**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, medical record (MR) review, and review of other pertinent facility documentation on [DATE], [DATE], and [DATE], it was determined that the facility failed to provide services necessary to prevent physical harm when a Resident (Resident #2) with a known history and diagnosis of Major Depressive Disorder and Anxiety, had changes in behavior, which included an increase in anger and anxiousness and had expressed concerns about changes in sleep and appetite. The facility also failed to follow its policy titled Abuse and Neglect - Clinical Protocol. This deficient practice was identified for 1 of 4 residents (Resident #2) and was evidenced by the following: On [DATE], the facility submitted a Facility's Reportable Event (FRE), a New Jersey Department of Health (NJDOH) document used by healthcare facilities to report incidents to NJDOH. The FRE had an event date of [DATE] and a time of event of 6:05 AM and revealed the following: According to the Timeline of Events (TLE) indicated on [DATE] at approximately 6:05 AM, the Certified Nursing Assistant (CNA) went into Resident #2's room to provide care to the Resident's roommate. The CNA headed to the bathroom with care supplies, and when she went to open the door, she felt weight against the door. Resident #2 fell backward from the bathroom as the CNA opened the door. The CNA attempted to lower the Resident to the floor, but the Resident landed on the CNA's shoes as he/she fell to the ground. The CNA immediately called for the Licensed Practice Nurse (LPN) and Registered Nurse (RN) Supervisor on duty. The TLE also indicated the RN Supervisor and LPN #1 assessed Resident #2 at that time; the Resident had no pulse and was seen with his/her bathrobe tied around his/her neck. The RN supervisor and LPN #1 did not resuscitate the Resident due to the DNR (Do Not Resuscitate) status but immediately called 911. Resident #2 was noted as deceased . The Director of Nursing (DON), the Licensed Nursing Home Administrator (LNHA), the Medical Examiner (ME), and the local police department were notified. A review of the Individual Statement Form (ISF) dated [DATE], written by the CNA, revealed at 4:15 AM, Resident #2 was sitting on his/her bed facing the wall; the Resident was usually up at night. The CNA further noted in her statement, During my last round of the shift, I came into the room to change A bed resident. I came in [and] spoke to A bed resident, letting [the Resident] know I was going to change him/her. I grabbed my washcloths and headed to the bathroom. I went to open the door, and it felt like something was against the door. I went to open the bathroom door, and Resident #2 came falling out. I attempted to catch him/her but failed. [The Resident's] head fell onto my shoes as he/she fell towards the ground. I screamed for the nurse. A review of the ISF dated [DATE], written by LPN #1, revealed that Resident #2 was in bed sleeping during the night. The last time Resident #2 was checked by staff was 4:00 AM. The LPN further noted in his statement, At around 6:15 AM, I'm on the 1st floor with the supervisor; staff called this writer and reported that the Resident (Resident #2) is on the toilet floor. Upon arrival in the Resident's toilet room, I found the Resident in a supine position, wearing a bathrobe. Immediately called the supervisor, this writer checked the Portable Medical Orders (POLST) with code status: Do not resuscitate (DNR), Do not intubate (put a breathing tube in the throat) (DNI), Do not hospitalize (DNH). The supervisor arrived on the scene, and we both noticed the robe ring tied tight on Resident #2's neck, and both untied the ring immediately. Resident unresponsive and warm, no pulse and no vitals. A review of the Employee Statement form dated [DATE] at 7:16 AM, written by the RN, noted, Around 6:10 AM, this writer was paged to the 3rd floor. Upon arriving at the unit, I was met by the floor nurse (LPN #1). He was explaining the current situation on the unit for Resident #2's bathroom. While he was talking, we walked to the room. At approximately 6:12 AM, [Resident #2] was lying on the floor on the left side/back position as if he/she had dropped out of the bathroom once the door opened. According to the statement, Resident #2's tongue was discolored and protruding from the mouth; unable to obtain a pulse or note respirations, this writer observed the bathrobe belt wrapped around [the Resident's] neck and knotted. I quickly removed the belt from [Resident #2's] throat. Multiple knots were undone (3) and unwrapped twice from around [the Resident's] throat. This writer opened the Resident's mouth to allow air around his/her tongue. Air escaped, but no breaths were taken in. The floor nurse notified this writer of the Resident's