**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the resident, who had diagnosis of depression (mental health disorder characterized by persistently low mood or loss of interest in activities, causing significant impairment in daily life ) and a history of suicidal ideation (thinking about or formulating plans for suicide [the act or an instance of ending one's own life voluntarily and intentionally) did not commit suicide for one of three sampled residents out of 38 residents with a diagnosis of depression (Resident 1). The facility failed to: 1. Ensure Licensed Vocational Nurse (LVN 1) initiated continuous Resident 1's assessment and closed monitoring of Resident 1's change in behavior, mood, cognition (ability to think, understand, learn, and remember), presence of hallucinations (sights, sounds, smells, tastes, or touches that a person believes to be real but are not real), and delusions (believing things that are not true), and suicidal ideation, when Certified Nursing Assistant (CNA 1) reported to LVN 1 that Resident 1 was observed sobbing (crying spells) and accusing CNA 1 of putting poison in his water pitcher on 9/14/2024 @ 12:15 a.m. 2. Ensure a change of condition ([COC] a sudden, clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional status) assessment was completed when Resident 1 was having crying spells, shaking hands, anxious (uneasy or worried), and verbalizing being scared and that someone was trying to kill him. 3. Ensure staff followed Resident 1's care plan titled Resident uses antidepressant (Lexapro- medication for depression) related to depression initiated on 9/12/2024, indicated interventions to monitor, document, and report as necessary changes in Resident 1's behavior, mood, cognition, hallucinations, delusions, and suicidal thoughts, withdrawal (removes themselves from interactions with others), and notify the physician of COC. 4. Ensure Resident 1 primary care physician was notified when Resident 1 experienced a COC, when Resident 1 was observed sobbing (crying) and accusing CNA 1 of putting poison in his water pitcher on 9/14/2024 at 12:15 a.m. 5. Ensure Social Services Director (SSD) reviewed and assessed Resident 1's history of wanting to die on 2/29/2024 as documented in Resident 1's medical record from Resident 1's previous admissions to the facility. 6. Ensure SSD assessed Resident 1 upon admission and gather information to complete Resident 1's Patient Health Questionnaire ([PHQ 9- a validated interview that screens for symptoms of depression) on the 7th day after admission 7. Ensure nursing staff followed the facility's policy and procedure (P&P) titled, Resident Safety, which indicated the residents will be evaluated whenever there is a change in condition, to identify circumstances that pose a risk for the safety and wellbeing of the resident. As a result of these failures, Resident 1 was found hanging in the bathroom with a phone charging cord around his neck, on 9/14/2024 at 4:40 a.m. The resident was lowered to the floor, cardiopulmonary resuscitation ([CPR]-an emergency procedure that can save a person life if their breathing or heart stops) was initiated and 911 (emergency services) was called. The Emergency Medical Services ([EMS]- medical professionals providing emergency medical care) arrived at the facility and pronounced Resident 1 dead on 9/14/2024 at approximately 5:25 a.m. On 9/18/2024 at 6:16 p.m., the Immediate Jeopardy ([IJ] a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident) was called in the presence of Administrator (ADM) and the Director of Nursing (DON) due to the facility's failure to assess, monitor and inform Resident 1's primary physician when Resident 1 exhibited changes in behavior. On 9/20/2024 at 6:55 p.m., the facility submitted an acceptable IJ Removal Plan ([IJRP] interventions to immediately correct the deficient practices). After onsite verification of the facility's IJRP implementation through observation, interview, and record review, the IJ was removed on 9/20/2024 at 7:07 p.m., in the presence of the ADM and the DON. The IJRP included the following immediate actions: 1.On 09/18/24-9/19/2024, the DON provided a 1:1 (individualized instruction) education to LVN 1, CNA 1, Registered Nurse Supervisor (RNS), LVNs and CNAs that worked on 09/13/24 on 11 p.m. to 7 p.m. shift regarding COC process, with emphasis on the following: a. Assessment and close monitoring of residents with change in