral to the DON or management to let them know what was stated. <BR/>In a telephone interview with CR #1's NP on 06/01/2023 at 12:33 p.m., she stated she visited CR #1 on 05/22/2023, after he was admitted on [DATE]. She said she was notified about CR #1's suicidal ideations on 05/21/2023 and when she saw him on 05/22/2023, she asked him about the day before. She said she asked him if he still wanted to harm himself and he said no, he just wanted to go home and did not want to be in the facility. The NP said she documented in her notes that she put in an urgent request for psych services. The NP said the order was urgent based on CR #1's history of depression. She said she was familiar with the facility's referral process and the request had to be submitted to the SW then sent thru the referral portal. She said the process took a little while, so it was urgent to be done timely. She said she knew the psych provider saw patients at the facility on Mondays, so she knew CR #1 probably would not have been seen Monday, 05/22/2023. She said she was not aware CR #1's discharging facility recommended he be evaluated by psych services. She said had CR #1 exhibited behaviors, the facility staff could have notified psych for medication if needed. The NP said she had no prior knowledge of CR #1's history of suicidal ideations. She said she saw CR #1 again on 05/24/2023 and staff notified her CR #1 had eloped. She said she was not notified of any other incident of suicidal ideations. She said had staff notified her or the on-call doctor that CR #1 made a throat cutting motion (on the morning of 05/27/2023), she would have sent him out to the hospital at that time. <BR/>In an interview with the SW on 06/01/2023 at 1:00 p.m., she stated, usually, the NP or doctor would write an order and the nurse would print the order and give it to her. She said she sent an email to the psychiatric provider and made the referral. The SW said the process usually only took one day and the provider came on Mondays. She said she never received a referral or request for CR #1 to receive psych services. She said she was on vacation 05/14/2023 - 05/24/2023. She said when she returned from vacation, she did not see any request for CR #1 under her door. The SW said nobody ever asked her about any referral for CR #1. She said the facility's nurses could do the referrals if she was not here. The SW said if the psych provider was in the building and the nurses let them know someone needed to be seen, psych would have evaluated CR #1 even without the referral. She said if the referral was already in their computer system, they could have given it to him (psych) and he could have sent the referral to his (psych) office. The SW provided a copy of CR #1's order for psych services from the computer system and said the order did not say anything about urgency. She said she never saw a psych referral mention urgency. She said that (06/01/2023) was the first time she saw CR #1's referral for psych services. <BR/>Observation of the facility on 06/01/2023 at 1:30 p.m. revealed the library was located in a room (not open to the rest of the building) between the reception desk (front entrance) and the nurse's station. Further observation revealed someone would have to pass the entrance to the library to see if anyone was inside the library. There was a telephone with a cord on a small table next to a chair. <BR/>In a telephone interview with LVN C on 06/01/2023 at 1:22 p.m. revealed she usually worked the 2:00 p.m. - 10:00 p.m. and 10:00 p.m. - 6:00 a.m. shift, but she rarely worked on weekends. She said one night (she could not recall the date), she was about to pass medications and CR #1 thanked her for caring for him and said he was leaving, but it was dark. LVN C said she asked CR #1 if his family was coming, but he said no, he was leaving. She said she told CR #1 he was there for therapy and that was it, he went back to sleep. LVN C said on another night (she could not recall the day), CR #1 said he was leaving, and she (LVN C) called his RP (he was his own RP, but he did have an emergency contact), but she did not answer. LVN C said earlier on that day, another staff told her CR #1 had gotten outside (eloped) so, that night CR #1 was assigned a sitter (a facility housekeeper and maintenance staff). LVN C said to her knowledge, that was the only night he had a sitter. LVN C said the night he made the cutting motion was the same night she called CR #1's RP. She said they had to watch CR #1 because he would try to elope, and she noticed he went towards one of the doors. LVN C said CR #1 said they (the nurses) would not let him out the front, so he would get out one way or another, then he made cutting motion across his throat. LVN C said she asked CR #1 if that meant he would cut himself, and he said, If you think that's what I'm saying. LVN C said she told CR #1 if that was what he was saying, she would have to call the police. LVN C said CR #1 told her he would go brush his teeth. She said the Administrator said to go talk to CR #1 and ask if he was going to harm himself. LVN C said CR #1 acted like he did not recall doing that (making the cutting motion) or anything that happened that night. LVN C said CR #1 said he was going to bed. LVN C said she did not have the DON's phone number at that time. LVN C said she did not call CR #1's doctor because, to be honest, it slipped her mind. LVN C said she waiting to see if CR #1 would react or do anything else. She said now, she probably would have called the doctor. She said she was not aware of any referral for psych services for CR #1. <BR/>In a telephone interview with RN D on 06/01/2023 at 1:34 p.m., she stated she was the weekend supervisor and she only worked weekends. She said she interacted with CR #1 on weekends quite a bit. RN D said CR #1 kept wanting to go home and tried to elope several times. RN D said she was never made aware of CR #1's suicidal ideations the weekend before (05/21/2023) his suicide attempt and she worked 6:00 a.m. - 10:00 p.m. RN D said she worked on the weekend the ST worked (05/21/2023) but she was never made aware of CR #1 saying he wanted to die. RN D said CR #1 did not seem depressed and he had dementia but was able to have a conversation and express his feelings. RN D said on 05/27/2023, CR #1 made his usual attempts to elope and kept trying. She said eventually, she heard someone calling for a nurse to check on CR #1 and she followed afterwards. RN D said when she got to the library, CR #1 was in there sitting on a chair and LVN A was assessing him. She said she was not made aware that CR #1 had a referral for psych services. RN D said on weekends, they contact the primary care doctor or NP for a referral order and then they contact the provider they refer to. She said they could make a referral over the phone and then fax it in. She said she had never done a referral over the weekend and unless it was an emergency, they would wait until following week to do it. She said if the situation was emergent, she would do the referral or send the resident out. She said if she felt there was an active plan for suicide, she would notify the doctor and keep the resident on 1:1 monitoring until the doctor determined their next step.<BR/>In an interview with the DON on 06/01/2023 at 2:00 p.m., she said the Administrator called her on 05/26/2023 after CR #1 made the cutting motion across his throat. She said the Administrator told her about CR #1 making the cutting motion, and she asked him if CR #1 had a plan and some other questions. The DON said the Administrator said he would call the facility back to ask those questions and call back if there was anything else. The DON said when the nurse went back in to talk to CR #1, he was no longer expressing suicidal ideations. The DON said in hindsight, she probably should have called CR #1's doctor just in case she wanted her to do anything different. The DON said she had in serviced the nurses on when to communicate with physicians. The DON said she did not know if CR #1's referral was ever sent off to the psych provider. She said the SW handled all referrals and she did not know who to contact about referrals at their psych services provider. She said she believed the Administrator was handling referrals when the SW went on vacation. <BR/>In a follow up telephone interview with the Administrator on 06/01/2023 at 2:25 p.m., he stated if the SW was out, he would have done referrals but, he was never made aware of CR #1's order or referral. He said CR #1's referral was never sent out. <BR/>In a telephone interview with the ST on 06/01/2023 at 2:31 p.m. She said CR #1 did not have suicidal ideations. She said CR #1 told her his wife died at the facility 8-9 years prior and then he said, I guess I'm going to die here too. The ST said it was not an ideation. She said she was working with him and showing him how to swallow safer and he said, Lady, why do you care so much, just let me die. She said [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 11 residents (CR #1) reviewed for accidents and supervision.<BR/>The facility failed to provide adequate supervision and monitoring for CR #1 when he expressed suicidal ideations and attempted to elope from the facility several times which resulted in actual elopements on 05/23/2023 and 05/27/2023 and an actual suicide attempt on 05/27/2023. <BR/>An Immediate Jeopardy (IJ) situation was identified on 06/02/2023 at 1:25 p.m. While the IJ was removed on 06/07/2023, the facility remained out of compliance at the severity level of actual harm with a scope identified as pattern due to the facility's need to evaluate the effectiveness of the corrective systems.<BR/>This failure placed residents with a history of suicidal ideations and exit seeking behaviors at risk of serious harm and possible death from not receiving adequate supervision/monitoring and safety interventions.<BR/>Findings include:<BR/>Record review of CR #1's face sheet dated 06/01/2023 revealed he was an [AGE] year-old male who was admitted to the facility on [DATE]. His admitting diagnoses included with Parkinson's Disease (a disease of the central nervous system that affects movement, often including tremors), rhabdomyolysis (a breakdown of muscle tissue that releases a damaging protein into the blood), acute kidney failure (a condition in which the kidneys suddenly cannot filter waste from the blood), weakness, repeated falls, depression (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and dementia (a condition characterized by progressive or persistent loss of intellectual functioning). CR #1 was also diagnosed with suicidal ideations (often called suicidal thoughts or ideas, is a broad term used to describe a range of contemplations, wishes, and preoccupations with death and suicide). CR #1 was transferred to a local acute care hospital on [DATE]. <BR/>Record review of CR #1's MDS dated [DATE] revealed he had a BIMS score of 7 (severe cognitive impairment); he felt down, depressed, or hopeless between 7-11 days; he did not experience hallucinations or delusions; he rejected care daily; he wandered daily which placed him at significant risk of getting to potentially dangerous places; he required supervision with no physical assistance for bed mobility, transfers, walking, dressing, and bathing; he required supervision with setup assistance with eating and personal hygiene; he ambulated independently with a walker; he was always continent of bowel and bladder; he experienced coughing or choking during meals or when swallowing medications; and he was prescribed antidepressant medication.