The Pavilion At Creekwood

F-F742

1/3/25

Resident #[1] was assessed by psychiatry services on 1/2/25 and resident was not deemed a threat to herself, per psychiatry provider transfer to hospital not appropriate at this time and resident agreed. Social Services Director completed a suicide ideation assessment on 1/3/25 and resident was not deemed a threat to herself. Resident #[1] will continue to follow up with psychiatry while remaining in the facility

A review of the facility activity report and the 24hour reports from 1/1/25 were reviewed by the Director of Nursing/Designee to identify additional residents that have voiced suicidal ideation. None were identified.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 23 676388 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676388 B. Wing 01/05/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Pavilion at Creekwood 2100 Cannon Dr Mansfield, TX 76063

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0742 Licensed Nurses and Social Services Director will be re-educated by the Director of Nursing/Designee by 1/4/25 on suicidal precaution management including : Level of Harm - Immediate jeopardy to resident health or If a resident voices or indicates in some manner suicidal ideations the licensed nurse will implement 1:1 safety supervision immediately and notify the social Services Director. If a safe environment cannot be maintained with 1:1 supervision, the resident will be transported to an acute care setting for evaluation and treatment. Residents Affected - Few

The Social Services Director will complete the Columbia Suicide Severity Rating Scale in the medical record

Should the assessment reveal concerns, the Social Services Director will immediately notify the administrator, DON and primary physician for further orders.

Licensed Nurses not receiving this education by 1/4/25 will receive it prior to their next scheduled shift.

The Director of Nursing/designee will review the 24hour report and facility activity report in clinical morning meeting Monday - Friday beginning 1/5/25 to identify residents who have voiced or are indicating in some manner suicidal ideations and validate assessments and notifications were completed. This will be completed by the weekend supervisor on the weekends.

Ad Hoc QAPI was held on 1/3/25. The Medical Director was notified of the Immediate Jeopardy and contents of this plan on 1/3/25.

The facility's implementation of the IJ Plan of Removal was verified on 01/05/25 through the following:

Review of Resident #1's Psychiatric Subsequent assessment dated [DATE REDACTED] reflected the following: Staff reported current symptoms of loss of interest and psychomotor agitation. Patient stated I'm fine. When asked about current/recent sx of depression patient reported to have made statement regarding self-harm the night prior to exam, at this time patient denies any current suicide ideation, thoughts of self-harm or thought of believing she would be better dead. Primary treating dx. Anxiety, secondary dx. Major depressive disorder recurrent.

Review of the Suicide Ideation Assessment completed by the Social Worker, dated 01/03/25 reflected that Resident #1 was not deemed a threat to herself. Resident #1 will continue to follow up with psychiatry while remaining in the facility.

An observation on 01/04/25 at 2:30 PM revealed Resident #1 was sleeping in bed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 23 676388 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676388 B. Wing 01/05/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Pavilion at Creekwood 2100 Cannon Dr Mansfield, TX 76063

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0742 Review of the facility's inservice titled Suicide Prevention and Precaution Management dated 01/02/25, presented by the DON reflected: review policy, including who to notify interventions needed If a resident Level of Harm - Immediate voices or indicates in some manner suicidal ideations the licensed nurse will implement 1:1 supervision jeopardy to resident health or immediately and notify the social Services Director. If a safe environment cannot be maintained with 1:1 safety supervision, the resident will be transported to an acute care setting for evaluation and treatment. The Social Services Director will complete the Columbia Suicide Severity Rating Scale in the medical record Should the Residents Affected - Few assessment reveal concerns, the Social Services Director will immediately notify the administrator, DON and primary physician for further orders. 63 staff (16 LVNs, 24 CAN, 8 RN, MD, Activity Director, Housekeeping Supervisor, 5 Med Aides, Social Worker Assistant, ADON, 2 MDS Nurses and the Social) had signed the inservice.

Interviews were conducted on 01/05/25 from 1:10 PM to 4:57 PM with staff from various shifts. The staff included CNA A, LVN G, CNA H, CNA I, RN J, LVN K, LVN L, LVN M, CNA N, LVN O, and LVN P. All staff were able to verbalize policy, including who to notify and interventions needed If a resident voices or indicates in some manner suicidal ideations the licensed nurse will implement 1:1 supervision immediately and notify the social Services Director. If a safe environment cannot be maintained with 1:1 supervision, the resident will be transported to an acute care setting for evaluation and treatment.

In an interview on 01/05/25 at 4:45 PM with the DON revealed she had reviewed the facility activity report and the 24hour reports from 1/1/25. The DON stated the purpose of the review was to identify additional residents that have voiced suicidal ideation. The DON stated no new residents were identified. The DON stated she would be responsible for reviewing the 24hour report and facility activity report in clinical morning meeting Monday - Friday beginning 01/05/25, the purpose was to identify residents who have voiced or are indicating in some manner suicidal ideations and validate assessments and notifications were completed.

The DON stated that during the weekend, will be completed by the weekend supervisor on the weekends

An interview was attempted on 01/05/25 at 4:26 PM with the Medical Director. The Medical Director did not return the call of the Surveyor.

An IJ was identified on 01/03/25. The IJ template was provided to the facility on [DATE REDACTED] at 5:09 PM. While

the IJ was removed on 01/05/25, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with the potential for more than minimal harm and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 23 676388