Failure to Follow Aspiration Precautions and Provide One-to-One Feeding Assistance
Summary
The facility staff failed to have the necessary skills and competencies to meet the healthcare needs of a resident (R1), resulting in the resident's acute change of condition and subsequent death. R1 was admitted with multiple medical diagnoses, including pneumonitis due to inhalation of food and vomit, dysphagia, and cerebral infarction. The care plan for R1 required the head of the bed to be elevated 45 degrees during and 30 minutes after tube feeding, and for R1 to receive one-to-one feeding assistance with a pureed diet and honey-thick liquids. However, these precautions were not followed by the staff on multiple occasions. On the day of the incident, a Certified Nurse Assistant (CNA) provided R1 with a dinner tray without repositioning or elevating the head of the bed. The CNA was unaware that R1 required one-to-one feeding assistance and did not read the swallowing precautions posted above R1's bed. As a result, R1 was found lying flat in bed, vomiting, and experiencing difficulty breathing. Despite the efforts of the nursing staff to stabilize R1 through suctioning and oxygen administration, R1 continued to show signs of distress and ultimately passed away the following morning. Interviews with the facility staff revealed a lack of awareness and adherence to R1's care plan and physician orders. The CNA admitted to not knowing about the one-to-one feeding requirement and not noticing the swallowing precautions sign. The Registered Nurse (RN) and Licensed Practical Nurse (LPN) involved in the incident also failed to document vital signs and did not call 911, believing the situation could be managed with nursing interventions. The facility's Director of Nursing and other staff members acknowledged that residents with gastric feeding tubes should never be laid flat and emphasized the importance of following aspiration precautions to prevent such incidents.
Penalty
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Staff were not trained or in-serviced on trauma, trauma-informed care, PTSD, or trauma assessments, despite the facility’s policy requiring all staff to receive education on these topics and nursing staff to be trained on screening tools and identifying triggers. The in-service schedule showed no trauma-related training, employee files for sampled CNAs, an LVN, and RNs had no documentation of such training, and the SSD, DSD, and DON all stated that these topics had not been part of routine training or onboarding.
Staff were not consistently informed of PTSD triggers for two residents with PTSD. One resident’s care plan identified being touched by male personnel as a trigger, and another resident’s care plan identified loud noises and yelling; however, CNAs stated they were not made aware of these triggers unless the residents told them directly. Interviews with the resident, CNAs, RNS, and DON confirmed that staff awareness of PTSD triggers was lacking despite the residents having intact cognition and requiring maximal assistance with ADLs.
Failure to assess and care plan PTSD-related behaviors: A resident receiving prazosin for chronic PTSD with night terrors had no PTSD, trauma, nightmare, or medication-related focus in the care plan, and the MDS and EHR did not reflect the diagnosis. Staff documented crying, yelling, pushing, grabbing, and calling out, but the MAR lacked behavior monitoring and staff interviews showed they were unaware of the PTSD diagnosis, triggers, or any non-pharmacological interventions.
Failure to Ensure Staff Competency for Behavioral Health Needs: The facility identified residents with Level II PASRRs, intellectual disabilities, dementia, and behavioral symptoms, but did not provide requested staff competency assessments or a competency policy. Although its education calendar listed topics such as Dementia and Behavior Management and Caring for Residents with Mental/Psychosocial Disorders, the facility could not produce documentation showing the education was provided as scheduled. Staff interviews showed limited, inconsistent training on managing aggressive behaviors and psychiatric conditions, with some staff relying mainly on experience or sending residents to the ER when behaviors escalated.
Inadequate 1:1 Staffing Assignment: A resident with significant behavioral health diagnoses, including suicidal ideations, was placed on facility-issued 1:1 supervision, but staffing records and staff interviews showed the assigned CNA was also pulled to work another hall. The CNA was away from the resident’s room for a period of time, and the schedule did not clearly identify the resident for the 1:1 assignment, resulting in inadequate staffing to meet the resident’s behavioral safety needs.
