**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3a. Resident #64 was admitted to the facility in February 2024 with diagnoses including major depression. Review of Resident #64's most recent Minimum Data Set (MDS) dated [DATE], indicated Resident #64 had a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15, which indicated he/she was cognitively intact. The MDS also indicated Resident #64 was independent with daily functional tasks. Review of Resident #64's record indicated he/she completed the PHQ-9 (an assessment of depression) upon admission and scored a 0, which indicated he/she was displaying no symptoms of depression. Review of the Psychiatric Nurse Practitioner note on 4/4/24 indicated the following: - Resident is very withdrawn, limited interaction with peers, upon assessment resident with limited communication ability, (he/she) uses one word response, unable to express (him/herself). Present with flat affect. Review of Resident #64's record indicated he/she completed the PHQ-9 (an assessment of depression) again on 5/10/24 and scored a 12, which indicated he/she was displaying symptoms of moderate depression. Review of the Psychiatric Nurse Practitioner note on 5/10/24 indicated the following: - Resident reports; Little interest in doing things for several days. Feeling depressed for more than half the days. Having trouble falling and staying asleep for more than half the days. Having little energy for more than half the days. Denies having poor appetite/overeating. Feeling bad about (him/herself) for several days. Trouble with concentration for several days. Moving slowly nearly every day. Denies any thoughts/plans of hurting (him/herself)/or others. PHQ-9 score 12-moderate depression. Review of Resident #64's mood care plan last revised 5/9/24, indicated the following intervention: -Behavioral Health Services as ordered and treat as indicated. Review of Resident #64's medical record failed to indicate the Resident received any additional behavioral health services after the PHQ-9 indicated an increasing level of depression. During an interview on 6/6/24 at 9:36 A.M., the Social Services Assistant said that he is not a social worker or licensed for social work or counseling services. He said that the facility had a contract company that has since closed. He said that if a Resident expressed an increase in depression the facility would make a referral to support services and the social worker would check in with these residents. During an interview on 6/6/24 at 10:38 A.M., the Psychiatric Nurse Practitioner (Psych NP) said she reviews all of the referrals for behavioral health given by the nurses. She said the referrals are either given verbally or kept in a folder on the floors. The Psych NP said she provides medication management and will briefly talk to the residents, if necessary, but said she does not provide talk therapy. During an interview on 6/6/24 at 11:15 A.M., the Director of Nursing (DON) said the Psych NP does medication management and the facility has social services and emotional therapy support would be provided by a psychiatric provider. She said there is a psychologist that comes into the building, and she would expect all available options of behavioral health services to be involved with anyone expressing increased levels of depression. The DON said that Resident's with depression should have behavioral monitoring that would pick up a change in status like not engaging, or not attending activities, more isolation, etc. The DON said that she would want those residents to have therapy beyond medications. During an interview on 6/7/24 at 7:36 A.M., Physician #1 said that he believes that Residents would benefit from counseling services and non-pharmacological interventions, but that he feels the facility needs more support to provide those services. 3b. Resident #73 was admitted to the facility in February 2024 with diagnoses including depression. Review of Resident #73's most recent Minimum Data Set (MDS) dated [DATE], indicated Resident #73 had a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15, which indicated he/she was cognitively intact. The MDS also indicated Resident #73 required substantial assistance with daily functional tasks. Review of Resident #73's record indicated he/she completed the PHQ-9 (an assessment of depression) on 2/16/24 and scored a 14, which indicated he/she was displaying symptoms of moderate depression. Review of the Psychiatric Nurse Practitioner note on 4/4/24 indicated the following: - Resident is very withdrawn, limited interaction with peers, upon assessment resident with limited communication ability, (he/she) uses one word response, unable to express (him/herself). Present with flat affect. Review of Resident #73's record indicated he/she completed the PHQ-9 (an assessment of depression) again on 5/13/24 and scored a 15, which indicated he/she was displaying symptoms of moderately severe depression, an increase from the previous PHQ-9. Review of the Psychiatric Nurse Practitioner note dated 4/8/24 indicated Resident #73 was at risk for worsening mood and behavior. Review of the Psychiatric Nurse Practitioner note dated 5/10/24 indicated the following: - Resident reports; little interest in doing things for more than half the days. Feeling depressed nearly every day. Having trouble falling and staying asleep for more than half the days. Having little energy for more than half the days. Poor appetite for more than half the days. Feeling bad about (him/herself) for several days. Denies having trouble with concentration. Moving slowly nearly every day. Denies any thoughts plans of hurting (him/herself)/others. PHQ-9 score 15 - moderately severe depression. Review of the Psychiatric Nurse Practitioner note dated 5/13/24 indicated the following: - Resident reports having poor sleep in the past weeks. (He/she) reports (he/she) can't sleep more than 2 hours straight, (he/she) has poor sleep and depressed mood. -Resident #73's anti-depressant was increased at this time. Review of Resident #73's psychotropic medication care plan last revised 5/28/24, indicated the following intervention: -Behavioral Health Services PRN (as