Health inspection·September 21, 2023

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify one of two resident's (Resident 1) physician and/or psychiatrist (a physician who specialized in mental health) when nursing staff observed Resident 1 verbalizing suicidal ideation (SI, thoughts of self-harm or killing oneself). This failure had the potential for Resident 1's change in mental status and/or behavior to go untreated which put the resident at risk for self-harm. Findings: A review of Resident 1's facility admission Record indicated, the resident was admitted on [DATE] with diagnoses to include bipolar disorder (mental disorder with extreme changes in mood, thought, energy, and behavior and characterized by periods of mania and depression) and depression (a mood disorder that caused persistent feelings of sadness, hopelessness, and loss of interest). A review of Resident 1's admitting paperwork from the general acute care hospital (GACH) 2 dated 8/2/23, indicated the resident had a history of SI. A review of facility nursing progress notes dated 8/20/23, indicated, .Pt [patient] stated she was very upset with her care here and feels like she is in prison. Pt is very upset with [family members] for putting her here and they don't come and visit her. Pt refusing medications at this time and believes that if she stops taking her medications she will die faster .asked pt if she has thoughts of hurting herself and pt denies .will follow up with doctor On 8/29/23 at 3 P.M., an interview was conducted with certified nursing assistant (CNA) 3. CNA 3 stated she often provided care to Resident 1 and the resident made statement such as, I want to go home, and I don't belong here. CNA 3 stated Resident 1 would frequently yell and cuss at the nurses and had a behavior of putting herself on the floor for attention. CNA 3 stated Resident 1 had told her, I want to kill myself, on three different occasions since admission to the facility. CNA 3 was asked what she had done when the resident verbalized SI. CNA 3 stated she kept a closer eye on the resident. On 8/30/23 at 10:57 A.M., an interview was conducted with licensed nurse (LN) 7. LN 7 stated she was familiar with Resident 1 and that the resident would scream and had, Lots of suicidal ideation. LN 7 stated Resident 1 would speak negatively about herself and would say things like certain family members did not like her, she was not worthy of living, and that she would rather die. LN 7 stated Resident 1 often said, I just want to die. LN 7 stated Resident 1's verbalizations of SI were not a Page 1 of 30 555723 555723 09/21/2023 Santa Fe Post-Acute 247 E. Bobier Drive Vista, CA 92084

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few change of condition and did not required intervention. LN 7 stated, [Resident 1] was on the psych unit [residents with mental disorders] and not everything residents say makes sense. LN 7 stated Resident 1's frequency of verbalizing SI had been increasing. LN 7 stated it would be a change reportable to the physician if the resident had a suicide plan. On 8/30/23 at 2:05 P.M., a joint interview and record review was conducted with the director of nursing (DON). The DON reviewed Resident 1's clinical record and stated when Resident 1 made statements on 8/20/23 about wanting to stop taking her medications so she would die faster, she had instructed her staff to do a change of condition report and frequent monitoring. The DON stated her directions had not been followed. The DON stated when LN 7 noticed Resident 1's increased frequency of verbalizing SI, this was a change in the resident's condition and should have been reported to the physician. On 9/6/23 at 9:30 A.M., a joint interview and record review was conducted with LN 9. LN 9 stated when Resident 1 verbalized SI, the psychiatrist should have been notified. LN 9 stated the psychiatrist could have evaluated Resident 1 and may have ordered the resident to be transferred to the acute care. LN 9 stated when the LN noticed Resident 1's SI increasing in frequency, that was considered a change in the resident's mental and psychosocial condition, and it should have been promptly assessed and reported to the psychiatrist right away. LN 9 stated Resident 1's increased frequency of verbalizing SI, should have been treated seriously as it indicated the resident was becoming unstable and further mental health services were needed. LN 9 stated when the LN communicated with a physician or other provider, it had to be documented in the resident's clinical record. LN 9 reviewed Resident 1's nursing progress notes, dated 8/20/23, .Pt refusing medications at this time and believes that if she stops taking her medications she will die faster . will follow up with doctor LN 9 stated there was no documentation this incident had been followed up or reported to the doctor. LN 9 stated this, and other verbalizations of SI, should have been reported to the facility's psychiatrist, medical doctor (MD) 8. On 9/6/23 at 11:33 A.M., a joint interview and record review was conducted with the MDS coordinator (MDSC). The MDSC reviewed Resident 1's clinical record and stated there was no documentation Resident 1's verbalizations of SI to different nursing staff had been reported to the physician or psychiatrist. The MDSC stated when the LN noticed the frequency of Resident 1's SI increasing, that required immediate action and the psychiatrist should have been notified right away. On 9/6/23 at 2:17 P.M., an interview was conducted with the facility's psychiatrist, MD 8. MD 8 stated he saw Resident 1 during an initial visit and the resident had depression, bipolar disorder and a borderline personality disorder (a disorder with unstable moods, behavior, and relationships). MD 8 stated these diagnoses posed an increased risk of suicide for Resident 1. MD 8 stated when Resident 1 verbalized SI, he should have been notified. MD 8 stated when Resident 1's verbalizations of SI increased in frequency, it was a, Definite warning sign that the resident was focusing on SI or beginning to formulate a plan. MD 8 stated when LN 7 noticed Resident 1's SI increasing in frequency, he should have been notified right away. MD 8 stated residents verbalizing SI should always be taken seriously. MD 8 stated he had not been aware that Resident 1 had verbalized SI to staff and that it was something he would have wanted to know. MD 8 stated that he should have been notified and that he would have evaluated Resident 1 right away. A review of the facility's titled Change of Condition Notification, dated 4/1/23, indicated, .The Licensed Nurse will notify the resident's attending physician when there is . C. A significant change 555723 Page 2 of 30 555723 09/21/2023 Santa Fe Post-Acute 247 E. Bobier Drive Vista, CA 92084

F 0580 Level of Harm - Minimal harm or potential for actual harm in the resident's physical, mental or psychosocial status .The licensed nurse will assess the resident's change of condition and document the observations and symptoms .The attending physician will be notified timely Residents Affected - Few 555723 Page 3 of 30 555723 09/21/2023 Santa Fe Post-Acute 247 E. Bobier Drive Vista, CA 92084

F 0740 Ensure each resident must receive and the facility must provide necessary behavioral health care and services. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the necessary behavioral healthcare and services were provided to one of three residents (Resident 1) who was diagnosed with mental disorders (a syndrome characterized by a clinically significant disturbance in an individual's cognition, emotion regulation, or behavior) when: 1. Resident 1's mental disorders and history of suicidal ideation (SI, thoughts of self-harm or of killing oneself), identified upon admission, were care planned with resident-specific interventions to include providing an environment free of items that could be used to inflict self-harm. 2. A written care plan to address Resident 1's depression (a mood disorder that caused persistent feelings of sadness, hopelessness, and loss of interest) was developed after the resident's Minimum Data Set Assessment (MDS, a comprehensive assessment) was completed to indicate the resident was showing signs/symptoms of depression. 3. Resident 1's verbalizations and increased frequency of SI were promptly acted upon by nursing staff or reported to the physician and/or psychiatrist (physician who specialized in mental disorders). As a result of these deficient practices, most of the staff providing care to Resident 1 were aware of the resident's history of SI and did not have a plan of care to follow for providing resident-centered mental and behavioral health services. In addition, on 8/24/23, Resident 1 verbalized to staff on several occasions that she wanted to kill herself, told certified nursing assistant (CNA) 3 that she would swallow glass. Resident 1 was left alone in her room with a glass vase which the resident then broke and ingested. Resident 1 was sent out to the hospital on 8/24/23, experienced pain, sustained shards of glass throughout the gastrointestinal tract (GI tract, path where food travels through the body) that cut the organs of the GI tract, developed sepsis (infection in the blood) and later died at the hospital on 8/29/23. Cross reference F741 and F838. Findings: On 8/29/23 at 1:48 P.M., an on-site visit was conducted at the facility to investigate a facility reported incident alleging Resident 1 had swallowed glass on 8/24/23. The administrator (ADM) and director of nursing (DON) were interviewed at this time. The ADM stated he was still conducting an investigation into the incident. The ADM and DON both stated they were recently informed that Resident 1 had died at the hospital. A review of Resident 1's facility admission Record indicated, the resident was admitted on [DATE] with diagnoses to include bipolar disorder (mental disorder with extreme changes in mood, thought, energy, and behavior and characterized by periods of mania and depression) and depression (a mood disorder that caused persistent feelings of sadness, hopelessness, and loss of interest). A review of Resident 1's Minimum Data Set assessment dated [DATE], indicated, the resident scored 555723 Page 4 of 30 555723 09/21/2023 Santa Fe Post-Acute 247 E. Bobier Drive Vista, CA 92084

F 0740 15 on the brief interview of mental status (a score of 15 meant the resident was cognitively intact). Level of Harm - Actual harm A review of Resident 1's facility History and Physical exam, signed by the physician on 8/16/23, indicated the resident had fluctuating capacity to understand and make decisions. Residents Affected - Few A review of Resident 1's admitting paperwork from the general acute care hospital (GACH) 2 dated 8/2/23, indicated, the resident had a history of SI. A review of Resident 1's facility nursing progress notes indicated, on: 8/7/23, The resident became very upset during the medication administration and was yelling at the licensed nurse (LN). 8/9/23, Pt [patient] presented with behavioral problems today demanding to be discharged , aggressive, calling nurses out their name or title with bad language and profanity, slammed telephone and slammed door. She demanded to speak to social services to be discharged . 8/10/23, Resident .started yelling and demanded me to go out from her room. She wants to go home. No one paying attention to her. Resident left alone. 8/20/23, .Pt stated she was very upset with her care here and feels like she is in prison. Pt is very upset with [family members] for putting her here and they don't come and visit her. Pt refusing medications at this time and believes that if she stops taking her medications she will die faster .asked pt if she has thoughts of hurting herself and pt denies .will follow up with doctor 8/20/23, Late entry for 8/20/23: .Pt was sitting in room with [family member, FM 1] laughing and eating chips 8/24/23, At 12:05 AM Resident came out from the room and stating she swallowed a glass. We would like to come to the room she wont [sic] let us in and she pushed the bed at the door .physician notified . Resident hold the phone and saying you are not my [expletive] doctor .911 called and with difficulty evaluating her and took her at 110 AM. Room has been assessed broken glass found at the window. A review of Resident 1's facility clinical record indicated, the resident's suicidal risk had not been assessed upon admission and there was no written plan of care developed with person-centered interventions to address the resident's bipolar disorder (a mental illness that can be chronic (persistent or constantly recurring) or episodic (occurring occasionally and at irregular intervals), depression, and SI until 8/25/23. A review of Resident 1's GACH 1 physician documentation dated 8/24/23, indicated, .Patient was seen and evaluated by writer and the SW [social worker] at the ED [emergency department]. Pt appears to be restless, maintained no eye contact, report feeling depressed, overwhelmed and frustrated which has been getting worse in the last few days to week and started feeling increasingly irritable and has been feeling on edge. Report that she has been feeling worthless, useless and she had been feeling suicidal and decided to swallow some glasses with the intention to hurt herself. Report poor sleep for days and loss of appetite. Pt remain guarded and refused to elaborate further. Pt report that [family member] put her in a nursing home and she would rather kill herself than staying in the 555723 Page 5 of 30 555723 09/21/2023 Santa Fe Post-Acute 247 E. Bobier Drive Vista, CA 92084

