**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to protect a resident's right to be free from neglect by not obtaining his history of actual attempts to end his life and neglected to provide appropriate care and services for behavioral needs for 1 of 3 residents reviewed for neglect, out of a total sample of 11 residents, (#1). Resident #1, a [AGE] year-old male, with physical and cognitive impairment was admitted to the facility on [DATE]. The facility failed to obtain the resident's history of suicide attempts from his family and on [DATE], resident #1 threatened to end his life. The facility implemented one-to-one (1:1) supervision and consulted the psychologist and psychiatrist. The 1:1 supervision was discontinued the following day and despite the psychologist's recommendation to remove all ligature risks from the resident's room, the facility did not implement this recommendation. On [DATE] at approximately 3:10 PM, resident #1, ended his life with a shower hose positioned around his neck. He was found in his bathroom by his wife, who was also a resident in the nursing home. The resident's wife then alerted the nurses near his room. The facility's failure to obtain the resident's history of suicide attempts and failure to follow the psychologist's recommendation placed all residents who suffered from mental illness and had history of suicidal ideations at risk. These failures resulted in Immediate Jeopardy starting on [DATE]. The Immediate Jeopardy was removed on [DATE]. The scope and severity of the deficiency was decreased to D, no actual harm, with potential for more than minimal harm, that is not Immediate Jeopardy after verification of the facility's immediate corrective actions. Findings: Cross Reference F740 Resident #1's diagnoses included dementia, severe and recurrent major depressive disorder with psychotic symptoms, schizoaffective disorder, bipolar type, anxiety, and history of suicidal behavior. Review of resident #1's admission Minimum Data Set (MDS) with Assessment Reference Date [DATE] revealed he had a Brief Interview for Mental Status score of 3 out of 15 which indicated his cognition was severely impaired. The MDS assessment showed resident #1 required limited assistance from staff for bed mobility, transfers, dressing, toilet use, and personal hygiene. He used a wheelchair for mobility. The assessment noted no rejection of care necessary to obtain goals for his health and well-being. The assessment revealed a Mood Interview was conducted and no symptoms were identified. The Admission/readmission Data Collection evaluation dated [DATE] revealed resident #1 was alert and oriented to person and place. It was noted resident #1's daughter was present and provided information for the assessment. The form showed resident #1 did not have a Preadmission Screening and Resident Review (PASARR) level II or a provisional PASARR completed. Review of a Psychosocial History and Assessment form completed by the Social Services Director (SSD), dated [DATE], revealed resident #1 had family support and noted the name and contact information for the resident's daughter. The assessment indicated resident #1's daughter and his 2 sons were involved in his life. It was noted the resident's wife resided in the facility. Mental Health issues listed Psychiatric Diagnosis of schizoaffective disorder, anxiety and depression treated with psychotropic medications. His cognitive skills/daily decision making was described as moderately impaired with no change in mood, behavior, or cognitive status in the last 6 months. A referral to a Mental Health Service Provider was selected. Review of resident #1's care plan revealed a focus for psychosocial well-being related to schizoaffective disorder, depression, anxiety, insomnia, and history of suicidal behaviors created on [DATE]. The interventions listed Learn to recognize/help the resident to identify the resident's stressors which may be early warning signs of problem behavior. Intervene and remove stressors where possible. Review of a Progress Notes dated [DATE] read, admission review of plan of care with IDT (Interdisciplinary team). [daughter's name] invited, not in attendance, left voicemail. Plan of care remains appropriate with no significant changes noted. Review of a Progress Notes dated [DATE] revealed resident #1 was having severe anxiety and stated he wanted to be with his wife, but his daughter did not allow it. The note indicated the resident was crying and the nurse tried to talk to him and took him for a walk. The nurse noted resident #1's daughter mentioned he tried to kill himself before, and she was afraid he might try that again. The note read, He stated and I quote He wants to die. As for now resident sitting in my view, and daughter is here. Review of a second Progress Note dated [DATE] revealed resident #1's assigned nurse notified her supervisor about resident #1's