needed). Review of Resident #73's medical record failed to indicate the Resident received any additional behavioral health services after the PHQ-9 indicated an increasing level of depression. During an interview on 6/6/24 at 9:36 A.M., the Social Services Assistant said that he is not a social worker or licensed for social work or counseling services. He said that the facility had a contract company that has since closed. He said that if a Resident expressed an increase in depression the facility would make a referral to support services and the social worker would check in with these residents. During an interview on 6/6/24 at 10:38 A.M., the Psychiatric Nurse Practitioner (Psych NP) said she reviews all of the referrals for behavioral health given by the nurses. She said the referrals are either given verbally or kept in a folder on the floors. The Psych NP said she provides medication management and will briefly talk to the residents, if necessary, but said she does not provide talk therapy. During an interview on 6/6/24 at 11:15 A.M., the Director of Nursing (DON) said the Psych NP does medication management and the facility has social services and emotional therapy support would be provided by a psychiatric provider. She said there is a psychologist that comes into the building, and she would expect all available options of behavioral health services to be involved with anyone expressing increased levels of depression. The DON said that Resident's with depression should have behavioral monitoring that would pick up a change in status like not engaging, or not attending activities, more isolation, etc. The DON said that she would want those residents to have therapy beyond medications. During an interview on 6/7/24 at 7:36 A.M., Physician #1 said that he believes that Residents would benefit from counseling services and non-pharmacological interventions, but that he feels the facility needs more support to provide those services. Based on record review and interview, the facility failed to provide behavioral health services for four Resident's (#192, #91 #64, and #73) with a history of suicidal ideation (SI) and/or depression, out of a total universe of 67 residents. Specifically, 1. Resident #192 expressed suicidal ideation and the facility failed to provide the appropriate services, which resulted in staff finding Resident #192 with a tightly tied plastic bag around his/her head during an attempted suicide, 2. the facility failed to provide behavioral health services timely for Resident #91, 3. failed to provide behavioral health services after an increase in depression scores for Resident #64 and #73. Findings include: Review of the facility policy titled Suicide Prevention, dated 8/1/23, indicated the following: - Suicidal Ideation is defined as self-reported thoughts about engaging in suicide-related behaviors. - All staff members will immediately report any suicidal ideation to the resident's charge nurse and facility social worker. - Immediately notify the resident's physician if the resident presents with suicidal ideation, even if he or she isn't specific about a plan or intent. - Objectively and thoroughly document the resident's mood and behaviors, as well as actions taken, in the medical record. - All staff will be trained annually on risk factors and warning signs of suicide, as well as how to respond to a resident with suicidal ideation. Review of the facility policy titled Suicide Assessment, revised February 2023, indicated the following: - Residents will be assessed for suicide risk upon admission and as indicated. The facility social worker or designee will conduct and medical record review and then interview the resident regarding any risk factors that have been identified. Protective factors will be explored with the resident as well. - Risk factors include, but are not limited to: * History of prior suicide attempts or self-injurious behavior * Current or past psychiatric disorders and/or recent change in psychiatric treatment * Symptoms such as hopelessness, helplessness, anxiety/panic, and impulsivity * Triggering events that lead to despair such as the loss of a relationship, health decline, chronic pain, death of a loved one, family turmoil/chaos .etc. - If the assessment indicates the resident is having suicidal thoughts, specific discussions about thoughts, plans, behaviors, and intent will occur. Review of the facility policy titled Behavioral Health Services, revised February 2023, indicated the following: - It is the policy of this facility to ensure all residents receive the necessary behavioral health services to assist them in reaching and maintaining their highest level of mental and psychosocial functioning. - 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, psychosocial difficulty, and trauma or post-traumatic stress disorders. - The facility will ensure that necessary behavioral health care services are person-centered and reflect the resident's goals for care, while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety. - The facility utilizes the comprehensive assessment process for identifying and assessing a resident's mental and psychosocial status and providing person-centered care . Staff will: * Complete PASARR (pre-admission screening and resident review) * Obtain history from medical records, the resident, and as appropriate the resident's family and friends * Monitor the resident closely for expressions or indications of distress * Assess and develop a person-centered care plan for concerns identified in the resident's assessment. - Facility staff will implement person-centered care approaches designed to meet the individual goals and needs of each resident, which includes non-pharmacological interventions. - The Social Services Director shall serve as the facility's contact person for questions regarding behavioral health services provided by the facility and outside sources such as physician, psychiatrist, or neurologist. Review of the facility assessment, revised 3/19/24, indicated the facility is able to 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/PTSD, other psychiatric diagnoses, intellectual or developmental disabilities. On