behavior, mood, cognition, hallucinations, delusions, and suicidal thoughts, disruptive vocalizations (verbal noises [screaming, yelling, nonsense talking, cursing] which are generally considered unusual, inappropriate or are upsetting to others, and difficulty sleeping. b. Ensuring a COC assessment was completed for residents having a change in behavior; paranoid behavior (distrust and suspicion of others), verbalization of hurting self, hallucinations, delusions, that is disruptive vocalizations, yelling, difficulty sleeping. c. Monitoring, documenting, and reporting as necessary any change in resident's behavior, mood, cognition, hallucinations, delusions, and suicidal thoughts, and notifying the physician of the COC. d. Non-Pharmacological Interventions ( healthcare interventions that do not primarily rely on medication) to care for residents with depression; include removing stressors, offering food and beverages, increasing therapeutic activities of choice/routine, psychosocial (mind and emotions) support, encouraging family involvement, other non-pharmacological interventions to include but not limited to physical comfort (food, activities of daily living (ADL) assistance), environmental (offer soothing activities such as, TV, reading book, music, getting fresh air, offer a walk). Continuously monitoring the resident's mood and adjusting interventions as necessary to ensure the environment is maintained safe. e. Informing physician and responsible party when resident had COC in behavior, mood, delusions, hallucinations, and suicidal thoughts, and recognition of residents who were depressed and have a history of suicidal ideation. f. Behavior management. g. Suicide prevention. 2. On 9/18/24, the Administrator provided a 1:1 in - service education to SSD regarding completion of Assessments, including PHQ-9 following the Resident Assessment Instrument (RAI-standardized assessment tool) Manual guidelines. 3. On 9/18/24, the DON/designee conducted an audit of current residents with diagnosis of serious mental illness such as schizophrenia (a serious mental disorder in which people interpret reality abnormally), major depression, bipolar disorders (a mental health condition that causes extreme mood swings that include emotional highs [mania] and lows[depression] that make it difficult to carry out day-to-day tasks and activities), mood disorders, psychotic disorders (severe mental illnesses that cause people to lose touch with reality and have an abnormal thinking) and other psychiatric (mental) diagnoses to determine residents who have had a change in behavior, mood, cognition, hallucinations, delusions, within the last 30 days, and current or history of suicidal ideations or suicide attempt, to ensure that: a. Residents are assessed and closely monitored for changes in mood (that is disruptive vocalizations, yelling, difficulty sleeping, mood, cognition, hallucinations, delusions, and suicidal thoughts). b. A COC is completed as indicated for changes in behavior such as disruptive vocalizations, yelling, difficulty sleeping, mood, cognition, hallucinations, delusions, and suicidal thoughts, i.e. disruptive vocalizations, yelling, difficulty sleeping. c. Care plan initiated, and interventions are implemented to be followed. d. Primary Care Physician is notified of COC, and e. SSD Assessments are completed within 7 days of the resident's admission,quarterly/annually, and based on significant change of condition. PHQ-9 Assessment is completed per assessment reference date schedule following admission, quarterly, and for significant change of condition assessments. 4. On 09/18/2024, SSD conducted an audit of current residents with diagnosis of serious mental illness such as schizophrenia, major depression, bipolar disorders, mood disorders, psychotic disorders, and other psychiatric diagnoses. Out of 99 residents there were 38 residents identified to have a diagnosis of depression. One resident was identified to have exhibited a change in mood and was assessed by licensed nurse, COC was competed, and the attending physician was notified. A PHQ-9 Assessment of other 37 identified residents with diagnosis of depression were completed by the SSD on 9/18/2024 through 9/19/2024. 5. On 9/18/24, the DON/Designees conducted interviews of current interviewable residents to identify any potential changes in behavior or mood. 6.On 9/14/24, the DON/Designee provided an in-service education to the staff on Behavior Management/Suicide Management. 