Immanuel Campus Of Care

Based on clinical record review, facility documentation, and staff interviews, the facility failed to protect the rights of one resident #222 to be free from abuse by another resident #333. The deficient practice could result in further abuse.

Based on clinical record review, facility documentation, and staff interviews, the facility failed to protect the rights of one resident #222 to be free from abuse by another resident #333. 

Based on observation the facility failed to provide a fire extinguisher near the generator. Failing to have an available fire extinguisher during an emergency could result in harm to the patients and/or staff.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.5.12 "Portable fire extinguishers shall be provided in all health care occupancies in accordance with 9.7.4.1" Section 9.7.4.1 "Where required by the provisions of another section of this Code, portable fire extinguishers shall be installed, inspected, and maintained in accordance with NFPA 10, Standard for portable Fire Extinguishers." 9.7.4 Manual Extinguishing Equipment. 9.7.4.1 Where required by the provisions of another section of this Code, portable fire extinguishers shall be selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. NFPA 10 2010 Edition 6.3.1.1 Minimum sizes of fire extinguishers for the listed grades of hazard shall be provided in accordance with Table 6.3.1.1, 6.3.1.2 Fire extinguishers shall be located so that the maximum travel distances do not exceed those specified in Table 6.3.1.1. NFPA 30 2012 edition 4.2.2 Combustible liquids Any liquid that has a closed cup flash point at or above 100 f as determined by the test procedures and apparatus set forth in section 4.4 NFPA 10 2012 edition 5.2.2 Class B fires are fires in flammable liquids, combustible liquids, petroleum greases, tars, oils, oil-based paints, solvents, lacquers, alcohols, and flammable gases. 6.3.1 Other Than for Fires in Flammable Liquids of Appreciable Depth. 6.3.1.1 Minimum sizes of fire extinguishers for the listed grades of hazard shall be provided in accordance with Table 6.3.1.1, except as modified by 6.3.1.5. Table 6.3.1.1 Fire Extinguisher Size and Placement for Class B Hazards Type of Hazardv Basic Minimum Extinguisher Rating (moderate) 20-B maximum travel distance to extinguishers 50ft.

Findings include:

Observations made while on tour on February 10, 2025, revealed the following:

There was no a fire extinguisher installed within 50 feet of the generator.

The management team confirmed during the facility tour and exit conference on February 10, 2025, that a fire extinguisher was not readily available for the generator.

Based on observation the facility failed to maintain several doors in the building. Failing to maintain doors in the facility could allow heat and/or smoke to transfer which will cause harm to the patients and/or staff.

NFPA 101, Life Safety Code, 2012 edition, Chapter 19, Section 19.3.6.3.5. "Doors shall be provided with a means for keeping the door closed that is acceptable to the authority having jurisdiction." NFPA 80 2010 edition, Chapter 5 Section 5.2.14 Maintenance of Closing Mechanisms. 5.2.14.1 Self-closing devices shall be kept in working condition at all times. Chapter 19, Section 19.3.6.3 Corridor Doors Section 19.3.6.3.1* Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 1-3/4 inch solid-bonded core wood, or capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Doors shall be provided with a means suitable for keeping the door closed.

Findings include:

Observations made while on tour on February 10, 2025, revealed the following:

