**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, family interview, staff interviews, and review of facility documentation, the facility's staff failed to identify, address, and obtain necessary psychiatric services for the behavioral health care needs of 1 of 15 residents (Resident #1), in the survey sample who had self-harming behaviors that ultimately caused the resident's death and identification of Immediate Jeopardy. The findings included: The facility's staff failure resulted in Resident #1 self-harming behavior on [DATE] by putting her hands around her neck until bruising and bleeding occurred, throwing herself on the floor multiple times and sustaining a left periorbital subcutaneous hematoma on [DATE] and finally on [DATE] the resident swallowed a wooden object which lodged in her throat, blocked her airway, caused seizure activity, respiratory distress and cardiac arrest causing the resident's death. Resident #1 was originally admitted to the facility on [DATE] after an acute care hospital stay for mental health problems which resulted in deconditioning. The resident's diagnoses included nervous debility, serotonin syndrome, and schizophrenia with episodes of catatonic-like symptoms (lack of movement, activity, or expression) and selective dysphagia. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of [DATE] coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 6 out of a possible 15. This indicated Resident #1's cognitive abilities for daily decision-making were severely impaired. In section GG (Functional Abilities and Goals), the resident was coded as requiring supervision with eating, dependent with oral care, toileting, showers and bathing, upper and lower body dressing, putting on and taking off footwear, personal hygiene, partial/moderate assistance with moving from lying to sitting, moving from sitting to standing, and moving from the chair to the bed. The resident required substantial/maximal assistance with toilet transfers and was dependent for tub transfers. Attempts at walking were not assessed. In section D (Mood), the resident was coded for having little interest or pleasure in doing things 7-11 days, feeling down, depressed, or hopeless 7-11 days, trouble falling or staying asleep, or sleeping too much 7-11 days, feeling tired or having little energy 7-11 days, feeling bad about yourself or that you are a failure or have let yourself or your family down 2-6 days, over the last two weeks. The resident's total mood score was 9. A score of 9 indicated the resident was experiencing mild depressive symptoms. An interview was conducted with the Social Worker (SW) on [DATE] at 11:32 AM regarding the results from the Mood assessment of the [DATE] MDS assessment. The SW stated after the Mood information was obtained, she did not share it with the Interdisciplinary team to assist in determining if psychiatric services were warranted for the resident. The SW also stated the severity score was not used to ensure the residents received a referral for psychiatric services or to develop a care plan related to the identified mood symptoms. The facility's staff did not refer Resident #1 for psychiatric services based on her mood score indicating depressive symptoms. An interview was conducted with the Social Services Assistant (SSA) on [DATE] at 11:58 AM regarding the new admission Preadmission Screening and Resident Review (PASRR). The SSA stated that PASRR for all new admissions should be validated by the Social Services Department (SSD) and if the level I was not sent by the referring hospital the assessment would be conducted by the SSD with a referral for a level II as deemed necessary. The SSA stated after reviewing the PASARR audit book and the resident's records a PASRR could not be located. The facility staff did not ensure Resident #1 had a Level I PASRR completed, knowing that she had a diagnosis of a serious mental illness, schizophrenia. PASRR is an important tool for states to use to evaluate all applicants for serious mental illness (SMI) and/or intellectual disability (ID). The PASRR is also used in rebalancing services away from institutions and towards supporting people in their homes, and to comply with the Supreme Court decision, [NAME] vs L.C. (1999), under the Americans with Disabilities Act, individuals with disabilities cannot be required to be institutionalized to receive public benefits that could be furnished in community-based settings. PASRR can also advance person-centered care planning by assuring that psychological, psychiatric, and functional needs are considered along with personal goals and preferences in planning long-term care (https://www.medicaid.gov/medicaid/long-term-services-supports/institutional-long-term-care/preadmission-screening-and-resident-review/index.html). An interview was conducted with Family member (FM) #1 on [DATE] at 11:00 AM. FM #1 stated that Resident #1 had a lifelong history of mental illness and during psychosis, she had attempted to hurt herself and would pick up a knife, while stating I don't want to be here. FM #1 also stated the resident had been residing in a group home until she had an altercation with a peer and the staff contacted the police. FM #1 stated the resident was detained by the police and the police had the resident evaluated for mental competency at a mental hospital. FM #1 stated after the mental hospital adjusted the resident's medication regimen she returned to her baseline and was eating and walking. During the interview, FM #1 stated the resident was discharged from the mental hospital back to jail on a Friday in late [DATE] so she could appear in court the following Monday. FM #1 stated when the resident arrived at court, she was wheelchair bound and she had declined significantly in comparison to her state on Friday. FM #1 stated the court released the resident to him and no one offered information as to what had taken place over the weekend that caused the decline in her condition. FM #1 stated by [DATE] the resident was not eating, was unable to walk, and just stared therefore he took her to a local hospital for treatment because he knew they had her health records and would likely be able to get her back to her baseline. FM #1 further stated the resident was discharged from the local hospital to the rehabilitation facility on [DATE] to regain her strength after