7. On 9/18/24, the DON/Designee initiated an in - service education to the Department heads which consist of Director of Staff Development, Case Manager, Activity Director, Director of Rehab, Infection Preventionist, Dietary Manager, Minimum Data Set Coordinators (MDSC), Maintenance Supervisor, Housekeeping Supervisor, Social Services Director, Social Service Aide, Social Services Assistant, Medical Records Director, Business Office Manager, Business Office Assistant, and admission Coordinator, licensed nurses and CNAs regarding the policies and procedures for: Behavior/Psychoactive (affective the mind or behavior) Medication Management, Change of Condition Notification, Behavior - Threats to Harm Self, and Comprehensive Care Planning. 8. On 9/19/24, the Regional Social Service Consultant provided an in-service education to the Social Service Designee on the Policy and Procedure titled Social Service Assessment and Policy and Procedure titled Social Service Program, emphasizing the importance of completing required Social Service Assessments, including the PHQ-9 within the required timeframe, per regulatory guidelines. 9. The ADM and the DON will present the results of the Admission/Readmission, and Change in Condition Audits, and Resident Interviews to the Quality Assurance and Performance Improvement Committee for monthly review and recommendations for three months or until substantial compliance is achieved. Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] and re-admitted [DATE]. On 4/2/2024 Resident 1 was discharged home and readmitted back to the facility on 9/10/2024 with diagnoses including depression, cerebral infarction (damage to the brain from interruption of its blood supply) with right sided hemiplegia (paralysis of one side of the body and right hemiparesis( weakness of one side of the body), and failure to thrive (a syndrome that describes a decline in an older adult's health that can include weight loss, poor nutrition, and inactivity). During a review of Resident 1's History & Physical (H&P) dated 9/11/2024, the H& P indicated Resident 1 had the capacity to understand and make decisions. During a review of Minimum Data Set ([MDS] a standardized assessment and care screening stool) dated 3/15/2024, the MDS indicated Resident 1 had moderate cognitive (ability to think, understand, learn, and remember) impairment for daily decision making and required supervision or touching assistance (helper provides verbal cues) with bed mobility, transfer from chair/bed-to-chair transfer (ability to transfer to and from a bed to chair or wheelchair), walking 10 feet (ability to walk at least 10 feet in a room, corridor or similar space once standing) and personal hygiene. During a review of Resident 1's MDS dated [DATE], the MDS indicated Resident 1 had an active diagnosis of depression and was taking anti-depressant (prescription medications that can help treat depression and other mental health conditions) medication. During a review of Resident 1's baseline care plan (a document that provides instructions for a resident's care in a nursing home), dated 9/10/2024, the baseline care plan indicated, under Social Services, Resident 1 was being monitored for depression, and SSD to complete PHQ-9 assessment. During a review of Resident 1's Informed Consent (the process in which a healthcare provider educated a patient about the risks, benefits, and alternatives of a given procedure, treatment, or intervention), dated 9/10/2024, the Informed Consent indicated Resident 1 was prescribed Lexapro (medication used to treat depression) for depression and persistent verbalization of sadness. During a review of Resident 1's Care Plan titled Resident 1 uses antidepressant medication Lexapro related to depression initiated on 9/12/2024, the Care Plan indicated a goal for Resident 1 was to decrease resident's episodes of signs and symptoms of depression. The Care Plan's interventions included to administer antidepressant medications as ordered by the physician, monitoring, documenting, reporting as needed change in behavior/mood/cognition (mental process involved in knowing, learning, and understanding things), hallucinations (false perception of reality), delusions, social isolation (no relationships with other), suicidal thoughts, and withdrawal. During a review of Resident 1's initial Psychiatric Evaluation (a comprehensive examination of a person's mental, emotional, and behavioral health), dated 