statement and behavior. Resident #1 was placed on 1 to 1 supervision. The physician, Director of Nursing (DON) and resident #1's daughter were notified. The psychologist was notified and indicated he would evaluate resident #1 the following day. Review of resident #1's care plan revealed a new focus for behavior problem related to suicidal ideation which was created on [DATE]. Interventions included, Observe for behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behaviors and potential causes. Review of a Progress Notes dated [DATE] revealed resident #1 was found by his assigned night nurse sitting on the side of his bed crying. When asked what was wrong, the resident stated he fell. A Progress Note dated [DATE] read, resident was observed in a crouched position with a handheld shower head hose positioned around his neck, and he did not have a pulse. The note indicated 911 Emergency Personnel and Law Enforcement responded and pronounced the resident dead. On [DATE] at 10:45 AM, Certified Nursing Assistant (CNA) D explained she was assigned to resident #1 from 7 on the day he died. She stated she was not aware of any previous suicide attempts by resident #1. On [DATE] at 12:07 PM, the first floor Unit Manager (UM) said resident #1 was not sleeping well at night a couple of days before he died. She explained resident #1 had expressed he wanted to hurt himself last month and was seen by the psychologist. She said he was placed on 1:1 supervision which was later lifted when he no longer expressed any suicidal thoughts. She indicated the psychologist told the nursing staff to remove any cables, belts, or any large bands from his room which they did. She could not recall the items that were removed and there was no documentation in the medical record of which items were removed from the resident's room. On [DATE] at 1:38 PM, resident #1's daughter stated her father had psych problems since he was young. She said, He has always attempted against his life. She indicated that when her father lived at her home, he attempted to hang himself with a belt and another time he ingested bleach. She explained he was admitted to local psychiatric hospitals following the attempts where he was stabilized and discharged . She indicated prior to this facility, he lived in 3 or 4 different nursing homes. She recalled a few years ago, she received a call from the nursing home informing her he was found with a belt around his neck. She indicated he was sent to the hospital, stabilized, and returned to that nursing home where he was kept in a separate area with someone always sitting with him. She said she had attended care plan meetings but was not asked about his previous suicide attempts. She recounted during a visit last month, her father told her he was going to take his life and take his wife with him. She stated this was the first time he had mentioned anything about hurting someone else. She said he had never mentioned killing her mother before. She stated she was worried and informed the assigned nurse about her father's remarks. She noted he was evaluated by the psychologist at that time resulting in adjustment of his medications. On [DATE] at 11:15 AM, the Social Services Director (SSD) explained her responsibilities included monitoring psychosocial wellbeing of the residents, performing assessments, participating in care conferences and clinical meetings, reviewing PASARR for all admissions and initiating psych consults. She stated resident #1 was referred to psych at admission as he had diagnoses of depression and suicidal ideation. She recalled she became aware of resident #1's comments about ending his life on [DATE], and she followed up when she returned to work a few days later. She stated psych had evaluated the resident prior to this incident. She indicated she visited resident #1 to check on his wellbeing while he was on 1:1 supervision. She recalled she asked him how he was doing, and he did not have any recollection of wanting to end his life and she did not notice any signs of psychological distress. She confirmed the resident was not seen by the psychiatrist until [DATE], one week before he died. She stated the psychiatrist wrote that no psychotic symptoms were noted or reported. She acknowledged the resident's daughter visited daily but could not recall talking to her about his past behavioral history. The SSD said she created a new behavior care plan on [DATE] and validated it did not address removal of ligature risks from the resident's room, did not include suicidal ideation, behaviors he demonstrated nor the 1:1 supervision intervention. The SSD indicated knowing the manner he had attempted to end his life before this happened would have been helpful. On [DATE] at 12:32 PM, the DON explained he was notified on [DATE] by the weekend supervisor that resident #1 verbalized he wanted to kill himself. He indicated he instructed the supervisor