the lengthy hospital stay. He stated she required care from staff for all her activities of daily living including walking. FM #1 stated that at the time the resident was admitted to the rehabilitation facility he made it clear to the facility's staff the type of care she required and the importance of her receiving her medications, especially her mental health drugs. FM #1 also stated he asked if the facility could coordinate the medication regimen between the local hospital and what the mental hospital had prescribed for the resident was better with the mental hospital's medication regimen. The facility's staff did not notify psychiatric services to address FM #1's concerns regarding the resident's medication regimen. The facility's staff did not contact FM #1 to obtain any additional mental health history regarding Resident #1. A review of the local hospital's Discharge summary dated [DATE] accompanied the resident to the rehabilitation facility. The discharge summary stated that the local hospital recommended that Haldol 5 mg (an antipsychotic) at night be continued, and the resident to receive a psychiatric evaluation when she arrived at the rehabilitation facility for continued management of underlying chronic psychiatric illness. The facility staff did not refer the resident for psychiatric services until a few days before she was assessed by the Psychiatric Nurse Practitioner (PNP) on [DATE]. The history and physical written by the resident's primary physician dated [DATE] stated that the resident was to be administered Haldol for schizophrenia in the evening hours and to continue a follow-up with psychiatry. A follow-up was not scheduled for psychiatric services. The following information was obtained from the internet on [DATE]: Schizophrenia is a serious mental illness that affects how a person thinks, feels, and behaves. People with schizophrenia may seem like they have lost touch with reality, which can be distressing for them and their family and friends. The symptoms of schizophrenia can make it difficult to participate in usual, everyday activities, but effective treatments are available. Many people who receive treatment can engage in school or work, achieve independence, and enjoy personal relationships. Schizophrenia symptoms can differ from person to person, but they generally fall into three main categories: psychotic, negative, and cognitive. Negative symptoms include loss of motivation, loss of interest or enjoyment in daily activities, withdrawal from social life, difficulty showing emotions, and difficulty functioning normally. For people with schizophrenia, the risk of self-harm and violence to others is greatest when the illness is untreated. It is important to help people who are showing symptoms to get treatment as quickly as possible (https://www.nimh.nih.gov/health/topics/schizophrenia). The resident's active care plan had a problem dated [DATE] which read, I sometimes have behaviors which include self-isolation. The goal read, My behavior will stop with staff intervention through the next review, [DATE]. The interventions included an attempt to engage me in activities that would draw me out of the room. Let my physician know if my behaviors are interfering with my daily living. Offer me something I like as a diversion. Please refer me to my Psychologist/Psychiatrist as needed. Give me my medications as my doctor has ordered. A review of a nurse's note dated [DATE] at 6:36 AM revealed Resident #1 was noted to be self-isolating in her room and pushing the bedside table and chair behind the closed door to keep others out. On [DATE] at 12:56 PM, a nurse's note stated the resident was identified as withdrawing from participation in out-of-room activities and would not engage with staff or other residents. An intervention was to contact the Psychiatric Nurse Practitioner (PNP) and the Psychologist. The facility's staff did not notify the PNP and/or the Psychologist to visit the resident. An interview was conducted with the PNP on [DATE] at 1:36 PM. The PNP stated she was not contacted about visiting Resident #1 until a few days before the [DATE] initial visit, around [DATE]. A review of a nurse's note dated [DATE] at 8:53 PM revealed a nurse walked into the resident's room to find her with her hands around her neck with bruising to the neck and forehead. The resident stated she was trying to harm herself and said she was tired and wanted to go. The resident was transferred to the hospital for an evaluation and returned to the nursing facility on [DATE] with no medication adjustments or a change in the treatment plan. The local hospital's After Visit Summary dated [DATE] read under the title Suicide Prevention Information, Your response to questions about suicide indicates an elevated risk. It is recommended that you follow up with a behavioral health provider after discharge. If you experience suicidal thoughts, call 911. An additional 24/7 resource is the National Suicidal Prevention Lifeline at 988. The facility staff failed to contact psychiatric services for a behavioral health visit as recommended by the local emergency room physician. A nurse's note dated [DATE] at 4:50 AM stated the resident was found sitting on the floor beside her bed. A nurse's note dated [DATE] at 2:15 PM stated that the resident would not take the medication ordered by the NP, and she was repeatedly forcing herself on the floor at the nurse's station therefore an order was obtained for one-to-one observation care. A nurse's note dated [DATE] at 10:09 AM stated the resident refused all medications. A nurse's note dated [DATE] at 5:49 PM stated the resident refused all medications and a nurse's note dated [DATE] at 5:52 PM stated that the resident was on the floor where she put herself and refused to get up. The note further stated the resident pulled away from the staff as they tried to get her up. Another nurse's note dated [DATE] at 10:00 AM stated the resident refused her medications. The resident was assessed by the primary NP and treated for a urinary tract infection (UTI). An interview was conducted with the primary Nurse Practitioner (NP) on [DATE] at 3:15 PM. The primary NP stated that she gave the order for one-to-one care for Resident #1 on [DATE] because of the resident's behaviors and she discontinued the order for one-to-one care by request of the ADON on [DATE] shortly after 4:00 PM. The primary NP stated that she treated Resident #1 for her physical health problems, diabetes, high blood pressure, and blood clots. The primary NP stated she does not treat mental illness or behavior problems related to mental illness. The primary NP also stated on [DATE] when she was informed that the resident was refusing her medications, continuing to throw herself on the floor and with cloudy urine, that most likely she had a UTI therefore she initiated treatment. The primary NP stated because of the interview with the resident and the report from the primary NP that the resident potentially had a UTI the primary NP recommendations were to follow up with Resident #1 mental status once the laboratory results are obtained. The primary NP also stated to continue the current medication regimen because the patient was receiving neuroprotective benefits with improvement in function. Staff to continue to monitor for changes in mood and/or behaviors and notify the practice as needed. A Psychiatric Nurse Practicioner (PNP) progress note dated [DATE] stated that an initial visit was conducted with Resident #1 for refusing medications, and mental status changes. The PNP progress note further stated that the resident was sitting behind the nurse's station quiet and cooperative, therefore the PNP escorted the resident to her room so she could conduct an interview. The PNP findings interview revealed that the resident was alert, oriented to self, denied feelings of harm toward self or others, reported she was sleeping, her appetite was okay, and denied auditory or visual hallucinations. On [DATE] at 3:22 PM, another interview was conducted with the PNP. The PNP stated the request to see Resident #1 came by email along with a request to see two additional residents whom the ADON asked her to see a few days before the [DATE] visit, around [DATE]. The PNP stated that the request to see Resident #1 stated she was experiencing mental status changes. The PNP stated she had not been informed that Resident #1 was exhibiting isolative and self-injurious behaviors, making negative statements, or that she had been evaluated in the emergency room for the behaviors, refusing medications and throwing herself on the floor. The PNP also denied she was not informed that the resident had been evaluated in a local emergency room for suicidal ideations and was discharged back to the facility with recommendations for psychiatric services. The PNP further stated she would have evaluated the resident sooner if she had been contacted sooner with the resident mental health history and ongoing behaviors because she is in the facility one to two days per week. The facility staff failed to convey the resident's current and past mental health status including exhibited behaviors to the PNP to aid in identifying appropriate goals and interventions for the resident's acute and chronic mental health problems. The written psychiatric referrals from January, 2024 (1/2024) to [DATE] ([DATE]) did not include Resident #1's name. A nurse's note dated [DATE] at 6:58 AM stated that Resident #1 approached the nurse's station at approximately 3:15 AM on [DATE] stating I don't feel well. Soon after, the resident began having seizure-like activity and she quickly became unresponsive. Vital signs revealed the resident was absent of a pulse, cardiopulmonary resuscitation (CPR) was initiated and 911 was called. CPR was started and performed until the emergency medical technicians (EMT) arrived and assumed care of the resident. The EMTs performed CPR for approximately 20 minutes before they decided to intubate the resident for the airway was initially managed with a bag valve mask. An attempt was made to intubate and upon insertion of the glide scope, a foreign object was identified in the resident's airway. It appeared to be a wooden knob to a dresser. A [NAME] forceps was used to successfully remove the foreign object, intubation was performed, and confirmed with a capnography, visualization, and breath sounds. Efforts were continued for approximately 20 minutes before a decision was made to contact medical control for orders to terminate. The ending rhythm was [NAME] pulseless electrical activity. An order to terminate resuscitative measures was received from a physician at a local hospital. The time of death was called at 3:54 AM on [DATE]. On [DATE] at approximately 2:30 PM the survey Team contacted the Long-term Care Supervisor and two additional OLC Long-term Care Supervisors of the above findings, observations, and interviews. On [DATE] at 2:52 PM the facility's Administrator Director of Nursing, Regional Director of Clinical Services, and [NAME] President of Operations were informed of the non-compliance which constituted Immediate Jeopardy identified in F-740 Behavioral Health Services at a Scope and Severity Level 4, pattern (K). The facility's staff presented several unaccepted Removal Plans on [DATE] which required revisions for the removal plans failed to detail how other residents identified would receive the necessary behavioral health services to avoid risk for serious injury, serious harm, serious impairment, or death because of their noncompliance. The Facility's Final/Accepted Removal Plan dated [DATE] at 5:00 PM: *(Name of the Provider) is taking immediate action to prevent serious harm, from occurring or recurring for other residents who are identified and/ or demonstrated dangerous and imminent harm to self and/or others through some recent act, attempt, or threat by: *Reviewing the residents with one-to-one observations in the last 30 days to confirm they are safe, and the observed behavior has improved. If behavior has not improved, they will be placed on one-to-one observation until medically and psychologically evaluated and the behavior improves or no longer occurs. *Current residents will be interviewed by a member of the IDT regarding thoughts of self-harm or harming others. One previously identified resident who is currently on one-to-one verbalized thoughts of harm. Resident assessed by the Medical Director and Psychiatric Services NP on [DATE]. Remains on one-to-one. *Residents being admitted hospital documentation with past medical and psychiatric history will be reviewed by the Nursing Home Administrator (NHA) and DON / designee prior to allowing admission of the referred