Health inspection·July 31, 2025

F580 §483.10(g)(14) Notification of Changes. (i) A facility must immediately inform the resident; consult with the resident’s physician; and notify, consistent with his or her authority, the resident representative(s) when there is— (A) An accident involving the resident which results in injury and has the potential for requiring physician intervention; (B) A significant change in the resident’s physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); (C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or (D) A decision to transfer or discharge the resident from the facility as specified in §483.15(c)(1)(ii). (ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in §483.15(c)(2) is available and provided upon request to the physician. (iii) The facility must also promptly notify the resident and the resident representative, if any, when there is— (A) A change in room or roommate assignment as specified in §483.10(e)(6); or (B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section. (iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident representative(s). §483.10(g)(15) Admission to a composite distinct part. A facility that is a composite distinct part (as defined in §483.5) must disclose in its admission agreement its physical configuration, including the various locations that comprise the composite distinct part, and must specify the policies that apply to room changes between its different locations under §483.15(c)(9).

F740 §483.40 Behavioral health services. Each resident must receive and the facility must provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Behavioral health encompasses a resident’s whole emotional and mental well-being, which includes, but is not limited to, the prevention and treatment of mental and substance use disorders. On 6/18/2025 at 10:15 AM an unannounced complaint investigation was conducted at the facility regarding resident safety. The facility failed to provide treatment and services to attain the highest practicable mental and psychosocial well- being for Resident 1 who was diagnosed with major depressive disorder, anxiety and schizophrenia (a mental illness that affect how person think, feel, behave, mixed symptoms such as hallucination, delusion, disorganized thinking and who was identified as having behavioral issues and verbalization of wanting to go to the hospital on 6/16/2025 at 8:15 PM to 11 PM by failing to: 1. Ensure one-to-one sitter (provide one to one nursing or observation care to an individual patient for a period of time) intervention was put in place for Resident 1 whose behaviors were escalating on 6/16/2025 in accordance with the facility’s Policy and procedure titled Behavioral Assessment, Intervention and Monitoring. 2. Inform Resident 1 ' s physician of Resident 1 ' s complaint chest pain and fall on 6/16/2025 and Residents’ request to go to the acute hospital. Follow up with Resident 1 ' s physician for any new order when Resident 1 ' s physician did not give any instructions or orders on 6/16/2025 at 8:58 PM, upon Licensed Vocational Nurse (LVN) 1 ' s notification that Resident 1 had been readmitted back to the facility, in accordance with the facility ' s P&P on "Change in a Resident's Condition or Status" 3. Ensure additional follow up and intervention was developed for Resident 1 to ensure Resident 1 ' s safety and prevent injury and harm to self or to others after resident ' s behavior was observed to be escalating and not managed as reported by CNAs 1 and 2 to LVNs 1, 2 and 3, in accordance with the facility ' s P&P on Behavioral Assessment, Intervention and Monitoring." 4. Ensure the facility meet Resident 1 ' s mental health needs when LVNs 1, 2, and 3 did not address Resident 1 ' s request to go to the hospital and threatening behavior of putting herself on the floor, in accordance with the facility ' s P&P on Behavioral Assessment, Intervention and Monitoring." 5. Provide a safe environment by ensuring Resident 1 was supervised/monitor adequately to prevent accidents/hazards that may put Resident 1 or others in danger, in accordance with the facility ' s P&P on Behavioral Assessment, Intervention and Monitoring." As a result, Resident 1’s behavior escalated resulting in the resident smashing a glass window and obtaining a sharp object (broken glass), which she was actively brandishing (wave or flourish something or a weapon, as a threat or in anger or excitement) and holding toward her neck, in an attempt to leave the facility and be transferred to the acute hospital. This failure has the potential to cause physical injury to Resident 1. Resident 1 was transferred to the General Acute Care Hospital (GACH) 1 on 6/17/2025 via 911 emergency services for "Suicide Attempt." A review of Resident 1 ' s Admission Records (AR), the AR indicated the facility admitted a 66 year old female Resident on 5/29/2025 and readmitted to the facility on 6/16/2025 