9/13/2024, the initial Psychiatric Evaluation indicated Resident 1 was oriented to person, place, and time. The initial Psychiatric Evaluation, under the treatment plan, indicated to observe the resident for deterioration in function, resident was educated to report worsening of symptoms and to report if noted with changes in mood and behavior. Gradual dose reduction ([GDR] a step in tapering a dose of a medication) for Lexapro was contraindicated at this time as it may exacerbate (to make something worse) resident symptoms (not specified). During a review of Resident 1's Nurses Progress Notes, dated 2/8/2024, the Nurses Progress Notes indicated Resident 1 was on monitoring due to hallucination episode. The Nurses Progress Notes indicated Resident 1 could not sleep because he was experiencing strange things in the room during the night such as pages of a book in his closet flipping by themselves. During a review of Resident 1's PHQ-2-9 questionnaire, dated 2/25/2024, the PHQ 2-9 indicated a score of 10 (a score of 10-14 is moderate depression). During a review of Resident 1's Nurses Progress Notes, dated 2/29/2024, the Nurses Progress Notes indicated a Social Worker met with Resident 1 for verbalization of wanting to die and Lexapro was increased to 20 milligrams ([mg]-unit of measurement). During a review of Resident 1's Nurses Progress Notes, dated 3/3/2024, the Nurses Progress Notes indicated Resident 1 was being monitored for episodes of verbalization of wanting to die. During a review of Resident 1's Nurses Progress Notes, dated 3/22/2024, the Nurses Progress Notes indicated Resident 1 was being monitored for panic attacks (a sudden episode of intense fear or discomfort that can cause physical and mental symptoms) and tachycardia (a heart rate that is faster than 100 beats per minute). During a review of Resident 1's Nurses Progress Notes dated 9/14/2024 timed at 12:51 a.m., the Nurses Progress Notes indicated on 9/14/2024 at around 12:15 a.m., CNA 1 called Resident 1's assigned charge nurse (LVN 1) to resident's room. The Nurses Progress Notes indicated LVN 1 entered Resident 1's room and found Resident 1 sitting on the side of his bed appeared worried and stated someone was trying to poison him pointing to his water pitcher/cup. The Nurses Progress Notes indicated Resident 1's blood pressure ([BP] force of blood pushing against artery [blood vessel] walls when the heart pumps blood throughout the body) was 171/89 millimeters of mercury (mm/Hg unit of measurement [reference range for normal blood pressure is less than 120/80], the resident had a headache rated four out of 10 on a pain scale (tool to measure pain intensity by asking patient to rate their pain on a scale of 0 to 10, where zero is no pain and 10 is the worse pain possible ). The Nurses Progress Notes indicated at 12:18 a.m., Resident 1 received Tylenol (medicine used to relieve pain) and at 12:38 a.m. Resident 1 received Clonidine (medicine used to lower blood pressure) for high BP. The Nurses Progress Notes indicated on 9/14/2024, at around 4:40 a.m., CNA 3 entered the Resident 1's bathroom and found Resident 1 kneeling on the floor facing the wall with a red cord around his neck, and the cord was tied around the handrail. The Nurses Progress Notes indicated Resident 1 was unresponsive, not breathing and the staff was unable to obtain a blood pressure reading. The Nurses Progress Notes indicated Resident 1's pulse rate was 186 beats per minute (reference range for adult pulse is 60 to 90 beats per minute). The Nurses Progress Notes indicated a facility staff (unknown) called 911 (emergency services) and initiated CPR. At 5:01 a.m., paramedics (Emergency Medical Services) arrived and continued CPR. Resident 1 was pronounced dead at around 5:25 a.m. During an interview on 9/16/2024 at 2:50 p.m., with Resident 1's roommate (Resident 2), Resident 2 stated on the night of 9/13/2024, he could not sleep well as Resident 1 was not sleeping and crying a lot. Resident 2 stated a staff member (unknown) came into the room to calm Resident 1 down on 9/14/2024 at 3:00 a.m., and after staff member left Resident 1 began crying again. Resident 2 stated around 4 am. he heard Resident 1 struggling to walk to the bathroom, as he was holding onto the walls while walking. Resident 2 stated after that he went back to sleep and did not hear anything until someone told him the next day what happened to Resident 1 (committed suicide). During an interview