§483.40(b) Based on the comprehensive assessment of a resident, the facility must ensure that-
§483.40(b)(1)
A resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder, receives appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being;
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Observations:
Based on review of facility documentation, observation and staff interview it was determined that the facility failed to ensure that the residents received appropriate treatment and services to correct assessed problems associated to an event of self-harm for one of two residents reviewed (Resident R1) resulting in actual harm, transfer to the hospital (Resident R1); and the investigation also determined that the facility had no system in place to ensure that other residents in the facility with similar needs were receiving the appropriate mental health services, resulting in an Immediate Jeopardy situation for one of 108 residents (Resident R1).
Findings include:
Review of facility policy "Behaviors: Management of Systems" indicated that based on the comprehensive assessment, staff must ensure that a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty receives appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being.
Review of the clinical record indicated Resident R1 was re-admitted to the facility on 10/25/25, with diagnoses that included toxic effects of glycols (suspected antifreeze oral consumption), Parkinson's Disease (chronic and progressive movement disorder that initially causes tremor in one hand, stiffness or slowing of movement), and depression.
Review of Resident R1's care plan updated 10/30/25, indicated Resident R1 had potential risk for ideations of self-harm related to PTSD (post-traumatic stress disorder (stress after trauma), glycol toxicity, and hallucinations (a false perception of sensory experiences, they seem real but are not).
Review of Resident R1's physician orders from 10/25/25, through 12/3/25, revealed orders for psychiatry/psychology consultation and pharmacy orders for medications to treat insomnia, anxiety, depression, and overdose reversal medications.
Review of the progress notes indicated the following:
On 9/15/25, at 2:02 p.m. a Medical Practitioner Note stated "Pt (patient) had recent hospitalization to [hospital] 201 (voluntary admission) for Seroquel (anti-psychotic medication) overdose" and requested for the Seroquel to be increased.
On 9/25/25, at 6:41 p.m. a general progress note indicated Resident R1 was to be discharged at 5:00 p.m. on 9/25/25, but when they went into Resident R1's room, her belongings were gone. When they called Resident R1 she was already at home.
Review of hospital "Discharge Clinical Summary" dated 10/25/25, indicated Resident R1 was admitted to the hospital on 9/28/25, with acute kidney injury (AKI) (kidneys suddenly lose their ability to filter waste from the blood), and metabolic acidosis due to ethylene glycol (when ethylene glycol is ingested causing kidney damage).
Further review of the progress notes indicated the following:
-On 10/27/25, at 11:57 a.m. a Practitioner progress note indicated the emergency room evaluation was consistent with ethylene glycol toxicity. Resident R1 does have a history of cocaine use and Seroquel overdose.
-On 10/28/25, at 11:39 a.m. an acute progress note indicated Resident R1 was hospitalized from 9/28/25 through 10/25/25, for suspected self-harm attempt with ingestion of ethylene glycol that required ICU (intensive care unit) with intubation (placed on a ventilator to assist with breathing), and temporary dialysis (a machine filters wastes, salts and fluid from your blood when your kidneys are no longer healthy enough to do this work adequately), Resident R1 also had a recent psychiatric hospital admission.
-On 10/30/25, at 12:00 a.m. an initial psychiatry progress note indicated Resident R1 has an extensive psychiatric history including inpatient hospitalization. History of possible self-harm attempts which the resident denies. Requests for Seroquel increase, not advisable due to history of overuse.
Review of behavior charting for October 2025, revealed three of six shifts without documented behavior monitoring (50% missed documentation).
Review of behavior charting for November 2025, revealed 24 of 90 shifts without documented behavior monitoring (approximately 27% missed documentation).
Review of behavior charting for December 2025, revealed 26 of 61 shifts without documented behavior monitoring (approximately 43% missed documentation).
Further review of Resident R1's medical records failed to include consistent lack of any behavioral health interventions to address residents previous histories of suicidal attempts/ideations.
Review of a facility submitted documents dated 12/21/25, indicated Resident R1 was noted to have altered mental status (change in a person's usual mental function) and was transferred to the local emergency room for evaluation. On 12/22/25, the facility received a telephone call from the hospital concerning Resident R1 possibly ingesting antifreeze and requested staff to search her room for suspicious items. Staff found a gallon of Peak 50/50 Prediluted Antifreeze in Resident R1's room.
During an interview on 1/13/25, at 3:35 p.m. the Nursing Home Administrator (NHA) and Director of Nursing (DON) stated they were unaware of Resident R1's history of self-harm, and the facility did not have a procedure to ensure residents with prior self-harm attempts were referred to mental health services.
An immediate jeopardy situation was identified to the NHA on 1/13/26, at 3:46 p.m. the facility failed to ensure appropriate treatment and services to attain the highest practicable mental health and psychosocial well-being were provided for Resident R1, resulting in hospitalization from ingesting antifreeze, and had no system in place to ensure that other residents in the facility with similar needs were receiving the appropriate mental health services.