F 0740 nursing home Level of Harm - Actual harm A review of Resident 1's GACH 1 physician documentation dated 8/24/23, indicated, . [Resident 1] tried to kill herself by swallowing broken glass; I screwed up now I have pain at the back of my throat; c/o [complained of] not liking the living facility; also CT [computerized tomography, machine able to visualize inside the body] chest pneumomediastinum [air in the chest cavity near the esophagus (tube connecting mouth to the stomach)] and possible foreign body glass at the upper pharynx [throat] and smaller pieces in small intestine Residents Affected - Few A review of Resident 1's GACH 1 physician documentation dated 8/24/23, indicated, .Patient currently endorsing pain over her throat and abdominal area .Patient states that she is in severe pain in her lower neck and upper chest and now wishes that she did not swallow the class [sic] because of the pain and also reports right lower quadrant pain that started after swallowing glass A review of GACH 1 Discharge summary dated [DATE], physician documentation, indicated, the resident had a 3.5 by 4 cm (centimeter) slightly curved piece of glass with sharp edges removed that had caused a 2 cm tear the resident's esophagus. Resident 1 was transferred to GACH 2 with physician's recommendation to keep sedated and intubated (breathing with a breathing tube). A review of Resident 1's GACH 2 documentations dated 8/24/23, indicated, the resident had prior suicide attempts on 1/18/22 and 8/31/22. The admission History and Physical, dated 8/24/23, indicated, .Patient was at [SNF] .when she was found to have swallowed about 5 handfuls of broken glass from a vase .She had severe pain in her neck and upper chest. Reported to be remorseful for her actions . CT [computerized tomography, machine able to visualize inside the body] showed extensive shards of glass from the proximal esophagus [upper part/near the mouth of the tube connecting the mouth to the stomach] through the colon [large intestine]. She had subcutaneous emphysema [air that's trapped under the skin] near her cricopharynx [in the throat area]. Underwent direct esophagoscopy [scope that goes in the esophagus] . which revealed a 3x4 cm [centimeter] shard of glass which was removed. There was a 2 centimeter tear posterior wall of the esophagus and into the prevertebral fascia [layer of tissue surrounding the spine] as well as a small laceration in the posterior oropharynx [back of the throat directly behind the roof of the mouth] that was thought to be the source of subcutaneous emphysema . She remained intubated [with a breathing tube] for safety. Transferred to [GACH 2] for further care . Found to have glass shards throughout the GI [gastrointestinal] tract .Patient is septic [blood infection] by SIRS [systemic inflammatory response in the presence of a known or suspected source] and GI/oral source . Apparent suicide attempt GACH 2 Discharge summary, dated [DATE] indicated, .Following admission, the patient was initially cared for in the ICU [intensive care unit] and then transitioned to comfort care. Active hospital problems .Severe sepsis, esophageal perforation [tear], foreign body in digestive tract . Prognosis felt to be guarded to poor [not likely to recover] .She passed away in the hospital on 8/29/23 at 0758 [7:58 AM] According to the National Institute of Mental Health's online article titled Depression, dated April 2023, .Depression is a serious mood disorder . What are the signs and symptoms of depression? . Feelings of guilt, worthlessness, or helplessness . Increased irritability or anger . becoming withdrawn, negative, or detached .Thoughts of death, suicide, or suicide attempts . bipolar disorder . also experience depressive episodes . also experiences .unusually elevated moods, in which they might 555723 Page 6 of 30 555723 09/21/2023 Santa Fe Post-Acute 247 E. Bobier Drive Vista, CA 92084

F 0740 feel very happy, irritable, or up with a marked increase in activity level Level of Harm - Actual harm On 8/29/23 at 3 P.M., an interview was conducted with certified nursing assistant (CNA) 3. CNA 3 stated she often provided care to Resident 1 and the resident made statements like, I want to go home and I don't belong here. CNA 3 stated Resident 1 would frequently yell and cuss at the nurses and had a behavior of putting herself on the floor for attention. CNA 3 stated Resident 1 had told her, I want to kill myself, on three different occasions since her admission. CNA 3 was asked what she had done when the resident verbalized that. CNA 3 stated she kept a closer eye on the resident. Residents Affected - Few CNA 3 stated she began her shift at 2:30 P.M. on 8/23/23 and had worked double shift (from 2:30 P.M. on 8/23/23 to 7 A.M. on 8/24/23). CNA 3 stated at the start of the shift, Resident 1 was at the nurses' station yelling and cussing at the nurse. CNA 3 stated Resident 1 went to her room after a while and seemed to calm down. CNA 3 stated sometime around midnight, Resident 1's call light went off and she responded to it. CNA 3 stated that she asked Resident 1 what she needed, and the resident told her to, Get the [expletive] out of here. CNA 3 stated she reminded Resident 1 that she had the call light on, and the resident told her, I'm going to swallow glasses. CNA 3 stated the resident normally spoke with a slightly slurred speech. CNA 3 stated she checked the resident's room and inside the resident's mouth. CNA 3 stated she did not see any glass or broken glass anywhere. CNA 3 stated Resident 1 noticed that she did not find anything and told her, You can't find it. CNA 3 stated she left the resident's room to get LN 4 and that Resident 1 wanted her (CNA 3) to close the door to the room and she closed it. CNA 3 stated, [Resident 1] wants me to slam the door so it closes tight. CNA 3 stated when she located LN 4, and they were speaking, they both heard the sound of glass breaking. CNA 3 stated they went to Resident 1's room and the resident was closing her door and pushing her body against the door, and they could not open it. CNA 3 stated when she was able to open the door, Resident 1 was seated in her wheelchair and there was a broken glass vase on the floor next to the resident. CNA 3 stated the resident was strong enough to move fast without the need of an assistive device. CNA 3 stated the glass vase had been at the resident's bedside that the resident had kept with artificial flowers in it. CNA 3 stated Resident 1 made pushing motions toward her that ushered her out of the resident's room and the resident closed the door. CNA 3 stated she remained outside Resident 1's closed door and did not open the door because the resident would become upset. CNA 3 stated she remained outside Resident 1's closed door for approximately two minutes while LN 4 called the physician. CNA 3 stated Resident 1 had been alone in her room with broken glass on the floor. CNA 3 stated she was afraid the resident was going to swallow the glass. CNA 3 stated LN 4 returned with the physician on the mobile phone, and LN 4 was able to get the resident's door open enough to pass the phone through the door to the resident. CNA 3 stated Resident 1 said, You're not my [expletive] doctor, and threw the phone into the hallway. CNA 3 stated 911 came and took Resident 1 to the hospital. CNA 3 stated she had not received any facility training for residents with SI. CNA 3 stated, I didn't know what to do in that situation. On 8/30/23 at 9:32 A.M., a telephone interview was conducted with LN 4. LN 4 stated she worked regularly on Station 2. LN 4 stated she was providing care to Resident 1 during the NOC shift (10:30 P.M. on 8/23/23 to 7 A.M. on 8/24/23) and she had seen Resident 1 around 10:45 P.M., at which point the resident seemed calm. LN 4 stated she was unaware of Resident 1 having had any history of SI or making SI statements. LN 4 stated, I would have wanted to know that .I didn't know. LN 4 stated it was important to know how to monitor a resident who had SI. LN 4 stated all staff should have known of Resident 1's SI to keep the resident safe from self-harm. LN 4 stated residents with mental disorders should have a written plan of care with individualized interventions to include suicide prevention if resident had a history of SI. 555723 Page 7 of 30 555723 09/21/2023 Santa Fe Post-Acute 247 E. Bobier Drive Vista, CA 92084

F 0740 Level of Harm - Actual harm Residents Affected - Few LN 4 stated she became aware of the incident with Resident 1 when the resident came up to the nurses' station and told her, I swallowed glass. LN 4 stated she did not recall CNA 3 informed her that Resident 1 had threatened to swallow glass. LN 4 stated she remembered hearing the sound of glass breaking prior to Resident 1 informing her that she had swallowed glass. LN 4 stated both her and CNA 3 tried to get into Resident 1's room, and that the resident had closed the door and place herself against the door. LN 4 stated she left CNA 3 outside of the resident's closed door and went to call the physician. LN 4 stated CNA 3 tried to get back inside the resident's room while they waited for the physician's call. LN 4 stated she brought the mobile phone to Resident 1 and the resident threw it into the hall and said, That's not my [expletive] doctor. LN 4 stated she called 911 and they came right away for the resident. LN 4 stated if she had known Resident 1 verbalized the threat of swallowing glass, she would have had a staff remain inside the resident's room. LN 4 stated the resident should have been placed on 1:1 supervision (one staff to remain with the resident) as soon as the suicide threat was made. LN 4 stated the resident's room would have been thoroughly searched until all dangers were removed. LN 4 stated doing those things could have prevented Resident 1 from swallowing glass. On 8/30/23 at 10:57 A.M., an interview was conducted with LN 7. LN 7 stated she was familiar with Resident 1 who would scream and had, Lots of suicidal ideation. LN 7 stated Resident 1 would speak negatively about herself and would say things like certain family members did not like her, she was not worthy of living, and that she would rather die. LN 7 stated Resident 1 often said, I just want to die. LN 7 stated Resident 1's verbalizations of SI were not a change of condition and did not required intervention. LN 7 stated, [Resident 1] was on the psych unit [residents with mental disorders] and not everything residents say makes sense. LN 7 stated Resident 1's frequency of verbalizing SI was increasing prior to the incident (8/24/23). LN 7 stated it would be a change of condition reportable to the physician if the resident had a plan. LN 7 stated she had not received training related to providing care to residents with SI. On 8/30/23 at 11:22 A.M., an interview was conducted with Resident 1's family member (FM) 1. FM 1 stated that they visited Resident 1 nearly every day. FM 1 stated Resident 1 had their mind made up that they were not going to remain in this world. FM 1 stated Resident 1 had felt that way for a while and would appear happy at times even though the resident did not truly feel happy. FM 1 stated to their knowledge, Resident 1 did not have a formal suicide plan, but Resident 1 did not want to live. FM 1 stated Resident 1 had expressed wanting to talk to someone about how they felt. FM 1 stated it may have helped Resident 1 to speak to a psychologist or someone. FM 1 stated if Resident 1 was verbalizing SI, that would have been a warning the resident was thinking of committing suicide. FM 1 stated facility staff told them that Resident 1, Never said anything about wanting to die so they [facility staff] didn't know. FM 1 stated they worried something like this would have happened to Resident 1 eventually because the resident had made it clear that they no longer wanted to live. On 8/30/23 at 2:05 P.M., a joint interview and record review was conducted with the director of nursing (DON). The DON reviewed Resident 1's clinical record and stated the resident was admitted with mental disorders and a history of SI and that this should have been care planned upon admission. The DON stated Resident 1's suicide risk should have also been assessed upon admission. The DON stated when Resident 1 made statements on 8/20/23 about wanting to stop taking her medications so she would die faster, she had instructed her staff to do a change of condition report and frequent monitoring. The DON stated her directions had not been followed. The DON stated a written plan of care should have been developed immediately to address Resident 1's current mood and SI. The DON stated when LN 7 noticed Resident 1's increased frequency of verbalizing SI, this was a change in the resident's condition and should have been reported to the 555723 Page 8 of 30 555723 09/21/2023 Santa Fe Post-Acute 247 E. Bobier Drive Vista, CA 92084