on 9/17/2024, at 6:25 a.m., CNA 1 stated on 9/14/2024 at 12:00 a.m., Resident 1 was restless standing next to his (Resident 1) bed crying. CNA 1 stated she informed LVN 1 that Resident 1 was restless and crying. CNA 1 stated Resident 1 continues to cry when he was assisted back to bed. CNA 1 stated it was important to report to the charge nurse any changes in a resident's behavior so the charge nurse can check on the resident and assess the behavior. CNA 1 stated she returned to check on Resident 1 at 1:00 a.m. and observed Resident 1 was awake lying in bed. CNA 1 stated at 4 a.m., she saw Resident 1 standing up next to his bed talking with CNA 3 and LVN 1. CNA 1 stated when Resident 1 saw her he pointed at her and stated, that was her, she was trying to kill me, you poisoned the water, while pointing to his water pitcher. During an interview on 9/17/2024, at 6:45 a.m., LVN 1 stated CNA 3 informed her that Resident 1 appeared worried and concerned and was telling CNA 3 someone was trying to poison him. LVN 1 stated she went to assess him, and Resident 1 was alert and oriented and did not appear to be confused. LVN 1 stated Resident 1 calmed down after she explained to him that the CNAs were delivering the new water pitchers and offered to get him a new CNA but Resident 1 declined. LVN 1 stated she felt there was a misunderstanding between her (LVN 1) and Resident 1 and not a change of condition, and that was the reason she did not call Resident 1's doctor to inform of the resident's behavior. During an interview on 9/17/2024, at 7 a.m., with CNA 3 stated when she was passing out water pitchers at approximately 12:00 a.m. on 9/14/2024, Resident 1 verbalized to CNA 3 that another CNA (unknown) was trying to poison him. CNA 3 stated Resident 1 appeared nervous, scared, his hands were shaking, and verbalized repeatedly that a lady was trying to poison him. CNA 3 stated she stayed with Resident 1 to listen to his concerns and then reported his behavior to LVN 1. During a concurrent interview and record review on 9/17/2024, at 7:25 a.m., with LVN 1, Resident 1's medication administration record (MAR) was reviewed. LVN 3 stated she gave Resident 1 Tylenol for his headache at 12:18 a.m., and Clonidine at 12:30 a.m. LVN 1 stated it was difficult to obtain Resident 1's blood pressure because he was moving a lot and was pointing at his water pitcher. LVN 1 stated Resident 1 had depression and high blood pressure, and when Resident 1 was stating someone was trying to poison him it could have been related to his depression. LVN 1 stated Resident 1 was taking Lexapro for his depression for targeted behaviors of persistent verbalization of sadness. LVN 1 stated when she saw Resident 1, he appeared anxious, worried, and had a lot of concerns (not specified). LVN 1 stated she should have done a COC when Resident 1 had changes in his behavior so they could have better monitored him. LVN 1 stated she failed to inform Resident 1's physician when Resident 1 had changes in his behavior. LVN 1 stated they (facility staff) did not do any monitoring but visually checked on him more frequently but did not document it was done. LVN 1 stated Resident 1 was exhibiting delusions when he continued to think that someone was trying to poison him. LVN 1 stated Resident 1 suicide could have been prevented if she would have stayed with Resident 1, called his doctor, and placed the resident on 1:1 (a type of care where a patient is constantly observed by a healthcare professional to ensure patient safety) observation/monitoring but because he calmed down, she did not think she needed to do so. During a phone interview on 9/17/2024, at 10:05 a.m., LVN 3 stated on 9/14/2024 approximately 4:40 a.m., she was called by CNA 3 to Resident 1's room and found Resident 1 in the bathroom of his room, on his knees, facing the wall on the right side of the toilet, with a cord around his neck. LVN 3 stated she used scissors to cut the cord around Resident 1's neck. LVN 3 stated Resident 1 was still warm to touch and thought he had a faint carotid (neck) pulse. LVN 3 stated Resident 1 was not breathing so she initiated CPR with CNA 5. During an interview on 9/17/2024, at 11:05 a.m., the Social Services Director (SSD) stated Resident 1 was admitted on [DATE] and she only saw him once on 9/11/2024. The SSD stated she did not complete Resident 1's required screenings (Brief Interview for Mental Status [BIMS], PHQ9, depression screening, social