code status of DNR/DNI. No Cardiopulmonary Resuscitation (CPR) started. Called 911 to report the alleged suicide with a police response. Call also place to DON, the LNHA, and the 3rd-floor unit manager. All paperwork prepared for 911 and awaited police. A review of the Electronic Medical Records (EMRs) was as follows: According to the Face Sheet, Resident #2 was admitted to the facility on [DATE] with diagnoses that included but were not limited to Major Depressive Disorder (MDD), anxiety disorder, chronic pain syndrome, and legal blindness. According to the Quarterly Minimum Data Set (MDS), an assessment tool dated [DATE], Resident #2 has a Brief Interview for Mental Status (BIMS) score of 13/15, which indicated the Resident was cognitively intact. Resident #2 had a mood score of 6, which indicated mild depression. Also, in the MDS under Section D D0200 Resident Mood Interview (PHQ-9), a depression screen revealed Resident #2 showed little interest and pleasure in doing things and had episodes of feeling down, depressed, or hopeless. The depression screen indicated that Resident #2 had a total of 6 episodes of feeling down, depressed or hopeless, and had trouble falling asleep or sleeping too much, being present at least once for several days, and feeling tired or having little energy nearly every day. The MDS also showed Resident #2 was independent, needed one-person assistance with Activities of Daily Living (ADLs), and had severely impaired vision. Review of the Care Plan (CP) dated [DATE] and revised on [DATE] revealed under Focus, Resident #2 was at risk for psychosocial well-being related to a diagnosis of Depression/Anxiety. Under Interventions, Encourage me to express [my] feelings of depression that I may be experiencing, offer support and offer 1:1 as needed; and Monitor for any change in mood, behavior, routine, negativity, isolation, withdrawal, hopelessness, decreased participation in [the] treatment plan. Further review of Resident #2's CP revealed under Focus, Special Instructions listed, Monitor target behaviors (Alprazolam - nervousness), Zoloft sadness, and Buspar anxiety voiced by the Resident. Under Goals, included but were not limited to I will verbalize/communicate any feelings of depression or diagnosis-related symptoms while in the facility. Also noted on Resident #2's CP was independent with daily routine and decisions re: daily routine, with interventions to Encourage me to express feelings and any frustrations I may be experiencing; Monitor for any change in my mood, behavior, routine, negativity, isolation withdrawal, hopelessness, decreased participation in the treatment plan; and Provide me with support, encourage, motivation, remind me of my progress and capabilities, reassure PRN. A review of the Physician's Orders (PO) dated [DATE] revealed the following: Psychiatry Evaluation and Treatment, Psychiatry Evaluation with NYNJ (NewYork, New Jersey) Psych, Psychotherapy evaluation and treatment as indicated. Sertraline Oral Capsule 200 milligrams (mg). Give 1 capsule by mouth one time a day related to Major Depressive Disorder (MDD). Buspirone HCL tablet 10mg, Give 1 tablet by mouth three times a day for Anxiety. Xanax Oral Tablet 0.25mg, Give 1 tablet by mouth one time a day related to Anxiety. Xanax Oral Tablet 1mg, Give 1 tablet by mouth at bedtime related to Anxiety Disorders. Review of the Progress Note (PN) dated 5/23 included the following: On [DATE] at 8:57 PM, the Registered Nurse (RN) marked YES for Resident #2 had a behavior that was observed. The RN was not specific in her progress note of the Resident's behavior and what interventions were implemented. However, the RN was unavailable for an interview at the time of the survey. On [DATE] at 5:33 PM, the Medical Doctor's (MD) progress note revealed Resident #2 said he/she was getting anxious about the outcome of his/her follow-up with the eye specialist to see if anything could be done about his/her vision. On [DATE] at 8:49 PM, the Licensed Practical Nurse (LPN) noted increased anger as soon as scheduled medication administration for Resident #2. The Resident was upset because the LPN touched his left arm to get his attention prior to giving the Resident his/her medications. On [DATE] at 2:39 PM, Resident #2 expressed to the Advanced Practice Nurse (APN), I haven't been feeling well; I couldn't sleep all night. According to the PN, Resident #2 went on to report that the Resident will find out if he/she is permanently blind in the next few days. Additionally, Resident #2 reported that he/she had a poor appetite and some nausea. Resident #2 stated, I just don't feel right. I think I need my medications increased. The APN noted the Resident was referring to his pain and psychiatric medications. However, the APN did not further question Resident #2 