to place resident #1 on 1:1 supervision and to notify the physician and psych services. He indicated resident #1 was evaluated by the psychologist on [DATE] and the psychiatrist saw him on [DATE]. He acknowledged that an IDT meeting was not held after the resident made remarks to end his life. He confirmed he did not talk to resident #1's daughter about any previous suicide attempts. I did not ask and she did not share. The DON stated after resident #1's death, he learned the resident had attempted to end his life in 2021 and his grandson found him with a belt around his neck. He said, his grandson basically saved his life. The DON stated he was not aware how to recognize behaviors which could trigger an event like this or how quickly it could escalate. He stated if he had known about the resident's previous attempts to end his life, they may have been able to help the resident more effectively. On [DATE] at 2:13 PM, during a telephone interview, the resident's Psychiatrist stated she had knowledge of resident #1 suicidal ideation because the psychologist had mentioned it in his note. She indicated she did not see his daughter during her visits, and she did not know the details of his previous attempts against his life. On [DATE] at 12:46 PM, Licensed Practical Nurse (LPN) B said she was assigned to resident #1 on the 3 PM to 11 PM shift on [DATE]. She explained the resident walked to the bathroom on his own, but he used a wheelchair for mobility. She recalled resident #1's family visited almost every day, and took him and his wife to the dining room, sat with them, or took them out to their home for a few hours. She said she was not aware of his history of suicide attempts and no one ever mentioned about his talk of ending his life. She remembered she had asked why resident #1 and his wife did not share the same room and was told his family had requested them to be separate because his wife tried to get him up. She said she was not aware of any interventions on the resident's care plan about suicidal behaviors and noted she seldom checked the care plans. On [DATE] at 11:57 AM, resident #1' assigned nurse on [DATE], Registered Nurse (RN) A stated she had taken care of resident #1 before, including the previous week. She explained she was not aware of the resident's prior verbalization or attempts to end his life. She noted that he always wanted to have the privacy curtains closed and wanted to stay by himself all the time. She did not recall reviewing any interventions about safety or suicide watch on his care plan. On [DATE] at 5:25 PM, the Administrator stated they were working on their investigation and had not determined their root cause that led to this event. He mentioned during their Ad Hoc Quality Assurance & Performance Improvement (QAPI) meeting on [DATE], they identified problem areas such as Operational and Clinical meeting process not followed as per their policy and lack of documentation of what was discussed, and any follow up with the IDT. On [DATE] at 10:01 AM, resident #1's Attending Physician stated the resident and his wife were always together, sitting in the hallway by the nurses' station. She explained she was not aware of his previous attempts to end his life. She said they were all in shock when they learned of the resident's death last week. She stated if she had known he had attempted suicide before, she would have discussed this with his family to learn more about his past behaviors, and inquired if he had a psychologist previously and requested access to those records. On [DATE] at 1:47 PM, the Medical Director explained resident #1 had diagnoses of dementia, history of anxiety and depression but review of his medical records did not reveal previous attempts of suicide. He indicated he was not aware of the clinical team talking to the family to get additional details. He stated he attended the Ad Hoc QAPI meeting and discussed the need to open lines of communication among all team members, IDT, and the subspecialties to the medical team. He mentioned they needed to discuss the rationale of care with subspecialty providers for a better understanding. On [DATE] at 3:58 PM, in a telephone interview, the Psychologist explained he communicated with resident #1 in Spanish. He indicated resident #1 was referred to their services for symptoms of depression and wanting to leave. He recalled he asked nursing staff if resident #1 used oxygen and they discussed items to remove from his room such as call light cord, any cables, belts or long sleeves shirts. He explained this was discussed in general terms because he did not have specific details of resident #1's prior suicidal attempts. Review of the policy and procedure titled Abuse Prevention Program revised on [DATE] defined neglect as, The failure of the facility, its employees or service providers to provide good and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The