F 0740 Level of Harm - Actual harm physician. The DON stated when Resident 1 threatened to swallow glass on 8/24/23, the resident should have been placed on 1:1 supervision right away, the room should have been swept for anything that could be used for self-harm and any glass removed. The DON stated this could have prevented the resident from swallowing glass. Residents Affected - Few On 8/30/23 at 6:42 P.M., a telephone interview was conducted with the facility's medical director (MDR). The MDR stated he expected staff to be fully trained and knowledgeable in providing care to residents with SI. The MDR stated when Resident 1 verbalized SI, staff should have responded immediately by notifying the physician and psychiatry, assessing, and care planning to include the removal of objects that could be used for self-harm as an intervention. The MDR stated when Resident 1 threatened to swallow glass, the resident should have been placed on immediate 1:1 supervision and all glass removed from the resident's room. On 9/6/23 at 9:30 A.M., a joint interview and record review was conducted with LN 9. LN 9 stated the purpose of developing a plan of care for residents was to alert the LN to any problems and provide resident-specific interventions to prevent the problem from occurring or reoccurring. LN 9 stated when the LN admitted a resident, the past medical history on the admitting paperwork should be reviewed and start a baseline care plan to guide the resident's care. LN 9 stated residents with mental disorders should have individualized care plans developed to identify what services were required to address the disorder, and to include non-pharmacological interventions (not using medications). LN 9 stated SI was a problem area that required an individualized care plan to keep the resident safe from self-harm. LN 9 stated residents with a history of SI should be assessed for suicide risk upon admission in order to develop a personalized care plan. LN 9 reviewed Resident 1's clinical record and stated the resident was admitted with a documented history of SI and that the resident had not been assessed for suicide risk upon admission. LN 9 stated Resident 1 had depression and bipolar disorder, there should have been a written care plan developed specific to mental disorders. LN 9 stated when Resident 1 verbalized SI, the written care plan should have included interventions to prevent the resident from being able to act upon the SI, and remove any objects in the resident's room that could be used to cause self-harm, frequent monitoring, or 1:1 supervision. LN 9 further stated when Resident 1 verbalized SI, the psychiatrist (physician who specialized in mental disorders) should have been notified and evaluated Resident 1 and may have ordered the resident to be transferred to the acute care. LN 9 stated when the LN noticed Resident 1's SI increasing in frequency, that was considered a change in the resident's mental and psychosocial condition, and the resident should have been promptly assessed and reported to the psychiatrist right away. LN 9 stated Resident 1's increased frequency of verbalizing SI, should have been treated seriously as it indicated the resident was becoming unstable and further mental health services were needed. LN 9 stated when the LN communicated with a physician or other provider, it had to be documented in the resident's clinical record. LN 9 reviewed Resident 1's nursing progress notes dated 8/20/23, .Pt refusing medications at this time and believes that if she stops taking her medications she will die faster . will follow up with doctor LN 9 stated there was no documentation this incident had been followed up or reported to the doctor. LN 9 stated this, and other verbalizations of SI, should have been reported to the facility's psychiatrist, medical doctor (MD) 8. On 9/6/23 at 11:33 A.M., a joint interview and record review was conducted with the MDS coordinator (MDSC). The MDSC stated she would review hospital admission paperwork to check the residents' diagnosis and problem areas as part of completing residents' MDS assessments. The MDSC stated the admission MDS assessment was considered the final catch to develop resident care plans based off document review and the comprehensive (evaluation of the patient's current condition as well as any changes 555723 Page 9 of 30 555723 09/21/2023 Santa Fe Post-Acute 247 E. Bobier Drive Vista, CA 92084

F 0740 Level of Harm - Actual harm Residents Affected - Few since the last assessment) assessment. The MDSC stated care plan development was important to make sure problem areas were addressed with appropriate services and personalized, non-pharmacological interventions. The MDSC stated resident care plans communicated any problem areas and how to provide resident-centered care to all staff taking care of the resident. The MDSC reviewed Resident 1's clinical record and stated the resident's mental disorders: depression and bipolar disorder should have been care planned upon admission. The MDSC stated Resident 1's SI history was a problem area and that the resident should have been assessed for suicidal risk upon admission. The MDSC stated after the suicide risk assessment was completed, a care plan should have been developed for the resident's SI. The MDSC stated they could not say what services and non-pharmacological interventions had been provided to Resident 1 to manage the resident's disorders and behaviors because there was no written plan of care. The MDSC reviewed Resident 1's admission MDS assessment Section D, Mood, dated 8/8/23. The assessment indicated: Resident 1 experienced little interest or pleasure in doing things for 2-6 days (several days); felt down, depressed, or hopeless for 7-11 days (half or more of the days); felt tired or had little energy for 2-6 days (several days); had poor appetite or overeating for 7-11 days (half or more of the days); felt bad about themselves or that they were a failure or have let themselves or family down for 7-11 days (half or more of the days); and moved slowly so others could have noticed or have been fidgety or restless for 2-6 days (several days). The Mood assessment had a total severity score of 09. The MDSC stated Resident 1's MDS assessment captured the resident's mood from admission on [DATE] through 8/8/23. The MDSC stated based off Resident 1's Mood assessment score of 09, [Resident 1's] depressed. The MDSC stated after the Mood assessment was completed, Resident 1's care plan should have been developed to address the resident's depression. The MDSC stated the care plan should have been developed by the social services department. The MDSC stated some possible interventions based off Resident 1's Mood assessment would have been to refer to psychiatry services, daily visits by social services, visits or calls with family, resident-specific activities, clergy visits, and increased monitoring. The MDSC stated Resident 1's verbalizations of SI to staff should have been identified on the resident's written care plan with interventions in place to remove any items from the resident's room that could cause self-harm. The MDSC further stated when the LN noticed the frequency of Resident 1's SI was increasing, that required immediate action and the psychiatrist should have been notified right away. The MDSC stated there was no documentation Resident 1's verbalizations of SI had been reported to the psychiatrist. On 9/6/23 at 2 P.M., a joint interview and record review was conducted with the DON. The DON reviewed Resident 1's clinical record and stated she had signed the resident's MDS assessment dated [DATE]. The DON stated based off Resident 1's Mood assessment, a care plan should have been developed and completed by the social services director to address the resident's symptoms of depression. The DON stated there had been multiple occasions where a plan of care should have been developed to manage Resident 1's mental disorders and SI. The DON further stated the social services director was unavailable for interview. On 9/6/23 at 2:17 P.M., an interview was conducted with the facility's psychiatrist, MD 8. MD 8 stated he saw Resident 1 during an initial visit and the resident had depression, bipolar disorder and a borderline personality disorder (a disorder with unstable moods, behavior, and relationships). MD 8 stated these diagnoses posed an increased risk of suicide for Resident 1. MD 8 stated residents with prior suicide attempts also ran a higher risk of attempting suicide again. MD 8 stated residents with a history of SI should have their suicide risk assessed and a plan of care in place upon 555723 Page 10 of 30 555723 09/21/2023 Santa Fe Post-Acute 247 E. Bobier Drive Vista, CA 92084

F 0740 Level of Harm - Actual harm Residents Affected - Few admission. MD 8 stated when Resident 1 verbalized SI, he should have been notified. MD 8 stated when Resident 1's verbalizations of SI increased in frequency, it was a, Definite warning sign that the resident was focusing on SI or beginning to formulate a plan. MD 8 stated when LN 7 noticed Resident 1's SI increasing in frequency, he should have been notified right away and this should always be taken seriously. MD 8 stated he had not been aware that Resident 1 had verbalized SI to staff and it was something he would have wanted to know, notified right away to evaluate the resident. MD 8 stated when Resident 1 made the suicide threat of swallowing glass, the resident should not have been left alone for any length of time, other staff should have responded, the entire room should have been thoroughly searched for glass, and other dangers and hazards should have been removed. MD 8 stated in crisis, staff had to get inside the resident's room even if the resident did not want staff inside the room. MD 8 stated if the facility had adequately trained and evaluated the competencies of their staff and had systems in place to respond to SI and behavioral emergencies, including the written care plan, that addressed the resident's mental disorders and SI, a good chance the outcome for Resident 1 would have been different. On 9/6/23 at 3:06 P.M., an interview was conducted with LN 10. LN 10 stated her background was psychiatric nursing. LN 10 stated she was familiar with Resident 1 and had not known the resident had a history of SI, suicide attempts, or had been verbalizing SI to nursing staff. LN 10 stated Resident 1's depression and bipolar disorder should have been care planned to include the resident's verbalizing of SI. LN 10 stated everyone providing care to Resident 1 should have known of her SI history so the resident could have been monitored appropriately. LN 10 stated increased verbalization of SI meant the resident's mental condition was worsening and that should have been reported to the psychiatrist immediately. LN 10 further stated when Resident 1 threatened to swallow glass, that was considered a suicide threat, and the resident should not have been left alone. LN 10 stated other staff should have responded to the situation, resident's room should have been thoroughly searched for items that could have been used to inflict self-harm. LN 10 stated the glass vase that had been in Resident 1's room was given to Resident 1 by another resident. LN 10 stated there should not have been any glass items allowed on the behavioral health unit (unit housing residents with mental disorders, and where Resident 1 resided) as they posed a general safety hazard. LN 10 stated as a standard, residents with verbalizations of SI should have had their rooms checked for items that could have been used for self-harm should be removed. LN 10 stated what happened to Resident 1 (on 8/24/23) could have been prevented had those things been done. On 9/19/23 at 1:18 P.M., a telephone interview was conducted with MD 13. MD 13 stated she treated Resident 1 at GACH 2 when the resident was placed on terminal comfort care. MD 13 stated Resident 1 sustained a lot of damage to her GI tract after swallowing glass. MD 13 stated resident 1 had developed sepsis from the cuts to her GI tract. MD 13 stated, The patient's swallowing of glass contributed to her demise. MD 13 was asked it Resident 1's swallowing glass on 8/24/23 was a substantial factor causing the resident's death. MD 13 stated, Yes, it was. MD 13 further stated, It was the direct cause of the patient's death. A review of the facility's policy titled Behavioral Health Services, revised February 2019, indicated, . The facility will provide and residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care . 2. Residents who exhibit signs of emotional/psychosocial distress receive services and support that address their individual needs and goals for care . 5. Staff training regarding behavioral health services includes, but is not limited to: a. recognizing changes in behavior that indicated psychological distress; b. implementing care plan interventions that are relevant to the resident's diagnosis and appropriate to his or her 555723 Page 11 of 30 555723 09/21/2023 Santa Fe Post-Acute 247 E. Bobier Drive Vista, CA 92084