<BR/>Record review of CR #1's care plan updated 05/27/2023 revealed the following:<BR/>-CR #1 had potential for elopement as evidenced by exit seeking behavior (05/23/2023 exited out the front door). Goals included: Maintain the least restrictive environment while providing safety. Interventions included: Have activities involved with favorite past times. Music. Exercise. Photo in Elopement risk book. All staff to be made aware of CR #1's risk status via staff sign-in book and verbal reports. If possible, have family or volunteers visit on a regular basis. Keep doctor and family informed. SW to make regular visits. Reorient/Redirect as needed. Reassess as needed. SW to obtain detailed prior routine of CR #1. <BR/>-CR #1 was taking psychotropic medications for Depression (Sertraline). Goals included: CR #1 will not experience adverse side effects. Interventions included: Monitor and record any displayed behavior or mood problems. Encourage appropriate behavior, discourage inappropriate behavior. Monitor effectiveness of psychotropic medications. Monitor for involuntary movements and repetitive behaviors and report to doctor. Review medications every three months for possible dose reduction. Allow CR #1 to express feelings. Protect CR #1 from self-harm or harm to others. Monitor for weight loss. Psych consult as needed. <BR/>-CR #1 had behavioral symptoms not directed toward others (05/27/2023- CR #1 attempted to harm himself by wrapping a phone cord around his neck- 911 was called- will re-evaluate interventions upon return. Goals included: Incidents of self-harm will be decreased. Interventions included: Gently remind CR #1 that behavior is not appropriate. Provide medication as ordered. Record behaviors on Behavior Tracking form. Monitor pattern of behavior (time of day, precipitating factors, specific staff, or situations). Head to toe assessment completed to check for any injuries (no injuries noted). 1 on 1 monitoring until EMS arrived. <BR/>-CR #1 exhibited wandering behaviors. Goals included: Current level of mobility will be maintained. Interventions included: Assess potential causes for wandering (need for toilet, water, food, pain relief). Provide diversional activities. Record behaviors on Behavior Tracking form. Redirect CR #1's behavior/activity when wandering is observed. <BR/>-CR #1 had other behavioral symptoms not directed toward others (refusal of care, threatening to break windows. Goals included: Incident will be decreased. Interventions included: Gently remind CR #1 that behavior is not appropriate. Provide medication as ordered. Record behaviors on Behavior Tracking form. Remove from situation; allow time to calm down. <BR/>-CR #1 was at risk for falls as evidenced by cognitive impairment, fall history, weakness, unsteady gait, and rhabdomyolysis. Goals included: Dignity will be maintained. CR #1 will not experience falls or injuries from falls. Interventions included: Encourage CR #1 to ask for assistance of staff. Ensure call light is in reach, answer promptly. Therapy to evaluate and treat per orders. Anticipate needs, provide prompt assistance. Assure lighting is adequate and areas are free of clutter. <BR/>Observation and interview of CR #1 at a psychiatric hospital on [DATE] at 9:00 a.m. revealed he was alert, oriented and ambulated independently with a walker. CR #1 said they went by the rules at the facility. He said he sneaked out the front door and tried to go to Whataburger. He said he did not like living there because there was no place to go, and he was the type of guy who liked to go places. He said they (he did not say who they were) would not let him go sit outside because he had a fall outside. He said he wanted to get some fresh air, but the nurses caught him. CR #1 said he did not do anything but sit at the facility because there were no activities he liked. He said two of the nurses stood at the door and would not let him out. He said he was going to get out one way or the other, either they would let him walk out, or kill himself and let the undertaker carry him out. He said the cops picked him up from the facility when he tried to kill himself. CR #1 said he wrapped a telephone cord around his neck. He said he had not been home in a very long time, and he wanted to go home. He said they gave him more medication and he felt better now. He said he did not want to kill himself anymore, he wanted to go home. <BR/>Record review of CR #1's hospital records dated 05/16/2023 revealed he was admitted to a local acute care hospital via the emergency room on [DATE] after he fell in his home and was on the floor several hours. The document read in part, . Patient states, 'You're wasting your time- I want to die . I don't have any family- They should have left me on the floor' . Precautions: Falls, Depressed state/ reports, 'I want to die' . Discharge Recommendations: Continue Rehab, Psych Consult. Precautions: Fall, Anxiety/Depression - Recommend Psych Consult . Home Medications: . Sertraline (Zoloft) 50 MG tablets daily . <BR/>Record review of CR #1's hospital records dated 06/02/2023 revealed he was transported to the emergency room by EMS on 05/27/2023. The records read in part, . presenting with EMS after possible strangulation attempt, patient was reported to have been found with a telephone cord around his neck, cyanotic (bluish or grayish color of the skin) appearing face, removed telephone cord and transported to hospital hemodynamically (how your blood flows through your arteries and veins and the forces that affect your blood flow) stable in route. When asked about this, patient reports he was just playing around with cord, had no suicidal intention. Patient would like to leave, does not know why is here, does not want to go back to the facility . patient with history of suicidal ideation . Assessment: Suicidal Attempt . Plan: Admit to floor . Sitter 1:1 . CR #1 was discharged to an inpatient psychiatric hospital on [DATE]. <BR/>Record review of CR #1's physician's orders for May 2023 revealed he was prescribed Sertraline, 50 mg tablets once daily for depression. Start date: 05/18/2023. <BR/>Record review of CR #1's MAR for May 2023 revealed he received Sertraline daily as ordered from 05/19/2023 until 05/26/2023. <BR/>Record review of CR #1's referral for a psychiatry consultation dated 05/21/2023 revealed CR #1's physician gave LVN A verbal orders to refer CR #1 for the consultation on 05/21/2023. The order was electronically signed by LVN A on 05/21/2023 at 8:12 p.m. <BR/>Record review of CR #1's physician progress notes dated 05/22/2023 revealed, . Chief Complaint: New skilled nursing patient seen and examined for admission visit. Patient sitting on side of bed in no apparent distress. Pleasantly confused. States he lives alone. No suicidal ideation today. States he is ready to go home and wants to go home . Physical Exam: . Psychiatric: Judgement/insight: Poor . Summary of Plans: . Consults: Psychiatry to follow . Diagnosis and Assessment: . Dementia - . Has tried to exit seek multiple occasions since admission . Depression - Consult psych. Continue Zoloft 50 mg daily. Per report, suicidal ideation yesterday. None today. Plan: . Urgent consult on psych to evaluate and treat. Recent history of suicidal ideation. None noted today. States he wants to go home and not be in a nursing home .<BR/>Record review of CR #1's physician progress notes dated 05/24/2023 revealed, Chief Complaint: Skilled nursing patient seen and examined in follow-up . Per staff, patient was found outside of the facility walking along the sidewalk stating that he wanted to go home .<BR/>Record review of CR #1's progress notes for May 2023 revealed the following:<BR/>*On 05/21/2023 at 8:05 p.m. (incident occurred at 5:15 p.m.), LVN A wrote, Resident was being evaluated by ST for swallowing issues that were reported. ST was introducing a mechanical soft diet. Resident stated he did not want to change diets. Asked ST 'What for?' He verbalized to ST that he wanted to die instead because he was tired. Will notify MD and refer resident for Psych evaluation.<BR/>*On 05/22/2023 at 12:24 p.m., LVN B wrote, . Resident wanders throughout facility via walker. He attempted to exit x2 despite redirection .<BR/>*On 05/23/2023 at 5:52 a.m., LVN C wrote, During rounds resident was noted to be sitting on the bed and asked this writer to come here. Resident thanked this writer for providing care to him and that he will be leaving today. Asked resident was family coming to get him, he stated no, 'I'm walking. I would walk now but it is dark.' Educated resident on the importance of staying at the facility, resident stated, 'I will think about it .'<BR/>*On 05/23/2023 at 9:54 a.m., LVN B wrote, . This shift, he eloped out of front door and started to walk down the sidewalk. This nurse and other nurses on duty spoke with resident and attempted to provide redirection. After some time, resident agreed to come back inside. Resident still upset, threatening to break windows. Administrator speaking with RP at this time to make a discharge decision. <BR/>*On 05/24/2023 at 3:33 a.m., LVN C wrote, . Resident is in bed resting quietly at this time, sitter is sitting outside of door . <BR/>*On 05/26/2023 at 8:10 p.m., LVN C wrote, Resident is walking around asking staff to help him leave, staff redirects resident. Currently resident is in his room stating that he is leaving as soon as he finds a window to go out of. All staff notified to keep an eye on resident due to him stating he is going to leave.<BR/>*On 05/27/2023 at 2:31 a.m. (incident occurred 05/26/2023 at 8:50 p.m.), LVN C wrote, This writer seen resident going towards the back door. This writer and another began to stand between resident and the door. Resident asked staff if we could move so he could leave. Asked resident where he was going, he stated, home to his bed because he had things to do. This writer explained to resident that I could not let him leave and I was responsible for his wellbeing. Resident stepped closer to staff and asked resident to please step back, he did. Resident continued to stand at the door. Resident then stated that he was going to leave one way or another, resident made a cutting sign (gesture) towards his neck. Asked resident what that was, he stated, 'Could you just let me leave?' Call placed to Administrator, advised resident that he would have to go to his room, or I will call 911, orders given from management. Aide offered popcorn, resident stated he guessed he would go brush his teeth and go to bed. Administrator called and asked if I could interview resident to see if he was a danger to himself. When interviewing resident, he could not recall making a cutting sign at his throat, resident also stated that he will never hurt himself, notified Administrator, resident is currently in bed resting quietly . rounds are made every 2 hours.