Based on interview and record review it was determined, for 2 out of 22 sampled residents, that the facility failed to ensure that each resident received and the facility provided the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Specifically, the facility failed to provide behavioral health care and services to a resident who had expressed a desire to commit suicide and interventions and monitoring were not implemented prior to the resident successfully committing suicide. …
Based on interview and record review it was determined, for 1 of 65 sampled residents, the facility did not provide the necessary behavioral health care and services to attain or maintain the highest practical physical, mental, and psychosocial well-being. Behavioral health encompasses a resident's whole emotional and mental well-being. Specifically, a resident with a history of suicidal ideation's had a traumatic life event occur with no behavioral health services provided. The resident was found to have taken 4 to 5 bottles of Tylenol and was sent to the emergency room for an overdose. Resident identifier: 45, 57.
Findings include:
1. …
D · No harm, potential for more than minimal, isolatedMay 14, 2026
Based on interview and record review, the facility did not provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Specifically, for 1 out of 54 sampled residents, the facility did not demonstrate reasonable attempts to provide or arrange behavioral health services for a resident who had requested those services. Resident identifier: 38.Findings included:Resident 38 was admitted to the facility on [DATE] with diagnoses which included depression, anxiety disorder, and attention-deficit hyperactivity disorder (ADHD).On 5/4/26 at 2:34 PM, an interview was conducted with resident 38. …
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