F 0740 needs; c. monitoring care plan interventions and reporting changes in conditions Level of Harm - Actual harm A review of the facility's policy titled Suicide Threats, revised December 20[TRUNCATED] Residents Affected - Few 555723 Page 12 of 30 555723 09/21/2023 Santa Fe Post-Acute 247 E. Bobier Drive Vista, CA 92084

F 0741 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure staff working on the facility's behavioral health unit (BHU, an area of the building that housed residents with mental and psychosocial disorders [syndromes characterized by a clinically significant disturbance in an individual's cognition, emotion regulation, or behavior]) had appropriate training, skill sets, and competencies (measurable pattern of knowledge, skills, abilities, and behaviors, and other characteristics in order to perform occupational functions successfully) to provide appropriate care to the 54 residents on the BHU with mental and psychosocial disorders, and residents experiencing suicidal ideation (SI- thoughts of self-harm and/or the killing oneself). In addition, the facility failed to have a system in place wherein staff were knowledgeable to respond immediately and efficiently to behavioral emergencies/crisis (when a resident was posing a danger to self and/or others). As a result: 1. Resident 1 verbalized to staff on several occasions that she wanted to kill herself, told certified nursing assistant (CNA) 3 that she would swallow glass; and was left alone in her room. Resident 1 successfully executed her plan. Resident 1 was sent to the hospital on 8/24/23 and later died due to sustained shards of glass throughout the gastrointestinal tract (GI tract, path where food travels through the body) that cut the organs of the GI tract, developed sepsis (infection in the blood). 2. Resident 2 who had a history of SI, verbalized to staff on 8/21/23 his plan to hang himself with his oxygen tubing (tube delivering oxygen to a resident). This failure placed Resident 2 and other 54 residents in the BHU in immediate danger of serious injury, harm, impairment, or death. On 8/30/23 at 5:37 P.M., the ADM and DON were informed of Immediate Jeopardy (IJ) related to the facility's failure to ensure staff were adequately trained and competent in providing care to residents with SI and responding to behavioral emergencies/crisis. The facility began to develop a plan to remove the immediacy. On 9/1/23 at 3:28 P.M., the IJ was removed, and the ADM, DON, and director of clinical operations were notified after verifying the facility's Plan of Action while on-site. Cross reference F740 and F838. Findings: On 8/29/23 at 1:48 P.M., an on-site visit was conducted at the facility to investigate a facility reported incident related to Resident 1 had swallowed glass on 8/24/23. The administrator (ADM) and director of nursing (DON) were interviewed. The ADM stated he was still conducting an investigating into the incident. The ADM and DON both stated they were recently informed that Resident 2 had died at the hospital on 8/29/23. 555723 Page 13 of 30 555723 09/21/2023 Santa Fe Post-Acute 247 E. Bobier Drive Vista, CA 92084

F 0741 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some A review of facility document titled Daily Census dated, 8/28/23, indicated, there were 152 residents in the facility, and 65 residents on the BHU (Station 2). Of the 65 residents on the BHU, 10 residents were identified as being part of the County Patch program (county funded program aiming to provide specialized care for residents with mental disorders). According to Optum, undated, online document titled San Diego County funded Skilled Nursing Facility (SNF) Patch Criteria, .An additional daily rate paid by San Diego County to contracted SNFs that have agreed to provide additional mental health services to San Diego County beneficiaries . The client must meet the following criteria for San Diego County funded SNF Patch: . 4. Cannot be safely managed in a less restrictive level of care . 8. Is gravely disabled as determined by the establishment of .Conservatorship [a legally appointed person who makes decisions on behalf of another individual deemed unable to] by the Superior Court . 10. Has an adequately documented .primary diagnosis of a serious, persistent, major mental disorder . a. The client's psychosocial functioning has deteriorated to the degree that the client is at risk for being unable to safely and adequately care for themselves in the community or at a less restrictive setting [such as assisted living facility] . https://www.optumsandiego.com A review of facility document titled Diagnosis Report dated 9/1/23, indicated: Eighteen residents on the BHU had a diagnosis of schizophrenia (a mental disorder characterized by a break from reality, paranoia, delusions, and hallucinations). Thirty-one residents on the BHU had a diagnosis of depression and/or major depression (a mood disorder that caused persistent feelings of sadness, hopelessness, and loss of interest). Five residents on the BHU had a diagnosis of bipolar disorder (mental disorder with extreme changes in mood, thought, energy, and behavior and characterized by periods of mania and depression). According to the National Institute of Mental Health's online article titled Depression, dated April 2023, .Depression is a serious mood disorder . What are the signs and symptoms of depression? . Feelings of guilt, worthlessness, or helplessness . Increased irritability or anger . becoming withdrawn, negative, or detached .Thoughts of death, suicide, or suicide attempts . Bipolar disorder . also experience depressive episodes . also experiences .unusually elevated moods, in which they might feel very happy, irritable, or up with a marked increase in activity level A review of Resident 2's facility admission Record indicated, the resident was admitted to the facility on [DATE] with diagnoses to include acute respiratory failure, major depressive disorder (major depression), and SI. A review of Resident 2's admitting paperwork from the general acute care hospital (GACH) 1 dated, 8/15/23 indicated, the resident was identified to have suicidal thoughts and had expressed SI to the licensed nurse during his hospital course. A review of Resident 2's facility nursing progress notes, dated 8/21/23, indicated, Resident verbalized to nursing staff I don't want to live, I want to die, What is there to live for. [sic] When asked if the resident had a plan, resident stated he will hang himself with O2 [oxygen] tubing A review of Resident 2's facility clinical record dated, 8/29/23 indicated, the resident's suicide risk had not been assessed and there was no written plan of care developed with person-centered 555723 Page 14 of 30 555723 09/21/2023 Santa Fe Post-Acute 247 E. Bobier Drive Vista, CA 92084

F 0741 interventions to address the resident's major depressive disorder and SI until 8/29/23. Level of Harm - Immediate jeopardy to resident health or safety A review of Resident 1's facility admission Record indicated the resident was admitted on [DATE] with diagnoses to include bipolar disorder and depression. Residents Affected - Some A review of Resident 1's Minimum Data Set Assessment (MDS- a comprehensive assessment tool) dated 8/8/23 indicated, the resident scored 15 on the brief interview of mental status (a score of 15 meant the resident was cognitively intact). A review of Resident 1's facility History and Physical exam, signed by the physician on 8/16/23, indicated the resident had fluctuating capacity to understand and make decisions. A review of Resident 1's admitting paperwork from the GACH 2 dated 8/2/23, indicated the resident had a history of SI. Review of Resident 1's facility nursing progress notes indicated on: 8/7/23, The resident became very upset during the medication administration and was yelling at the licensed nurse (LN). 8/9/23, Pt [patient] presented with behavioral problems today demanding to be discharged , aggressive, calling nurses out their name or title with bad language and profanity, slammed telephone and slammed door. She demanded to speak to social services to be discharged . 8/10/23, Resident .started yelling and demanded me to go out from her room. She wants to go home. No one paying attention to her. Resident left alone. 8/20/23, .Pt stated she was very upset with her care here and feels like she is in prison. Pt is very upset with [family members] for putting her here and they don't come and visit her. Pt refusing medications at this time and believes that if she stops taking her medications she will die faster .asked pt if she has thoughts of hurting herself and pt denies .will follow up with doctor 8/20/23, Late entry for 8/20/23: .Pt was sitting in room with [family member, FM 1] laughing and eating chips 8/24/23, At 12:05 AM Resident came out from the room and stating she swallowed a glass. We would like to come to the room she wont [sic] let us in and she pushed the bed at the door .physician notified . Resident hold the phone and saying you are not my [expletive] doctor .911 called and with difficulty evaluating her and took her at 110 AM. Room has been assessed broken glass found at the window. A review of Resident 1's facility clinical record indicated, the resident's suicide risk had not been assessed upon admission and there was no written plan of care developed with person-centered interventions to address the resident's bipolar disorder, depression, and/or SI until 8/25/23 (the resident did not return to the facility after leaving via 911 on 8/24/23). A review of Resident 1's GACH 1 physician documentation dated, 8/24/23, indicated, .Patient was seen and evaluated by writer and the SW [social worker] at the ED [emergency department]. Pt appears to be restless, maintained no eye contact, report feeling depressed, overwhelmed and frustrated which 555723 Page 15 of 30 555723 09/21/2023 Santa Fe Post-Acute 247 E. Bobier Drive Vista, CA 92084

F 0741 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some has been getting worse in the last few days to week and started feeling increasingly irritable and has been feeling on edge. Report that she has been feeling worthless, useless and she had been feeling suicidal and decided to swallow some glasses with the intention to hurt herself. Report poor sleep for days and loss of appetite. Pt remain guarded and refused to elaborate further. Pt report that [family member] put her in a nursing home and she would rather kill herself than staying in the nursing home A review of Resident 1's GACH 1 physician documentation dated 8/24/23, indicated, . [Resident 1] tried to kill herself by swallowing broken glass; I screwed up now I have pain at the back of my throat; c/o [complained of] not liking the living facility; also CT [computerized tomography, machine able to visualize inside the body] chest pneumomediastinum [air in the chest cavity near the esophagus (tube connecting mouth to the stomach)] and possible foreign body glass at the upper pharynx [throat] and smaller pieces in small intestine A review of Resident 1's GACH 1 physician documentation dated 8/24/23, indicated, .Patient currently endorsing pain over her throat and abdominal area A review of Resident 1's GACH 1 physician documentation dated 8/24/23, indicated, .Patient states that she is in severe pain in her lower neck and upper chest and now wishes that she did not swallow the class [sic] because of the pain and also reports right lower quadrant pain that started after swallowing glass A review of Resident 1's GACH 1 physician documentation, Discharge summary, dated [DATE], indicated the resident had a 3.5 by 4 cm (centimeter) slightly curved piece of glass with sharp edges removed that had caused a 2 cm tear the resident's esophagus. Resident 1 was transferred to GACH 2 with physician's recommendation to keep sedated and intubated (breathing with a breathing tube). A review of Resident 1's GACH 2 documentations dated, 8/24/23 indicated, the resident had prior suicide attempts on 1/18/22 and 8/31/22. A review of Resident 1's GACH 2 documentation, admission History and Physical, dated 8/24/23, indicated, .Patient was at [SNF] .when she was found to have swallowed about 5 handfuls of broken glass from a vase .She had severe pain in her neck and upper chest. Reported to be remorseful for her actions . CT [computerized tomography, machine able to visualize inside the body] showed extensive shards of glass from the proximal esophagus [upper part/near the mouth of the tube connecting the mouth to the stomach] through the colon [large intestine]. She had subcutaneous emphysema [air that's trapped under the skin] near her cricopharynx [in the throat area]. Underwent direct esophagoscopy [scope that goes in the esophagus] . which revealed a 3x4 cm [centimeter] shard of glass which was removed. There was a 2-centimeter tear posterior wall of the esophagus and into the prevertebral fascia [layer of tissue surrounding the spine] as well as a small laceration in the posterior oropharynx [back of the throat directly behind the roof of the mouth] that was thought to be the source of subcutaneous emphysema . She remained intubated [with a breathing tube] for safety. Transferred to [GACH 2] for further care . Found to have glass shards throughout the GI [gastrointestinal] tract .Patient is septic [blood infection] by SIRS [systemic inflammatory response in the presence of a known or suspected source] and GI/oral source . Apparent suicide attempt A review of Resident 1's GACH 2 documentation, Discharge summary, dated [DATE], .Following admission, the patient was initially cared for in the ICU [intensive care unit] and then transitioned to comfort care. Active hospital problems .Severe sepsis, esophageal perforation [tear], foreign body in 555723 Page 16 of 30 555723 09/21/2023 Santa Fe Post-Acute 247 E. Bobier Drive Vista, CA 92084