document revealed the Administrator, DON and/or designated individual were ultimately responsible for the following: Implementation, Ongoing monitoring, Investigation, Reporting and tracking and Trending. Review of the Facility Assessment updated on [DATE] revealed the facility could care for residents with psychiatric diagnosis. The document listed 44 residents with psychiatric disorders, and 37 with major depressive disorder. The facility received the services of Physician Specialists such as Psychiatrist(s) and Psychologist(s). Review of corrective measures implemented by the facility revealed the following, which were verified by the survey team: 1. Facility conducted a house-wide audit of PASARRs. Level II was completed and submitted for any residents identified as needing one. 2. A PHQ-9 (depression test) questionnaire was completed on all residents with a major depression diagnosis. All assessments were reviewed with facility psychologist and recommendations carried by facility staff. 3. A staff questionnaire was completed to identify residents that have voiced suicidal statements such as self-harm or change in mood 4. Facility IDT conducted a house-wide review of resident diagnosis list for suicidal ideations - no residents identified upon completion of the audit. 5. All facility staff educated on: a. Suicide Prevention Policy, b. Ideation Identification and interventions to put into place if identified, c. Environmental safety related to suicide prevention, d. Abuse-Neglect-Exploitation as it relates to supervision and inspection of the environment which could lead to self-harm. 6. Facility IDT members including the Administrator, DON, UMs, Staff Development Coordinator, Activities, SSD, MDS, Dietary manager, Director of Rehab, and Mental Health Provider were educated on the following: a. IDT Documentation related to suicidal ideation, b. Documentation related to enhanced monitoring of a resident, c. What should be included in the documentation if a resident is on a 1:1, d. Review of admissions and readmissions during the Clinical Morning Meeting including a comprehensive review of the residents H&P to identify any suicidal ideation or attempts, e. IDT documentation post discussion of a resident that was placed on a 1:1 f. IDT responsibilities related to an individualized care plan, g. IDT responsibilities related to the removal of a 1:1, h. IDT review of PASARR for completion and accuracy. 7. Facility conducted a 30 day look back review of all Mental Health Practitioner recommendations to ensure recommendations were put into place. 8. Ad-Hoc QAPI meeting held on [DATE] to review event and investigation. An additional Ad Hoc QAPI meeting was held on [DATE]. Interviews with 15 facility staff including 6 CNAs, 6 licensed nurses, 1 housekeeping staff, 1 therapist, and 1 Activities staff between [DATE] and [DATE] revealed all received the abuse and neglect and suicide prevention education. The sample was expanded to include 2 additional residents who were at risk for neglect. Observations, interviews, and record review conducted during survey revealed no concerns related to staff communication and implementation of care plan interventions for residents #3 and #5.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to prevent a vulnerable, cognitively, and mentally impaired resident, from ending his life and failed to implement the psychologist's recommendations and failed to do a Level II Preadmission Screening and Resident Review (PASARR) assessment for 1 of 3 residents reviewed for behavioral health services, out of a total sample of 11 residents, (#1). Resident #1, a [AGE] year-old male, with physical and cognitive impairment was admitted to the facility on [DATE]. The facility failed to obtain the resident's history of suicide attempts from his family and on [DATE], resident #1 threatened to end his life. The facility implemented one-to-one (1:1) supervision and consulted the psychologist and psychiatrist. The 1:1 supervision was discontinued the following day and despite the psychologist's recommendation to remove all ligature risks from the resident's room, the facility did not implement this recommendation. On [DATE] at approximately 3:10 PM, resident #1, ended his life with a shower hose positioned around his neck. He was found in his bathroom by his wife, who was also a resident in the nursing home. The resident's wife then alerted the nurses near his room. These failures contributed to the death by suicide of resident #1 and placed all residents who suffered from mental illnesses with history of suicidal ideations at risk for serious harm/death and resulted in Immediate Jeopardy starting on [DATE] and was removed on [DATE]. Findings: Cross Reference F600 Resident #1's diagnoses included dementia, severe and recurrent major depressive disorder with psychotic symptoms, schizoaffective disorder, bipolar type, anxiety, and