<BR/>*On 05/27/2023 at 10:12 a.m. (incident occurred at 9:15 a.m.), LVN A wrote, Receptionist was walking towards nursing station when she noted resident sitting in library. When she attempted to approach resident sitting in library, she noted that the resident had the phone cord wrapped around him and attempting to tighten it harder. Receptionist stated that the resident was turning blue when she ran in to intervene and remove the cord from the resident's neck. The Receptionist called for help and LVN E reached out to me on the way to assist resident and Receptionist.<BR/>*On 05/27/2023 at 10:16 a.m., LVN A wrote, . Assessed resident. Resident stabilized after removing cord from neck and having to sit down. Stated wanted to leave. Asked if he was attempting to kill himself and he stated, 'If that's the only way out then, yes?' Called 911 to have resident transferred to hospital for psych evaluation . RN D spoke with family and advised that resident was being sent out to hospital for Psych evaluation due to suicide attempt. Family stated that it was not the first time the resident has attempted suicide .<BR/>Record review of CR #1's, Elopement Risk Assessment dated 05/22/2023 revealed LVN F determined CR #1 was a moderate risk for elopements based on his cognitive impairment and wandering behaviors. Action included, Implement Elopement Risk care plan; Implement Frequent Monitoring Form (form was not completed) to determine elopement risk or until Interdisciplinary Team reviews and makes recommendation.<BR/>Record review of CR #1's, Elopement Risk Assessment dated 05/23/2023 revealed RN G determined CR #1 was an imminent risk for elopements based on his ambulation status, wandering behaviors, and his intentional or unintentional attempts to leave the community. Action included, Implement Elopement Risk care plan; Implement Frequent Monitoring Form (form was not completed) to determine elopement risk or until Interdisciplinary Team reviews and makes recommendation.<BR/>In an interview with the DON and the Regional Director of Clinical Services on 06/01/2023 at 9:45 a.m., the Regional Director of Clinical Services stated the DON was new to the facility and regional staff was not always in the building. The Regional Director of Clinical Services stated, based on what they knew, CR #1 had no previous suicidal ideations. The Regional Director of Clinical Services said CR #1's wife passed away in the facility many years prior and he had no other family other than a neighbor who helped him out prior to admission. The Regional Director of Clinical Services said CR #1's neighbor stated he (CR #1) previously talked about wanting to die. The DON stated to their (administration) knowledge, CR #1 spoke with the ST and referenced dying. The DON said CR #1's physician was notified and ordered an urgent referral for psychiatric services, but psych services was not able to see CR #1 before the suicide attempt. The Regional Director of Clinical Services stated CR #1's physician spoke with LVN A and that is where it ended. The Regional Director of Clinical Services stated LVN A was educated because something like that (suicidal ideations) should be escalated to the top (DON and Administrator). The Regional Director of Clinical Services said LVN A did not let anybody else know about the conversation between CR #1 and the ST. The Regional Director of Clinical Services said CR #1's physician documented his suicidal ideations and that she wanted an urgent psych consult. The Regional Director of Clinical Services said the incident was not communicated to the top (administration), so they did not have an opportunity to follow-up on the referral. The facility's elopement policy was requested, but the wandering policy was provided. <BR/>In an interview with the VP of Clinical Operations on 06/01/2023 at 11:00 a.m., she stated the facility did an emergency QAPI on 05/27/2023, after CR #1 attempted suicide. She said all staff involved were counseled and in-serviced. She said nursing staff talked to each resident who could speak and used a special psychiatric tool given to them by a psych provider to interview about depression and suicide. She said the residents who could not talk were assessed head to toe to insure nothing was out of the ordinary for them. She said the Administrator was suspended because their investigation found he may have known about CR #1's prior history of depression.<BR/>In a telephone interview with the Administrator on 06/01/2023 at 11:45 a.m., he stated he knew CR #1 kept saying he wanted to go home because he wanted to shampoo his carpet at home. He said it was not out of the ordinary for residents to express desires to go home. The Administrator said CR #1 had previously been admitted to the facility for rehab and he (CR #1) wanted attention, that was it. The Administrator said CR #1 was not depressed and he just wanted to go home and do chores. The Administrator said CR #1's depression, suicidal ideations, or behaviors were never brought to his attention prior to admission, and he never spoke to CR #1's family before or after his admission. The Administrator said the night before the suicide attempt (05/26/2023), LVN C called him around 10:00 p.m. He said he thought LVN C texted him, or he missed her call and then she texted saying CR #1 was trying to leave the building and that he wanted to kill himself. The Administrator said he sent LVN C a text to call 911, but she sent a text or called him, saying CR #1 was doing fine after they gave him popcorn. The Administrator said he called the LVN C back and she said CR #1 was fine and brushing his teeth. The Administrator said he told LVN C he needed to know what CR #1's state of mind was. He said LVN C said CR #1 could not even recall what he said earlier. He said he told LVN C to put CR #1 on monitoring (no monitoring was documented) and notify him if anything changed. He said he did not receive any more calls that night until incident on Saturday, 05/27/2023 when LVN A called and said CR #1 tried to hurt himself. <BR/>In a telephone interview with LVN A on 06/01/2023 at 11:59 a.m., he stated he was a charge nurse and he only worked weekends. He said on 05/21/2023, the ST approached him and said CR #1 had difficulty swallowing and she wanted to down grade his diet (to a mechanical soft diet). He said the ST told him CR #1 refused the food she used to assess him and said he (CR #1) was tired and wanted to die. LVN A said he went to follow-up with CR #1 in his room and asked about his diet. LVN A said he wanted CR #1 to say in his own words how he felt, but he did not express a desire to die to him. LVN A said he did not ask CR #1 about what he said to the ST. LVN A said he called CR #1's doctor and got an order for a psych consultation and he documented the situation. LVN A said the order was not an urgent order. He said orders for psychiatric services were usually turned in to the SW. LVN A said he slipped the referral under the SW's door on Sunday, 05/21/2023, and he did not hear anything else about CR #1's referral after that. He said he did not relay this information to the DON, the Administrator, or anybody else. He said he did not know the SW was on vacation, but had he known, he would have taken the referral order to someone else. He said no special monitoring or intervention was initiated for CR #1. LVN A said that next weekend, 05/27/2023, CR #1 said he wanted to go home, but that was nothing out of ordinary from his usual agitation. He said on 05/27/2023, he heard another nurse call his name and he ran to the library room and saw CR #1 there with the Receptionist. He said by the time he got to the library, other staff had removed the phone cord from CR #1's neck and he (CR #1) was just shaking. He said he got someone to stay with CR #1 while he called his doctor for an order to send him out and he called CR #1's family and the Administrator. LVN A said the police arrived while he was assessing CR #1 and CR #1 told the officer, Oh, I tried to kill myself, but it was nothing big. LVN A said the officer asked CR #1 again if he wanted to kill himself and CR #1 said yes. LVN A said he did not assign CR #1 a sitter the previous weekend when he initially expressing suicidal ideations. He said RN D called CR #1's family (after the suicide attempt) who said CR #1 had a history of suicidal ideations and had done this (attempted suicide) before. He said CR #1's family never mentioned prior to him having the cord around his neck that he had a history of suicide attempts. LVN A said after he was in-serviced (after CR #1's suicide attempt), he realized he should have expedited the information about the suicidal ideations and referral to the DON or management to let them know what was stated. <BR/>In a telephone interview with CR #1's NP on 06/01/2023 at 12:33 p.m., she stated she visited CR #1 on 05/22/2023, after he was admitted on [DATE]. She said she was notified about CR #1's suicidal ideations on 05/21/2023 and when she saw him on 05/22/2023, she asked him about the day before. She said she asked him if he still wanted to harm himself and he said no, he just wanted to go home and did not want to be in the facility. The NP said she documented in her notes that she put in an urgent request for psych services. The NP said the order was urgent based on CR #1's history of depression. She said she was familiar with the facility's referral process and the request had to be submitted to the SW then sent thru the referral portal. She said the process took a little while, so it was urgent to be done timely. She said she knew the psych provider saw patients at the facility on Mondays, so she knew CR #1 probably would not have been seen Monday, 05/22/2023. She said she was not aware CR #1's discharging facility recommended he be evaluated by psych services. She said had CR #1 exhibited behaviors, the facility staff could have notified psych for medication if needed. The NP said she had no prior knowledge of CR #1's history of suicidal ideations. She said she saw CR #1 again on 05/24/2023 and staff notified her CR #1 had eloped. She said she was not notified of any other incident of suicidal ideations. She said had staff notified her or the on-call doctor that CR #1 made a throat cutting motion (on the morning of 05/27/2023), she would have sent him out to the hospital at that time. <BR/>In an interview with the SW on 06/01/2023 at 1:00 p.m., she stated, usually, the NP or doctor would write an order and the nurse would print the order and give it to her. She said she sent an email to the psychiatric provider and made the referral. The SW said the process usually only took one day and the provider came on Mondays. She said she never received a referral or request for CR #1 to receive psych services. She said she was on vacation 05/14/2023 - 05/24/2023. She said when she returned