about his/her mental health or notify the physician regarding the Resident's concerns. On [DATE] at 9:41 PM, the LPN marked YES for Resident #2 that behavior was observed. The progress note was struck out on [DATE] at 3:56 PM, signed by the LPN after Resident #2 was deceased , indicating the documentation was an error. Further review of the PN showed the facility no evidence that the staff addressed Resident #2's aforementioned concerns. A review of the medical records for the Licensed Clinical Social Worker (LCSW) clinical visit notes revealed the following: On [DATE] at 12:40 PM to 1:15 PM, Resident #2 reported that he/she has high Anxiety a deep depression over his/her medical conditions. Resident #2 currently endorses anhedonia (inability to experience pleasure from activities usually found enjoyable), disturbed sleep and appetite, low self-esteem, difficulty concentrating, difficulty making a decision, anxiety, worry, tension, and difficulty relaxing. Under Ongoing symptoms, Symptoms that needed treatment and monitoring, sadness, anger outburst, high anxiety, restlessness, poor sleep, and family conflicts. On [DATE] at 12:37 PM to 1:15 PM, Resident #2 reported the following symptoms, Anxiety over his/her upcoming appointment regarding his/her eyesight. He/she is trying to stay positive. He/she is frustrated over his/her situation and feels the need to increase Xanax medication. She informed t/her to speak to the nurses and Psychiatrist. Resident #2 feels depressed over the situation with his/her spouse and wants to live with a spouse in ALF [Assisted Living Facility]. Review of the Psychiatric Notes from the Psychiatrist revealed the following: On [DATE], Resident #2 reported increased Anxiety and frustration at nighttime. Has been upset related to pain. On [DATE], Resident #2 was described as having a Chief Complaint of Agitation and Anxiety. Initially calm, cooperative, and pleasant, later becomes tearful [and] reports continued Anxiety and frustration at night. Reports frame of panic when laying in bed at night, anxious about eye exam and blindness. On [DATE], Resident #2 reported being tortured by Post Traumatic Stress Disorder (PTSD) symptoms. The Psychiatrist noted, Today patient states that he/she is miserable, and states he/she was hoping to be accepted at Assisted Living Facility (ALF) but was recently denied. The EMR for Resident #2 showed no evidence that the Psychiatrist was notified of the Resident's voiced concern to the LCSW on [DATE] or the APN on [DATE]. During a telephone interview on [DATE] at 11:23 AM, LPN #1 stated Resident #2 slept all night until about 5:00 AM. LPN #1 stated around 6:00 AM, while on the 1st floor, the CNA called the LPN and stated Resident #2 was on the floor. The bathroom door was open when he got to the room, while Resident #2 was flat on the floor. The LPN stated he looked at Resident #2 and asked the Resident if he/she was ok. The LPN then checked Resident #2's code status, saw he/she was a DNR/DNI/DNH, and immediately called the nurse supervisor. When the nursing supervisor came to the floor, we both noticed the bathrobe tie was around the lower part of the Resident's neck, which was tight around the neck. LPN #1 further stated, Initially, it was hard to see due to the resident's neck position. The LPN and the Nursing Supervisor immediately removed the bathrobe tie. The LPN explained the bathrobe tie was hard to remove because it was tight. They checked for a pulse and vital signs since the Resident was still warm when we found him/her. Resident #2 had no pulse and no vital signs. The nursing supervisor called the DON, LNHA, and the police to inform them of what happened. He continued he last saw Resident #2 at 11:00 PM after the report when he went to check on the Resident, and he/she was in bed asleep, which was the Resident's usual routine. The LPN added Resident #2 was legally blind and depressed because he/she couldn't see. During an interview on [DATE] at 1:50 PM, LPN #2 stated if a resident was suicidal, she would call the doctor immediately for safety precautions and to issue physician's orders. She would provide close supervision, and if necessary, the physician would determine if a resident needs to get sent out for evaluation. When asked by the Surveyor if the Resident had behaviors such as being depressed or anxious, she would document it in the Resident's chart under behaviors. On [DATE] at 9:30 AM, LPN #2 stated she would make a behavior note when it was out of the Resident's baseline. She further stated even though she marked YES for the [DATE] PN at 9:30 AM, which indicated Resident #2 as having a behavior that she described as being anxious. She considered it Resident #2's baseline. When asked by the Surveyor if this was considered a change in behavior for Resident #2, LPN #2 replied, It would be a behavior to me. When asked why the behavior note for Resident #2 was struck out on [DATE] at 3:56 PM, after the Resident had passed, LPN #2 stated, I don't remember why I struck out the entry. Whatever I struck out, I struck out on my shift on [DATE] since I didn't work on [DATE]. During an interview on [DATE] at 3:28 PM, the Advanced Practice Nurse (APN) stated she saw the Resident for a medical issue on [DATE] at 1:39 PM. Resident #2 reported, I haven't been feeling well; I couldn't sleep all night; and I don't feel right; I think I need my medications increased. The APN told the Resident that the facility psychiatrist had been following the Resident. Resident #2 stated, I missed her last week because I went outside to smoke. When the Surveyor asked the APN what she would do if a resident with MDD stated they didn't feel right, the APN replied, If someone said they don't feel right, she would ask about symptoms and do a head-to-toe physical assessment. The APN stated the Resident had complaints he/she wasn't feeling well, not sleeping well, and that he/she may be permanently blind, but no complaints of being upset or depressed. The APN indicated she made no further inquiry into the Resident's concerns or what Resident #2 meant when he/she made the statement, I don't feel right; I think I need my medications increased. When asked by the Surveyor why she did not inquire further about Resident #2's concerns or notify the Psychiatrist, she did not respond. During a telephone interview on [DATE] at 2:00 PM, the Psychiatrist stated that if a resident voiced concerns about not feeling right, she would ask the Resident what he/she meant by not feeling right. The Psychiatrist further stated whenever there is a problem, they (the nurses) could call my office. She stated that her office had a schedule about who she saw in a week, when at the facility, and if the number of residents is more than she could see in one day; she would talk to facility staff about who was stable and others who are a higher priority. After she sees residents, she leaves a list with all the Nurse Managers (NM) on the floor, with changes/ recommendations, and she will write notes and her office send them to the facility. She further stated The last time she saw Resident #2 was [DATE]. The Psychiatrist stated, [Resident #2] was supposed to be seen on [DATE] and was on her schedule, but [the Resident] wasn't seen because he/she was off the unit. During an interview on [DATE] at 12:19 PM, the Licensed Clinical Social Worker (LCSW) stated she last saw Resident #2 on [DATE], and he/she wanted Xanax increased for Anxiety about his/her upcoming medical appointment for his/her eyes. She wrote in her notes, Speak with the nurse and psychiatrist about his medications. The Surveyor asked the LCSW if she followed up with the nurse after the session, and the LCSW stated, No, I did not. The LCSW stated Resident #2's biggest frustration was being in the facility because he/she wanted to go home with his/her spouse. The CNA assigned to Resident #2 at the time of the incident was unavailable for an interview at the time of the survey. Review of the facility policy titled Abuse and Neglect - Clinical Protocol revealed the following under Assessment and Recognition, 2. The nurse will report the findings to the physician. As needed, the physician will assess the Resident to verify or clarify such findings, especially if the cause or source of the problem is unclear; under 4. The physician and staff will address causes of problematic Resident behavior where possible, such as mania, psychosis, and medication side effects.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** C#: NJ164217 Based on interviews, medical record review, and review of other pertinent facility documents on 5/25/2023, 5/31/2023, and 6/1/23, it was determined that the facility failed to reevaluate the effectiveness of the Care Plan and revise its interventions to prevent physical harm for a resident (Resident #2) with a known history of Major Depressive Disorder and Anxiety who had changes in behavior and committed suicide. The facility also failed to follow its policy, Care Planning - Interdisciplinary Team. This deficient practice was identified for 1 of 4 residents (resident #2) and was evidenced by the following: A review of the Electronic Medical Records (EMRs) was as follows: According to the Face Sheet, Resident #2 was admitted to the facility on [DATE] with diagnoses that included but were not limited to Major Depressive Disorder (MDD), anxiety disorder, chronic pain syndrome, and legal blindness. According to the Quarterly Minimum Data Set (MDS), an assessment tool dated 5/5/23, Resident #2 has a Brief Interview for Mental Status (BIMS) score of 13/15, which indicated the