patient. *Psychiatric Service Referrals for residents with behavior and affect appears disturbed or indicates distress, exhibiting signs or verbalizing behaviors of harming self or others. Residents receiving a psychoactive medication. New admissions seen upon admission and anyone on above agents. Referrals face sheet placed in the psychiatric services referral log for patient in referral book. Psychiatric services Practitioner makes center visits 1 to 2 times per week and as need is indicated. Social Services, Administrator or Director of Nursing to ensure process is followed. *During the center staffing calls with central scheduling, the center will notify scheduling of number of residents on one-to-one and the one-to-one will be indicated on the daily schedule. The Administrator or DON will designate on the schedule the designated one-to-one if assigned after the staffing call. *The residents PASRR level I will be reviewed by Social Services and referred for a level II if indicated based on history. Social Services will complete a PASRR as indicated. *Staff will be educated on the safety check process and reasons to place a resident on one-to-one or enhanced monitoring as indicated. *The Nursing Home Administrator (NHA) reviewed the Removal plan with the Medical Director. *The NHA is responsible for the implementation of this plan of correction. An onsite review of the Facility's Removal Plan validated the education provided to staff on [DATE] regarding Behavioral Health Care and was deemed mandatory for all staff before working a shift going forward. A staff member was interviewed from each department to ensure they were educated. An interview was conducted with the Social Services Assistant (SSA) on [DATE] at 11:58 PM regarding the new admission Preadmission Screening and Resident Review (PASRR). The SSA stated PASRR for all new admissions would be validated by the Social Services Department (SSD) and if the level I was not sent by the referring hospital the assessment would be conducted by the SSD with a referral for a level II as deemed necessary. A review of the PASRR audit book was conducted and it was found to be a reliable tool. An interview was conducted with the Administrator on [DATE] at 2:05 PM. The Administrator stated along with the DON/ADON the process for new admissions to the facility would include a review of a psychiatric history and a review of medications for the use of psychiatric medications. The Administrator stated if the use of behavioral health medications or a behavioral health diagnosis was identified the identified resident would be scheduled to be seen by the psychiatric practitioner during the next visit to the facility. The process was validated. An interview with the Regional Director of Clinical Services (RDCS) was conducted on [DATE] at 2:25 PM. The RDCS explained the Psychiatric referral book to the facility. The RDCS stated the staff would be utilizing a referral book for any resident with behaviors, those exhibiting signs of or verbalizing behaviors of harming themselves or others. It was validated through observations that the Psychiatric referral book included instructions for whom a referral would be made, what information to include in the book for each resident and to write their name on the log as well as to notify the Psychiatric Service Practitioners as indicated. After the facility's final Removal Plan was validated through observations, interviews, and review of facility documents the Immediate Jeopardy was removed on [DATE] at 6:00 PM. The deficient practice was reassigned a Scope and Severity level of level two, isolated (E). On [DATE] at approximately 2:50 PM the above findings were shared with the Administrator, Director of Nursing, Regional Director of Clinical Services, RN MDS Coordinator, LPN MDS Coordinator, Business Office Manager, and [NAME] President of Operations during the final interview. An opportunity was offered to the facility's staff to present additional information or voice concerns. No additional information was provided, and no concerns were voiced.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, clinical record review, and review of facility documents, the facility failed to provide care that met the needs of residents with mental health disorders and/or behaviors requiring frequent monitoring. The facility staff failed to ensure sufficient staff was provided frequent safety checks with one-to-one supervision by staff to address the resident's behavioral health care needs and safety for 4 of 15 residents (Resident #1, Resident #3, Resident #5, and Resident #11) in the survey sample which resulted in immediate jeopardy. The findings include: 1. For Resident #1 the facility failed to provide care, that met the needs of the resident's mental health disorder schizophrenia, history of past mental health disorders, suicide attempt at the facility, voiced suicidal ideations, and other behavioral health needs. The facility staff failed to ensure that Resident #1 had sufficient staff to provide one-to-one (1-1) supervision to address the resident's behavioral health care needs, suicidal ideations, isolation behavior, and safety. While unsupervised, Resident #1 managed to partially swallow and lodge a wooden dresser knob in her throat, experiencing cardiac seizures due to insufficient oxygen to her brain and expired in the facility. Resident #1 was originally admitted to the facility on [DATE] after an acute care hospital stay for mental health problems which resulted in deconditioning. The resident's diagnoses included nervous debility, serotonin syndrome, and schizophrenia with episodes of catatonic-like symptoms (lack of movement, activity, or expression) and selective dysphagia. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 1/10/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 6 out of a possible 15. This indicated Resident #1's cognitive abilities for daily decision-making were severely impaired. In section GG (Functional Abilities and Goals), the resident was coded as requiring supervision with eating, dependent with oral care, toileting, showers and bathing, upper and lower body dressing, putting on and taking off footwear, personal hygiene, partial/moderate assistance with moving from lying to sitting, moving from sitting to standing, and moving from the chair to the bed. The resident required substantial/maximal assistance with toilet transfers and was dependent for tub transfers. Attempts at walking were not assessed. In section D (Mood), the resident was coded for having little interest or pleasure in doing things 7-11 days, feeling down, depressed, or hopeless 7-11 days, trouble falling or staying asleep, or sleeping too much 7-11 days, feeling tired or having little energy 7-11 days, feeling bad about yourself or that you are a failure or have let yourself or your family down 2-6 days, over the last two weeks. The resident's total mood score was 9. A score of 9 indicated the resident was experiencing mild depressive symptoms. Resident #1 was originally admitted to the facility on [DATE]. The resident's diagnoses included schizophrenia, dementia, anxiety, depression, and hypertension. Resident #1's initial person-centered care plan dated 1/17/2024 mental health focus was, no complications with psychotropic drugs, and sometimes the resident had behaviors such as self-isolation. The care plan interventions were to engage the resident in activities, administer medications, and refer to a psychologist/psychiatrist as needed. The resident's revised active care plan had a problem dated 2/15/24 which read, I sometimes have behaviors which include self-isolation. The goal read, My behavior will stop with staff intervention through the next review, 4/23/24. The interventions included an attempt to engage me in activities that would draw me out of the room. let my physician know if my behaviors are interfering with my daily living. Offer me something I like as a diversion. Please refer me to my Psychologist/Psychiatrist as needed. Give me my medications as my doctor has ordered. A review of the local hospital's Discharge summary dated [DATE] accompanied the resident to the rehabilitation facility. The discharge summary stated that the local hospital recommended that Haldol 5 mg at night be continued, and the resident receive a psychiatric evaluation when she arrived at the rehabilitation facility for continued management of underlying chronic psychiatric illness and medication management. The facility staff did not refer the resident for psychiatric services until a few days before she was assessed by the Psychiatric Nurse Practitioner (PNP) on 2/29/24. The history and physical written by the resident's primary physician dated 1/17/24 stated that the resident was to be administered Haldol (an antipsychotic) for schizophrenia in the evening hours and to continue a follow-up with psychiatry. A follow-up was not scheduled for psychiatric services. The resident refused the Haldol on 2/29/24. The discharge summary listed Resident #1's other psychotropic medications that were stopped, and they were never restarted while she was at the facility. Those medications were: Paxil (paroxetine), Cogentin (benztropine), Remeron (mirtazapine), Prozac (fluoxetine), Depakote (valproic acid), Vraylar (cariprazine), and Paliperidone (invega sustenna). Progress notes indicated the following resident behavior and observations: On 1/11/24 the resident refused care; on 2/15/24 the resident was self-isolating, withdrawn, and barricading herself in her room with furniture; on 2/18/24 the resident was found on the floor with her hands around her neck attempting to choke herself and was sent out to the hospital for suicide attempt and a psychiatric evaluation; on 2/19/24 the resident returned to the facility. On 2/22/24 the facility's primary Nurse Practitioner (NP) saw the resident for post-self-harm hospitalization and wrote that the resident was being followed by the psychiatric NP (this was found to be false); on 2/27/24 the resident was found on the floor; on 2/27/24 the resident was placed on 1-1 observation, on 2/29/24 the resident taken off of one-to-one and was placed on every 2-hour observation per the progress note, on 3/2/24 at 3:15 AM, the resident came out the nursing station and expressed not feeling well, started having seizure-like activity, went unconscious, required resuscitation, EMS arrived and retrieved a foreign object in the resident's airway (later discovered to be a wooden dresser knob), she was pronounced deceased at the facility. On 3/14/24 at approximately 3:00 PM, an interview was conducted with the EMS Manager. He stated that they made an EMS run on 2/18/24 to the nursing facility due to the resident trying to strangle herself at which time the resident was transferred to the local hospital Emergency Department (ED) for evaluation. He said a second run to the nursing home resulted in finding the resident on the floor in front of the nurse's station, unresponsive with CPR in progress. He said when the EMS medics took over CPR and attempted to intubate the resident, a foreign object was identified in the resident's airway, and once extracted by [NAME] forceps the object appeared to be a wooden knob to a dresser. He said intubation was successful and CPR continued, but the resident was not revived and expired in the facility on 3/2/24 at 3:54 AM. The EMS Manager stated that it was obvious that the resident managed to carry out her attempts of suicide by swallowing the dresser knob to the extent that it blocked her airway which cut off oxygen to her brain causing cardiac seizures and death. There was no additional scheduled staffing evidence or recorded data provided by the Administrator, Director of Nursing, or Unit Manager that one-to-one supervision was ever provided by a dedicated staff member. An interview was conducted on 3/15/24 at 1:49 PM with LPN #4 who shared that when Resident #1 coded and died on 3/2/24, she was not on 1-1 observations. LPN #4 shared that EMS retrieved a foreign object from the resident's throat during the code. An interview was conducted with the primary NP on 3/18/24 at 12:19 PM. The primary NP said on 2/27/24 she ordered Resident #1 to be placed on 1-1 because she was told the resident was throwing herself on the floor repeatedly. She said on 2/29/24 she observed Resident #1 sitting at the nursing station with a staff person with no obvious observed behaviors. She received a call from the Assistant Director of Nursing (ADON) at the time, asking if the facility could take Resident #1 off 1-1 because they had staffing issues, and the resident did not seem to be having any behavioral concerns at that time. The primary NP said since