from vacation, she did not see any request for CR #1 under her door. The SW said nobody ever asked her about any referral for CR #1. She said the facility's nurses could do the referrals if she was not here. The SW said if the psych provider was in the building and the nurses let them know someone needed to be seen, psych would have evaluated CR #1 even without the referral. She said if the referral was already in their computer system, they could have given it to him (psych) and he could have sent the referral to his (psych) office. The SW provided a copy of CR #1's order for psych services from the computer system and said the order did not say anything about urgency. She said she never saw a psych referral mention urgency. She said that (06/01/2023) was the first time she saw CR #1's referral for psych services. <BR/>Observation of the facility on 06/01/2023 at 1:30 p.m. revealed the library was located in a room (not open to the rest of the building) between the reception desk (front entrance) and the nurse's station. Further observation revealed someone would have to pass the entrance to the library to see if anyone was inside the library. There was a telephone with a cord on a small table next to a chair. <BR/>In a telephone interview with LVN C on 06/01/2023 at 1:22 p.m. revealed she usually worked the 2:00 p.m. - 10:00 p.m. and 10:00 p.m. - 6:00 a.m. shift, but she rarely worked on weekends. She said one night (she could not recall the date), she was about to pass medications and CR #1 thanked her for caring for him and said he was leaving, but it was dark. LVN C said she asked CR #1 if his family was coming, but he said no, he was leaving. She said she told CR #1 he was there for therapy and that was it, he went back to sleep. LVN C said on another night (she could not recall the day), CR #1 said he was leaving, and she (LVN C) called his RP (he was his own RP, but he did have an emergency contact), but she did not answer. LVN C said earlier on that day, another staff told her CR #1 had gotten outside (eloped) so, that night CR #1 was assigned a sitter (a facility housekeeper and maintenance staff). LVN C said to her knowledge, that was the only night he had a sitter. LVN C said the night he made the cutting motion was the same night she called CR #1's RP. She said they had to watch CR #1 because he would try to elope, and she noticed he went towards one of the doors. LVN C said CR #1 said they (the nurses) would not let him out the front, so he would get out one way or another, then he made cutting motion across his throat. LVN C said she asked CR #1 if that meant he would cut himself, and he said, If you think that's what I'm saying. LVN C said she told CR #1 if that was what he was saying, she would have to call the police. LVN C said CR #1 told her he would go brush his teeth. She said the Administrator said to go talk to CR #1 and ask if he was going to harm himself. LVN C said CR #1 acted like he did not recall doing that (making the cutting motion) or anything that happened that night. LVN C said CR #1 said he was going to bed. LVN C said she did not have the DON's phone number at that time. LVN C said she did not call CR #1's doctor because, to be honest, it slipped her mind. LVN C said she waiting to see if CR #1 would react or do anything else. She said now, she probably would have called the doctor. She said she was not aware of any referral for psych services for CR #1. <BR/>In a telephone interview with RN D on 06/01/2023 at 1:34 p.m., she stated she was the weekend supervisor and she only worked weekends. She said she interacted with CR #1 on weekends quite a bit. RN D said CR #1 kept wanting to go home and tried to elope several times. RN D said she was never made aware of CR #1's suicidal ideations the weekend before (05/21/2023) his suicide attempt and she worked 6:00 a.m. - 10:00 p.m. RN D said she worked on the weekend the ST worked (05/21/2023) but she was never made aware of CR #1 saying he wanted to die. RN D said CR #1 did not seem depressed and he had dementia but was able to have a conversation and express his feelings. RN D said on 05/27/2023, CR #1 made his usual attempts to elope and kept trying. She said eventually, she heard someone calling for a nurse to check on CR #1 and she followed afterwards. RN D said when she got to the library, CR #1 was in there sitting on a chair and LVN A was assessing him. She said she was not made aware that CR #1 had a referral for psych services. RN D said on weekends, they contact the primary care doctor or NP for a referral order and then they contact the provider they refer to. She said they could make a referral over the phone and then fax it in. She said she had never done a referral over the weekend and unless it was an emergency, they would wait until following week to do it. She said if the situation was emergent, she would do the referral or send the resident out. She said if she felt there was an active plan for suicide, she would notify the doctor and keep the resident on 1:1 monitoring until the doctor determined their next step.<BR/>In an interview with the DON on 06/01/2023 at 2:00 p.m., she said the Administrator called her on 05/26/2023 after CR #1 made the cutting motion across his throat. She said the Administrator told her about CR #1 making the cutting motion, and she asked him if CR #1 had a plan and some other questions. The DON said the Administrator said he would call the facility back to ask those questions and call back if there was anything else. The DON said when the nurse went back in to talk to CR #1, he was no longer expressing suicidal ideations. The DON said in hindsight, she probably should have called CR #1's doctor just in case she wanted her to do anything different. The DON said she had in serviced the nurses on when to communicate with physicians. The DON said she did not know if CR #1's referral was ever sent off to the psych provider. She said the SW handled all referrals and she did not know who to contact about referrals at their psych services provider. She said she believed the Administrator was handling referrals when the SW went on vacation. <BR/>In a follow up telephone interview with the Administrator on 06/01/2023 at 2:25 p.m., he stated if the SW was out, he would have done referrals but, he was never made aware of CR #1's order or referral. He said CR #1's referral was never sent out. <BR/>In a telephone interview with the ST on 06/01/2023 at 2:31 p.m. She said CR #1 did not have suicidal ideations. She said CR #1 told her his wife died at the facility 8-9 years prior and then he said, I guess I'm going to die here too. The ST said it was not an ideation. She said she was working with him and showing him how to swallow safer and he said, Lady, why do you care so much, just let me die. She said CR #1 had diagnosis of depression already, but for her, the words he said to her were resistance from him to do the swallowing exercises and he had a lack of desire to get better. She said she told the charge nurse (LVN A) about it. <BR/>In an interview with the Regional Director of Clinical Services on 06/01/2023 at 2:52 p.m., he stated had CR #1's referral been escalated to the appropriate staff like it should have been, CR #1 would have received the help he needed before he attempted suicide. <BR/>In a telephone interview with the Receptionist[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident who displayed or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder, received appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being for 1 of 11 residents (CR #1) reviewed for psychosocial concerns. <BR/>The facility failed to initiate safety interventions or provide CR #1 with psychiatric services after his physician ordered an urgent consultation when he expressed suicidal ideations and attempted to elope from the facility several times and resulted in an actual suicide attempt on 05/27/2023. <BR/>The facility failed to review and follow recommendations from CR #1's discharging facility for a psychiatric consultation. <BR/>An Immediate Jeopardy (IJ) situation was identified on 06/02/2023 at 1:25 p.m. While the IJ was removed on 06/07/2023, the facility remained out of compliance at the severity level of actual harm with a scope identified as pattern due to the facility's need to evaluate the effectiveness of the corrective systems.<BR/>These failures placed residents with a history of depression or suicidal ideations at risk of experiencing emotional distress, psychiatric episodes, and possible death from not receiving adequate care, interventions, and psychiatric services.<BR/>Findings include:<BR/>Record review of CR #1's face sheet dated 06/01/2023 revealed he was an [AGE] year-old male who was admitted to the facility on [DATE]. His admitting diagnoses included with Parkinson's Disease (a disease of the central nervous system that affects movement, often including tremors), rhabdomyolysis (a breakdown of muscle tissue that releases a damaging protein into the blood), acute kidney failure (a condition in which the kidneys suddenly cannot filter waste from the blood), weakness, repeated falls, depression (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and dementia (a condition characterized by progressive or persistent loss of intellectual functioning). CR #1 was also diagnosed with suicidal ideations (often called suicidal thoughts or ideas, is a broad term used to describe a range of contemplations, wishes, and preoccupations with death and suicide). CR #1 was transferred to a local acute care hospital on [DATE]. <BR/>Record review of CR #1's MDS dated [DATE] revealed he had a BIMS score of 7 (severe cognitive impairment); he felt down, depressed, or hopeless between 7-11 days; he did not experience hallucinations or delusions; he rejected care daily; he wandered daily which placed him at significant risk of getting to potentially dangerous places; he required supervision with no physical assistance for bed mobility, transfers, walking, dressing, and bathing; he required supervision with setup assistance with eating and personal hygiene; he ambulated independently with a walker; he was always continent of bowel and bladder; he experienced coughing or choking during meals or when swallowing medications; and he was prescribed antidepressant medication.