Based on interview and record review, the facility failed to ensure the resident, who had diagnosis of depression (mental health disorder characterized by persistently low mood or loss of interest in activities, causing significant impairment in daily life ) and a history of suicidal ideation (thinking about or formulating plans for suicide [the act or an instance of ending one's own life voluntarily and intentionally) did not commit suicide for one of three sampled residents out of 38 residents with a diagnosis of depression (Resident 1).
The facility failed to:
1. …
Based on interview and record review, the facility failed to follow the policy and procedure (P&P) on Psychotherapeutic Drug (medication used to treat mental health disorders) Management for one of ten sampled residents (Resident 1) when Resident 1:1. Was not provided non-pharmacological (without using medications) interventions when Resident 1 verbalized increased sadness.2. Was not monitored every shift for 72 hours after his Lexapro (antidepressant [medication that treat depression [persistent feeling of sadness and loss of interest]-Lexapro black box warning, which is the U.S. [United States] Food and Drug Administration [FDA] most serious warning for prescription drugs. …
D · No harm, potential for more than minimal, isolatedAugust 12, 2026
Based on interviews and record reviews, the facility failed to ensure that Resident 1 received the necessary behavioral support services to address ongoing frustration related to physical impairment and having to remain in the facility, by failing to: Ensure licensed vocational nurse (LVN) 2 reported that Resident 1 verbalized being frustrated and failing to develop a plan of care to address this behavioral concern.Ensure registered nurse (RN)1 reviewed Resident 1's Psychological Consultation (PC) assessment, dated 7/21/2026 to address the resident's behavior of frustration due to physical impairment and having to be in the facility.Ensure an Interdisciplinary Team (IDT - a coordinated group of experts from several different fields) meeting was conducted to develop and implement a plan of… …
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