F 0741 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some digestive tract . Prognosis felt to be guarded to poor [not likely to recover] .She passed away in the hospital on 8/29/23 at 0758 [7:58 AM] On 8/29/23 at 2:45 P.M., an observation of the BHU was conducted. The double entry doors to the unit alarmed when opened. Approximately, 24 residents were observed siting closely together at several tables or were walking around the tables in the open space located in front of the nurses' station. A resident seated at one of the tables near the entry doors was making yelling and screaming sounds. Another resident was heard screaming unintelligibly from down the west hall. Two residents at one of the tables were playing cards. One resident at a table was rocking back and forth. One staff was observed sitting at the resident table and another staff was observed standing near a table. Two staff were observed in the nurses' station. On 8/29/23 at 3 P.M., an interview was conducted with certified nursing assistant (CNA) 3. CNA 3 stated she often provided care to Resident 1 and the resident made statements like, I want to go home and I don't belong here. CNA 3 stated Resident 1 would frequently yell and cuss at the nurses and had a behavior of putting herself on the floor for attention. CNA 3 stated Resident 1 had told her, I want to kill myself, on three different occasions since admission to the facility. CNA 3 was asked what she had done when the resident verbalized that. CNA 3 stated she kept a closer eye on the resident. CNA 3 stated she began her shift at 2:30 P.M. on 8/23/23, and had worked double shift (from 2:30 P.M. on 8/23/23 to 7 A.M. on 8/24/23). CNA 3 stated at the start of the shift, Resident 1 was at the nurses' station yelling and cussing at the nurse. CNA 3 stated Resident 1 went to her room after a while and seemed calm. CNA 3 stated sometime around midnight, Resident 1's call light went off and she responded to it. CNA 3 stated she asked Resident 1 what she needed, and the resident told her, Get the [expletive] out of here. CNA 3 stated she reminded Resident 1 that she had the call light on, and the resident told her, I'm going to swallow glasses. CNA 3 stated the resident normally spoke with a slightly slurred speech. CNA 3 stated she checked the resident's room and inside the resident's mouth. CNA 3 stated she did not see any glass or broken glass anywhere. CNA 3 stated, when Resident 1 noticed that she (CNA 3) did not find anything and told her, You can't find it. CNA 3 stated she left resident's room to get LN 4 and that Resident 1 wanted her to close the door and she closed it. CNA 3 stated, [Resident 1] wants me to slam the door so it closes tight. CNA 3 stated when she located LN 4, they both heard the sound of glass breaking. CNA 3 stated they went to Resident 1's room and the resident was closing her door and pushing her body against the door, and they could not open it. CNA 3 stated when she was able to open the door, Resident 1 was seated in her wheelchair and a broken glass vase on the floor next to the resident. CNA 3 stated the resident was strong enough to move fast and without the need of an assistive device. CNA 3 stated the glass vase had been at the resident's bedside and the resident had kept artificial flowers in it. CNA 3 stated Resident 1 made pushing motions toward her that ushered her out of the resident's room and then the resident closed the door. CNA 3 stated she remained outside Resident 1's closed door and did not open the door because the resident would become upset. CNA 3 stated she remained outside Resident 1's closed door for approximately two minutes while LN 4 called the physician. CNA 3 stated Resident 1 had been alone in her room with broken glass on the floor. CNA 3 stated she was afraid the resident was going to swallow the glass. CNA 3 stated LN 4 returned with the physician on the mobile phone, and LN 4 was able to get the resident's door open enough to pass the phone through the door to the resident. CNA 3 stated Resident 1 said, You're not my [expletive] doctor, and threw the phone into the hallway. CNA 3 stated 911 came and took Resident 1 to the hospital. CNA 3 stated the incident with Resident 1 had been a behavioral emergency. CNA 3 stated the 555723 Page 17 of 30 555723 09/21/2023 Santa Fe Post-Acute 247 E. Bobier Drive Vista, CA 92084

F 0741 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some facility did not have a protocol to handle behavioral emergencies and that she had not known what to do during the incident. CNA 3 stated she had needed help with Resident 1 and had not been able to handle the situation alone. CNA 3 stated there should be a process like a code (a systematic, organized emergency response) called so other staff can help in a behavioral emergency. CNA 3 stated she had not received any facility training for residents with SI. CNA 3 stated, I didn't know what to do in that situation. CNA 3 further stated the BHU did not feel safe without more training and a system in place to respond to emergencies. CNA 3 further stated the Station 2 used to be a dementia unit (residents with cognitive and memory issues), but It's gotten worse since they mixed psych [mental disorders] with the dementia. CNA 3 stated there was too much screaming on the unit now. CNA 3 stated staff received some training about residents who scream, but nothing on SI or psychiatric/behavioral emergencies. On 8/29/23 at 4 P.M., an interview was conducted with CNA 5. CNA 5 stated Station 2 used to be a dementia unit but recently it turned into a psych unit. CNA 5 stated, Mixing psych [residents] and dementia's [residents] not working. Lots of screaming from psych [residents] that upsets those with dementia. CNA 5 stated staff received in-services from the psychologist about behavior, But we still don't know how to deal with them. CNA 5 stated the staff training was rushed and there were no skills checks or competency evaluation done. CNA 5 stated he would not know how to respond in a behavioral emergency or if a resident had SI or threatened suicide. CNA 5 stated there should be training about SI and behavioral emergencies so everyone knows what to do and could form a coordinated response. CNA 5 stated staff often got hurt on the BHU and that he had been hit, kicked, and scratched by the psychiatric residents. CNA 5 stated, It's been a mess in there [BHU] . and unsafe. CNA 5 stated, We need better training . CNA 5 further stated that he was working the night of Resident 1's incident, but he did not know a behavioral emergency had taken place until the LN asked him to open the door for 911 responders. On 8/30/23 at 9:32 A.M., a telephone interview was conducted with LN 4. LN 4 stated she worked regularly on Station 2. LN 4 stated Station 2 used to be a dementia unit but now had a lot of psych residents and were adding Patch residents. LN 4 stated the Patch residents were difficult to manage and frequently screamed and yelled on the unit. LN 4 stated staff were getting hurt because the psych residents tried to fight with the staff. LN 4 stated mixing dementia residents with psych/behavioral residents made the unit chaotic. LN 4 stated she was providing care to Resident 1 during the NOC shift (10:30 P.M. on 8/23/23 to 7 A.M. on 8/24/23) and she had seen Resident 1 around 10:45 P.M., at which the resident seemed calm. LN 4 stated she was unaware of Resident 1 having had any history of SI or making SI statements. LN 4 stated, I would have wanted to know that .I didn't know. LN 4 stated it was important to know a resident had SI to monitor for that. LN 4 stated all staff should have known of Resident 1's SI to keep the resident safe from self-harm. LN 4 stated there had not been any training for providing care to residents with SI and that there should have been training provided. LN 4 stated SI training was needed because any resident could begin to experience SI. LN 4 stated she first became aware of the incident with Resident 1 because the resident came up to the nurses' station and told her, I swallowed glass. LN 4 stated she did not recall CNA 3 informed her that Resident 1 had threatened to swallow glass. LN 4 stated she remembered hearing of glass breaking prior to Resident 1 informing her that she had swallowed glass. LN 4 stated both her and CNA 3 tried to get into Resident 1's room and that the resident had closed the door and place herself against the door. LN 4 stated she left CNA 3 at the resident's closed door and went to call the 555723 Page 18 of 30 555723 09/21/2023 Santa Fe Post-Acute 247 E. Bobier Drive Vista, CA 92084

F 0741 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some physician. LN 4 stated CNA 3 tried to get back inside the resident's room while they waited for the physician to return the call. LN 4 stated she brought the mobile phone to Resident 1 and the resident threw it into the hall and said, That's not my [expletive] doctor. LN 4 stated she called 911 and they came right away for the resident. LN 4 stated the incident with Resident 1 was considered a behavioral emergency and had been a suicide threat. LN 4 stated the facility did not have a procedure for behavioral emergencies and that there should be one. LN 4 stated, We needed more help, and could not get inside the resident's room. LN 4 stated if she had known Resident 1 verbalized the threat of swallowing glass, she would have had a staff remained inside the resident's room. LN 4 stated the resident should have been placed on 1:1 supervision (one staff to remain with the resident) as soon as the suicide threat was made. LN 4 stated the resident's room would have been thoroughly searched until all dangers were removed. LN 4 stated doing those things could have prevented Resident 1 from swallowing glass. LN 4 stated, Training could have prevented this. LN 4 stated the number of staff on the unit had been enough but that there needed to be an organized, systematic response during a behavioral emergency and staff who were competent. On 8/30/23 at 10:43 A.M., an interview was conducted with CNA 6. CNA 6 stated the facility had not provided any staff training related to SI or behavioral emergency response. CNA 6 stated there should have been training so we all know what to do and could act quickly. On 8/30/23 at 10:57 A.M., an interview was conducted with LN 7. LN 7 stated she was familiar with Resident 1 and that the resident would scream and had, Lots of suicidal ideation. LN 7 stated Resident 1 would speak negatively about herself and would say things such as certain family members did not like her, she was not worthy of living, and that she would rather die. LN 7 stated Resident 1 often said, I just want to die. LN 7 stated Resident 1's verbalizations of SI were not a change of condition and did not required intervention. LN 7 stated, [Resident 1] was on the psych unit and not everything residents [on the BHU] say makes sense. LN 7 stated Resident 1's frequency of verbalizing SI was increasing prior to the incident (8/24/23). LN 7 stated it would be a change reportable to the physician if the resident had a plan. LN 7 stated there was currently a resident on the BHU, Resident 2, and he would say that he wants to die, too. LN 7 stated that she had not received training related to providing care to residents with SI. LN 7 stated she thought SI training would be beneficial. LN 7 stated an actual suicide threat was an emergency and it deserved an emergency response like calling a code. LN 7 stated the facility did not have a procedure or code for responding to behavioral emergencies. LN 7 stated training and competency evaluation was important for everyone involved to ensure, We know what to do. On 8/30/23 at 11:45 A.M., an interview was conducted with the director of staff development (DSD). The DSD stated she was responsible for staff training. The DSD stated there had not been any training provided to staff related to providing care to residents with SI. The DSD stated that there should have been SI training given to staff especially to those that worked in the BHU. The DSD stated corporate did staff trainings about residents with behaviors but there was no competency evaluation done. The DSD stated for a behavioral emergency such as what took place with Resident 1, a Code Grey (situational emergency response) should have been called. The DSD stated a Code Grey was called for combative residents which also included a resident trying to do self-harm. The DSD stated Code Grey training was mandatory for all staff in the facility especially before any staff worked in the BHU. The DSD stated she had not done staff knowledge checks or competencies after the Code Grey training was done and should have. The DSD stated what happened to Resident 1, Comes down to a lack of staff knowledge. 555723 Page 19 of 30 555723 09/21/2023 Santa Fe Post-Acute 247 E. Bobier Drive Vista, CA 92084