The immediate corrective action plan included the following interventions:
1. Initial audit will be completed on current and new admissions to determine any resident with a DX (diagnosis) of suicide attempt or suicidal ideation have care plans that will be updated with interventions 1/13/26.
2. NHA or designee will educate admission director and clinical liaison to attempt to identify potential needs related to suicide attempts or suicide ideations prior to admission. Prior to the start of their next shift, DON or designee will educate staff related to any new admission coming in with a history of past attempts for self-harm on the plan of care needs.
3. DON or designee will complete a weekly audit on new admissions for eight weeks to determine if any resident with history of suicide attempt or suicidal ideation is placed on psych services, care plan initiated and interventions added to Kardex
4. Results of the audit will be reported to the Quality Assurance Performance Improvement Committee monthly.
During an interview on 1/14/26, at 9:15 a.m. RN Employee E4 confirmed they received education on safety related to third party delivery services (door dash, uber eats, amazon etc.), incidents and accidents, and management and symptoms of behaviors prior to beginning work, and verbalized the education back during the interview.
During a group interview on 1/14/26, at 9:20 a.m. Nurse Aid (NA) Employee E5, E6, and E7, Housekeeping Employee E8, and LPN Employee E9 confirmed that they received education on safety related to third party delivery services (door dash, uber eats, amazon etc.), incidents and accidents, and management and symptoms of behaviors prior to beginning work, and verbalized the education back during the interview..
During an interview on 1/14/26, at 9:22 a.m. RN Employee E19 confirmed they received education on safety related to third party delivery services (door dash, uber eats, amazon etc.), incidents and accidents, and management and symptoms of behaviors prior to beginning work, and verbalized the education back during the interview.
During an interview on 1/14/26, at 9:23 a.m. LPN Employee E11 confirmed they received education on safety related to third party delivery services (door dash, uber eats, amazon etc.), incidents and accidents, and management and symptoms of behaviors prior to beginning work, and verbalized the education back during the interview.
During an interview on 1/14/26, at 9:25 a.m. Housekeeper Employee E12 confirmed they received education on safety related to third party delivery services (door dash, uber eats, amazon etc.), incidents and accidents, and management and symptoms of behaviors prior to beginning work, and verbalized the education back during the interview.
During an interview on 1/14/26, at 9:27 a.m. LPN Employee R13 confirmed they received education on safety related to third party delivery services (door dash, uber eats, amazon etc.), incidents and accidents, and management and symptoms of behaviors prior to beginning work, and verbalized the education back during the interview.
During an interview on 1/14/26, at 9:27 a.m. LPN Employee E10 and E11 confirmed they received education on safety related to dementia residents and chemical storage, prior to beginning work, and verbalized the education back during the interview.
During a group interview on 1/14/26, at 9:30 a.m. LPN Employee E14 , and NA Employee E15 confirmed they received education on safety related to third party delivery services (door dash, uber eats, amazon etc.), incidents and accidents, management and symptoms of behaviors prior to beginning work, and verbalized the education back during the interview.
During an interview on 1/14/26, at 9:33 a.m. Physical Therapy Assistance (PTA) Employee E17 confirmed they received education on safety related to third party delivery services (door dash, uber eats, amazon etc.), incidents and accidents, and management and symptoms of behaviors prior to beginning work, and verbalized the education back during the interview.
During an interview on 1/14/26, at 9:35 a.m. Laundry Employee E18 confirmed they received education on safety related third party delivery services (door dash, uber eats, amazon etc.), incidents and accidents, and management and symptoms of behaviors prior to beginning work, and verbalized the education back during the interview.
During an interview on 1/14/26, at 9:43 a.m. Front Desk Employee E19 confirmed they received education on safety related to third party delivery services (door dash, uber eats, amazon etc.), incidents and accidents, and management and symptoms of behaviors prior to beginning work, and verbalized the education back during the interview.
During an interview on 1/14/26, at 10:00 a.m. RN Unit Manager Employee E1 confirmed they received education on safety related to third party delivery services (door dash, uber eats, amazon etc.), incidents and accidents, and management and symptoms of behaviors prior to beginning work, and verbalized the education back during the interview.
During an interview on 1/14/26, at 11:00 a.m. RN Employee E20 confirmed that they received education on safety related to third party delivery services (door dash, uber eats, amazon etc.), incidents and accidents, and management and symptoms of behaviors prior to beginning work, and verbalized the education back during the interview.
During an interview on 1/14/26, at 11:00 a.m. NA Employee E21 confirmed that they received education on safety related to third party delivery services (door dash, uber eats, amazon etc.), incidents and accidents, and management and symptoms of behaviors prior to beginning work, and verbalized the education back during the interview.