1. The door leading to the administration office in the activities room gap at the top of the 20-minute door.
2. Room 130 door has a gap at the top handle side.
3. Room 338 the door does not latch.
4. Room 329 the door has a side gap from the handle down.
5. Room 331 the door has a gap handle side and top.
6. Room 332 the door has a gap at the top handle side.
7. Room 333 the door does not latch.
8. Room 428 the door has a gap along the side and at the top.
9. Room 415 the door has a gap from the handle down.
10. Room 407 the door has a side gap handle up and at the top.
11. Room 403 the door has a side gap handle up and at the top.
12. Room 404 the door has a side gap handle up and at the top.
13. Room 405 the door has a side gap handle up and at the top.
14. Room 406 side gap from the handle up.
15. Room 411 the door has a side gap handle up and at the top.
16. Room 412 the door has a side gap handle up and at the top.
17. Unit manager door in Sunshine Square has gaps along the handle side.
18. Room 302 missing the door latch.
19. Room 303 the door has a gap along the handle side.
20. Room 304 the door has a gap along the handle side.
21. Room 112 the door has a gap along the top.
22. Room 109 the door has a side gap handle up.
23. Room 108 the door has a notch out of the for at the handle.
24. Room 106 the door does not latch.
25. The southside dining room door at Garden Cove has a gap along the top.
26. The 20-minute door at the second-floor elevator does not latch.
27. Room 225 the door has a gap along the top.
28. Room 241 the door is not latching.
29. Room 240 the door is not latching.
30. Room 226 the door has a knob instead of a lever handle.
31. Room 228 the door is not latching.
32. Room 229 the door has a gap along the top.
33. Room 231 the door is not latching.
34. Room 232 the door has a knob instead of a lever handle.
35. Room 233 the door has a knob instead of a lever handle.
36. Room 235 the door has a knob instead of a lever handle.
37. Room 222 the door is not latching.
38. Room 202 the door has a knob instead of a lever handle.
39. Room 203 the door is not latching.
40. Room 221 the door has a knob instead of a lever handle.
41. Room 204 the door is not latching.
42. Room 220 the door is not latching.
43. Room 218 the door has a knob instead of a lever handle.
44. Room 217 the door is not latching and the door has a knob instead of a lever handle.
45. Room 216 the door is not latching and the door has a knob instead of a lever handle.
46. Room 215 the door is not latching and the door has a knob instead of a lever handle.
47. The dining room door in the 200 hall is not latching.
48. Room 213 the door has a knob instead of a lever handle.
49. Room 214 the door has a knob instead of a lever handle.
50. Room 212 the door has a knob instead of a lever handle.
51. Room 206 the door has a knob instead of a lever handle.
52. Room 207 the door has a knob instead of a lever handle.
53. Room 210 the door is not latching and has a knob instead of a lever handle.
54. Room 209 the door has a knob instead of a lever handle.
55. Room 208 the door does not latch and has a knob instead of a lever handle.

The management team acknowledged during the facility tour and exit conference on February 10, 2025, the door deficiencies.

Based on observation it was determined the facility failed to properly fill penetrations in multiple areas of the fire/smoke barriers in the facility. Failing to seal the penetrations, holes, and openings in the fire/ smoke barriers will allow smoke and heat to penetrate other wings or possibly the whole facility which could cause harm to the patients in the time of a fire.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.7.3 "Any required smoke barrier shall be constructed in accordance with Section 8.5 and shall have a fire resistance rating of at least \'bd hour." Chapter 8, Section 8.5.6.2 Penetrations for cables cable trays, conduits, pipes, tubes, vents wires and similar items to accommodate electrical, plumbing and communications systems that pass through a wall, floor or /ceiling assembly constructed as a smoke barrier, or through the ceiling membrane of the roof /ceiling of a smoke barrier assembly shall be protected by a system or material capable of restricting the transfer of smoke.

Findings include:

Observations made during a facility tour conducted on February 10, 2025, revealed that the facility failed to maintain the fire/ smoke barrier in the following areas:

1. Two wall penetrations measuring approximately 4 inches by 4 inches above the ceiling tiles at the employee entrance door and Canyon Suites.
2. Unsealed wall penetration above ceiling tile at the Canyon Suites entrance, cables going through the was.

The management team confirmed the unsealed penetrations in the fire/smoke barrier. during the facility tour and exit conference on February 10, 2025.

Based on observation and staff interview, the facility did not provide emergency lighting for the emergency generator in accordance with the requirements of NFPA 101 -2012 edition, Section 19.5.1, 9.1, 9.1.3 and NFPA 110 - 2010 edition, Section 7.3.1. This deficient practice could affect all of the 152 residents.

Findings include:

On February 10, 2025, observation at the emergency generator revealed there was no battery-powered emergency lighting located at the generator. The generator was located outside; however, was surrounded by an enclosure.

The management team confirmed during the facility tour and exit conference on February 10, 2025, that the emergency generator did not have a battery powered emergency light.