with diagnosis that included major depressive disorder, anxiety disorder and schizophrenia (a mental illness that affect how person think , feel, behave , mixed symptoms such as hallucination, delusion , disorganized thinking). A review of Resident 1 ' s "Hospital Progress Note" provided by the facility from General Acute Care Hospital (GACH) 1, with date of service of 6/13/2025, the Hospital Progress Note indicated Resident 1 was recently admitted to GACH 1 Emergency Department (ED) on 5/30/25 for seizure activity. The GACH 1 record indicated the resident was discharged back to the facility on 6/16/2025. A review of Resident 1 ' s "Minimum Data Set" (MDS, a resident assessment tool), dated 5/30/2025, the MDS indicated the resident was moderately impaired in cognition (problems with a person ' s ability to think, learn, remember, use judgement, and make decisions). A review of Resident 1 ' s Change of Condition (COC), dated 6/16/2025 timed at 8:15 PM documented by LVN 1 indicated Resident 1 was admitted back to the facility at 7:45 PM and then at 8:15 PM Resident 1 was observed lying on the floor on her back next to the bed. A review of a facility provided text message obtained on the facility's physician communication phone, between Physician 1 and LVN 1, on 6/16/2025 at 8:57 PM, the text message indicated LVN 1 texted Physician 1 and reported Resident 1 requested to go back to the hospital and was "found on the floor." The text message further indicated LVN 1 informing Physician 1 that "[Resident 1] was not happy." On 6/16/2025 at 8:58 PM, Physician 2 responded via text message asking if Resident 1 was sent back to the facility. On 6/16/2025 at 8:58 PM, LVN 1 responded via text "yes." On 6/16/2025 at 8:58 PM, Physician 1 asked via text message, "Where is she [Resident 1]?" On 6/16/2025 at 9:55 PM, LVN 1 responded via text message "At the facility." During a review of Resident 1 ' s Nurse Note dated, 6/16/2025 timed at 10:39 PM documented by LVN 1, the Note indicated Resident 1 was observed moving herself off the bed onto the floor two times, lying and screaming for no apparent reason stating, "I am going back on the floor." The Note indicated "Risks and benefits explained to the resident moving herself to the floor is unsafe. Frequent visual checks rendered." During a review of Resident 1's Nurses Note dated 6/17/2025 timed at 12:50 AM documented by LVN 3 indicated, "A behavioral emergency (Code Orange) was in progress, involving a newly readmitted resident. The Note indicated that [LVN 1] stated that [Resident 1] shattered her room window using an unknown object and is armed with a large shard of glass. The Note indicated LVN 3 observed Resident 1 obtained a sharp jagged piece of glass approximately 2 feet in length and several inches wide, which she [Resident 1] was actively brandishing and holding toward her neck. The Note indicated Resident 1 was stating loudly and repeatedly, to send her back to the hospital, and demanding her nitroglycerin (medication to provide relief of chest pain). The Note indicated Resident 1 ' s "Tone was threatening and unstable, subjective of acute psychological distress." The Note further indicated "It was later discovered that the glass shard had been concealed under her [Resident 1] bedsheet immediately after breaking the window, indication intent to avoid detection and possible premeditation." The Note indicated 911 EMS was contacted, and a staff was assigned to maintain line of sight observation. The Note indicated that at 1 AM, law enforcement and 911 EMS arrived at the facility and transferred Resident 1 back to GACH 1 for psychiatric evaluation. During a review of the "Police Report" dated 06/17/2025 timed at 12:56 AM, the Report indicated, on 06/17/25 at approximately 1 AM, the police officer arrived at the facility and upon arrival, medical (facility) staff informed the police officer that Resident 1 smashed the window by her bed and used the (broken) glass to threaten to take her own life. The Police Report further indicated that facility staff also stated that the resident was not ambulatory, however the resident (Resident 1) was in her bed, holding the piece of glass to her own neck. The Police Report indicated that after making contact with Resident 1 it was apparent that the resident was now holding the large piece of glass on her chest and a smaller piece in her right hand. The Police Report indicated when Resident 1 was asked why she was holding the glass; Resident 1 stated the facility staff mistreated her because they refused to give her medication. The Police Report indicated Resident 1 decided to threaten to take her own life. The Police Report indicated, after talking to Resident 1, she agreed to put down the glass as she wanted to transport her to the hospital. The Police Report indicated Resident 1 stated she had to act this way to get the appropriate attention so she could get her medication. The Police