<BR/>Record review of CR #1's care plan updated 05/27/2023 revealed the following:<BR/>-CR #1 had potential for elopement as evidenced by exit seeking behavior (05/23/2023 exited out the front door). Goals included: Maintain the least restrictive environment while providing safety. Interventions included: Have activities involved with favorite past times. Music. Exercise. Photo in Elopement risk book. All staff to be made aware of CR #1's risk status via staff sign-in book and verbal reports. If possible, have family or volunteers visit on a regular basis. Keep doctor and family informed. SW to make regular visits. Reorient/Redirect as needed. Reassess as needed. SW to obtain detailed prior routine of CR #1. <BR/>-CR #1 was taking psychotropic medications for Depression (Sertraline). Goals included: CR #1 will not experience adverse side effects. Interventions included: Monitor and record any displayed behavior or mood problems. Encourage appropriate behavior, discourage inappropriate behavior. Monitor effectiveness of psychotropic medications. Monitor for involuntary movements and repetitive behaviors and report to doctor. Review medications every three months for possible dose reduction. Allow CR #1 to express feelings. Protect CR #1 from self-harm or harm to others. Monitor for weight loss. Psych consult as needed. <BR/>-CR #1 had behavioral symptoms not directed toward others (05/27/2023- CR #1 attempted to harm himself by wrapping a phone cord around his neck- 911 was called- will re-evaluate interventions upon return. Goals included: Incidents of self-harm will be decreased. Interventions included: Gently remind CR #1 that behavior is not appropriate. Provide medication as ordered. Record behaviors on Behavior Tracking form. Monitor pattern of behavior (time of day, precipitating factors, specific staff, or situations). Head to toe assessment completed to check for any injuries (no injuries noted). 1 on 1 monitoring until EMS arrived. <BR/>-CR #1 exhibited wandering behaviors. Goals included: Current level of mobility will be maintained. Interventions included: Assess potential causes for wandering (need for toilet, water, food, pain relief). Provide diversional activities. Record behaviors on Behavior Tracking form. Redirect CR #1's behavior/activity when wandering is observed. <BR/>-CR #1 had other behavioral symptoms not directed toward others (refusal of care, threatening to break windows. Goals included: Incident will be decreased. Interventions included: Gently remind CR #1 that behavior is not appropriate. Provide medication as ordered. Record behaviors on Behavior Tracking form. Remove from situation; allow time to calm down. <BR/>-CR #1 was at risk for falls as evidenced by cognitive impairment, fall history, weakness, unsteady gait, and rhabdomyolysis. Goals included: Dignity will be maintained. CR #1 will not experience falls or injuries from falls. Interventions included: Encourage CR #1 to ask for assistance of staff. Ensure call light is in reach, answer promptly. Therapy to evaluate and treat per orders. Anticipate needs, provide prompt assistance. Assure lighting is adequate and areas are free of clutter. <BR/>Observation and interview of CR #1 at a psychiatric hospital on [DATE] at 9:00 a.m. revealed he was alert, oriented and ambulated independently with a walker. CR #1 said they went by the rules at the facility. He said he sneaked out the front door and tried to go to Whataburger. He said he did not like living there because there was no place to go, and he was the type of guy who liked to go places. He said they (he did not say who they were) would not let him go sit outside because he had a fall outside. He said he wanted to get some fresh air, but the nurses caught him. CR #1 said he did not do anything but sit at the facility because there were no activities he liked. He said two of the nurses stood at the door and would not let him out. He said he was going to get out one way or the other, either they would let him walk out, or kill himself and let the undertaker carry him out. He said the cops picked him up from the facility when he tried to kill himself. CR #1 said he wrapped a telephone cord around his neck. He said he had not been home in a very long time, and he wanted to go home. He said they gave him more medication and he felt better now. He said he did not want to kill himself anymore, he wanted to go home. <BR/>Record review of CR #1's hospital records dated 05/16/2023 revealed he was admitted to a local acute care hospital via the emergency room on [DATE] after he fell in his home and was on the floor several hours. The document read in part, . Patient states, 'You're wasting your time- I want to die . I don't have any family- They should have left me on the floor' . Precautions: Falls, Depressed state/ reports, 'I want to die' . Discharge Recommendations: Continue Rehab, Psych Consult. Precautions: Fall, Anxiety/Depression - Recommend Psych Consult . Home Medications: . Sertraline (Zoloft) 50 MG tablets daily . <BR/>Record review of CR #1's hospital records dated 06/02/2023 revealed he was transported to the emergency room by EMS on 05/27/2023. The records read in part, . presenting with EMS after possible strangulation attempt, patient was reported to have been found with a telephone cord around his neck, cyanotic (bluish or grayish color of the skin) appearing face, removed telephone cord and transported to hospital hemodynamically (how your blood flows through your arteries and veins and the forces that affect your blood flow) stable in route. When asked about this, patient reports he was just playing around with cord, had no suicidal intention. Patient would like to leave, does not know why is here, does not want to go back to the facility . patient with history of suicidal ideation . Assessment: Suicidal Attempt . Plan: Admit to floor . Sitter 1:1 . CR #1 was discharged to an inpatient psychiatric hospital on [DATE]. <BR/>Record review of CR #1's physician's orders for May 2023 revealed he was prescribed Sertraline, 50 mg tablets once daily for depression. Start date: 05/18/2023. <BR/>Record review of CR #1's MAR for May 2023 revealed he received Sertraline daily as ordered from 05/19/2023 until 05/26/2023. <BR/>Record review of CR #1's referral for a psychiatry consultation dated 05/21/2023 revealed CR #1's physician gave LVN A verbal orders to refer CR #1 for the consultation on 05/21/2023. The order was electronically signed by LVN A on 05/21/2023 at 8:12 p.m. <BR/>Record review of CR #1's physician progress notes dated 05/22/2023 revealed, . Chief Complaint: New skilled nursing patient seen and examined for admission visit. Patient sitting on side of bed in no apparent distress. Pleasantly confused. States he lives alone. No suicidal ideation today. States he is ready to go home and wants to go home . Physical Exam: . Psychiatric: Judgement/insight: Poor . Summary of Plans: . Consults: Psychiatry to follow . Diagnosis and Assessment: . Dementia - . Has tried to exit seek multiple occasions since admission . Depression - Consult psych. Continue Zoloft 50 mg daily. Per report, suicidal ideation yesterday. None today. Plan: . Urgent consult on psych to evaluate and treat. Recent history of suicidal ideation. None noted today. States he wants to go home and not be in a nursing home .<BR/>Record review of CR #1's physician progress notes dated 05/24/2023 revealed, Chief Complaint: Skilled nursing patient seen and examined in follow-up . Per staff, patient was found outside of the facility walking along the sidewalk stating that he wanted to go home .<BR/>Record review of CR #1's progress notes for May 2023 revealed the following:<BR/>*On 05/21/2023 at 8:05 p.m. (incident occurred at 5:15 p.m.), LVN A wrote, Resident was being evaluated by ST for swallowing issues that were reported. ST was introducing a mechanical soft diet. Resident stated he did not want to change diets. Asked ST 'What for?' He verbalized to ST that he wanted to die instead because he was tired. Will notify MD and refer resident for Psych evaluation.<BR/>*On 05/22/2023 at 12:24 p.m., LVN B wrote, . Resident wanders throughout facility via walker. He attempted to exit x2 despite redirection .<BR/>*On 05/23/2023 at 5:52 a.m., LVN C wrote, During rounds resident was noted to be sitting on the bed and asked this writer to come here. Resident thanked this writer for providing care to him and that he will be leaving today. Asked resident was family coming to get him, he stated no, 'I'm walking. I would walk now but it is dark.' Educated resident on the importance of staying at the facility, resident stated, 'I will think about it .'<BR/>*On 05/23/2023 at 9:54 a.m., LVN B wrote, . This shift, he eloped out of front door and started to walk down the sidewalk. This nurse and other nurses on duty spoke with resident and attempted to provide redirection. After some time, resident agreed to come back inside. Resident still upset, threatening to break windows. Administrator speaking with RP at this time to make a discharge decision. <BR/>*On 05/24/2023 at 3:33 a.m., LVN C wrote, . Resident is in bed resting quietly at this time, sitter is sitting outside of door . <BR/>*On 05/26/2023 at 8:10 p.m., LVN C wrote, Resident is walking around asking staff to help him leave, staff redirects resident. Currently resident is in his room stating that he is leaving as soon as he finds a window to go out of. All staff notified to keep an eye on resident due to him stating he is going to leave.<BR/>*On 05/27/2023 at 2:31 a.m. (incident occurred 05/26/2023 at 8:50 p.m.), LVN C wrote, This writer seen resident going towards the back door. This writer and another began to stand between resident and the door. Resident asked staff if we could move so he could leave. Asked resident where he was going, he stated, home to his bed because he had things to do. This writer explained to resident that I could not let him leave and I was responsible for his wellbeing. Resident stepped closer to staff and asked resident to please step back, he did. Resident continued to stand at the door. Resident then stated that he was going to leave one way or another, resident made a cutting sign (gesture) towards his neck. Asked resident what that was, he stated, 'Could you just let me leave?' Call placed to Administrator, advised resident that he would have to go to his room, or I will call 911, orders given from management. Aide offered popcorn, resident stated he guessed he would go brush his teeth and go to bed. Administrator called and asked if I could interview resident to see if he was a danger to himself. When interviewing resident, he could not recall making a cutting sign at his throat, resident also stated that he will never hurt himself, notified Administrator, resident is currently in bed resting quietly . rounds are made every 2 hours.<BR/>*On 05/27/2023 at 10:12 a.m. (incident occurred at 9:15 a.m.), LVN A wrote, Receptionist was walking towards nursing station when she noted resident sitting in library. When she attempted to approach resident sitting in library, she noted that the resident had the phone cord wrapped around him and attempting to tighten it harder. Receptionist stated that the resident was turning blue when she ran in to intervene and remove the cord from the resident's neck. The Receptionist called for help and LVN E reached out to me on the way to assist resident and Receptionist.<BR/>*On 05/27/2023 at 10:16 a.m., LVN A wrote, . Assessed resident. Resident stabilized after removing cord from neck and having to sit down. Stated wanted to leave. Asked if he was attempting to kill himself and he stated, 'If that's the only way out then, yes?' Called 911 to have resident transferred to hospital for psych evaluation . RN D spoke with family and advised that resident was being sent out to hospital for Psych evaluation due to suicide attempt. Family stated that it was not the first time the resident has attempted suicide .