average, the facility manages about 50 residents with behavioral health needs at a time. Resident #192 was admitted in December 2023 with diagnoses including bipolar disorder, depression, schizoaffective disorder, and generalized anxiety. Review of the admission Minimum Data Set (MDS), dated [DATE], indicated Resident #192 scored a 10 out of a possible 15 on the Brief Interview for Mental Status (BIMS), indicating moderate cognitive impairment. Review of the Resident's hospital discharge paperwork given to the facility upon admission and dated 12/1/23, indicated the following note from the psych team: - Pt now endorsing SI. Told Case Mgmt that he/she wants to end his/her life. I spoke with patient and he/she states that he/she has thought about suicide for a while and wishes he/she could end his/her life, but states 'he/she is not allowed'. Denies prior suicide attempts or access to firearms, but states if I did have access to firearms, I would kill myself and states I have nothing to live for. Endorses multiple prior psychiatric hospitalizations. Will place on Section 12, consult APS (Acute Psychiatric Stay). Per review of prior records, did note this during his/her prior hospital admission as well. Review of the PASARR Unit for Department of Mental Health, dated 11/29/23, indicated that Resident #192 had a PASARR Level II completed and was appropriate for a provisional emergency admission to a nursing facility that cannot exceed 7-calendar days. The PASARR (Pre-admission screening and resident review) evaluation indicated the following: - Upon admission to a nursing facility, it is the responsibility of the nursing facility to contact the PASARR authority in the event of a significant change in resident status, including: * Improvement or decline in condition, or * If the nursing facility newly identifies a condition that may impact the individual's PASARR disability status, appropriateness of nursing facility placement and/or specialized services, to determine whether a new PASARR evaluation is needed. At time of admission, a psychosocial well-being care plan was developed for Resident #192 and indicated the following: Focus: This resident is at risk for altered psychosocial well-being related to Adjustment to new environment/rehab setting, decline in functional/medical status, dx Schizoaffective d/o Bipolar 1, anxiety/panic d/o, depression, FTT (failure to thrive) in adult (initiated 12/2/23) Interventions: - Activities to meet with this resident to develop and activity plan (initiated 12/2/23) - Behavioral health services as ordered and needed (initiated 12/2/23) - Encourage family members/residents representatives to be involved as allowed by resident to also participate in this plan to be able to provide direct support (initiated 12/2/23) - Encourage the resident to make their own decisions when able (initiated 12/2/23) - Encourage the resident to see a positive view of themselves (initiated 12/2/23) - Following up with responses to concerns brought up (initiated 12/2/23) - Medications as ordered to help manage their mood and behaviors (initiated 12/2/23) - Monitor and document mood and behaviors (12/2/23) - Provide 1:1 to allow this resident to verbal feeling/concerns (12/2/23) - Provide the resident praise for all their efforts made (initiated 12/2/23) - Remind this resident of their goals and reassure them on progress made (12/2/23) Review of Resident #192's other comprehensive care plans failed to indicate a care plan was developed for the Resident's history of suicidal ideation (SI). Review of the Psychiatric Evaluation and Consultation note, dated 12/4/23, indicated Resident #192 has felt depressed since childhood and has had multiple hospitalizations related to SI. The note also indicated: Resident was admitted to unit with SI, aware of resident's verbalizing SI. The note indicated that Resident #192 was on an established medication regimen to manage his/her mood, depression, and anxiety. The psychiatric consultation note recommendations indicated the following: Monitor resident for safety, provide medications as prescribed, encourage resident to participate in unit activities. Continue to monitor acute changes in behaviors, nutrition status, and sleep patterns. Redirect when possible, maintain adequate safety precautions, appropriately use diversionary activities on the unit, and provide positive encouragement. Patient would benefit from continued treatment to promote mental wellness and emotional stability. Review of the Patient Health Questionnaire-9 (PHQ-9) (an assessment of depression), dated 12/4/23, indicated Resident #192 scored a 23 out of a possible 27 points, indicating severe depression. During an interview on 6/7/24 at 9:26 A.M., Certified Nursing Assistant CNA #4 said that if a resident had changes in their mood or behaviors, staff would document the changes on the behavior sheets. CNA #4 remembered Resident #192. CNA #4 said that Resident #192 could be mean to staff, but did not say that he/she refused care. Review of the progress notes, behavior monitoring sheets, and medication administration record (MAR) failed to indicate that the facility was monitoring for any change in Resident #192's daily mood and depression. Review of the progress note, dated 1/8/24, indicated the following: Resident stated that he/she wanted to die. Social Worker (SW) went to talk to Resident #192. Resident #192 stated he/she was afraid of a woman and that she will kill him/her. SW asked to describe the woman. Resident stated she worked here and gave the description of the CNA that is working with him/her. SW informed unit manager and DON (Director of Nursing). Review of the psych progress note, dated 1/8/24, indicated Resident #192 denied SI, but reported low mood. The progress note indicated that Resident #192 was on an established medication regimen with moderately severe depression. Review of the clinical record failed to indicate any changes had been made to Resident #192's plan of care, care plan, or that notification to the physician had occurred after the Resident had expressed suicide ideation. Review of the physician note, dated 1/9/24, did not indicate that the physician addressed Resident #192's suicidal ideation. During an interview on 6/7/24 at 9:29 A.M., Nurse #4 said that if a resident had changes in their mood or behavior, nursing staff would document the changes in the clinical record and leave a note for the Nurse Practitioner. Review of the clinical record indicated on 1/24/24, Resident #192 was sent to the hospital for a planned procedure. Resident #192 returned to the facility on 1/31/24. Review of the hospital discharge paperwork, dated 1/31/24, indicated Resident #192 reported suicidal ideation in the hospital and was provided a one on one sitter and was placed on a section 12 (an involuntary hospitalization if assessed to be a danger to self or others). During an interview on 6/10/24 at 8:52 A.M., the Director of Nursing said that the hospital discharge paperwork is reviewed by the clinical liaison team and the admitting nurse will review any discharge paperwork. The Director of Nursing said that the next day the whole team reviews discharge paperwork. During an interview on 6/10/24 at 9:24 A.M., the Director of Nursing said she wasn't notified of the section 12 that took place in the hospital. The Director of Nursing said that hospital discharge paperwork is reviewed by a clinical liaison team and the admitting nurse and then the full discharge summary is reviewed the next morning by the clinical team, which she is a part of. Review of the clinical record failed to indicate that, upon readmission to the facility, Resident #192's plan of care was reviewed or updated, despite Resident #192's vocalization of suicidal ideation in the hospital and a section 12. Review of the PHQ-9, dated 2/2/24, indicated Resident #192 scored a 19 out of 27, indicating moderately severe depression. There was no indication that Resident #192 was evaluated or seen by psych services, social services, or any behavioral health interventions were updated between 2/2/24 - 2/16/24. Review of the progress notes, behavior monitoring sheets, and medication administration record (MAR) failed to indicate that the facility was monitoring for any change in Resident #192's daily mood and depression. Review of the communication log from January 2024 through February 2024 for the 2nd floor unit failed to indicate any information related to Resident #192 or changes in his/her mood or behavior were communicated to psych services. Review of the progress note, dated 2/16/24, indicated the following: - Resident section 12'd 2:20 pm after acting oddly this morning refusing to talk and refusing therapy which continued after lunch. Resident was covering his/her face with his/her hands and refusing to speak but did eat lunch. Call placed to nurse practitioner to report and was given order to send to ED. When this nurse went back in to resident room he/she was found with a clear plastic bag tied around his/her head full of condensation. Bag [sic] removed and resident was attempting to take plastic bag from nurse. Awake, alert but still refusing to speak. Resident taken to nurses station for 1:1 monitoring and psych in the building section 12'd him/her. EMS notified and resident transferred to hospital [sic] for psych eval. Review of the psych note, dated 2/15/24, indicated the following: - Resident is AOx3 (alert and oriented), he/she was found by nursing staff with a plastic bag over his/her head. Resident has an extensive hx of SI but with no past activity. Resident section 12A to hospital d/t safety concern, further evaluation. Review of the hospital paperwork, dated 2/19/24, indicated the following: - Presents from his/her SNF(Skilled Nursing Facility) after staff there reportedly found him/her with a plastic bag over head in an attempt to self-harm. At that time he/she stated he/she felt like he/she 'wasn't being listened to' there and has made passive SI statement since then without much other detail . During an interview on 6/7/24 at 9:31 A.M., Nurse #5 said that Resident #192 was quiet and did not complain. She said that Resident #192 did not have a lot of issues and that he/she did not want to be here at the facility. During an interview on 6/7/24 at 8:38 A.M., the Activities Director said that Resident #192 was quiet and kept to himself/herself. The Activities Director said that Resident #192 was encouraged to leave his/her room but he/she declined and would not participate in activities. The Activities Director said that Resident #192 was upset because he/she did not want to be in the facility and felt that his/her family had left him/her here. During an interview on 6/6/24 at 9:36 A.M., the Social Services Assistant said that he is not a social worker or licensed for social work or counseling services. He said that the facility had a contract company that has since closed. He said that if a Resident expressed SI then he would contact the LICSW (Licensed Social Worker) from the company to do an evaluation via telehealth. During an interview on 6/10/24 at 8:31 A.M., Social Services Assistant #1 said that Resident #192 had some cognitive issues, but engaged the best that he/she could. Social Services Assistant #1 said that there was an adjustment period that he/she struggled with slightly due to his/her family and brother. Social Services Assistant #1 said that if a Resident verbalizes a recent SI, then that Resident should be followed on a regular basis and seen daily or once a shift to make sure they are feeling safe. Social Services Assistant #1 said that the care plan should be updated and supportive care in place During an interview on 6/6/24 at 10:38 A.M., the Psychiatric Nurse Practitioner (Psych NP) said she reviews all of the referrals for behavioral health given by the nurses. She said the referrals are either given verbally or kept in a folder on the floors. The Psych NP said she provides medication management and will briefly talk to the residents if necessary, but said she does not provide talk therapy. The Psych NP said that when a Resident expresses suicidal ideation, she would section 12 the Resident if they were actively suicidal. The psych NP said that she would consider SI was active if there was a plan behind the statement. The psych NP said that Resident #192 has an extensive and complex