F 0741 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some On 8/30/23 at 12:05 P.M., the lesson plans and attendance sheets for Code Grey training was requested from the DSD. On 8/30/23 at 12:20 P.M., a joint interview and record review was conducted with the DSD. The facility's Lesson plan for CPI- Crisis, Prevention, Intervention Code Grey, dated 7/6/23 was reviewed. The training did not include SI, had de-escalation tips, and Code Grey paging overhead for any behavioral occurrence where immediate available staff were needed promptly. A review of the sign in sheet for the CPI training dated 7/6/23, did not have LN 4, LN 7, CNA 3, CNA 4, and CNA 6 in the attendance. The DSD stated they should have had the mandatory training. The DSD stated that knowledge checks and competency evaluations had not been done. The DSD stated competency evaluation should have been done to ensure the training was learned and the staff were deemed competent. The DSD stated she was unsure what training was required to work competently and safely in the BHU. The DSD stated the BHU training automatically came from corporate and that she was not part of any discussion or planning of that staff training. The DSD stated facility staff should have been part of analyzing and planning the BHU training since they were most familiar with the facility and residents' needs. On 8/30/23 at 2:05 P.M., a joint interview and record review was conducted with the DON. The DON reviewed Resident 1's clinical record and stated on 8/20/23, after the resident made a statement of wanting to stop taking medications so she would die faster, she had instructed nursing staff to do a change of condition report and to closely monitor the resident. The DON stated there was no documentation nursing staff had carried out her directions, or that Resident 1 had received increased monitoring. The DON stated this should have been done. The DON stated as soon as Resident 1 threatened to swallow glass, the resident should not have been left alone at any time, should have been placed on 1:1 supervision, and the entire room swept for the removal of all glass objects and any other suicide hazards. The DON stated if this had been done, it could have prevented Resident 1 from being able to swallow glass. The DON stated a Code Grey should have been implemented immediately and that staff should have gained access to the resident's room by any means necessary to separate the resident from broken glass that was on the floor. The DON stated all staff should have been trained on how to deal with residents who have SI and how to respond to a Code Grey in an organized and immediate fashion. The DON stated staff competencies should have been evaluated. The DON further stated the residents housed in BHU with higher level of psychiatric diagnoses and mental disorders required more competency training for staff. The DON stated both Resident 1 and Resident 2 should have had their SI history assessed and mental disorders care planned with resident-specific interventions since their admission to the facility. The DON stated Resident 2 was still in the BHU and there were staff providing care to the resident who may not have been trained for SI and behavioral emergencies. The DON further stated the facility stopped admitting residents with mental disorders and Patch program as of 8/30/23 until all staff were trained and competent. The DON stated, We don't admit those residents [with SI history] here. The DON stated Resident 1 and Resident 2 should not have been admitted to the facility. The DON stated, [We] Shouldn't have admitted residents that we were not fully able to provide care to. On 8/30/23 at 5:30 P.M., an interview was conducted with the administrator (ADM). The DON was also present. The ADM stated he did not understand what the concern was about Patch residents in the BHU. The ADM stated they had the same needs as any other resident in the BHU only the funding was different. The ADM did not provide an answer related to staff training and competencies. 555723 Page 20 of 30 555723 09/21/2023 Santa Fe Post-Acute 247 E. Bobier Drive Vista, CA 92084

F 0741 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some On 8/30/23 at 5:37 P.M., the ADM and DON were informed of Immediate Jeopardy (IJ) related to the facility's failure to ensure staff were adequately trained and competent in providing care to residents with SI and responding to behavioral emergencies/crisis. The facility began to develop a plan to remove the immediacy. On 8/30/23 at 6:42 P.M., a telephone interview was conducted with the facility's medical director (MDR). The MDR stated he expected staff to be fully trained and knowledgeable in providing care to residents with SI. The MDR stated when Resident 1 verbalized SI, staff should have responded immediately by notifying the physician and psychiatrist, assess the resident, and develop a care plan. The MDR stated when Resident 1 threatened to swallow glass, the resident should have been placed on immediate 1:1 supervision and all glass removed from the resident's room. The MDR stated a Code Grey should have been called and carried out. The MDR stated staff should have been trained and competent to respond in a behavioral emergency. On 8/30/23 at 8:05 P.M., the facility's Plan of Action was reviewed with the DON. The Plan of Action included: Immediate corrective action and identification of residents affected: 1. [Resident 2] had verbalized hanging himself with oxygen tubing. Suicide risk assessment done, placed resident on 1:1 supervision with safety precautions in place and care planned. 2. Suicide risk assessment and high-risk assessment are in process and are being completed on all and was done on all residents in station 2 and all PATCH residents in the facility. Immediate systemic changes: 1. All staff tonight were given in-service on code gray and training how to respond to crisis in station 2 by DSD. A. Code gray in-service included how to call the code and [TRUNCATED] 555723 Page 21 of 30 555723 09/21/2023 Santa Fe Post-Acute 247 E. Bobier Drive Vista, CA 92084

F 0838 Level of Harm - Actual harm Residents Affected - Few Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility's Facility Assessment (determines the resources and training necessary to care for residents competently during the day-to-day operations) failed to: 1. Thoroughly assess its resident population and its ability to provide care for residents with suicidal ideation (SI, thoughts of self-harm or of killing oneself). 2. Evaluate and identify the needs of the resident in the behavioral health unit (BHU- section of the facility's building designated for residents with mental disorders [syndromes characterized by a clinically significant disturbance in an individual's cognition, emotion regulation, or behavior] and memory care issues) located in Station 2 and the provision of behavioral health services to residents with suicidal ideation (SI, thoughts of self-harm or of killing oneself), mental and psychosocial disorders, and Patch program residents (county funded program aiming to provide specialized care for residents with mental disorders). 3. Evaluate and provide adequate training and competencies to staff (measurable pattern of knowledge, skills, abilities, and behaviors, and other characteristics in order to perform occupational functions successfully) required to appropriately deliver care to residents with mental and psychosocial disorders, SI, and to respond to behavioral emergencies/crisis (such as harm to self and/or others). As a result, two residents (1, 2) were identified to have history of SI and mental disorders. Resident 1, verbalized to staff on several occasions that she wanted to kill herself, told certified nursing assistant (CNA) 3 that she would swallow glass. Resident 1 was left alone in her room with a glass vase which the resident then broke and ingested. Resident 1 was sent to the hospital, experienced pain, and later died at the hospital due to sustained shards of glass throughout the gastrointestinal tract (GI tract, path where food travels through the body) that cut the organs of the GI tract, developed sepsis (infection in the blood). These failures put Resident 2 and other residents with mental disorders, SI or the potential for SI, and/or behavioral emergencies at risk of serious injury, harm, impairment, or death. Cross reference F740 and F741. Findings: On 8/29/23 at 1:48 P.M., an on-site visit was conducted at the facility to investigate a facility reported incident alleging Resident 2 had swallowed glass on 8/24/23. The administrator (ADM) and director of nursing (DON) were interviewed at this time. The ADM and DON both stated they were recently informed that Resident 2 had died at the hospital. A review of facility document titled Daily Census dated 8/28/23, indicated, there were 152 residents in the facility, and 65 residents on the BHU (Station 2). Of the 65 residents on the BHU, 10 residents were identified as being part of the County Patch program. 555723 Page 22 of 30 555723 09/21/2023 Santa Fe Post-Acute 247 E. Bobier Drive Vista, CA 92084

F 0838 Level of Harm - Actual harm Residents Affected - Few According to Optum, undated, online document, titled San Diego County funded Skilled Nursing Facility (SNF) Patch Criteria, .An additional daily rate paid by San Diego County to contracted SNFs that have agreed to provide additional mental health services to San Diego County beneficiaries . The client must meet the following criteria for San Diego County funded SNF Patch: . 4. Cannot be safely managed in a less restrictive level of care . 8. Is gravely disabled as determined by the establishment of .Conservatorship [a legally appointed person who makes decisions on behalf of another individual deemed unable to] by the Superior Court . 10. Has an adequately documented .primary diagnosis of a serious, persistent, major mental disorder . a. The client's psychosocial functioning has deteriorated to the degree that the client is at risk for being unable to safely and adequately care for themselves in the community or at a less restrictive setting [such as assisted living facility] . https://www.optymsandiego.com A review of facility document titled Diagnosis Report dated 9/1/23, indicated: Eighteen residents in the BHU had a diagnosis of schizophrenia (a mental disorder characterized by a break from reality, paranoia, delusions, and hallucinations). Thirty-one residents in the BHU had a diagnosis of depression and/or major depression (a mood disorder that caused persistent feelings of sadness, hopelessness, and loss of interest). Five residents in the BHU had a diagnosis of bipolar disorder (mental disorder with extreme changes in mood, thought, energy, and behavior and characterized by periods of mania and depression). A review of Resident 2's facility admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses to include acute respiratory failure (lungs cannot release enough oxygen), major depressive disorder, and SI. A review of Resident 2's admitting paperwork from the general acute care hospital (GACH) 1 dated 8/15/23, indicated the resident had a diagnosis of suicidal thoughts and expressed SI to the licensed nurse during his hospital course. A review of Resident 2's facility nursing progress notes, dated 8/21/23, indicated, Resident verbalized to nursing staff I don't want to live, I want to die, what is there to live for. [sic] When asked if the resident had a plan, resident stated he will hang himself with O2 [oxygen] tubing A review of Resident 1's facility admission Record indicated, the resident was admitted on [DATE] with diagnoses to include bipolar disorder and depression. A review of Resident 1's admitting paperwork from the general acute care hospital (GACH) 2 dated 8/2/23, indicated, the resident had a history of SI. A review of Resident 1's facility nursing progress notes dated 8/24/23, indicated, At 12:05 AM Resident came out from the room and stating she swallowed a glass. We would like to come to the room she wont [sic] let us in and she pushed the bed at the door .physician notified . Resident hold the phone and saying you are not my [expletive] doctor .911 called and with difficulty evaluating her and took her at 110 AM. Room has been assessed broken glass found at the window. A review of Resident 1's GACH 1 physician documentation dated 8/24/23, indicated, .Patient was seen and evaluated by writer and the SW [social worker] at the ED [emergency department]. Pt appears to 555723 Page 23 of 30 555723 09/21/2023 Santa Fe Post-Acute 247 E. Bobier Drive Vista, CA 92084