she saw the resident and she appeared to be okay and it was her expectation that the psychiatric NP (PNP) was soon to see her, she discontinued Resident #1's 1-1 safety order. An interview was conducted on 3/18/24 at approximately 1:36 PM over the phone with the PNP. She answered no to getting a consult on Resident #1 when she was admitted to the facility on [DATE], and she answered no to getting a consult when Resident #1 attempted suicide on 2/18/24. On 3/21/24 at 3:22 PM, during another interview with the PNP, she shared that she recently on 2/25/24 got a consult from the DON via email which included a request for 3 residents to be evaluated by psychiatry with Resident #1 being one of the three. She indicated that there was no expressed urgency to see Resident #1, the resident's history was not shared, and nor was the suicide attempt or the resident's expressed suicidal ideations. The PNP said she did not discontinue or give any direction on Resident #1's one-to-one status. She said Resident #1 was not suicidal when she saw her on 2/29/24, but a full assessment to include a review and/or reinstatement of the resident's psychiatric medications was deferred pending the resident's urine lab results, which would medically clear her before she started any psychiatric medication management. The PNP further stated she would have evaluated the resident sooner if she had been contacted sooner with the resident mental health history and ongoing behaviors because she is in the facility one to two days per week. The facility staff failed to convey the resident's current and past mental health status including exhibited behaviors to the PNP to aid in identifying appropriate goals and interventions for the resident's acute and chronic mental health problems. The written psychiatric referrals from January, 2024 (1/2024) to March 3, 2024 (3/3/2024) did not include Resident #1's name. An interview was conducted on 3/18/24 at approximately 4:05 PM with the Registered Nurse (RN) Unit Manager of the unit where Resident #1 resided. She shared that Resident #1 was put on 1-1 safety checks after attempting to choke herself with her hands and stating she wanted to die. She said Resident #1 was seen by the psychiatric NP and the psychotherapist after the suicide attempt. It was discovered Resident #1 was not seen by the psych NP until 2/29/24 and was never seen by a psychotherapist at this facility. The Unit Manager said her knowledge of what a one-to-one meant was, that the resident must be always within eyesight or arm's length and that a sign-off checklist was completed every 15 minutes. On 3/18/24 at approximately 4:30 PM the DON stated, She (Unit Manager's name) told you wrong and I need to go tell her, that information is incorrect. One-to-one means you are always with the resident and there is no flowsheet or checklist we fill out every 15 minutes, but we will be starting a flow sheet. On 3/21/24 at approximately 5:30 PM, Corporate Consultant #2 shared the three levels of observation with one-to-one being the highest level of observation, always with the resident, with documentation every 15 minutes on the resident safety check flowsheet. She stated every 15-minute observation meant, checking on the resident at 15-minute intervals and every 2 hours meant, checking on the resident at two-hour intervals. On 3/19/24 at approximately 11:14 AM, a phone interview with the previous ADON of the facility who shared that the facility had issues with consistent psychiatric coverage. She indicated that she could not remember for sure what the staffing was during the time Resident #1's 1:1 supervision was discontinued, and said, If the NP said it was mentioned that staffing was an issue, it probably was. On 3/19/24 at 12:45 AM, a phone interview was conducted with Licensed Practical Nurse (LPN) #3. LPN #3 shared that when Resident #1 returned from the hospital after her suicide attempt, she did not have any orders for frequent monitoring or suicide precautions. She said she did not feel comfortable with that, so she put her on every 2-hour monitoring and wrote a note in the doctor's book notifying them of the intervention she initiated. She said she wrote in the nursing progress note when she has a resident placed on safety checks. She said she had some mental health behavior education in Relias but nothing in depth. LPN #3 indicated that the facility had a lot of residents with behaviors, and it was hard to care for them. She said Resident #1 was isolating herself and showing behaviors the entire time she was at the facility and the staff was instructed by leadership not to chart a lot of things to prevent them from getting tags. She stated, We did not do right by her. An interview was conducted with the DON on 3/21/24 at approximately 2:58 PM. The DON shared that the facility had no additional safety checklist forms, and that the staff were not doing them as they should have been. She shared she will be doing all that she can to educate and hold staff accountable for following the facility's policy and procedures for Resident Safety Checks. 2. For Resident #3 the facility failed to provide care, that met the needs of the resident's diagnosis of behavioral disturbance. The facility staff failed to ensure that Resident #3 had sufficient staff to provide one-to-one supervision to address the resident's verbal and physical aggressive behavior with residents and staff. Resident #3 was originally admitted to the facility on [DATE]. The resident's diagnoses also included dementia, anxiety, and major depressive disorder. