Based on observation, interview and record review, the facility failed to ensure recommended behavioral health care and services were provided to create an environment promoting emotional and psychosocial well-being for 1 of 1 sampled residents (#14) reviewed for behaviors. This failure placed residents at risk for loss of life, hopelessness, and a diminished quality of life. This caused harm to Resident #14 when the facility failed to remove potentially dangerous items from Resident #14's room, failed to provide consistent monitoring of the resident after returning to the facility and failed to establish interventions to ensure the resident's safety.
This failure resulted in an immediate jeopardy on 09/05/19. …
Based on interview and record review, the facility failed to provide the necessary behavioral healthcare to maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for 1 of 3 sample residents (1), reviewed for care and services. Specifically, Resident 1 was checked for toileting needs in an undignified manner, was upset and afraid the identified person (Staff A) was going to return, and did not receive any follow-up by the facility related to the incident, or the resident's expression of distress. This failure caused the resident actual psychosocial harm. Findings included:
A review of the record showed Resident 1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . …
E · No harm, potential for more than minimal, patternJuly 16, 2026
Based on interview and record review, the facility failed to ensure residents were provided psychotropic (mind altering) medications in response to mood/behavior issues for 4 of 5 sampled residents (Residents 4, 8, 46, and 59) reviewed for unnecessary medications. This failure placed residents at risk of avoidable medication side effects, sedation, possible chemical restraint, and a diminished quality of life. Findings included.
Resident 4
Review of the electronic health record (EHR) showed Resident 4 readmitted to the facility on [DATE] with diagnoses to include fracture of the left leg, anxiety disorder, and depressive disorder. …
Deficiency Index is independent and is not affiliated with, endorsed by, or approved by CMS, Medicare, or any government agency. About this data · Report a correction