history of suicidal behavior. Review of resident #1's admission Minimum Data Set Version 1.17.1 (MDS) with Assessment Reference Date [DATE] revealed he had a Brief Interview for Mental Status score of 3 out of 15 which indicated his cognition was severely impaired. The MDS assessment showed resident #1 required limited assistance from staff for bed mobility, transfers, dressing, toilet use, and personal hygiene. He used a wheelchair for mobility. The assessment noted no rejection of care necessary to obtain goals for his health and well-being. The assessment revealed a Mood Interview was conducted and no symptoms were identified. Review of resident #1's medical record revealed a State of Florida Agency for Health Care Administration Preadmission Screening and Resident Review (PASARR) form, dated [DATE]. Section I. A, Mental Illness (MI) or suspected MI, (check all that apply), was left blank. Section IV: PASARR Screen Completion showed No diagnosis or suspicion of Serious Mental Illness or Intellectual Disability indicated. Level II PASARR evaluation not required was checked. His medical record did not show that a new Level I PASARR was completed. Guidance included in Appendix PP of the State Operations Manual read, The resident's Level II PASARR identifies the specialized services required by the resident (retrieved on [DATE] from www.cms.gov). Review of resident #1's Psychology Evaluation note dated [DATE] revealed the resident was referred for evaluation and treatment for the stabilization of depressed mood and included past medical history of dementia, depression and anxiety. The evaluation noted the resident lived at the facility with his wife and staff reported the resident appeared depressed. According to the medical file, the patient has a history of depression and what appeared to be suicidal ideation. The psychologist listed the history information was obtained from the patient, chart review and nursing staff. It included The patient reports no history of trauma. Past Suicide Attempt: Yes, according to his medical file. The Mental Status Examination revealed resident #1 was calm, cooperative, well groomed, had good eye contact, was oriented to person, place and time, was anxious with flat and appropriate affect and had adequate fund of knowledge. The note revealed resident #1 refused to participate in the SLUMS (The St. Louis University Mental Status) test. The summary of session included resident #1 was doing well and denied symptoms of depression or suicidal ideation. The treatment plan was individual psychotherapy 2 times a month to address depression and anxiety. Review of a Psychiatric Evaluation dated [DATE] revealed resident #1 had history of suicide attempt according to his medical record. Resident #1 exhibited depressed mood and excessive worry but no psychotic symptoms, no suicidality or agitation. The treatment plan was to monitor for changes in mood or behaviors and continue medications as prescribed. Review of Progress Notes dated [DATE] revealed resident #1 experienced severe anxiety and stated he wanted to be with his wife, but his daughter said no. The note mentioned the nurse talked to resident #1 and took him for a walk, but nothing worked. Resident #1 was crying. The nurse wrote, per daughter he tried to kill himself before, she's afraid he might try that again. He stated and I quote He wants to die. Review of a second Progress Note dated [DATE] revealed resident #1's assigned nurse notified the supervisor about resident #1's statement and behavior. Resident #1 was placed on one-on-one (1:1) supervision. The physician, Director of Nursing (DON) and resident #1's daughter were notified. The psychologist was notified and indicated he would evaluate resident #1 the following day. Review of a PHQ (Patient Health Questionnaire)-9 form dated [DATE] showed a score of 15 which indicated he had moderately severe depression. Answer to question 9a. Thoughts that you would be better off dead, or of hurting yourself in some way was answered Yes and the symptom frequency was 2-6 days. The PHQ-9 is a brief, 9-item scale that includes only the depression-related items from the PHQ. The PHQ-9 has been validated for use in primary care settings and can be used to make a tentative diagnosis of depression and to monitor depression severity and response to treatment in the past 2 weeks. (Retrieved from www.