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 2/7/2024 coded Resident #3 as completing the Brief Interview for Mental Status (BIMS) and scoring 99 which indicated severely impaired cognition. In section D Mood, the resident was coded negative for all areas. In section E, the resident was noted to have verbally threatened others 1-3 times. In section G Activities of Daily Living Assistance (ADLs), the resident was coded as requiring extensive assistance to being dependent on ADLs. Resident #3's person-centered care plan was last revised on 1/11/2024 with a mental health focus to include her diagnosis of dementia and Alzheimer's, behavior monitoring, and anxiety. Also noted was an intervention for one-to-one monitoring since 12/8/2023. Observation was made of Resident #3 on 3/19/24 at approximately 1:30 PM and on 3/21/24 at approximately 4:18 PM, both times sitting at the nursing station in her wheelchair periodically screaming out. No staff addressed her needs. Nursing progress notes indicated the following: On 11/12/23 the resident had an altercation with another resident and obtained a skin tear; on 12/6/23 the resident had a stat facial bone x-ray series ordered due to complaints of pain after being struck (does not specify details); on 12/8/23 the resident had another physical altercation with another resident and placed on 1-1 observation checks; on 12/9/23, 12/10/23, 12/14/23, and 12/18/23 the resident continued with 1-1 observation with staff, on 1/6/24 the resident was observed instigating an argument, and on 3/22/24 note read to continue with 1-1 observation. There was no scheduled additional staffing evidence or recorded data provided by the Administrator, Director of Nursing, or Unit Manager that one-to-one supervision was ever provided by a dedicated staff member before 3/22/24 after the issue was brought to their attention on 3/20/24. 3. For Resident #5 the facility failed to provide care, that met the needs of the resident's diagnosis of metabolic encephalopathy, altered mental status (AMS), anxiety, and other behavioral health needs. The facility staff failed to ensure that Resident #5 had sufficient staff to provide one-to-one supervision to address the resident's wandering, hoarding, and verbal and physical aggressive behaviors. Resident #5 was originally admitted to the facility on [DATE]. The resident was also Vietnamese and did not speak English. During an interview with LPN #3 on 3/19/24 at approximately 12:45 AM, she shared that the staff could not understand what the resident's needs were. The facility did not have a working language phone or interpreter service. The resident was discharged on 12/27/23. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 12/27/2023 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 3 which indicated severely impaired cognition. In section D Mood, the resident was noted to have some social isolation. In section E Behavior, the resident was noted to 1-3 days have physical behaviors toward others and behaviors not directed toward others. In section GG Activities of Daily Living Assistance (ADLs), the resident was coded as being independent with eating and independent with set-up for all other ADLS. Resident #5's person-centered care plan dated 9/21/2023 had a mental health focus problem including a language barrier, wandering behaviors, and physical abuse towards others. Resident #5 was being followed by psychiatric services. It was noted that the resident hoarded knives and forks. Progress notes indicated the following: On 11/2/23 the resident had a fall; on 11/6/23 the resident was observed hoarding food; on 11/9/23 the resident was observed pacing in the hallway; on 11/12/23 the resident had a fall in the hallway unwitnessed, on 11/14/23 the resident continues to hoard food, pace, and now threatening staff; on 11/15/23 the resident charged at nurse with a butter knife; on 11/27/23 the resident hit his roommate in the face with his fist; on 12/9/23 the resident was spoken to by a police officer about his behavior; on 12/10/23 the resident was placed on one-to-one observation safety checks; on 12/11/23 the resident was on 1-1 and managed to still hit a staff member, on 12/17/23 and 12/18/23 notes read that the resident remains on 1-1, and on 12/25/23 the resident was on 1-1 and struck another resident. There was no scheduled staffing evidence or recorded data in the clinical record provided by the Administrator, Director of Nursing, or Unit Manager that one-to-one supervision was ever provided by a dedicated staff member. 4. For Resident #11 the facility failed to provide care, that met his behavioral health needs. The facility staff failed to ensure that Resident #3 had sufficient staff to provide one-to-one (1:1) supervision to address the resident's agitation, inappropriate defecating in public behavior, and inappropriate sexual behavior. Resident #11 was originally admitted to the facility on [DATE]. The resident's diagnoses included dementia and alcohol abuse. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 3/1/2024 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 4 which indicated severely impaired cognition. In section G Activities of Daily Living Assistance (ADLs), the resident was coded as requiring the supervision of one staff for ADLs. Resident #11's person-centered care plan was last revised on 1/11/2024 for a mental health focus problem that included rejecting care, wandering, social and sexual inappropriateness, and physical aggression. An intervention was put in place on the resident's care plan for a 1-1 safety check dated 3/20/24. A review of a psychiatric evaluation dated 2/1/24 for Resident #11, read he was seen for inappropriate behavior in public areas, agitation, and sexually inappropriate behavior. A review of Resident #11 progress notes read on 3/15/24 the resident was roaming around in other residents' rooms, and the resident was not redirectable, urinating and defecating on the floor. Also, the progress notes dated 3/16 /24 read Resident #11 urinated on the floor again. On 3/18/24 at approximately 1:00 PM, a staff person was seen in the resident's room. On 3/21/24 at approximately 3:55 PM an observation was made of Resident #11 in his room sitting on the bed with a 1-1 staff member sitter in the doorway. An interview was attempted with the resident, but he was confused. The Certified Nursing Assistant (CNA) #3 was the sitter and was observed using a safety check form. When asked how she got the form, she stated, They just gave me this form today and it is the first time I have ever used a safety check flow sheet and I have worked here for seven months. My assignment is usually 14-25 residents with sometimes not able to finish my work. I am currently assigned to (Resident #11). I am not sure why he is one-to-one, but I know he wanders and urinates on the floor. Before 3/21/24, there was no scheduled staffing evidence or recorded data in the clinical record provided by the Administrator, Director of Nursing, or Unit Manager that one-to-one supervision was provided for this resident by a dedicated staff member. Review of facility Policy and Procedure Title: Resident Safety Checks, effective 4/2021. Policy: Resident safety checks can be initiated by a physician or clinical nurse who deems a resident to be at risk to self or others Procedure: 1) Initiate resident safety check form with intervals designated by physician or clinical nurse noting reason for form. 2) Check resident at required intervals. 