<BR/>Record review of CR #1's, Elopement Risk Assessment dated 05/22/2023 revealed LVN F determined CR #1 was a moderate risk for elopements based on his cognitive impairment and wandering behaviors. Action included, Implement Elopement Risk care plan; Implement Frequent Monitoring Form (form was not completed) to determine elopement risk or until Interdisciplinary Team reviews and makes recommendation.<BR/>Record review of CR #1's, Elopement Risk Assessment dated 05/23/2023 revealed RN G determined CR #1 was an imminent risk for elopements based on his ambulation status, wandering behaviors, and his intentional or unintentional attempts to leave the community. Action included, Implement Elopement Risk care plan; Implement Frequent Monitoring Form (form was not completed) to determine elopement risk or until Interdisciplinary Team reviews and makes recommendation.<BR/>In an interview with the DON and the Regional Director of Clinical Services on 06/01/2023 at 9:45 a.m., the Regional Director of Clinical Services stated the DON was new to the facility and regional staff was not always in the building. The Regional Director of Clinical Services stated, based on what they knew, CR #1 had no previous suicidal ideations. The Regional Director of Clinical Services said CR #1's wife passed away in the facility many years prior and he had no other family other than a neighbor who helped him out prior to admission. The Regional Director of Clinical Services said CR #1's neighbor stated he (CR #1) previously talked about wanting to die. The DON stated to their (administration) knowledge, CR #1 spoke with the ST and referenced dying. The DON said CR #1's physician was notified and ordered an urgent referral for psychiatric services, but psych services was not able to see CR #1 before the suicide attempt. The Regional Director of Clinical Services stated CR #1's physician spoke with LVN A and that is where it ended. The Regional Director of Clinical Services stated LVN A was educated because something like that (suicidal ideations) should be escalated to the top (DON and Administrator). The Regional Director of Clinical Services said LVN A did not let anybody else know about the conversation between CR #1 and the ST. The Regional Director of Clinical Services said CR #1's physician documented his suicidal ideations and that she wanted an urgent psych consult. The Regional Director of Clinical Services said the incident was not communicated to the top (administration), so they did not have an opportunity to follow-up on the referral. The facility's elopement policy was requested, but the wandering policy was provided. <BR/>In an interview with the VP of Clinical Operations on 06/01/2023 at 11:00 a.m., she stated the facility did an emergency QAPI on 05/27/2023, after CR #1 attempted suicide. She said all staff involved were counseled and in-serviced. She said nursing staff talked to each resident who could speak and used a special psychiatric tool given to them by a psych provider to interview about depression and suicide. She said the residents who could not talk were assessed head to toe to insure nothing was out of the ordinary for them. She said the Administrator was suspended because their investigation found he may have known about CR #1's prior history of depression.<BR/>In a telephone interview with the Administrator on 06/01/2023 at 11:45 a.m., he stated he knew CR #1 kept saying he wanted to go home because he wanted to shampoo his carpet at home. He said it was not out of the ordinary for residents to express desires to go home. The Administrator said CR #1 had previously been admitted to the facility for rehab and he (CR #1) wanted attention, that was it. The Administrator said CR #1 was not depressed and he just wanted to go home and do chores. The Administrator said CR #1's depression, suicidal ideations, or behaviors were never brought to his attention prior to admission, and he never spoke to CR #1's family before or after his admission. The Administrator said the night before the suicide attempt (05/26/2023), LVN C called him around 10:00 p.m. He said he thought LVN C texted him, or he missed her call and then she texted saying CR #1 was trying to leave the building and that he wanted to kill himself. The Administrator said he sent LVN C a text to call 911, but she sent a text or called him, saying CR #1 was doing fine after they gave him popcorn. The Administrator said he called the LVN C back and she said CR #1 was fine and brushing his teeth. The Administrator said he told LVN C he needed to know what CR #1's state of mind was. He said LVN C said CR #1 could not even recall what he said earlier. He said he told LVN C to put CR #1 on monitoring (no monitoring was documented) and notify him if anything changed. He said he did not receive any more calls that night until incident on Saturday, 05/27/2023 when LVN A called and said CR #1 tried to hurt himself. <BR/>In a telephone interview with LVN A on 06/01/2023 at 11:59 a.m., he stated he was a charge nurse and he only worked weekends. He said on 05/21/2023, the ST approached him and said CR #1 had difficulty swallowing and she wanted to down grade his diet (to a mechanical soft diet). He said the ST told him CR #1 refused the food she used to assess him and said he (CR #1) was tired and wanted to die. LVN A said he went to follow-up with CR #1 in his room and asked about his diet. LVN A said he wanted CR #1 to say in his own words how he felt, but he did not express a desire to die to him. LVN A said he did not ask CR #1 about what he said to the ST. LVN A said he called CR #1's doctor and got an order for a psych consultation and he documented the situation. LVN A said the order was not an urgent order. He said orders for psychiatric services were usually turned in to the SW. LVN A said he slipped the referral under the SW's door on Sunday, 05/21/2023, and he did not hear anything else about CR #1's referral after that. He said he did not relay this information to the DON, the Administrator, or anybody else. He said he did not know the SW was on vacation, but had he known, he would have taken the referral order to someone else. He said no special monitoring or intervention was initiated for CR #1. LVN A said that next weekend, 05/27/2023, CR #1 said he wanted to go home, but that was nothing out of ordinary from his usual agitation. He said on 05/27/2023, he heard another nurse call his name and he ran to the library room and saw CR #1 there with the Receptionist. He said by the time he got to the library, other staff had removed the phone cord from CR #1's neck and he (CR #1) was just shaking. He said he got someone to stay with CR #1 while he called his doctor for an order to send him out and he called CR #1's family and the Administrator. LVN A said the police arrived while he was assessing CR #1 and CR #1 told the officer, Oh, I tried to kill myself, but it was nothing big. LVN A said the officer asked CR #1 again if he wanted to kill himself and CR #1 said yes. LVN A said he did not assign CR #1 a sitter the previous weekend when he initially expressing suicidal ideations. He said RN D called CR #1's family (after the suicide attempt) who said CR #1 had a history of suicidal ideations and had done this (attempted suicide) before. He said CR #1's family never mentioned prior to him having the cord around his neck that he had a history of suicide attempts. LVN A said after he was in-serviced (after CR #1's suicide attempt), he realized he should have expedited the information about the suicidal ideations and referral to the DON or management to let them know what was stated. <BR/>In a telephone interview with CR #1's NP on 06/01/2023 at 12:33 p.m., she stated she visited CR #1 on 05/22/2023, after he was admitted on [DATE]. She said she was notified about CR #1's suicidal ideations on 05/21/2023 and when she saw him on 05/22/2023, she asked him about the day before. She said she asked him if he still wanted to harm himself and he said no, he just wanted to go home and did not want to be in the facility. The NP said she documented in her notes that she put in an urgent request for psych services. The NP said the order was urgent based on CR #1's history of depression. She said she was familiar with the facility's referral process and the request had to be submitted to the SW then sent thru the referral portal. She said the process took a little while, so it was urgent to be done timely. She said she knew the psych provider saw patients at the facility on Mondays, so she knew CR #1 probably would not have been seen Monday, 05/22/2023. She said she was not aware CR #1's discharging facility recommended he be evaluated by psych services. She said had CR #1 exhibited behaviors, the facility staff could have notified psych for medication if needed. The NP said she had no prior knowledge of CR #1's history of suicidal ideations. She said she saw CR #1 again on 05/24/2023 and staff notified her CR #1 had eloped. She said she was not notified of any other incident of suicidal ideations. She said had staff notified her or the on-call doctor that CR #1 made a throat cutting motion (on the morning of 05/27/2023), she would have sent him out to the hospital at that time. <BR/>In an interview with the SW on 06/01/2023 at 1:00 p.m., she stated, usually, the NP or doctor would write an order and the nurse would print the order and give it to her. She said she sent an email to the psychiatric provider and made the referral. The SW said the process usually only took one day and the provider came on Mondays. She said she never received a referral or request for CR #1 to receive psych services. She said she was on vacation 05/14/2023 - 05/24/2023. She said when she returned from vacation, she did not see any request for CR #1 under her door. The SW said nobody ever asked her about any referral for CR #1. She said the facility's nurses could do the referrals if she was not here. The SW said if the psych provider was in the building and the nurses let them know someone needed to be seen, psych would have evaluated CR #1 even without the referral. She said if the referral was already in their computer system, they could have given it to him (psych) and he could have sent the referral to his (psych) office. The SW provided a copy of CR #1's order for psych services from the computer system and said the order did not say anything about urgency. She said she never saw a psych referral mention urgency. She said that (06/01/2023) was the first time she saw CR #1's referral for psych services. <BR/>Observation of the facility on 06/01/2023 at 1:30 p.m. revealed the library was located in a room (not open to the rest of the building) between the reception desk (front entrance) and the nurse's station. Further observation revealed someone would have to pass the entrance to the library to see if anyone was inside the library. There was a telephone with a cord on a small table next to a chair. <BR/>In a telephone interview with LVN C on 06/01/2023 at 1:22 