[NAME].nih.gov on [DATE]). On [DATE] at 11:15 AM, the Social Services Director (SSD) stated resident #1 was referred to psych at admission, because his diagnoses included depression and suicidal ideation and he took psych medications. The SSD reviewed the PASARR Level 1 form completed [DATE] and acknowledged a new PASARR was needed after resident #1 verbalized suicidal ideation on [DATE]. She said the PASARR was not reviewed and she was not sure if he needed a Level II. She indicated she did not recall resident #1's PASARR mentioned or reviewed during their clinical meetings. She acknowledged she did not ask the resident's daughter specifically about his previous mental health history or previous suicide attempts. Review of a Psychotherapy Note dated [DATE] read, Suicidal Ideation: Denied. Staff reports statements. Has a history of needing increased supervision. The summary of session read, Patient was seen in his room. He was alert and oriented. Staff reported he had been making statements regarding wanting to die. Patient denied suicidal ideation. He states that he often says that when he is upset. Discussed with nursing staff, recommended that they search his room to remove things that he can use to harm himself. Recommended removing lines and cables and pants and shirts that he can use to self harm. Recommend limiting and supervising visits with his wife, who is in another room at the facility because nursing staff reports that he gets into arguments with her. Added him to the list of patients the psychiatrist will see tomorrow and reminded the nurse to have the psychiatrist see him. The note included resident #1 was to be followed by a new provider as this was the last session with the current provider. On [DATE] at 12:32 PM, the DON said he did not recall reviewing resident #1's PASARR form and was not aware a Level II PASARR was needed. He acknowledged facility staff would have reviewed the PASARR form they received at admission and said a new one was not completed after the resident made comments of wanting to end his life. The DON stated on [DATE] he was notified resident #1 wanted to kill himself. He stated he instructed the nurse to place the resident on 1:1 supervision and to notify both his physician and psych. He explained on Monday [DATE], the psychologist assessed the resident. He explained the psychologist recommended to discontinue one to one supervision, limit his wife's visits as much as possible the next few days, and remove items that could cause harm in any way. He stated the items mentioned included pens, belts, and scissors. The DON explained the list of items the psychologist mentioned verbally that could cause harm to resident #1 were not documented but he recalled it from his conversation with the psychologist. The DON stated he searched resident #1's room with his daughter's consent and checked he had no possession of any of those items. He stated at that point he went by the items mentioned by the psychologist but did not deem the call light cord or the handheld shower hose harmful. He stated he spoke with the resident's daughter about items not to bring her dad. The DON validated there was no documentation of resident #1's searches or items removed from his room. Review of a Progress Note dated [DATE] entered by the DON noted the psychologist came to the facility to evaluate the resident due to recent change in mental condition and verbalized suicidal ideation. The note indicated the resident stated he should not have said that and conveyed he would never cause any harm to himself or his wife. Psychologist recommended to discontinue 1:1, limit wife visit as much as possible, during the next few days and also to keep item that can cause any harm away. Staff continue with frequents rounds, daughter at bedside aware of recent evaluation and agreed with new recommendations. Resident currently resting in bed and participating in daily activities as usual. Review of antipsychotic Evaluation (Amended) dated [DATE] noted the resident was seen as nursing staff reported the wife said he was thinking of killing himself and killing his wife. The psychiatrist noted he discussed the resident with the DON who reported the resident's daughter said he had made these kind of statements in the past. His wife is also a resident in the facility in a different room due to family request she is very anxious and can appear to feed his anxiety. He has a history of depression and anxiety and advanced dementia with insomnia. The evaluation indicated the resident currently denied suicidally and had no plan. He has no history of suicidally. Patient has been screened for depression and is currently being treated. History of suicide attempt answered, Yes, according to his medical file. The treatment plan included increase of Zoloft to 100 mg daily for depression, monitor for changes in mood or behaviors and follow up in 4-6 weeks or sooner if needed. An addendum to the note read, History of present illness corrected to state resident has history of suicidal statements but has no history of attempts. Review of a Psychiatric Progress Note dated [DATE] described resident #1 as calm and cooperative with no adverse effects noted from medications. The note read, He has history of suicide ideation. He has a history of becoming agitated at times. His depression is treated with Zoloft and Trazadone. Mood appears to be slightly improved since recent increase of Zoloft. There