Based on observation and staff interviews, the facility failed to ensure that a remote stop or kill switch for the generator was installed. This could affect the entire facility and could result in a loss of power due to a generator malfunction during an emergency power outage. Failure to have an emergency stop on the generator could cause a fire or harm the residents and staff.

Code reference: NFPA 110 2010 Edition; Standard for Emergency and Standby Power Systems 5.6.5.6 All installations shall have a remote manual stop station of a type to prevent inadvertent or unintentional operation, located outside the room housing the prime mover, where so installed, or elsewhere on the premises where the prime mover is located outside the building. A.5.6.5.6 For systems located outdoors, the manual shut-down should be located external to the weatherproof enclosure and should be appropriately identified.

Findings include:

During observations during a tour conducted on February 10, 2025, it was revealed that the facility's generator did not have the required remote stop or kill switch. Per facility management, this switch is currently out for bid.

The management teamconfirmed during facility tour and the exit conference on February 10, 2025, that the facility did not have an emergency shut of for the generator.

Based on observation, documentation, resident and staff interviews, and the facility policy and procedures, the facility failed to ensure that residents (#55 and #33) were allowed to leave their rooms during a COVID-19 outbreak.

Findings include:

Resident #55 was admitted to the facility on August 16, 2023 with diagnoses that included dementia in other diseased classified, traumatic brain injury, adjustment disorder, schizoaffective disorder, and bipolar disorder.

The minimum data set (MDS) dated August 14, 2024 included a brief interview for mental status score of 9 indicating the resident had a moderate cognitive impairment.

The COVID-19 line listing documentation revealed that resident #55 tested positive for COVID-19 on December 2, 2024 and was asymptomatic.

Note: resident #55 remained quarantined on December 20, 2024, which was a total of 18 days.

-Resident #33 was admitted to the facility on June 4, 2024 with diagnoses that included major depression, general anxiety, and borderline personality disorder.

The minimum data set (MDS) dated June 12, 2024 included a brief interview for mental status score of 14 indicating the resident was cognitively intact.

The COVID-19 line listing documentation revealed that resident #33 tested positive for COVID-19 on December 2, 2024 and was asymptomatic.

Note: resident #33 remained quarantined on December 20, 2024, which was a total of 18 days.

An interview was conducted on December 19, 2024 at 4:15 p.m. with resident #55, who stated that he is not allowed to go out of his room because of COVID-19. He stated that he is not sick and has not been allowed to go for a cigarette. The resident was upset as evidenced by the increased volume and irritated tone of his voice. During the interview, resident #66 called out from across the hall and wanted to report that he was told that he can't come out of his room, but he did have COVID-19. During this time, another resident #33 ambulated in her wheelchair to the door of her room and stated that she is not allowed out of her room and no one answered her call light. Then, a certified nursing assistant (CNA/staff #6) was observed carrying a food tray towards resident #33's room and heard telling resident #33 to get back in her room, "your not supposed to be out of your room" in an unwelcoming tone. Staff #6 went into resident #33's room to deliver the food tray and resident #33 was heard saying, don't you like me to staff #6 and staff #6 said, don't talk like that, in an unfriendly and gruff voice, and walked out of the resident's room. The surveyor stopped staff #6 and asked for an interview. Staff #6's tone and general demeanor softened and she stated that there is COVID-19 on the unit and this is why residents are not supposed to come out of their rooms and why she is delivering food trays to the residents' rooms.

During an interview was conducted on December 20, 2024 at 8:30 a.m. with the Nursing Administrator Staff (LPN/staff 17), staff reviewed the COVID-19 Line List and stated that resident #55 and #33 tested positive for COVID-19 on December 2, 2024, so they should have been able to come out of their room as of December 10, 2024. She stated that residents out of quarantine and residents who are COVID-19 negative should have been allowed to come out of their rooms, eat meals and do activities in the public area. She stated that if staff are telling residents that they can't come out of their rooms, it is a violation of resident rights and seclusion is a form of abuse. She stated that if she heard a staff telling a resident to get back in his or her room, she would consider a dignity and respect issue. She stated that she never told staff the the residents could not come out of their rooms because COVID-19 was spreading.