determinants of health, social service assessments, because she had seven days to complete from the time of Resident 1's admission on [DATE]. During a phone interview on 9/17/2024, at 11:45 a.m., the Psychiatric Nurse Practitioner ([PNP] a registered nurse with advanced training who provides mental health care to residents), stated Resident 1's doctor should have been notified immediately of Resident 1's new behavior when he was observed crying and stating someone was trying to poison him. The PNP stated possible interventions to prevent the resident's suicide would have been closed monitoring of the resident for behavioral symptoms. The PNP stated Resident 1's behavior could have been a delusion when he verbalized somebody was putting poison in his water, a symptom of mental illness, or a symptom of another medical illness. During an interview on 9/17/2024, at 12:24 p.m., Registered Nurse Supervisor (RNS 2) stated when CNA 1 informed her that Resident 1 verbalized someone was trying to poison him, she thought it was because Resident 1 was confused. RNS 2 stated she failed to do a COC as she thought Resident 1's delusion was because he was confused. RNS 2 stated she was not aware of Resident 1's behavior of crying spells, having hands tremor (shaking), feeling scared, and being anxious. RNS 2 stated she was not told by LVN 1 about Resident 1's change in behavior and if she would have known, she would have placed Resident 1 on 1:1 monitoring to keep him safe, call Resident 1's primary physician, complete a COC, and transfer Resident 1 to a higher level of care. During an interview on 9/18/2024, at 10:10 a.m., the Minimum Data Set Coordinator (MDSC) stated the SSD was responsible for completing Section D (Mood) of the MDS and should be continuously assessing residents (through observation, interview, and record review) during the Assessment Reference Date ([ARD] marks the end of a seven-day period during which a resident is observed and assessed) from admission. The MDSC stated the SSD should have started Resident 1's assessments upon admission and to have an ongoing resident's assessments during the seven days following admission and not just one visit with the resident. The MDSC stated psychosocial assessments (an evaluation of a resident's mental health, and social well-being) was a part of the residents needs so it was important to conduct the assessments continuously from the time of admission. During an interview on 9/18/2024, at 11:05 a.m., SSD stated knowing a resident's (in general) past medical history was important so you can develop a person-centered care plan. The SSD stated she does not review previous notes for those that were previously admitted to the facility because she prefers to do her own assessment of the resident. The SSD stated she was made aware by staff that Resident 1 was admitted to the facility in the past but did not review his previous records. The SSD stated she did not complete the PHQ9 or BIMS for Resident 1 because she was busy and did not have time to complete her assessment after seeing him on 9/11/2024. The SSD stated her progress notes and Resident 1's assessment that she completed on 9/14/2024 was based on one-time interaction with the resident (on 9/11/2024). The SSD stated she started to write a note for Resident 1 assessment on 9/11/2024 but did not submit it until 9/14/2024 because she wanted to include her conversation with Resident 1's son. The SSD stated, she should have reviewed Resident 1's progress notes from previous admission to the facility. The SSD stated moving forward she will incorporate review of records in her assessment. The SSD stated, if she would have reviewed Resident 1's previous SSD notes from previous admission, she would have completed her assessments right away when he was admitted , would initiate plans for monitoring and assessing, and would push for the psychologist (mental health professional who help resident cope with mental health conditions) to see him. During an interview on 9/18/2024, at 12:00 p.m., RNS 3 stated if he had observed Resident 1 crying and stating someone was poisoning his water, he would have done a COC and let the resident's primary care physician know. RNS 3 stated this behavior could have been due to infection or depression. RNS 3 stated a COC was an important monitoring and communication tool to let other staff members aware of what was going on with a resident. RNS 3 stated if he had been Resident 1's nurse, he