resident was cognitively intact. Resident #2 had a mood score of 6, which indicated mild depression. Resident #2 had a pain intensity score of 8, indicating severe chronic pain. The MDS also showed Resident #2 was independent, needed one-person assistance with Activities of Daily Living (ADLs), and had severely impaired vision. A review of the medical records for the Licensed Clinical Social Worker (LCSW) clinical visit notes revealed the following: On 4/21/23 at 12:40 PM to 1:15 PM, Resident #2 reported that he/she has high Anxiety a deep depression over his/her medical conditions. Resident #2 currently endorses anhedonia (inability to experience pleasure from activities usually found enjoyable), disturbed sleep and appetite, low self-esteem, difficulty concentrating, difficulty making a decision, anxiety, worry, tension, and difficulty relaxing. Under Ongoing symptoms, Symptoms that needed treatment and monitoring, sadness, anger outburst, high anxiety, restlessness, poor sleep, and family conflicts. On 5/12/23 at 12:37 PM to 1:15 PM, Resident #2 reported the following symptoms, Anxiety over his/her upcoming appointment regarding his/her eyesight. He/she is trying to stay positive. He/she is frustrated over his/her situation and feels the need to increase Xanax medication. She informed him/her to speak to the nurses and Psychiatrist. Resident #2 feels depressed over the situation with his/her spouse and wants to live with the spouse in ALF [Assisted Living Facility]. Review of the Psychiatric Notes from the Psychiatrist revealed the following: On 4/13/23, Resident #2 reported increased Anxiety and frustration at nighttime. Has been upset related to pain. On 4/26/23, Resident #2 was described as having a Chief Complaint of Agitation and Anxiety. Initially calm, cooperative, and pleasant, later becomes tearful [and] reports continued Anxiety and frustration at night. Reports frame of panic when laying in bed at night, anxious about eye exam and blindness. On 5/3/23, Resident #2 reported being tortured by Post Traumatic Stress Disorder (PTSD) symptoms. The Psychiatrist noted, Today patient states that he/she is miserable, and states he/she was hoping to be accepted at Assisted Living Facility (ALF) but was recently denied. The Care Plan dated 11/9/21 and revised on 7/16/22 indicated under Resident #2 Focus I am at risk for psychosocial well-being related to a diagnosis of depression/Anxiety. Under Interventions to 'Encourage me to express feelings of depression that I may be experiencing, offer support and offer 1:1 as needed; and Monitor for any change in mood, behavior, routine, negativity, isolation, withdrawal, hopelessness, decreased participation in the treatment plan; and at risk for pain related to chronic pain syndrome, with interventions to provide me with my medication as indicated by my doctor. The Special Instructions listed, monitor target behaviors (Alprazolam - nervousness), Zoloft sadness, and Buspar anxiety voiced by the resident. The Goals listed included but were not limited to I will verbalize/communicating any feelings of depression or diagnosis-related symptoms while in the facility. In addition, Resident #2's CP included under Focus Resident I am independent with daily routine and decisions re: daily routine, with interventions to Encourage me to express feelings and any frustrations I may be experiencing; Monitor for any change in my mood, behavior, routine, negativity, isolation withdrawal, hopelessness, decreased participation in the treatment plan; and Provide me with support, encourage, motivate, remind me of my progress and capabilities, reassure as needed. However, there was no documentation to address Resident #2's new symptoms of increased Anxiety and depression after a psychiatrist visit on 5/3/23 or after the clinical visits with the LCSW. During an interview on 5/25/23 at 10:57 AM, the LPN/Unit Manager (UM) stated if the resident had a major depressive disorder, it would be on the CP with interventions, and the UM would update the care plans. The CP would be updated right away if there was a change in the resident's condition. If the resident required supervision or monitoring, it would be on the CP too. During an interview on 6/1/23 at 12:45 PM, the Director of Nursing (DON), in the presence of the Licensed Nursing Home Administrator (LNHA), stated, The whole Interdisciplinary Team (IDT) updates the CP. The CP is updated as needed and quarterly. The CP would note refer to psych as needed as an intervention. A review of the facility policy, Care Planning - Interdisciplinary Team, under Policy Statement: Our facility's care planning/interdisciplinary team is responsible for the development of an individualized comprehensive care plan for each resident. REF: F600 NJAC-8:39-11.2(e)(2)(i) NJAC-8:39-27.1(a)