An interview was conducted on December 20, 2024 at 9:16 a.m. with the Quality Assurance and Performance Improvement (QAPI) nurse, who identified herself as the Infection Control Preventionist (staff #20). She stated that after the seven days, she notifies the staff that the resident can come out of his or her room. She reviewed the COVID-19 Line List and stated that resident #55 and #33 tested positive for COVID-19 on December 2, 2024, so they should have been able to come out of their rooms as of December 10, 2024 and meals and activities should have been offered in the dining room. She stated that staff cannot tell residents to get back in their rooms because it is a form of seclusion and is a matter of dignity and respect. She stated that if she witnessed a staff telling a residents to get back in their rooms, she would remove the resident from the unit, re-educate the staff, and write the staff up if this was a pattern of behavior and seclusion if a form of abuse. She stated that she never told staff that the residents had to stay in their rooms, but may have told staff to encourage the residents to stay in their rooms because COVID-19 is spreading. Then, (staff #20) stated that this never applied to all the residents, just the residents who were COVID-19 positive. She also stated that the Nursing Administrator Staff (LPN/staff 17) never assisted her with implementing procedures or monitoring the COVID-19 outbreak.

An interview was conducted on December 20, 2024 at 4:35 p.m. with a licensed practical nurse (LPN/staff #14), who stated that she was told by the nursing administrator staff (LPN/staff #17) and the QAPI nurse (LPN/staff #20) that none of the residents are allowed to come out of their rooms because people keep getting sick.

The facility policy, "Resident Rights" states that Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include to be treated with respect, kindness, and dignity, and to be free from corporal punishment or involuntary seclusion, and physical or chemical restraints not required to treat the resident's symptoms.

Based on documentation, resident and staff interviews, and the facility policy and procedures, the facility failed to ensure that residents (#55 and #33) were offered activities when they were COVID-19 positive and the residents on their unit were not allowed to attend activities in the common area.

Findings include:

Resident #55 was admitted to the facility on August 16, 2023 with diagnoses that included dementia in other diseased classified, traumatic brain injury, adjustment disorder, schizoaffective disorder, and bipolar disorder.

The minimum data set (MDS) dated August 14, 2024 included a brief interview for mental status score of 9 indicating the resident had a moderate cognitive impairment.

The COVID-19 line listing documentation revealed that resident #55 tested positive for COVID-19 on December 2, 2024 and was asymptomatic.

Note: resident #55 remained quarantined on December 20, 2024, which was a total of 18 days.

-Resident #33 was admitted to the facility on with diagnoses that included

The minimum data set (MDS) dated June 12, 2024 included a brief interview for mental status score of 14 indicating the resident was cognitively intact.

The COVID-19 line listing documentation revealed that resident #33 tested positive for COVID-19 on December 2, 2024 and was asymptomatic.

Note: resident #55 remained quarantined on December 20, 2024, which was a total of 18 days.

An interview was conducted on December 19, 2024 at 4:15 p.m. with resident #55, who stated that he is not allowed to go out of his room because of COVID-19. He stated that he is not sick and has not been allowed to go for a cigarette. The resident was upset as evidenced by the increased volume and irritated tone of his voice. During the interview, resident #66 called out from across the hall and wanted to report that he was told that he can't come out of his room, but he did have COVID-19. During this time, another resident #33 ambulated in her wheelchair to the door of her room and stated that she is not allowed out of her room. Then, a certified nursing assistant (CNA/staff #6) was observed carrying a food tray towards resident #33's room and heard telling resident #33 to get back in her room, "your not supposed to be out of your room" in an unwelcoming tone. Staff #6 went into resident #33's room to deliver the food tray and resident #33 was heard saying, don't you like me to staff #6 and staff #6 said, don't talk like that, in an unfriendly and gruff voice, and walked out of the resident's room. The surveyor stopped staff #6 and asked for an interview. Staff #6's tone and general demeanor softened and she stated that there is COVID-19 on the unit and this is why residents are not supposed to come out of their rooms and why she is delivering food trays to the residents' rooms.