would have provided 1:1 monitoring for the resident's safety, called the resident's doctor, and completed a COC because the resident's behavior was not his usual/normal behavior for him. During a concurrent interview and record review on 9/18/2024, at 12:30 p.m., the DON stated it was important to review the residents (in general) past medical history and past admissions records from the facility prior to seeing the residents upon their admission. The DON stated LVN 1 should have done a COC, notified resident 1's doctor, and maybe transferred Resident 1 to a higher level of care when he was exhibiting behavior manifested by crying spells, shaking his hands, feeling scared anxious, and verbalized that someone was trying to kill him. The DON stated there was no COC completed for Resident 1, but one should have been done because Resident 1 was not at his baseline and his behavior indicated there was a medical problem occurring. The DON stated the COC was a tool to inform the nurses for what to assess, monitor and plan Resident 1's care. The DON stated LVN 1 should have assessed and monitored Resident 1 after he exhibited change in behavior because one time look at the resident does not provide enough information. The DON stated LVN 1 should have read previous admission notes and evaluated more in depth as to why Resident 1 was taking Lexapro. The DON reviewed Resident 1 care plan for Lexapro dated 9/12/2024 and stated one of the interventions was to monitor the resident for changes in behavior, mood, and other adverse reactions to the medication, and Resident 1's change in behavior should have been reported to the doctor but was not done. During an interview on 9/20/2024, at 9:55 a.m., the SSD stated when she assessed Resident 1 on 9/11/2024, Resident 1 was not very talkative, giving brief one-word responses. The SSD stated if she had engaged in more conversation with Resident 1, he might have opened up more and she would have learned more about him. The SSD stated a single interaction was insufficient for her to conduct a thorough behavioral assessment. During a concurrent interview and record review on 9/20/2024, at 10:43 a.m., LVN 5 stated the importance of the care plan was to serve as a guideline for caring for Resident 1 and monitoring his progress towards meeting the objectives of the care plan. LVN 5 stated Resident 1 had a personalized care plan reflecting the resident's treatment of his depression with Lexapro. LVN 5 stated staff should adhere with the interventions and to report any changes in the resident's behavior. LVN 5 stated should any changes in the resident's behavior occur including hallucination or delusion, or mood changes like increased crying or expressing fears of being harmed, these signs must be documented and reported to Resident 1's doctor, completed a COC assessment, provide closed monitoring, and transferred to higher level of care. During a review of the facility's Assessment Tool, updated 7/31/2024, the Assessment Tool indicated The purpose of the facility assessment is to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. Using a competency-based approach focuses on ensuring that each resident is provided care that allows the resident to maintain or attain the highest practicable physical, mental, and psychosocial well-being. Services we offer and care we are able to provide is based on the needs of the resident include mental health and behavior: manage the medical conditions and medication, related issues, causing psychiatric symptoms and behavior, identify and implement interventions to help support individuals with issues, such as dealing with anxiety, care of someone with cognitive impairment, care of individuals with depression, trauma/post-traumatic stress disorder (PTSD- a mental and behavioral disorder that can develop after experiencing a traumatic event), other psychiatric (mental) diagnosis, intellectual and developmental disabilities. During a review of the facility's Charge Nurse Job Description, undated, the Charge Nurse Job Description indicated, Qualifications: Ability to provide patient care in accordance with applicable standards, policies, and procedures; Possess critical thinking skills to analyze, synthesize, and evaluate clinical data and observations in developing a nursing plan of care; Comprehensive knowledge of applicable nursing principles, practices, and standards of care. Duties: Makes daily rounds to interview physical and e[TRUNCATED]