were no changes to medications and the treatment plan was to monitor for changes in mood or behaviors and follow up in 4-6 weeks or sooner if needed. A Progress Note dated [DATE] read, resident was observed in a crouched position with a handheld shower head hose positioned around his neck, and he did not have a pulse. [Resident's last name] was last observed approximately 20- 30 minutes prior to this while he was resting in bed for an afternoon nap, and remained in his usual demeanor as apparently happy, interacting with staff, with no changes or concerns. On [DATE] at 12:07 PM , the first floor Unit Manager (UM) explained some time after 3:00 PM on [DATE], she was at the nurses station when she heard screaming and saw RN A coming out of resident #1's room. She stated resident #1 was found kneeling by the shower tub, facing the bathtub. She explained she asked LPN B to hold his body while she unwrapped the handheld shower cord which was wrapped 2 times around his neck. She stated they moved his body from the bathroom and placed him face up on the floor to assess him. She explained she left the room to call 911 while LPN B and a CNA stayed with resident #1. She indicated the Paramedics and police responded, and resident #1 was a Do Not Resuscitate (DNR). On [DATE] at 11:57 AM, Registered Nurse (RN) A stated she was about to unlock the medication cart to start her shift on [DATE] when she heard someone crying behind her. She recalled she turned around and saw resident #1's wife sitting in her wheelchair by his door, crying and talking in Spanish. RN A said she kept repeating resident #1's name and pointing inside his room. She said she thought he needed help and entered resident #1's room. She noticed his wheelchair was by the bathroom and when she entered, she saw him hanging from the shower hose. She remembered the shower hose was tightly wrapped around his neck twice, and his legs were bent. She noted his head drooped down, and his feet touched the shower floor. She stated she was in shock, and her immediate reaction was to scream. She recalled resident #1's wife was still at the door crying. On [DATE] at 12:46 PM, Licensed Practical Nurse (LPN) B explained she was near RN A when they they heard resident #1's wife repeating his name, trying to get their attention. She said they asked the wife what was wrong and she replied, shower, shower. She recalled both she and RN A ran inside resident #1's room and noticed his bed was empty. They entered the bathroom and saw resident #1 inside the bathtub, looking down with his knees bent. She said he had the shower hose wrapped around his neck twice. She stated when RN A saw him, she screamed, and ran out of the bathroom. She indicated she started touching him and calling his name and tried to untwist the hose while he was still in the shower tub with the help of a CNA who came in. She stated they removed the hose and brought him out of the bathroom to lay him down. She said he had no pulse and they learned he had a Do Not Resuscitate order. LPN B stated she learned about the resident's history of attempts to end his life after he died but if she had known this before, maybe I would have paid closer attention to him. On [DATE] at 1:38 PM, resident #1's daughter stated she visited her parents the day before her dad died and noticed he was not talking as much as before, but she did not notice any unusual statements or behaviors. The daughter wept as she explained she received a call from the facility on [DATE] informing her father was on the floor with no pulse. She recalled when she arrived at the parking lot, she saw police activity and hoped everything was okay with her dad. She thought maybe the police were called because of the way they found him. She said there were 2 police officers by her dad's room and when she asked to go inside, she was told no because they were investigating. She said, It was then I felt he must had done something, something to himself. On [DATE] at 2:13 PM, in a telephone interview, the Psychiatrist explained residents actively expressing a desire to die would be transferred to a psychiatric facility for evaluation under a [NAME] Act. She stated other interventions that could be implemented included one to one supervision, 15-minute checks, or removing objects that could be used to self harm such as silverware. She stated the DON informed her last Tuesday that they learned about resident #1's past suicide attempts. She stated, If you are not fully informed, it is really challenging. This is a very important factor. She said, 'I think this was a failure on getting the knowledge of the extensiveness of his suicidally. They all would have a red alert going on. How could you not? Every time something like this happen is a learning experience. They always say the best predictor of future behavior is past behavior. On [DATE] at 1:47 PM, the Medical Director explained the