3) Initial form indicating check was complete. 4) Form is to be filed in the medical record . On 3/19/24 at approximately 2:30 PM the survey Team contacted the Long-term Care Supervisor and two additional OLC Long-term Care Supervisors of the above findings, observations, and interviews. On 3/20/24 at 2:52 PM the facility's Administrator Director of Nursing, Regional Director of Clinical Services, and [NAME] President of Operations were informed of the non-compliance which constituted Immediate Jeopardy identified in F-741 Sufficient and Competent Staff - Behavioral Health Needs at a Scope and Severity Level 4, pattern (K). The facility's staff presented several unaccepted Removal Plans on 3/21/24 through 3/22/24 which required revisions for the removal plans failed to detail how other resident identified would receive the necessary behavioral health services to avoid risk for serious injury, serious harm, serious impairment, or death because of their noncompliance. The Facility's Final/Accepted Removal Plan dated 3/22/24 at 12:15 PM: *(Name of the Provider Portsmouth Health and Rehab is taking immediate action to prevent serious harm, from occurring or recurring for other residents who are identified and/or demonstrated dangerous and imminent harm to self and/or others through some recent act, attempt, or threat by completing the following. Current residents will be reviewed that have like behaviors, demonstrated dangerous behaviors, imminent harm to self and/or others and residents with suicidal ideation. Those residents will be placed 1:1 until further evaluation by medical and/or psychiatric provider. The attached Resident Safety Check is required for all 1:1, 15-minute check, 30-minute checks etc. otherwise you will not be able to prove you had them on these very important checks. o Should be care planned and kardexed as a task for each C NA to sign every shift o the form should be collected and brought to the stand-up meeting DAILY reviewed by the IDT - looking for continued behavior or improvement in behavior to possibly take down to the next level o this decision requires an IDT note by either SSD or clinical to memorialize the decision o psych input is great however you are responsible for the fact and psych does not understand SNF regulations so please do not allow them to dictate your 1;1 or safety checks - but use them as a great resource o the form will need to be filed in the medical record after reviewed On-going re-education by the DON/Designee with staff regarding safety check process as identified. Social Services Coordinator/designee will complete a psychosocial assessment on current identified residents. Current residents interviewed by a member of the IDT regarding thoughts of self-harm or harming others. One previously identified resident who is currently on 1:1 verbalized thoughts of harm. Resident assessed by the Medical Director and Psychiatric Services NP on 03/21/2024. Remains on 1:1. Shift to shift education will be completed by the DON or designee on behavior monitoring, the safety check form, and the importance of not leaving the resident for any reason. The DON/Designee will oversee shift to shift confirmation of safety checks for Residents and the one-to-one observer is in place. Staffing will be reviewed no less than 3 days prior to confirm staffing is sufficient to provide the one-to-one observation. During the center staffing calls with central scheduling, the center will notify scheduling of number of residents on 1:1 and the 1:1 will be indicated on the daily schedule. The Administrator or DON will designate on the schedule the designated 1:1 if assigned after the staffing call. Psychiatric Service Referrals for residents with behavior and affect appears disturbed or indicates distress, exhibiting signs or verbalizing behaviors of harming self or others. Residents receiving a psychoactive medication. New admissions seen upon admission and anyone on above agents. Referrals face sheet placed in the psychiatric services referral log for patient in referral book. Psychiatric services Practitioner makes center visits 1 to 2 times per week and as need is indicated. Social Services, Administrator or Director of Nursing to ensure process is followed. NHA reviewed Removal plan with the Medical Director. NHA is responsible for the implementation of this plan of correction. An onsite review of the Facility's Removal Plan was conducted by the Survey Team. The review validated the removal plan was implemented by on site observations, interviews, and record review to verify that the proposed measures were being implemented. The Survey Team observed two (2) residents with active one-to-one order who had a designated staff member with them during observations. The safety check flowsheets were reviewed in use for those residents. The residents care plans were reviewed to assure they were updated to reflect the need for one-to-one observation. The Survey Team reviewed the education in-service records for residents with behaviors, safety checks, and one-to-one observations. The Survey Team interviewed the facility staff on 3/21/2024 and 3/22/2024 to assure the education received was understood. The Survey Team discussed the removal plan with Regional [NAME] President of Operations, Administrator, Director of Nursing, and Regional Director of Clinical Services. The fourth revision was accepted. After the facility's final Removal Plan was validated through observations, interviews and review of facility documents the Immediate Jeopardy was removed on 3/22/24 at 1:30 PM. The deficient practice was reassigned a Scope and Severity level of level two, isolated (E). On 2/22/24 at approximately 2:50 PM the above findings were shared with the [NAME] President of Operations, Administrator, Director of Nursing, Business Office Manager, Minimum Data Set Coordinator, MDS Assistant, and Registered Dietician. An opportunity was offered to the facility's staff to present additional information, but no additional information was provided.