history and that he/she was supposed to be in the facility on respite. She said she didn't want to change the Resident's medications because he/she was supposed to be in the facility short-term. The psych NP said that even if Resident #192 made a passive statement of SI, she would expect something to be put in place like 15-minute checks or moving his/her room closer to the nurses station for monitoring. The psych NP said that Resident #192 was alert and oriented and knew everything that was going on and felt like his/her brother was keeping him/her in the facility. The psych NP said that Resident #192 would have benefited from ongoing supportive talk therapy services because of his/her history, but that those services are provided by another provider. During an interview on 6/6/24 at 11:15 A.M., the Director of Nursing (DON) said that anyone with a history of SI should have a care plan developed and implemented and that the interventions are related to the safety of the Resident. The DON said the Psych NP does medication management and the facility has social services and emotional therapy support would be provided by a psychiatric provider. She said there is a psychologist that comes into the building and said if there was a recent expression of SI from a resident, she would expect all available options of behavioral health services to be involved. The DON said that Residents with depression should have behavioral monitoring that would pick up a change in status like not engaging, or not attending activities, more isolation, etc. The DON said that she would want those residents to have therapy beyond medications. During an interview on 6/7/24 at 7:36 A.M., Physician #1 said that he believes that Residents would benefit from counseling services and non-pharmalogical interventions, but that he feels the facility needs more support to provide those services. During an interview on 6/10/24 at 11:47 A.M., the psych NP said that she was not made aware of Resident #192's suicidal ideation during his/her hospital stay and would have seen him/her upon return to the facility. During an interview on 6/10/24 at 11:47 A.M., the Director of Nursing said that the facility was never made aware of the Resident's suicidal ideation expressed during the most recent hospital stay on 1/31/24 and, if she had known, the facility wouldn't have taken Resident #192 back to the facility. 2. Resident #91 was admitted in December 2023 with diagnoses including major depressive disorder, schizoaffective disorder, and dementia. Review of the Minimum Data Set (MDS), dated [DATE], indicated Resident #91 scored a 4 out of a possible 15, indicating severe cognitive impairment. Review of the progress note, dated 12/28/2023, indicated the following: Note Text: This nurse was notified by speech, that pt voiced to her that he/she was depressed and mentioned SI. This nurse went to speak with pt voiced he/she hated his/her sister for putting him/her here, that there is no need for him/her to be here. Pt went on to say more about living with his/her sister, getting a job but his/her sister dropped him/her off here Resident said he/she was going to take care of the situation by killing him/her self, asked pt if he/she had a plan, he/she stated yes he/she did. Asked him/her what it was, he/she said he/she was just going to do it and isn't telling me how. Asked pt if he/she felt suicidal now, he/she stated yes because he/she is so upset and hates his/her sister. DON notified. Safety maintained. Review of the clinical record failed to indicate that Resident #91's suicidal ideation was addressed by psych or social services. Review of the care plan for Resident #91 indicated the following: Focus: The resident exhibits behaviors putting themselves, by making suicidal statements and/or others at risk for potential injury R/T choosing to not participate or allow care to be completed. History of physical abuse toward others, History of withdrawal from usual daily activities (group or independent), refusal of care (initiated 12/28/23). Interventions: - Administer medication as ordered (initiated 12/28/23) - Behavioral health services as ordered and treat as indicated (initiated 12/28/23) - Encourage attendance to activities (initiated 12/28/23) - Identify and implement nonpharmacological interventions (identify what these are for this resident): _________ (initiated 12/28/23) - Keep resident representative informed of changes or continued behaviors impacting the residents care (initiated 12/28/23) - Monitor and document behaviors for further review (initiated 12/28/23) - Social worker to provide routine visits and provide support as needed (initiated 12/28/23) Review of the care plan failed to indicate that a suicidal ideation care plan was developed with appropriate interventions for the Resident's safety. Review of the care plan failed to indicate that any interventions were carried out after Resident #91 verbalized suicidal ideation. Review of the psych Nurse Practitioner note, dated 1/8/24, 11 days after the initial suicidal ideation, indicated Resident #91 presented with low mood and was upset about his/her sister not visiting while at the facility. The progress note did not mention Resident #91's suicidal ideation. During an interview on 6/10/24 at 11:47 A.M., the psych NP said that she is aware of Resident #91's suicidal ideation expressions and that his/her story changes because of memory issues. The psych NP said that Zoloft (a medication used to treat depression) was started on 12/29/23, but it takes 2 weeks for that medication to take effect. The psych NP could not say if she assessed Resident #91.