F 0838 Level of Harm - Actual harm Residents Affected - Few be restless, maintained no eye contact, report feeling depressed, overwhelmed and frustrated which has been getting worse in the last few days to week and started feeling increasingly irritable and has been feeling on edge. Report that she has been feeling worthless, useless and she had been feeling suicidal and decided to swallow some glasses with the intention to hurt herself. Report poor sleep for days and loss of appetite. Pt remain guarded and refused to elaborate further. Pt report that [family member] put her in a nursing home and she would rather kill herself than staying in the nursing home A review of Resident 1's GACH 1 physician documentation dated 8/24/23, indicated, . [Resident 1] tried to kill herself by swallowing broken glass; I screwed up now I have pain at the back of my throat; c/o [complained of] not liking the living facility; also CT [computerized tomography, machine able to visualize inside the body] chest pneumomediastinum [air in the chest cavity near the esophagus (tube connecting mouth to the stomach)] and possible foreign body glass at the upper pharynx [throat] and smaller pieces in small intestine A review of Resident 1's GACH 1 physician documentation dated 8/24/23, indicated, .Patient currently endorsing pain over her throat and abdominal area A review of Resident 1's GACH 1 physician documentation dated 8/24/23, indicated, .Patient states that she is in severe pain in her lower neck and upper chest and now wishes that she did not swallow the class [sic] because of the pain and also reports right lower quadrant pain that started after swallowing glass A review of Resident 1's GACH 1 physician documentation, Discharge summary, dated [DATE], indicated the resident had a 3.5 by 4 cm (centimeter) slightly curved piece of glass with sharp edges removed that had caused a 2 cm tear the resident's esophagus. Resident 1 was transferred to GACH 2 with physician's recommendation to keep sedated and intubated (breathing with a breathing tube). A review of Resident 1's GACH 2 documentations dated 8/24/23, indicated the resident had prior suicide attempts on 1/18/22 and 8/31/22. A review of Resident 1's GACH 2 documentation, admission History and Physical, dated 8/24/23, indicated, .Patient was at [SNF] .when she was found to have swallowed about 5 handfuls of broken glass from a vase .She had severe pain in her neck and upper chest. Reported to be remorseful for her actions . CT [computerized tomography, machine able to visualize inside the body] showed extensive shards of glass from the proximal esophagus [upper part/near the mouth of the tube connecting the mouth to the stomach] through the colon [large intestine]. She had subcutaneous emphysema [air that's trapped under the skin] near her cricopharynx [in the throat area]. Underwent direct esophagoscopy [scope that goes in the esophagus] . which revealed a 3x4 cm [centimeter] shard of glass which was removed. There was a 2 centimeter tear posterior wall of the esophagus and into the prevertebral fascia [layer of tissue surrounding the spine] as well as a small laceration in the posterior oropharynx [back of the throat directly behind the roof of the mouth] that was thought to be the source of subcutaneous emphysema . She remained intubated [with a breathing tube] for safety. Transferred to [GACH 2] for further care . Found to have glass shards throughout the GI [gastrointestinal] tract .Patient is septic [blood infection] by SIRS [systemic inflammatory response in the presence of a known or suspected source] and GI/oral source . Apparent suicide attempt A review of Resident 1's GACH 2 documentation, Discharge summary, dated [DATE], .Following admission, the patient was initially cared for in the ICU [intensive care unit] and then transitioned to 555723 Page 24 of 30 555723 09/21/2023 Santa Fe Post-Acute 247 E. Bobier Drive Vista, CA 92084

F 0838 Level of Harm - Actual harm Residents Affected - Few comfort care. Active hospital problems .Severe sepsis, esophageal perforation [tear], foreign body in digestive tract . Prognosis felt to be guarded to poor [not likely to recover] .She passed away in the hospital on 8/29/23 at 0758 [7:58 AM] On 8/29/23 at 2:45 P.M., an observation of the BHU was conducted. The BHU was separated from the rest of the building by double entry doors that alarmed when opened. Approximately, there were 24 residents in the BHU. Some residents were sitting closely at the tables, other residents were walking around the tables in the open space located in front of the nurses' station. Another resident was seated at the table near the entry door and making yelling and screaming sounds. Another resident was heard screaming unintelligibly from down the west hall. Two residents at one of the tables were playing cards. One resident at a table was rocking back and forth. One of the staff was sitting at the resident table and another staff was standing near a table. Two staff were in the nurses' station. On 8/29/23 at 3 P.M., an interview was conducted with CNA 3. CNA 3 stated she often provided care to Resident 1 and the resident made statements such as, I want to go home and I don't belong here. CNA 3 stated Resident 1 would frequently yell and cuss at the nurses and had a behavior of laying on the floor for attention. CNA 3 stated Resident 1 had told her, I want to kill myself, on three different occasions since admission to the facility. CNA 3 was asked what she had done when the resident verbalized that. CNA 3 stated she kept a closer eye on the resident. CNA 3 stated she began her shift at 2:30 P.M. on 8/23/23 and had worked a double shift (from 2:30 P.M. on 8/23/23 to 7 A.M. on 8/24/23). CNA 3 stated at the start of the shift, Resident 1 was at the nurses' station yelling and cussing at the nurse. CNA 3 stated Resident 1 went to her room after a while and seemed to calm down. CNA 3 stated sometime around midnight, Resident 1's call light went off and she responded to it. CNA 3 stated that she asked Resident 1 what she needed, and the resident told her to, Get the [expletive] out of here. CNA 3 stated she reminded Resident 1 that she had the call light on, and the resident told her, I'm going to swallow glasses. CNA 3 stated the resident normally spoke with a slightly slurred speech. CNA 3 stated she checked the resident's room and inside the resident's mouth. CNA 3 stated she did not see any glass or broken glass anywhere. CNA 3 stated Resident 1 noticed that she did not find anything and told her, You can't find it. CNA 3 stated she left to get LN 4 and that Resident 1 wanted her to close the door to the room and she closed it. CNA 3 stated, [Resident 1] wants me to slam the door so it closes tight. CNA 3 stated when she located LN 4, they both heard the sound of glass breaking. CNA 3 stated they went to Resident 1's room and the resident was closing her door and pushing her body against the door, and they could not open it. CNA 3 stated when she was able to open the door, Resident 1 was seated in her wheelchair and a broken glass vase on the floor next to the resident. CNA 3 stated the resident was strong enough to move fast and without the need of an assistive device. CNA 3 stated the glass vase had been at the resident's bedside and the resident had kept artificial flowers in it. CNA 3 stated Resident 1 made pushing motions toward her that ushered her out of the resident's room and then the resident closed the door. CNA 3 stated she remained outside Resident 1's closed door and did not open the door because the resident would become upset. CNA 3 stated she remained outside Resident 1's closed door for approximately two minutes while LN 4 called the physician. CNA 3 stated Resident 1 had been alone in her room with broken glass on the floor. CNA 3 stated she was afraid the resident was going to swallow the glass. CNA 3 stated LN 4 returned with the physician on the mobile phone, and LN 4 was able to get the resident's door open enough to pass the phone through the door to the resident. CNA 3 stated Resident 1 said, You're not my [expletive] doctor, and threw the phone into the hallway. CNA 3 stated 911 came and took Resident 1 to the hospital. CNA 3 stated the incident with Resident 1 had been a behavioral emergency. CNA 3 stated the 555723 Page 25 of 30 555723 09/21/2023 Santa Fe Post-Acute 247 E. Bobier Drive Vista, CA 92084

F 0838 Level of Harm - Actual harm Residents Affected - Few facility did not have a protocol to handle behavioral emergencies and that she had not known what to do during the incident. CNA 3 stated she had needed help with Resident 1 and had not been able to handle the situation alone. CNA 3 stated there should be a process like a code (a systematic, organized emergency response) called so other staff can help in a behavioral emergency. CNA 3 stated she had not received any facility training for residents with SI. CNA 3 stated, I didn't know what to do in that situation. CNA 3 stated the BHU did not feel safe without more training and a system in place to respond to emergencies. CNA 3 further stated the Station 2 used to be a dementia unit (residents with cognitive and memory issues), but It's gotten worse since they mixed psych [mental disorders] with the dementia. CNA 3 stated there was too much screaming in the unit. CNA 3 stated staff received some training about residents who scream, but nothing on SI or psychiatric/behavioral emergencies. On 8/29/23 at 4 P.M., an interview was conducted with CNA 5. CNA 5 stated Station 2 used to be a dementia unit but recently it turned into a psych unit. CNA 5 stated, Mixing psych [residents] and dementia's [residents] not working. Lots of screaming from psych [residents] that upsets those with dementia. CNA 5 stated staff received in-services from the psychologist about behavior, But we still don't know how to deal with them. CNA 5 stated the staff training was rushed and there were no skills checks or competency evaluation done. CNA 5 stated he would not know how to respond in a behavioral emergency or if a resident had SI or threatened suicide. CNA 5 stated there should be training about SI and behavioral emergencies so everyone knows what to do and could form a coordinated response. CNA 5 stated staff often got hurt on the BHU and that he had been hit, kicked, and scratched by the psychiatric residents. CNA 5 stated, It's been a mess in there [BHU] . and unsafe. CNA 5 stated, We need better training . CNA 5 further stated that he was working the night of Resident 1's incident, but he did not know a behavioral emergency had taken place until the LN asked him to open the door for 911 responders. On 8/30/23 at 9:15 A.M., the Facility Assessment was requested from the DON. On 8/30/23 at 9:20 A.M., an interview was conducted with the DON. The DON stated the Facility Assessment was kept in the ADM's office and it would be available upon the ADM's arrival to the facility. On 8/30/23 at 9:32 A.M., a telephone interview was conducted with LN 4. LN 4 stated she worked regularly on Station 2. LN 4 stated Station 2 used to be a dementia unit but now had a lot of psych residents and were adding Patch residents. LN 4 stated the Patch residents were difficult to manage and frequently screamed and yelled in the unit. LN 4 stated staff were getting hurt because the psych residents tried to fight with the staff. LN 4 stated mixing dementia residents with psych/behavioral residents made the unit chaotic. LN 4 stated she was providing care to Resident 1 during the NOC shift (10:30 P.M. on 8/23/23 to 7 A.M. on 8/24/23) and she had seen Resident 1 around 10:45 P.M., at which the resident seemed calm. LN 4 stated she was unaware of Resident 1 having had any history of SI or making SI statements. LN 4 stated, I would have wanted to know that .I didn't know. LN 4 stated it was important to know a resident had SI to monitor for that. LN 4 stated all staff should have known of Resident 1's SI to keep the resident safe from self-harm. LN 4 stated there had not been any training for providing care to residents with SI and that there should have been training provided. LN 4 stated SI training was needed because any resident could begin to experience SI. LN 4 stated she first became aware of the incident with Resident 1 because the resident came up to the nurses' station and told her, I swallowed glass. LN 4 stated she did not recall CNA 3 informed her that Resident 1 had threatened to swallow glass. 555723 Page 26 of 30 555723 09/21/2023 Santa Fe Post-Acute 247 E. Bobier Drive Vista, CA 92084