During an interview conducted on December 20, 2024 at 8:30 a.m. with the Nursing Administrator Staff (LPN/staff 17), she reviewed the COVID-19 Line List and stated that resident #55 and #33 tested positive for COVID-19 on December 2, 2024, so they should have been able to come out of their rooms as of December 10, 2024. She stated that residents out of quarantine and residents who are COVID-19 negative should have been aloud to come out of their rooms, eat meals and do activities in the public area. She stated that she told the staff that residents are allowed to come out of their rooms to attend activities and staff could encourage residents to wear masks.

An interview was conducted on December 20, 2024 at 9:16 a.m. with the the Quality Assurance and Performance Improvement (QAPI) nurse, who identified herself as the Infection Control Preventionist (staff #20). She stated that the quarantine time for COVID-19 is seven days. She stated that after the seven days, she notifies the staff that the resident can come out of his or her room. She reviewed the COVID-19 Line List and stated that resident #55 and #33 tested positive for COVID-19 on December 2, 2024, so they should have been able to come out of their rooms as of December 10, 2024 and meals and activities should have been offered in the dining room.

An interview was conducted on December 20, 2024 at 10:05 a.m. with the activity assistant/Life Enrichment Associate (staff #26) and the Life Enrichment Director (staff #35). Staff #26 stated that the purpose of activities is to keep the residents entertained, out of bed, and happy. She stated that each resident is assessed and asked what he or she likes to do and if a resident is not attending activities, she would assume that something is wrong, such as the resident is sad, and would report it to the nurse. Then, she stated that she doesn't document the types of activities or the number of times any resident attends activities, so she guesses that she wouldn't really know if a resident had a change of condition. She stated that during the COVID-19 outbreak, she did not offer any of the residents who were COVID-19 positive any activity materials and did not want to put on the personal protective equipment (PPE) to enter their rooms, but it was her understanding that she was supposed to offer them activity packets. She thought that the quarantine was ten days and stated that she was told by a nurse when the quarantine ended for a resident. She stated that the COVID-19 outbreak made her nervous and she didn't offer any activities to the residents on the unit who tested positive for ten days. She stated that there is a risk of residents not having anything to do and she was not following the activity care plan when she didn't offer activities to the residents. She stated that she had been offering activities to a few of the residents in the dining room. During the interview, (staff #35) stated that the purpose of activities is to improve lives, help with depression, physical and emotional well being, and it creates a sense of community. She stated that she reviews the residents quarterly and when their is a change in condition or concern regarding activity participation, but didn't have any documentation for any of these residents.

An interview was conducted on December 20, 2024 at 10:51 a.m. with the Director of Nursing (DON/staff #1), who stated that all residents who were COVID-19 free, were allowed to move around on the unit. She stated that one-to-one activities were offered to the residents who were COVID-19 positive in their rooms and the other residents were allowed to attend regular activities. It was her expectation that activities are documented: attended, not attending, passive and self-directed for each resident. The activity assistant/Life Enrichment Associate (staff #26) should be following the activity care plan for each resident and the purpose of activities is keep the residents engaged, happy, and to decrease behaviors. She stated that the risk of not offering activities is that residents may experience depression, self-isolation, and anxiety sometimes.

An interview was conducted on December 20, 2024 at 4:35 p.m. with a licensed practical nurse (LPN/staff #14), who stated that she was told by the nursing administrator staff (LPN/staff #17) and the QAPI nurse (LPN/staff #20) that none of the residents are allowed to come out of their rooms because people keep getting sick.

Review of the facility policy, "Resident Rights" revealed that employees shall treat all residents with kindness, respect, and dignity. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: communication with and access to people and services.

Based on documentation, staff interviews, and the facility policy and procedures, the facility failed to ensure one resident (#77) was provided the supervision needed to maintain her health and safety.

Findings included:

Resident #77 was admitted to the facility on May 8, 2023 and readmitted on September 26, 2024 with diagnoses that included borderline personality disorder, schizoaffective disorder, major depression, and generalized anxiety.

The behavior psychiatric evaluation dated September 21, 2024 revealed that the chief complaint was depressed mood and suicidal thoughts. The patient was admitted with depressed mood and suicidal attempt. As per the clinical and multidisciplinary team (MDT) assessment, the patient is functionally impaired due to influence of symptoms and is risky to get discharged from the inpatient unit.