p.m. revealed she usually worked the 2:00 p.m. - 10:00 p.m. and 10:00 p.m. - 6:00 a.m. shift, but she rarely worked on weekends. She said one night (she could not recall the date), she was about to pass medications and CR #1 thanked her for caring for him and said he was leaving, but it was dark. LVN C said she asked CR #1 if his family was coming, but he said no, he was leaving. She said she told CR #1 he was there for therapy and that was it, he went back to sleep. LVN C said on another night (she could not recall the day), CR #1 said he was leaving, and she (LVN C) called his RP (he was his own RP, but he did have an emergency contact), but she did not answer. LVN C said earlier on that day, another staff told her CR #1 had gotten outside (eloped) so, that night CR #1 was assigned a sitter (a facility housekeeper and maintenance staff). LVN C said to her knowledge, that was the only night he had a sitter. LVN C said the night he made the cutting motion was the same night she called CR #1's RP. She said they had to watch CR #1 because he would try to elope, and she noticed he went towards one of the doors. LVN C said CR #1 said they (the nurses) would not let him out the front, so he would get out one way or another, then he made cutting motion across his throat. LVN C said she asked CR #1 if that meant he would cut himself, and he said, If you think that's what I'm saying. LVN C said she told CR #1 if that was what he was saying, she would have to call the police. LVN C said CR #1 told her he would go brush his teeth. She said the Administrator said to go talk to CR #1 and ask if he was going to harm himself. LVN C said CR #1 acted like he did not recall doing that (making the cutting motion) or anything that happened that night. LVN C said CR #1 said he was going to bed. LVN C said she did not have the DON's phone number at that time. LVN C said she did not call CR #1's doctor because, to be honest, it slipped her mind. LVN C said she waiting to see if CR #1 would react or do anything else. She said now, she probably would have called the doctor. She said she was not aware of any referral for psych services for CR #1. <BR/>In a telephone interview with RN D on 06/01/2023 at 1:34 p.m., she stated she was the weekend supervisor and she only worked weekends. She said she interacted with CR #1 on weekends quite a bit. RN D said CR #1 kept wanting to go home and tried to elope several times. RN D said she was never made aware of CR #1's suicidal ideations the weekend before (05/21/2023) his suicide attempt and she worked 6:00 a.m. - 10:00 p.m. RN D said she worked on the weekend the ST worked (05/21/2023) but she was never made aware of CR #1 saying he wanted to die. RN D said CR #1 did not seem depressed and he had dementia but was able to have a conversation and express his feelings. RN D said on 05/27/2023, CR #1 made his usual attempts to elope and kept trying. She said eventually, she heard someone calling for a nurse to check on CR #1 and she followed afterwards. RN D said when she got to the library, CR #1 was in there sitting on a chair and LVN A was assessing him. She said she was not made aware that CR #1 had a referral for psych services. RN D said on weekends, they contact the primary care doctor or NP for a referral order and then they contact the provider they refer to. She said they could make a referral over the phone and then fax it in. She said she had never done a referral over the weekend and unless it was an emergency, they would wait until following week to do it. She said if the situation was emergent, she would do the referral or send the resident out. She said if she felt there was an active plan for suicide, she would notify the doctor and keep the resident on 1:1 monitoring until the doctor determined their next step.<BR/>In an interview with the DON on 06/01/2023 at 2:00 p.m., she said the Administrator called her on 05/26/2023 after CR #1 made the cutting motion across his throat. She said the Administrator told her about CR #1 making the cutting motion, and she asked him if CR #1 had a plan and some other questions. The DON said the Administrator said he would call the facility back to ask those questions and call back if there was anything else. The DON said when the nurse went back in to talk to CR #1, he was no longer expressing suicidal ideations. The DON said in hindsight, she probably should have called CR #1's doctor just in case she wanted her to do anything different. The DON said she had in serviced the nurses on when to communicate with physicians. The DON said she did not know if CR #1's referral was ever sent off to the psych provider. She said the SW handled all referrals and she did not know who to contact about referrals at their psych services provider. She said she believed the Administrator was handling referrals when the SW went on vacation. <BR/>In a follow up telephone interview with the Administrator on 06/01/2023 at 2:25 p.m., he stated if the SW was out, he would have done referrals but, he was never made aware of CR #1's order or referral. He said CR #1's referral was never sent out. <BR/>In a telephone interview with the ST on 06/01/2023 at 2:31 p.m. She said CR #1 did not have suicidal ideations. She said CR #1 told her his wife died at the facility 8-9 years prior and then he said, I guess I'm going to die here too. The ST said it was not an ideation. She said she was working with him and showing him how to swallow safer and he said, Lady, why do you care so much, just let me die. She said CR #1 had diagnosis of depression already, but for her, the words he said to her were resistance from him to do the swallowing exercises and he had a lack of[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to have the resident's comprehensive care plan, reviewed, and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for 1 (Resident #27) of 6 residents reviewed for care plan timing and revision. <BR/>The facility failed to review and revise the comprehensive care plan for Resident #27.<BR/>This failure could place residents at risk of a diminished quality of life leading to a variety of emotional and physical problems/issues.<BR/>Findings included:<BR/>Record review of Resident #27's face sheet revealed a [AGE] year-old male who was admitted on [DATE]. His diagnosis was dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment), and cerebral infraction (occurs because of disrupted blood flow to the brain due to problems with blood vessels that supply it).<BR/>Record review of resident #27's Comprehensive MDS dated [DATE] revealed Resident #27 had a BIMs score of 06 indicating the resident was severely cognitively impaired. The resident required extensive assistance with two persons physical assist with bed mobility. He required total dependence and one-person physical assistance for dressing, total dependence and two persons assistance for toilet use, supervision, and setup for eating, and total dependence and two persons assistance for transfer. He also requires total dependence and one-person assistance for personal hygiene. <BR/>Record Review of resident #27's care plan, revision date not listed, revealed Resident #27 was not care planned for a low bed. <BR/>Record Review of Resident #27's care plan, revision date not listed, revealed Resident #27's was care planned for falls that occurred on 7/21/2022, 7/24/2022, 9/15/2022, 4/07/2023, and 4/13/2023. His goals revealed he will demonstrate the ability to ambulate/transfer without fall related injuries over the next 90-day review period. The interventions revealed, place call bell/light within easy reach, remind [NAME] to call for assistance before moving from bed-to-chair and from chair to bed. Respond promptly to calls for assist to the toilet, footwear will fit properly and have non-skid soles, and provide reminders to use ambulation and transfer assist devices.<BR/>Observation on 5/2/2023 at 10:55a.m., revealed Resident #27, lying down on a bed that was very low to the ground. His legs were touching the ground and his diaper was hanging off him.<BR/>Interview on 5/2/2023 at 11:00a.m., with CNA A, said Resident #27 bed was low because he sometimes hangs his legs off the bed, and it keeps him from hurting himself. She said Resident #27 moved a lot which moved his diaper off him. She said Resident #27 had an indwelling catheter. <BR/>Interview on 5/4/2023 at 9:34a.m., with Charge nurse/LVN P, said Resident #27 reposition himself when he was lying in bed. He said he will put his feet off the bed and when he was tired, he would put his feet back up. He said the bed was low because Resident #27 is a fall risk. <BR/>Interview on 5/4/2023 at 1:32p.m., with LVN X, said whenever something has changed with a resident, it was important to write it in the care plan. She said the plan of care is in place to make sure everything was good with the resident. LVN X said she looked through the care plan and said the low bed for Resident #27 was not documented in his care plan. She said the nurse would usually tell her if they needed help with something and she would help them with the care plan. She said all the licensed nurses are responsible for putting things in the care plan. She said she edited and took things out of the care plan if it was no longer needed or when she does their next assessment. She said a nurse never shared with her that Resident #27's low bed needed to be documented in his care plan. She said the nurse working with Resident #27 on the hall would inform her of any changes with Resident #27. She said the PCC, ADON, the unit manager, and the treatment nurse does the care plans. <BR/>Interview on 5/4/2023 at 1:52p.m., the ADON, said the importance of having a care plan was so they know how to care for the patient. She said anyone can go into the system and see what needed to be done for the patient. She said they have 24 hours reports that they use to write information regarding the residents, and they also use clinical notes and daily care guides on how to care for the residents. She said they have morning meetings and discuss the things that were needed or added to the care plan. She said the MDS was on top of things like that. She said if the nurses were lowering Resident #27's bed, it should be documented in the care plan. She said it could be a risk of the patient being off the low bed and having a risk for injury if it was not noted in the care plan. She said for accuracy of the care plans, it was normally done as a team, to ensure everyone was on the same page. She said the care plan should be update quarterly or as needed.<BR/>Interview on 5/4/2023 at 2:15p.m., with unit manager LVN Y, said she tried to keep Resident #27's catheter on the bed, and if the bed is high, he will reposition himself and might pull the catheter. She said it was safer for the catheter to be near the bed. She said she knows that it is a low bed because it is a particular type of bed. She said Resident #27 has a low bed in his room. <BR/>Record Review of the facility's policy titled Patient Care Management System, revised on 11/2017 read in part . Each care plan must be reviewed and updated by the interdisciplinary Care Plan team quarterly, upon each change in condition and upon re-admission. <BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide pharmaceutical services to meet the needs of each resident for 3 of 5 residents (Resident #56, Resident #69 and Resident #72) reviewed for pharmacy services. <BR/>- The facility failed to ensure that the 200 Hall Nursing Cart did not contain expired insulin pens for Resident #56, Resident #69 and Resident #72.