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide the appropriate treatment and services for one Resident (#192), with a known history of mental disorders, suicidal ideation, and adjustment difficulty. Specifically, the facility failed to develop, implement, and update the plan of care, resulting in an attempted suicide after the vocalization of suicidal ideation. Findings include: Review of the facility policy titled Suicide Prevention, dated 8/1/23, indicated the following: - Suicidal Ideation is defined as self-reported thoughts about engaging in suicide-related behaviors. - All staff members will immediately report any suicidal ideation to the resident's charge nurse and facility social worker. - Immediately notify the resident's physician if the resident presents with suicidal ideation, even if he or she isn't specific about a plan or intent. - Objectively and thoroughly document the resident's mood and behaviors, as well as actions taken, in the medical record. - All staff will be trained annually on risk factors and warning signs of suicide, as well as how to respond to a resident with suicidal ideation. Review of the facility policy titled Suicide Assessment, revised February 2023, indicated the following: - Residents will be assessed for suicide risk upon admission and as indicated. The facility social worker or designee will conduct and medical record review and then interview the resident regarding any risk factors that have been identified. Protective factors will be explored with the resident as well. - Risk factors include, but are not limited to: * History of prior suicide attempts or self-injurious behavior * Current or past psychiatric disorders and/or recent change in psychiatric treatment * Symptoms such as hopelessness, helplessness, anxiety/panic, and impulsivity * Triggering events that lead to despair such as the loss of a relationship, health decline, chronic pain, death of a loved one, family turmoil/chaos .etc. - If the assessment indicates the resident is having suicidal thoughts, specific discussions about thoughts, plans, behaviors, and intent will occur. Review of the facility policy titled Behavioral Health Services, revised February 2023, indicated the following: - It is the policy of this facility to ensure all residents receive the necessary behavioral health services to assist them in reaching and maintaining their highest level of mental and psychosocial functioning. - 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, psychosocial difficulty, and trauma or post-traumatic stress disorders. - The facility will ensure that necessary behavioral health care services are person-centered and reflect the resident's goals for care, while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety. - The facility utilizes the comprehensive assessment process for identifying and assessing a resident's mental and psychosocial status and providing person-centered care . Staff will: * Complete PASARR screening * Obtain history from medical records, the resident, and as appropriate the resident's family and friends * Monitor the resident closely for expressions or indications of distress * Assess and develop a person-centered care plan for concerns identified in the resident's assessment. - Facility staff will implement person-centered care approaches designed to meet the individual goals and needs of each resident, which includes non-pharmalogical interventions. - The Social Services Director shall serve as the facility's contact person for questions regarding behavioral health services provided by the facility and outside sources such as physician, psychiatrist, or neurologist. Review of the facility assessment, revised 3/19/24, indicated the facility is able to 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/PTSD, other psychiatric diagnoses, intellectual or developmental disabilities. On average, the facility manages about 50 residents with behavioral health needs. Resident #192 was admitted in December 2023 with diagnoses including bipolar disorder, depression, schizoaffective disorder, and generalized anxiety. Review of the admission Minimum Data Set (MDS), dated [DATE], indicated Resident #192 scored a 10 out of a possible 15 on the Brief Interview for Mental Status (BIMS), indicating moderate cognitive impairment. Review of the Resident's hospital discharge paperwork given to the facility upon admission and dated 12/1/23, indicated the following note from the psych team: - Pt now endorsing SI. Told Case Mgmt that he/she wants to end his/her life. I spoke with patient and he/she states that he/she has thought about suicide for a while and wishes he/she could end his/her life, but states 'he/she is not allowed'. Denies prior suicide attempts or access to firearms, but states if I did have access to firearms, I would kill myself and states I have nothing to live for. Endorses multiple prior psychiatric hospitalizations. Will place on Section 12, consult APS (Acute Psychiatric Service). Per review of prior records, did note this during his/her prior hospital admission as well. At time of admission, a psychosocial well-being care plan was developed for Resident #192 and indicated the following: Focus: This resident is at risk for altered psychosocial well-being related to Adjustment to new environment/rehab setting, decline in functional/medical status, dx Schizoaffective d/o Bipolar 1, anxiety/panic d/o, depression, FTT (failure to thrive) in adult (initiated 12/2/23) Interventions: - Activities to meet with this resident to develop and activity plan (initiated 12/2/23) - Behavioral health services as ordered and needed (initiated 12/2/23) - Encourage family members/residents representatives to be involved as allowed by resident to also participate in this plan to be able to provide direct support (initiated 12/2/23) - Encourage the resident to make their own decisions when able (initiated 12/2/23) - Encourage the resident to see a positive view of themselves (initiated 12/2/23) - Following up with responses to concerns brought up (initiated 12/2/23) - Medications as ordered to help manage their mood and behaviors (initiated 12/2/23) - Monitor and document mood and behaviors (12/2/23) - Provide 1:1 to allow this resident to verbal feeling/concerns (12/2/23) - Provide the resident praise for all their efforts made (initiated 12/2/23) - Remind this resident of their goals and reassure them on progress made (12/2/23) Review of Resident #192's other comprehensive care plans failed to indicate a care plan was developed for the Resident's history of suicidal ideation (SI) or any interventions related to the safety of Resident #192. Review of the progress note, dated 1/8/24, indicated the following: Resident