Report indicated the police officer spoke with [LVN 1] who stated Resident 1 arrived at 7:30 PM that evening (6/16/25) and had been complaining about treatment since her arrival, stating that she [Resident 1] needed medication. The Police Report indicated [LVN 1] also stated she found that the resident got herself out of bed and positioned herself on the floor multiple times. The Police Report indicated [LVN 1] stated that due to the fact that they refused to give Resident 1 medication, Resident 1 broke the glass and threatened to take her own life, at which point the staff called the police department and Resident 1 was transported to the hospital. During a review of the "Transfer Form" dated, 6/17/2025 timed at 1:36 AM, documented by LVN 3, the Form indicated Resident 1 was transferred to GACH 1 for suicide attempt. During an interview on 6/18/2025 at 10:25 AM with the ADON, the ADON stated on 6/17/2025 at around 1 AM, Resident 1 broke her room ' s window glass and placed the glass next to her neck. The ADON stated Resident 1 was transferred to the hospital for attempted suicide. During an interview on 6/18/2025 at 10:48 AM with the Administrator, the Administrator stated on 6/17/2025 around 1:30 AM, he was informed by LVN 3 that Resident 1 broke the window in her room and held the glass next to her neck. The Administrator stated he arrived at the facility on 6/17/2025 at around 2 AM but Resident 1 was already transferred to GACH 1 and observed that Resident 1 ' s window glass inside the room was broken. The Administrator stated it was not usual for the facility to have a resident break the glass and attempt suicide. During an interview on 6/18/2025 at 12:03 PM with LVN 1, LVN 1 stated she was working on 6/16/2025 from 3 PM to 6/16/2025 at 11 PM, however LVN 1 stayed longer due to the incident that happened that night with Resident 1. LVN 1 stated Resident 1 was admitted to the facility on 6/16/2025 at around 7:45 PM. LVN 1 stated that on 6/16/2025 at around 8:15 PM, LVN 1 was informed by CNA 1 that Resident 1 was on the floor. LVN 1 stated Resident 1 was agitated and screaming that she does not want to stay at the facility. LVN 1 stated she sent a text message to Physician 1 that Resident 1 does not want to stay at the facility. LVN 1 stated Physician 1 asked where Resident 1 was but did not give any instructions or orders. LVN 1 stated she did not follow up or call Physician 1 to clarify any orders. LVN 1 stated about 30 minutes later, after Physician 1 ' s text message, Resident 1 started screaming for no reason and try to get out of the bed and asked to send her to the hospital. During the same interview on 6/18/2025 at 12:03 PM with LVN 1, LVN 1 stated she asked CNA 1 to do frequent rounds and check on Resident 1 to prevent her from getting out of bed and fall. LVN 1 stated Resident 1 behavior (yelling and screaming) was escalating through the night, and it was not manageable try to talk to her [Resident 1] and redirect, but Resident 1 did not want to stay at the facility. LVN 1 stated on the same night at around 11:39 PM, Resident 1 was found again on the floor and screaming and agitated demanding to go back to hospital. LVN 1 stated Resident 1 was assisted back to bed but at around 12:30 AM to 1 AM (12/17/25), the facility staff heard a noise and observed Resident 1 inside her room with a broken glass in her hand and holding it close to her neck and saying she has chest pain and wants to go to the hospital. LVN 1 stated Resident 1 was not redirectable and behavior was not managed. LVN 1 stated she was scared for the safety of Resident 1 and other residents, and staff. LVN 1 stated she did not follow up or called Physician 1 that Resident 1 ' s behavior was escalating and behavior is not being managed in the facility. LVN 1 stated she did not document a change in condition [COC] form for Resident 1 ' s behavior. During an interview on 6/18/2025 at 12:55 PM with LVN 3, LVN 3 stated he was at the facility on 6/16/2025 from 3 PM to 11 PM, however stayed longer due to the incident that happen. LVN 3 stated on 6/16/2025 at around 10:30 PM, LVN 1 informed her that Resident 1 was on the floor, and she need help to transfer Resident 1 back to bed. LVN 3 stated he delegated to CNA 1 to help LVN 1. LVN3 stated he asked CNA 2 around 11 PM to do frequent rounds on Resident 1 and stay with her, however CNA 2 would come to the Nursing Station and informed LVN 3 that Resident 1 ' s behavior (getting out of bed) was not manageable. LVN 3 stated he reinstructed CNA 2 to stay with Resident 1. LVN 3 stated he was informed by LVN 1 around 1 AM that Resident 1 broke the window glass. LVN 3 stated he went to Resident 1 ' s room and observed Resident 1 holding a big glass next to her neck. LVN 3 stated he called 911 EMS. LVN 3 stated if a resident ' s behavior is not managed and escalating (screaming and demanding to go back to hospital), staff should call and notify the phy