<BR/>This failure could place residents at risk of not receiving the therapeutic benefit of medications, uncontrolled blood sugars and/or adverse reactions to medications. <BR/>Findings Included<BR/>Resident #69<BR/>Record review of Resident #69's Face Sheet dated 05/03/23 revealed, a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included: dementia, muscle weakness and type 2 diabetes.<BR/>Record review of Resident #69's admission MDS signed 09/05/22 revealed, use of corrective lenses, moderately impaired cognition as indicated by a BIMS score of 12 out of 15, supervision for most ADLs and occasionally incontinent of both bladder and bowel.<BR/>Record review of Resident #69's undated Care Plan revealed, no care plan problem areas related to citation. The care plan did not include diabetes.<BR/>Record review of Resident #69's Patient Medication Profile dated 05/03/23 revealed, HumaLOG Insulin- check blood sugar and follow sliding scale four times starting 03/17/23.<BR/>Resident #56<BR/>Record review of Resident #56's Face Sheet dated 05/03/23 revealed, an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included: high cholesterol, pressure ulcer of the left heal and type 2 diabetes.<BR/>Record review of Resident #56's Annual MDS signed 03/29/23 revealed, severely impaired cognition as indicated by a BIMS score of 04 out of 15, extensive assistance with most ADLs and always incontinent of both bladder and bowel.<BR/>Record review of Resident #56's undated Care Plan revealed, problem- risk for high or low blood sugar episodes secondary to diabetes; interventions- medication as ordered.<BR/>Record review of Resident #56's Patient Medication Profile dated 05/03/23 revealed, NovoLOG( Insulin Aspart)- check blood sugar and follow sliding scale four times a day starting 06/30/22. Lantus Insulin- 30 units under the skin two times daily starting 05/01/23.<BR/>Resident #72<BR/>Record review of Resident #72's Face Sheet dated 05/03/23 revealed, a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included: irregular heartbeat, nicotine dependence and diabetes.<BR/>Record review of Resident #72's Annual MDS signed 03/04/23 revealed, moderately impaired cognition as indicated by a BIMS score of 11 out of 15, occasionally incontinent of bladder, always continent of bowel and supervision for most ADLs.<BR/>Record review of Resident #72's undated Care Plan revealed, no care plan problem areas related to citation. The care plan did not include diabetes.<BR/>Record review of Resident #72's Patient Medication Profile dated 05/03/23 revealed, HumaLOG Insulin- check blood sugar and follow sliding scale under the skin four times day with start date 03/14/22. Lantus- inject 10 units under the skin two times daily.<BR/>An observation and interview on 05/04/23 at 09:04 AM AM, inventory of the 200 Hall Nursing Cart with LVN A revealed:<BR/>- 1 expired, open and in-use Insulin Lispro vial for Resident #69 with an open date of 03/28/23. <BR/>- Expired, open and in-use Insulin Aspart (NovoLOG) and Lantus Insulin vials for Resident #56 with an open dates of 03/28/23.<BR/>- Expired, open and in-use Insulin Lispro and Lantus Insulin vials for Resident #72 with an open dates of 03/28/23.<BR/>LVN A said nursing staff are expected to check their carts daily as used for expired medications including insulin. She said the insulin pens should only be used for 30 days once opened (04/27/23) so they were expired and could no longer be used. LVN A said when insulin expires it loses it efficacy and use could place residents at risk for uncontrolled blood sugars. She said she would reorder the medication and then ask her ADON on the appropriate way to dispose of the expired insulin.<BR/>In an interview on 05/03/23 at 11:00 AM, the ADON said nursing staff are expired to check their carts daily for expired medications. She said when insulin expires it is was not as effective so they should be discarded in the drug disposal bin in the medication room. The ADON said the use of expired insulin could place residents at risk of uncontrolled blood sugars.<BR/>Record review of the facility's policy titled 'Storage of Medications' revised 04/2007 revealed, 4- the facility shall not use discontinued, outdated or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed.<BR/>Record review of the facility's policy titled 'Drug Destruction' dated 09/2013 revealed, expired medications shall be removed and disposed of through monthly drug destruction.<BR/>Record review of the undated facility documents titled 'Medication Storage Review' revealed, check insulins and remove those open &gt;28 days, except Levemir 42 days and Ozempic is 56 days. Date open must be on vial/pen, vial/pen must be in fully labeled bag/box/bottle.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 2 of 4 medication carts (300 Hall Nursing Cart and 400 Hall Nursing Cart) reviewed for medication storage. <BR/>- The facility failed to ensure the 400 Hall Nursing Cart did not contain medications without pharmacy labels identifying the patients or medication administration instructions.<BR/>- The facility failed to ensure the 300 Hall Nursing Cart did not contain insulin pens without open dates.<BR/>This failure could place residents at risk of uncontrolled health conditions and adverse medication reactions.<BR/>Findings Included:<BR/>400 Hall Nursing Cart<BR/>An observation and interview on [DATE] at 09:08 AM, inventory of the 400 Hall Nursing Cart with LVN B revealed: <BR/>- An Enoxaparin Sodium (a blood thinner) 40 mg/0.4 ml Injection without a pharmacy label.<BR/>- A vial of Nitroglycerin (treatment of chest pain) 0.4mg tablets without a pharmacy label.<BR/>LVN B said nursing staff are expected to check their carts daily for inappropriately labeled medications. She said all medications must have a pharmacy label with patient identifiers and prescription information. LVN B said since the Enoxaparin and Nitroglycerine had no labeling there could not be used and must be discarded in the drug disposal bin located in the medication room. She said the use of medications without the appropriate labels could place residents at risk for med errors because of the potential to give the medications to the wrong resident or administer the wrong dose.<BR/>300 Hall Nursing cart<BR/>Resident #51<BR/>Record review of Resident #51's Face Sheet dated [DATE] revealed, a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included: repeated falls, anxiety disorder, high cholesterol and type 2 diabetes.<BR/>Record review of Resident #51's admission MDS signed [DATE] revealed, moderately impaired cognition as indicated by a BIMS score of 09 out of 15, extensive assistance with most ADLs and always incontinent of both bladder and bowel.<BR/>Record review of Resident #51's undated Care Plan revealed, problem- risk of hyper or hypoglycemic episodes secondary to diabetes; interventions- medication as ordered.<BR/>Record review of Resident #51's Patient Medication Profile dated [DATE] revealed, Insulin Glargine (Lantus)- Inject 25 units under the skin one time daily starting [DATE].<BR/>Resident #8<BR/>Record review of Resident #8's Face Sheet dated [DATE] revealed, an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of: anxiety disorder, heart failure and type 2 diabetes.<BR/>Record review of Resident #8's Annual MDS signed [DATE] revealed, intact cognition as indicated by a BIMS score of 15 out of 15, extensive assistance with most ADLs, and occasionally incontinent of both bladder and bowel.<BR/>Record review of Resident #8's undated Care Plan revealed, Problems- risk of hyper or hypoglycemic episodes secondary to diabetes. Medication: Lantus Insulin.<BR/>Record review of Resident #8's Patient Medication Profile dated [DATE] revealed, Tresiba- 20 units under the skin one time daily starting [DATE].<BR/>An observation and interview on [DATE] at 09:14 AM inventory of the 300 Hall Nursing Cart with LVN C revealed:<BR/>- An open an in-use vial of Insulin Glargine (Lantus) with pharmacy fill date of [DATE] for Resident #51 with no open date.<BR/>- An open and in-use Tresiba Insulin Pen for Resident #8 with no open date. <BR/>LVN C said nursing staff are expected to check their carts daily as used for inappropriately labeled medications. She said insulin pens/vials should be labeled with the date opened in order to track the expiration date. LVN C said when insulin expires it could become less effective and since the insulin found had no open date their expiration dates could not be determined so they must be discarded in the sharps container after they were reordered. She said the use of expired insulin could place residents at risk of uncontrolled blood sugars. <BR/>In an interview on [DATE] at 11:00 AM, the ADON said nursing staff are expected to check their carts daily as used for inappropriately labeled medications. She said all prescription medications must have a pharmacy labeled with patient identifiers and drug information. The ADON said all multi-dose insulin containers [NAME] be labeled with the date opened in order to track their expiration since insulin could become less effective once expired. She said any insulin containers without open dates or inappropriately labeled medications must be discarded in the drug disposal bin located in the medication room since the expiration dates or patient information are unknown. The ADON said the use of medications without pharmacy identifiers or insulin containers with no open date could place residents at risk of uncontrolled blood sugars and adverse reactions.<BR/>Record review of the facility's policy titled 'Storage of Medications' revised 04/2007 revealed, 3- drug containers that have missing, incomplete, improper, or incorrect labels shall be returned to the pharmacy for proper labeling before storing.<BR/>Record review of the facility's policy titled 'Administering Medications' revised 04/2019 revealed, 12- expiration/beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container.<BR/>Record review of the facility's policy titled 'Labeling of Medication Container' revised 04/2019 revealed, 3- labels for individual resident medications include all necessary information such as: resident's name, prescribing physician, pharmacy contact information, the prescription number, the date the medication was dispensed, and the directions for use.<BR/>Record review of the undated facility documents titled 'Medication Storage Review' revealed, check-multi dose containers for date open on container( . vials/pens for injectable meds and diluent fluid vials). Date open must be on vial/pen, vial/pen must be in fully labeled bag/box/bottle.