F 0838 Level of Harm - Actual harm Residents Affected - Few LN 4 stated she remembered hearing glass breaking prior to Resident 1 informed her that she had swallowed glass. LN 4 stated that both her and CNA 3 tried to get into Resident 1's room and that the resident had closed the door and place herself against the door. LN 4 stated she left CNA 3 at the resident's closed door and went to call the physician. LN 4 stated CNA 3 tried to get back inside the resident's room while they waited for the physician to return the call. LN 4 stated she brought the mobile phone to Resident 1 and the resident threw it into the hall and said, That's not my [expletive] doctor. LN 4 stated she called 911 and they came right away for the resident. LN 4 stated the incident with Resident 1 was considered a behavioral emergency and had been a suicide threat. LN 4 stated the facility did not have a procedure for behavioral emergencies and that there should be one. LN 4 stated, We needed more help, and could not get inside the resident's room. LN 4 stated if she had known Resident 1 verbalized the threat to swallow glass, she would have had a staff remain inside the resident's room. LN 4 stated the resident should have been placed on 1:1 supervision (one staff to remain with the resident) as soon as the suicide threat was made. LN 4 stated the resident's room would have been thoroughly searched until all dangers were removed. LN 4 stated doing those things could have prevented Resident 1 from swallowing glass. LN 4 stated, Training could have prevented this. LN 4 stated the number of staff on the unit had been enough but that there needed to be an organized, systematic response during a behavioral emergencies and staff who were competent. On 8/30/23 at 10:10 A.M., the DON provided a copy of the facility assessment titled, Facility Assessment Tool, dated 7/28/23. A review of the facility document titled Facility Assessment Tool, dated 7/28/23, indicated, .Part 1: Our Resident Profile .Psychiatric/Mood Disorders: Depression disorder, anxiety disorder, schizophrenia, PTSD [post-traumatic stress disorder, anxiety and flashbacks triggered by traumatic event], co-occurring disorders, trauma, dementia, bipolar, ADHD [attention-deficit/hyperactivity disorder, characterized by attention difficulty, hyperactivity, and impulsiveness] .During a typical month the facility could provide services to the number of residents noted .Mental Health Behavioral health 15, Substance Abuse 6 .Part 2: Services and Care We Offer Based on our Resident's Needs . Mental health and behavior: Medications as ordered, Counseling services as ordered . Part 3: Facility Resources Needed to Provide Competent Support and Care for our Resident Population Every Day and During Emergencies . Staff training/education and competencies . All staff receive the required orientation to their position, department and facility emergency procedures with annual review as well. Competencies reviewed annually usually during annual performance reviews The facility assessment did not provide a clear description and assessment for residents with SI potential, the facility's participation in the Patch program, Station 2's designation as a BHU, the acuity of residents and staff needed on the BHU, nor the training and competencies required for staff to provide care to residents with mental and psychosocial disorders, SI, or to respond to a behavioral emergency. On 8/30/23 at 10:57 A.M., an interview was conducted with LN 7. LN 7 stated she was familiar with Resident 1 and that the resident would scream and had, Lots of suicidal ideation. LN 7 stated Resident 1 would speak negatively about herself and would say things such as certain family members did not like her, she was not worthy of living, and that she would rather die. LN 7 stated Resident 1 often said, I just want to die. LN 7 stated Resident 1's verbalizations of SI were not a change of condition and did not required intervention. LN 7 stated, [Resident 1] was on the psych unit and not everything residents [on the BHU] would say makes sense. LN 7 stated Resident 1's frequency of 555723 Page 27 of 30 555723 09/21/2023 Santa Fe Post-Acute 247 E. Bobier Drive Vista, CA 92084

F 0838 Level of Harm - Actual harm Residents Affected - Few verbalizing SI was increasing prior to the incident (8/24/23). LN 7 stated it would be a change reportable to the physician if the resident had a plan. LN 7 stated there was currently a resident on the BHU, Resident 2, and he would say that he wants to die, too. LN 7 stated that she had not received training related to providing care to residents with SI. LN 7 stated she thought SI training would be beneficial. LN 7 stated an actual suicide threat was an emergency and it deserved an emergency response like calling a code. LN 7 stated the facility did not have a procedure or code for responding to behavioral emergencies. LN 7 stated training and competency evaluation was important for everyone involved to ensure, We know what to do. On 8/30/23 at 11:45 A.M., an interview was conducted with the director of staff development (DSD). The DSD stated she was responsible for staff training. The DSD stated there had not been any training provided to staff related to providing care to residents with SI. The DSD stated that there should have been SI training given to staff especially to those that worked in the BHU. The DSD stated corporate did staff trainings about residents with behaviors but that there was no competency evaluation done. The DSD stated for a behavioral emergency such as what took place with Resident 1, a Code Grey (situational emergency response) should have been called. The DSD stated a Code Grey was called for combative residents which also included a resident trying to do self-harm. The DSD stated Code Grey training was mandatory for all staff in the facility, especially before any staff worked on the BHU. The DSD stated she had not done staff knowledge checks or competencies after the Code Grey training was done and should have. The DSD stated what happened to Resident 1, Comes down to a lack of staff knowledge. On 8/30/23 at 12:20 P.M., a joint interview and record review was conducted with the DSD. The DSD stated she was unsure what training was required to work competently and safely in the BHU. The DSD stated the BHU training automatically came from corporate and that she was not part of any discussion or planning of that staff training. The DSD stated facility staff should have been part of analyzing and planning the BHU training since they were most familiar with the facility and residents' needs. The DSD stated she did not recall working on the facility assessment. On 8/30/23 at 2:05 P.M., a joint interview and record review was conducted with the DON. The DON stated as soon as Resident 1 threatened to swallow glass, the resident should not have been left alone at any time, should have been placed on 1:1 supervision, and the entire room swept for the removal of all glass objects and any other object that could be used for self-harm. The DON stated if this had been done, it could have prevented Resident 1 from being able to swallow glass. The DON stated a Code Grey should have been implemented immediately and staff should have gained access to the resident's room by any means necessary to separate the resident from broken glass that was on the floor. The DON stated all staff should have been trained on how to deal with residents who have SI and how to respond to a Code Grey in an organized and immediate fashion. The DON stated staff competencies should have been evaluated. The DON further stated the residents housed in the BHU with higher level psychiatric diagnoses and mental disorders required more training for staff. The DON stated both Resident 1 and Resident 2 were admitted with a history of SI on their admission paperwork. The DON reviewed the Facility Assessment Tool dated 7/28/23 and stated it should have assessed their Patch program and BHU more thoroughly to include the training staff required to be competent to provide care to those residents. The DON stated the facility stopped admitting residents with mental disorders and Patch program as of 8/30/23 until all staff were trained and competent. The DON stated residents with SI were not identified on the Facility Assessment Tool because, We don't admit those 555723 Page 28 of 30 555723 09/21/2023 Santa Fe Post-Acute 247 E. Bobier Drive Vista, CA 92084

F 0838 Level of Harm - Actual harm Residents Affected - Few residents [with SI history] here. The DON stated Resident 1 and Resident 2 should not have been admitted to the facility. The DON stated, [We] Shouldn't have admitted residents that we were not fully able to provide care to. On 8/30/23 at 5:30 P.M., an interview was conducted with the ADM. The DON was also present. The ADM stated he did not know when the facility began admitting Patch residents. The ADM stated he did not understand what the concern was about Patch residents on the BHU. The ADM stated they had the same needs as any other resident on the BHU only the funding was different. The ADM did not provide an answer related to what additional mental health services were being provided to Patch residents or staff training and competencies. On 8/30/23 at 6:42 P.M., a telephone interview was conducted with the facility's medical director (MDR). The MDR stated he expected staff to be fully trained and knowledgeable in providing care to residents with SI. The MDR stated staff should have been trained and competent to respond in a behavioral emergency. On 9/1/23 at 11:40 A.M., a joint interview and record review was conducted with the DON. The DON reviewed the Facility Assessment Tool dated 7/28/23. The DON, ADM, DSD, and others were listed as Persons (names/titles) involved in completing the assessment. The medical director was not listed. The DON stated she had been part of the discussion the team held when completing the facility assessment. The DON stated the team's discussions of the type of residents the facility admitted , essential training, and staff competencies had not been rigorous enough. On 9/6/23 at 10:45 A.M., an interview was conducted with the admissions marketer (AM) and admissions coordinator (AC). The AM stated they reviewed resident admissions and determined if a resident was appropriate to be admitted to the facility. The AM stated they would then bring their recommendation to the morning meetings where it was discussed with some members of the interdisciplinary team (facility leadership from different disciplines). The AM stated Resident 1 and Resident 2's history of SI got missed during her admissions review. The AM and AC both stated there was no document that guided admission criteria. At 9/6/23 at 11:13 A.M., an interview was conducted with CNA 11. CNA 11 stated they had a background working in behavioral health. CNA 11 stated the facility's BHU had residents with dementia and psych diagnoses and that was, Not the best mix. CNA 11 stated when the psych residents yell and make bizarre statements, the residents with dementia do not understand what was happening and become distressed and agitated. CNA 11 stated, The milieu [social environment/open space] is frequently disturbed because the yelling spreads. CNA 11 stated the facility's BHU did not feel well-planned out. CNA 11 stated they noticed an influx of psych residents being placed on the dementia unit when the current ADM started working at the facility sometime last year. CNA 11 stated the staff who had worked on the dementia unit did not know what to do or how to provide care to the new psych residents. CNA 11 stated an in-service was not sufficient and that there needed to be a more in-depth training for taking care of residents with mental disorders and SI. On 9/6/23 at 2:17 P.M., an interview was conducted with the facility's psychiatrist (physician who specialized in mental disorders), medical doctor (MD) 8. MD 8 stated he saw Resident 1 during an initial visit and the resident had depression, bipolar disorder, and a borderline personality disorder (a disorder with unstable moods, behavior, and relationships). MD 8 stated these diagnoses posed an increased risk of suicide for Resident 1. MD 8 stated residents with mental disorders had an increased suicide risk compared to that of the general population. MD 8 stated residents with prior suicide 555723 Page 29 of 30 555723 09/21/2023 Santa Fe Post-Acute 247 E. Bobier Drive Vista, CA 92084

F 0838 Level of Harm - Actual harm Residents Affected - Few attempts also ran a higher risk of attempting suicide again. MD 8 stated residents with a history of SI should have their suicide risk assessed and a plan of care in place beginning upon admission. MD 8 stated when Resident 1 verbalized SI, he should have been notified. MD 8 stated when Resident 1's verbalizations of SI increased in frequency, it was a, Definite warning sign that the resident was focusing on SI or beginning to formulate a plan. MD 8 stated when LN 7 noticed Resident 1's SI increasing in frequency, he should have been notified right away. MD 8 stated residents verbalizing SI should always be taken seriously. MD 8 stated he had not been aware that Resident 1 had verbalized SI to staff and that it was something he would have wanted to know. MD 8 stated that he should have been notified. MD 8 stated when Resident 1 made the suicide threat of swallowing glass, the resident should[TRUNCATED] 555723 Page 30 of 30