stated that he/she wanted to die. Social Worker (SW) went to talk to Resident #192. Resident #192 stated he/she was afraid of a woman and that she will kill him/her. SW asked to describe the woman. Resident stated she worked here and gave the description of the CNA that is working with him/her. SW informed unit manager and DON. Review of the psych progress note, dated 1/8/24, indicated Resident #192 denied SI, but reported low mood. The progress note indicated that Resident #192 was on an established medication regimen with moderately severe depression. Review of the clinical record failed to indicate any changes had been made to Resident #192's plan of care, care plan, or that notification to the physician had occurred after the Resident had expressed suicide ideation. Review of the clinical record indicated on 1/24/24, Resident #192 was sent to the hospital for a planned procedure. Resident #192 returned to the facility on 1/31/24. Review of the hospital discharge paperwork, dated 1/31/24, indicated Resident #192 reported suicidal ideation in the hospital and was provided a one on one sitter and was placed on a section 12 (an involuntary hospitalization if assessed to be a danger to self or others). During an interview on 6/10/24 at 8:52 A.M., the Director of Nursing said that the hospital discharge paperwork is reviewed by the clinical liaison team and the admitting nurse will review any discharge paperwork from the hospital. The Director of Nursing said that the next day, when she is in the facility, the whole interdisciplinary team, including her, reviews the discharge paperwork. During an interview on 6/10/24 at 9:24 A.M., the Director of Nursing said she wasn't notified of the section 12 that took place in the hospital. The Director of Nursing said that hospital discharge paperwork is reviewed by a clinical liaison team and the admitting nurse and then the full discharge summary is reviewed the next morning by the clinical team. Review of the clinical record failed to indicate that, upon readmission to the facility, Resident #192's plan of care was reviewed or updated, despite Resident #192's vocalization of suicidal ideation in the hospital and a section 12. Review of the progress note, dated 2/16/24, indicated the following: - Resident section 12'd 2:20 pm after acting oddly this morning refusing to talk and refusing therapy which continued after lunch. Resident was covering his/her face with his/her hands and refusing to speak but did eat lunch. Call placed to nurse practitioner to report and was given order to send to ED. When this nurse went back in to resident room he/she was found with a clear plastic bag tied around his/her head full of condensation. Bag [sic] removed and resident was attempting to take plastic bag from nurse. Awake, alert but still refusing to speak. Resident taken to nurses station for 1:1 monitoring and psych in the building section 12'd him/her. EMS notified and resident transferred to hospital [sic] for psych eval. Review of the psych note, dated 2/15/24, indicated the following: - Resident is AOx3 (alert and oriented), he/she was found by nursing staff with a plastic bag over his/her head. Resident has an extensive hx of SI but with no past activity. Resident section12A to hospital d/t safety concern, further evaluation. Review of the hospital paperwork, dated 2/19/24, indicated the following: - Presents from his/her SNF(Skilled Nursing Facility) after staff there reportedly found him/her with a plastic bag over head in an attempt to self-harm. At that time he/she stated he/she felt like he/she 'wasn't being listened to' there and has made passive SI statement since then without much other detail . During an interview on 6/6/24 at 11:15 A.M., the Director of Nursing said when a resident is admitted with a history of suicidal ideation, a care plan should be developed with interventions to keep the Resident safe and supportive services would be put in place, including psych and social services. During an interview on 6/6/24 at 10:38 A.M., the Psych Nurse Practitioner said she would consider someone with a history of SI who has recently expressed SI to be put on 15 minute checks or moved closer to the nursing station. The Psych NP said she was not notified of Resident #192's return from the hospital with a verbalization of SI. The psych NP said that Resident #192 had some issues with being at the nursing facility and with his/her brother placing him/her here. During an interview on 6/6/24 at 9:36 A.M., the Social Services Assistant (SSA) #1 said that he is not a social worker, but at the time Resident #192 was admitted , an outside contract service provided social worker support as needed. SSA #1 said he would expect a care plan to be developed for suicidal ideation and if a Resident expressed suicidal ideation then the Resident should be seen immediately. During an interview on 6/10/24 at 8:30 A.M., SSA #1 said that if a resident expressed SI then that Resident should be checked in on daily from social services to make sure they are safe. SSA #1 said that Resident #192 was having a difficult time adjusting to the facility and his/her brothers decision to keep him/her at the facility. Review of the clinical record did not indicate that any interventions were put in place or updated after return from the hospital, between 1/31/24 - 2/16/24, for Resident #192 with a known history of suicidal ideation and adjustment difficulty.