The Approach Plan/behavior plan date May 9, 2023 revealed that the resident had a self-harming/suicidal history. Interventions included to be aware of history of self-harm, suicidal ideation and/or prior attempted suicides and ensure the resident knows she is a valued person. If observing an increase in mood or harm is being expressed, contact the psych provider.

The minimum data set (MDS) dated October 24, 2024 included a brief interview mental status score of 15 indicating the resident was cognitively intact.

Review of the care plan dated November 4, 2024 revealed that the resident had a history of suicidal ideations/attempts. Interventions included to see the behavior plan.

A behavior note dated December 18, 2024 revealed that the resident was transferred to a unit to be monitored for suicidal safety reason. The resident was to remain on one-to-one supervision care.

Review of the 5-day written investigation dated December 20, 2024 revealed that prior to the resident being left unsupervised, one staff had left the unit to assist with an emergency in another area, adding to the strain on staff.

A progress note dated December 18, 2024 revealed that at approximately 7:10 p.m. staff went into the resident's room and noted that the resident had a sheet wrapped around her neck. The resident was pink in color and responsive. The sheet was removed from her neck and she was taken to the nurses station. She verbalized that she was depressed and wanted to harm herself. The resident was assessed for injury and vital signs (VS) were taken. VS: 127/104, 155, 99% RA, 98 F, 24. Crisis line was called and advised to call the fire department. The Director of Nursing (DON), Administrator, nurse practitioner (NP), power of attorney (POA), and the assistant director of nursing (ADON) were notified. The emergency medical services (EMS) arrived at approximately 7:30 p.m. and the resident left the facility at approximately 7:40 p.m.

An interview was conducted on December 20, 2024 at 10:51 p.m. with the Director of Nursing (DON/staff #1), who stated that resident #77 was supposed to have a one-to-one staffing ratio because she was having a hard time. She stated that the one-to-one left resident #77 to assist staff with another resident. Resident #77 was found standing on her bed with a sheet wrapped around her neck and 911 was called. She was transferred to the hospital because she stated that she wanted to harm herself. Staff #1 stated that since then, the staff are being retrained not to leave a resident if staff is assigned as the one-to-one even if there is a situation with another resident.

An interview was conducted on December 20, 2024 at 2:29 p.m. with a licensed practical nurse (LPN/staff #12), who stated that the resident had just transferred to the unit and was supposed to have a one-to-one staff. The one-to-one was the only male staff on the unit and when another male resident was trying to break through the locked door, the male staff was the only one strong enough to handle him. The male resident was kicking and screaming. When the male staff went to help with the male resident, resident #77 was left unsupervised. Resident #77 went into her room and was found with a sheet wrapped around her neck trying to hang herself from the ceiling. Staff #12 pointed and identified the male resident #99 as the resident who was trying to break down the doors to get out.

The facility policy, "Safety and Supervision of Residents" states that the resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment.

Based on clinical record reviews, resident/staff interviews, facility documentation and the State Agency (SA) complaint tracking system, the facility failed to provide written notification within two working days after a self-inflicted injury for one resident (#36) that required emergency medical services. The deficient practice could result in the state agency being uninformed of residents with self-inflicted injuries requiring emergency medical services.

Findings include:

Resident #36 was admitted to the facility September 8, 2023 with a discharge on September 19,2024. Resident was re-admitted September 26, 2024 with diagnosis that including borderline personality disorder, schizoaffective disorder, unspecified, personal history of other mental and behavioral disorders, personal history of suicidal behavior, major depressive disorder, recurrent severe without psychotic features.

Review of Quarterly Minimum Data (MDS) Set dated October 24, 2024 revealed a Brief Interview for Mental Status (BIMS) was conducted, revealing a BIMS score of 15 which indicated the resident's cognition was intact. Moreover, the MDS revealed the resident had no indictors for mood or behaviors. Active diagnosis was anxiety disorder, depression (other than bipolar), Bipolar Disorder, Psychotic Disorder (other than schizophrenia), Schizophrenia, other than schizophrenia), Post-Traumatic Stress Disorder (PTSD), borderline personality disorder, personal history of suicidal behavior. The MDS indicated the resident had orders for antipsychotics, antianxiety and antidepressant medication. On October 1, 2024 the physician documented a gradual dose reduction for the medications were clinically contraindicated.