facility cared for residents with behaviors and psychiatric illnesses and they had psychology and psychiatric services available as needs dictated. He stated resident #1 had diagnoses of dementia, history of anxiety and depression but review of his medical records did not reveal previous attempts to end his life. He explained when evaluating a resident who had verbalized suicidal ideations, he would ask if they had a plan and based on the response, it was escalated. He indicated after [DATE], there was no repeated mention by resident #1 of any thoughts of hurting himself. The answer was always I am feeling fine, I would not do anything like that. The Medical Director stated medications were working and felt the resident was medically stable. On [DATE] at 3:58 PM, in a telephone interview, the Psychologist recalled his visit to resident #1 on [DATE]. He explained resident #1 told him he did not have any issues and he made that comment of harming himself because he was upset. The Psychologist stated he spoke to his daughter, and she mentioned he had a very long history of similar behavior. He stated he told the nursing staff of items to remove from resident #1's room but he could not remember the specific items. He explained if he had known details of his previous suicidal attempts, his approach would have been the same, removing potential harmful things from his room and have him reassessed by the psychiatrist. Review of the policy and procedure titled Behavior Management Program Overview dated [DATE] read, The facility Behavior Management Program is provided by the interdisciplinary team and recognizes that behaviors exhibited by residents require appropriate identification, data collection, intervention, management, and evaluation to assist the resident in obtaining their highest practicable level of functioning. The interdisciplinary team works in partnership with the resident/resident representative to establish effective interventions and goals. Review of the policy and procedure titled PASARR Requirements Level I & Level II dated February 2021 read, Determine if a serious mental illness . exists while reviewing the PASARR form completed by the Acute Care Facility.(Trigger for Level II Completion). Review of corrective measures implemented by the facility revealed the following, which were verified by the survey team: 1. Facility conducted a house-wide audit of PASARRs. Level II was completed and submitted for any residents identified as needing one. 2. A PHQ-9 (depression test) questionnaire was completed on all residents with a major depression diagnosis. All assessments were reviewed with facility psychologist and recommendations carried by facility staff. 3. A staff questionnaire was completed to identify residents that have voiced suicidal statements such as self-harm or change in mood 4. Facility IDT conducted a house-wide review of resident diagnosis list for suicidal ideations - no residents identified upon completion of the audit. 5. All facility staff educated on: a. Suicide Prevention Policy, b. Ideation Identification and interventions to put into place if identified, c. Environmental safety related to suicide prevention, d. Abuse-Neglect-Exploitation as it relates to supervision and inspection of the environment which could lead to self-harm. 6. Facility IDT members including the Administrator, DON, UMs, Staff Development Coordinator, Activities, SSD, MDS, Dietary manager, Director of Rehab, and Mental Health Provider were educated on the following: a. IDT Documentation related to suicidal ideation, b. Documentation related to enhanced monitoring of a resident, c. What should be included in the documentation if a resident is on a 1:1, d. Review of admissions and readmissions during the Clinical Morning Meeting including a comprehensive review of the residents H&P to identify any suicidal ideation or attempts, e. IDT documentation post discussion of a resident that was placed on a 1:1 f. IDT responsibilities related to an individualized care plan, g. IDT responsibilities related to the removal of a 1:1, h. IDT review of PASARR for completion and accuracy. 7. Facility conducted a 30 day look back review of all Mental Health Practitioner recommendations to ensure recommendations were put into place. 8. Ad-Hoc QAPI meeting held on [DATE] to review event and investigation. An additional Ad Hoc QAPI meeting was held on [DATE]. Interviews with 15 facility staff including 6 CNAs, 6 licensed nurses, 1 housekeeping staff, 1 therapist, and 1 Activities staff between [DATE] and [DATE] revealed all received the abuse and neglect and suicide prevention education. The sample was expanded to include 2 additional residents who were at risk for neglect. Observations, interviews, and record review conducted during survey revealed no concerns related to staff communication and implementation of care plan interventions for residents #3 and #5.