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews the facility failed to ensure it was administered in a manner that enabled the facility to use its resources effectively to attain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the facility administration failed to ensure the appropriate behavioral health services were in place for one Resident (#192) who attempted suicide after verbalizing suicidal ideation. Findings Include: During the survey process it was identified that the Administration's failure to ensure adequate behavioral health services were provided for residents with mental health disorders. Out of a total universe of 67 residents identified with depression disorder, 7 residents were not provided the behavioral health services after an identification of decreased mood through the PHQ-9 (personal health questionnaire-9) (a tool used to measure depression). Review of the facility assessment, revised 3/19/24, indicated the facility is able to 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/PTSD (post traumatic stress disorder), other psychiatric diagnoses, intellectual or developmental disabilities. On average, the facility manages about 50 residents with behavioral health needs. Review of the Behavioral Health Service Agreement, dated December 2022, indicated the following services were provided to the facility: - Provide psychiatric evaluations at the request of the attending physician for the purpose of assessing the specific needs of residents of the facility with psychiatric symptomology and recommending therapeutic interventions. - Perform psychopharmacological consults and monitoring; and psychotherapeutic services. - Act as a liaison for emergency situations in the event of a psychiatric crisis - Maintain certain that all residents that have a referral for behavioral health management services receive an evaluation within 10 days. Resident #192 was admitted in December 2023 with diagnoses including bipolar disorder, depression, schizoaffective disorder, and generalized anxiety. Review of the admission Minimum Data Set (MDS), dated [DATE], indicated Resident #192 scored a 10 out of a possible 15 on the Brief Interview for Mental Status (BIMS), indicating moderate cognitive impairment. Review of the Resident's hospital discharge paperwork given to the facility upon admission and dated 12/1/23, indicated Resident #192 verbalized that he/she would kill him/herself if he/she had a gun in the hospital. The Resident was placed on a section 12 (an emergent mental health measure to prevent a patient from harming themselves) and cleared prior to admission. Review of the clinical record did not indicate that any SI (suicide ideation) care plan had been developed or any interventions for safety were put into place following admission. Review of the progress note, dated 1/8/24, indicated Resident #192 verbalized SI and was subsequently evaluated by the behavioral health services (Psychiatric Nurse Practitioner) for immediate safety. No changes were made to the Resident's plan of care. Review of the clinical record failed to indicate any changes had been made to Resident #192's plan of care, care plan, or that notification to the physician had occurred after the Resident had expressed suicide ideation. Review of the clinical record indicated on 1/24/24, Resident #192 was sent to the hospital for a planned procedure. Resident #192 returned to the facility on 1/31/24. Review of the hospital discharge paperwork, dated 1/31/24, indicated Resident #192 reported suicidal ideation in the hospital and was provided a one on one sitter and was placed on a section 12 hospitalization. Review of the clinical record failed to indicate that, upon readmission to the facility, Resident #192's plan of care was reviewed or updated, despite Resident #192's vocalization of suicidal ideation in the hospital and a section 12. There was no indication that Resident #192 was evaluated or seen by behavioral health services, social services, or any additional behavioral health interventions were updated between 2/2/24 - 2/16/24. Review of the record indicated, on 2/16/24, Resident #192 attempted suicide by placing a bag tightly over his/her head. Resident #192 was subsequently sent to the hospital and never returned to the facility. During an interview on 6/6/24 at 10:38 A.M., the psych NP said that she does not provide talk therapy to residents and that the other provider within her contract company should be utilized. The psych NP said she primarily focuses on medication management and checking in with residents. The psych NP said that Resident #192 would have benefited from talk therapy given everything that was going on with him/her. The psych NP also said that if a Resident is expressing suicidal ideation then certain safety measures should be put in place and a care plan should be developed to keep the Resident safe. During an interview on 6/7/24 at 9:21 A.M., the Administrator said that he brought supportive care services on board when the facility opened a behavioral health unit (around September 2023) to provide oversight and the Psychiatric NP is in a couple of times per week. The Administrator said that the psych NP is a consultant and sometimes meets with the residents to provide support and make recommendations to the doctor. He said he is unsure what she does when she sees them, but would assume she goes in to meet and talk with the residents. The Administrator said that social workers would be providing talk therapy to the residents, but that he doesn't differentiate the difference between talk therapy and when the psych NP goes to meet with residents. The Administrator said that if a Resident expresses suicidal ideation then the interdisciplinary team should be involved (department heads), as well as, psych services. The Administrator was not aware that the psych NP was not providing talk therapy services and just providing medication management. During an interview on 6/6/24 at 11:15 A.M., the Director of Nursing said emotional therapy and support would be provided by a contract provider that comes in (a psychologist), but could not say why Resident #192 had not been provided those services. During an interview on 6/10/24 at 11:54 A.M., the Director of Nursing said that she came on board last year and the social services department needs some work. She said she was never made aware of Resident #192's SI in the hospital and would not have taken him/her back if she knew. During an interview on 6/7/24 at 7:36 A.M., Physician #1 said that he believes that Residents would benefit from counseling services and non-pharmalogical interventions, but that he feels the facility needs more support to provide those services. The Administrator or Director of Nursing were unable to provide evidence throughout survey that the behavioral contract services were meeting the facilities expectations for behavioral health services provided to residents.