During a group interview on 1/14/26, at 11:01 a.m. Therapy Director Employee E22, NA Employees E23 and E24 confirmed that they received education on safety related to third party delivery services (door dash, uber eats, amazon etc.), incidents and accidents, and management and symptoms of behaviors prior to beginning work, and verbalized the education back during the interview.
During an interview on 1/14/26, at 11:04 a.m. NA Employee E25 confirmed that they received education on safety related to third party delivery services (door dash, uber eats, amazon etc.), incidents and accidents, and management and symptoms of behaviors prior to beginning work, and verbalized the education back during the interview.
During a group interview on 1/14/26, at 11:08 a.m. Assistant Director of Therapy Employee E26, and NA Employees E27 and E28, confirmed that they received education on safety related to third party delivery services (door dash, uber eats, amazon etc.), incidents and accidents, and management and symptoms of behaviors prior to beginning work, and verbalized the education back during the interview.
During an interview on 1/14/26, at 11:12 a.m. Physical Therapy (PT) Employee E29 confirmed that they received education on safety related to third party delivery services (door dash, uber eats, amazon etc.), incidents and accidents, and management and symptoms of behaviors prior to beginning work, and verbalized the education back during the interview.
During an interview on 1/14/26, at 11:15 a.m. Speech Therapy (ST) Employee E34 confirmed that they received education on safety related to third party delivery services (door dash, uber eats, amazon etc.), incidents and accidents, and management and symptoms of behaviors prior to beginning work, and verbalized the education back during the interview.
During a group interview on 1/14/26, at 11:21 a.m. Maintenance Director Employee E30, and Maintenance worker Employee E31 confirmed that they received education on safety related to third party delivery services (door dash, uber eats, amazon etc.), incidents and accidents, and management and symptoms of behaviors prior to beginning work, and verbalized the education back during the interview.
During an interview on 1/14/26, at 11:30 a.m. Physical Therapy Assistant (PTA) Employee E32 confirmed that they received education on safety related to third party delivery services (door dash, uber eats, amazon etc.), incidents and accidents, and management and symptoms of behaviors prior to beginning work, and verbalized the education back during the interview.
During an interview on 1/14/26, at 11:33 a.m. Central Supply Coordinator Employee E33 confirmed that they received education on safety related to third party delivery services (door dash, uber eats, amazon etc.), incidents and accidents, and management and symptoms of behaviors prior to beginning work, and verbalized the education back during the interview.
During a group interview on 1/14/26, at 11:35 a.m. Certified Occupational Therapy Assistant (COTA) Employee E35 and PTA Employee E36 confirmed that they received education on safety related to third party delivery services (door dash, uber eats, amazon etc.), incidents and accidents, and management and symptoms of behaviors prior to beginning work, and verbalized the education back during the interview.
During an interview on 1/14/26, at 11:37 a.m. Scheduler/Payroll Employee E37 confirmed that they received education on safety related to third party delivery services (door dash, uber eats, amazon etc.), incidents and accidents, and management and symptoms of behaviors prior to beginning work, and verbalized the education back during the interview.
The Immediate Jeopardy was removed on 1/14/26, at 2:38 p.m. after it was verified that the corrective action plan was implemented.
28 Pa. Code 201.14 (a) Responsibility of licensee
28 Pa. Code 201.18(a) Management
28 Pa. Code 201.18 (b)(1)(3)(e)(1) Management
28 Pa. Code 211.5(f) Clinical records
28 Pa. Code 211.5(h) Clinical records
28 Pa. Code 211.11(c) Resident care plan
28 Pa. Code 211.11(d) Resident care plan
28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing Services
28 Pa. Code 211.16(a) Social services
| | Plan of Correction - To be completed: 02/11/2026
New admission will be reviewed prior to admission to identify residents with a history of suicide attempt/ideation prior to admission so that plan of care can be initiated to include care plan, intervention,Psych services and staff education related to plan of care if resident is accepted to the facility
The facility management will review OPS 100 policy and update as applicable.
NHA or designee will educate all facility staff to attempt to identify potential needs related to suicide attempt or suicidal ideation..
DON or designee will educate staff related to any new admission coming in with a history past attempts for self-harm on their plan of care needs
A directed inservice will be conducted on 2/6/2026 by Lewis Litigation Support and Clinical Consulting, LLC. The directed inservice will include presentations on Ftag 689 and Ftag 742 for all facility staff. The presentation will also be recorded for staff unable to participate for the live training.
DON or designee will complete a weekly audit on new admissions x 8 weeks to determine if any resident identified with history of suicide attempt and/or suicidal ideation are followed by Psych services and care plan interventions are being utilized. DON or designee will complete a weekly audit x8 to verify care plan interventions are being followed.
Results of the audit will be reported to the Quality Assurance Performance Improvement Committee monthly.
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