Review of the Care Plan revised October 27, 2024 revealed resident was identified as having a positive (Pre-Admission Screening and Resident Resident Review) PASRR Level II mental illness status related to diagnosis of major depression, generalized anxiety, stimulant dependence, mixed obsessional thoughts and acts, borderline personality. However, did not require specialized mental health services. The goal was to maintain the highest level of practicable wellbeing through review, interventions included reporting any needs to re-evaluate for additional specialized services as needed or upon request. Moreover, the care plan revealed the resident #36 was monitored for any signs and symptoms related to use of antipsychotics, antidepressant and antianxiety medications. The resident was also provided with behavior management program in providing alternatives to promote safety and well-being.

Review of the Suicide Risk Assessment dated October 3, revealed a score of 5.0 indicating resident was a low risk. A quarterly Suicide Risk Assessment was completed on October 24, 2024 revealing a score of 11.0 indicating resident was considered a moderate risk for suicide.

Review of a behavior note dated September 15, 2025 revealed: At 1900 resident came out of room crying stating, "I don't want to be here anymore." Writer noticed resident have a red area around her neck; writer asked resident what she did, resident remained silent and continued to cry. Writer asked resident if she could go into her room , writer and other nurse entered room with resident to find a sheet tied up on the ceiling above residents bed . Writer placed resident on a 1 on 1 and contacted Crisis Center at 7:15 pm who contacted Fire dept to get a medical clearance. At 7:25 pm Fire Department arrived on unit to asses resident, during assessment fire dept stated that they will be transporting resident to the hospital to be evaluated by psychitry. Resident agreed to go; she was transported via gurney and left the unit at 8pm. Writer then contacted guardian to inform her of residents current situation.

Review of a behavior note dated September 19, 2024 revealed the following: Resident was standing on her bed with the bed in highest position with a sheet around the ceiling panels and then around her neck. Approached resident and caught her from falling to the floor and was able to catch her and remove sheet. Resident left her room and sat in hallway with her 1:1. 911 was called for an emergency removal to Hospital. Officer stated they will go to hospital. Paper work given to them and they removed resident from the facility. DON contacted along with Unit Manager.

Review of a hospital psychiatric evaluation dated September 21, 2024 revealed resident was admitted to the hospital with depressed mood and suicidal attempt. The symptoms and associated risks had not changed in the previous 24 hours. The onset of symptoms were gradual and were currently rated as severe.

An interview was conducted with Unit Manger (Staff #18/UM/LPM) on October 29, 2024 at approximately 3:30p.m. Staff #18 stated every staff is CPI certified, which is the training provided on de-escalation for residents who are trying to harm themselves or others. Staff #18 stated all suicide attempts are considered reportable and any attempts are immediately reported to the caser manger, DON, physician and family with immediate implementation of interventions. Staff#18 stated those interventions include; 1:1 supervision, crisis intervention, conduct a score assessment to determine if they are a risk to the facility or to the residents or staff. Staff #18 stated Crisis completes an evaluation of the facility to determine if the resident continues to be safe at the facility. She further stated any orders or discontinuance for 1:1 supervision come directly from the physician.

An interview was conducted with Certified Nursing Assistant (CNA/Staff#10) stated any time a resident either threatens or attempts suicide 1:1 is immediately implemented and staff are notified. Staff #10 stated crisi is called when a resident threatens harm to self or to others and 1:1 continues until management makes the decision the resident is safe on their own.

An interview was conducted with Director of Nursing (Staff/DON #23) who stated that the facility's process if a resident threatens or attempts self-harm counseling is frequent monitoring, ensure resident has nothing to harm themselves and continue with the plan to keep the resident safe. She further stated the facility has never reported any suicide attempts from the facility, that the crisis makes the decision when to clear the resident.

Review of the facility policy titled "Behavior Monitoring Policy" states the purpose of this policy is to outline the guidelines and procedures for monitoring resident behaviors within the psychiatric secure unit. This policy aims to enhance resident safety , ensure staff readiness to intervene appropriately, and maintain a therapeutic environment that supports both residents'-being and staff safety.