A resident with bipolar disorder, anxiety, depression, PTSD, substance abuse, opioid dependence, and tobacco use had repeated aggressive, disruptive, and unsafe smoking-related behaviors, including smoking in the room despite O2 concerns, arguing with staff, refusing care, attempting to light a cigarette near an O2 tank, and encouraging another resident to pull an exit door alarm. Although staff repeatedly documented the behaviors and gave education, the care plan did not include individualized interventions for the resident’s verbal aggression or disruptive conduct, and staff, including the DON and Administrator, were observed failing to redirect or de-escalate the behavior.
Staff Not Trained on Trauma-Informed Care
Penalty
Summary
The facility failed to implement its Trauma Informed Care policy by not ensuring staff received training or in-services on trauma, trauma-informed care, PTSD, or trauma assessments. A review of the 2026 in-service schedule did not show any trauma-related education scheduled for staff, and employee files for five sampled staff members, including CNAs, an LVN, and RNs, did not contain records of training on these topics. During interviews, the LVN stated she had not received trauma-related training or in-services. The SSD stated that she or the SSA were primarily responsible for completing the Brief Trauma Questionnaire and that, to her knowledge, no other staff were trained to complete the questionnaire or assess residents for trauma and triggers. The DSD stated that trauma-informed care or PTSD in-services had not been conducted and had never been on the training calendar, and the DON stated that trauma-related in-services were not provided and were not part of routine onboarding or ongoing training. The facility policy stated that all staff were to receive in-service training about trauma, its impact on health, and PTSD, and that nursing staff were to be trained on screening tools, trauma assessments, and identifying triggers associated with re-traumatization.
Failure to Inform Staff of PTSD Triggers
Penalty
Summary
The facility failed to ensure staff were informed of and provided individualized, trauma-informed care for residents with PTSD. Two of three residents reviewed for PTSD, Residents 28 and 66, had care plans identifying specific triggers, but staff interviews showed that CNAs were not consistently aware of those triggers. Resident 28’s care plan identified being touched by male personnel as a trigger, and Resident 66’s care plan identified loud noises and yelling as triggers. Both residents had diagnoses including PTSD, and both MDS assessments indicated intact cognition and maximal assistance with ADLs. During interviews, Resident 66 stated his PTSD triggers included loud noises and fighting people. CNA 4 stated she had not been made aware of which residents had PTSD or their triggers unless residents told her themselves, and she knew Resident 66’s triggers only because he informed her. CNA 3 stated she had not been aware that Resident 28 had PTSD or what his triggers were. RNS 1 and the DON stated staff needed to know which residents had PTSD and their triggers so they would not trigger the residents and so the residents would feel safe and comfortable. The facility policy stated residents with trauma and/or PTSD would receive appropriate person-centered and individualized treatment and services to meet assessed needs.
Failure to Assess and Care Plan PTSD-Related Behaviors
Penalty
Summary
The facility failed to address a resident’s PTSD-related needs in the assessment and care planning process. Admission paperwork scanned into the facility documented that the resident took prazosin 1 mg at bedtime for chronic PTSD with trauma-related nightmares, but the admission care plan did not include focus areas, goals, or interventions for PTSD, nightmares, trauma, or prazosin. The MDS dated 3/08/2026 documented severe cognitive impairment, diagnoses of non-Alzheimer’s dementia, anxiety disorder, and depression, and did not check the PTSD box. A later provider visit note did not include PTSD in the past medical history, and the resident’s EHR did not contain a PTSD diagnosis until staff later located it on the admission orders. Behavior monitoring and symptom documentation were also incomplete. The EHR task section included monitoring behavior symptoms, and the 30-day look back documented episodes of crying, yelling, pushing, grabbing, and yelling/screaming, but the MAR for May 2026 did not include behavior monitoring even though it documented prazosin administration for chronic PTSD with night terrors. During observations, the resident was heard calling out, humming, and yelling in bed. Staff interviews showed they knew the resident sometimes yelled or screamed and called out, but they did not know the cause, were not aware of the PTSD diagnosis or nightmares/night terrors, and could not identify triggers or find documentation of a plan for non-pharmacological interventions.
Failure to Ensure Staff Competency for Behavioral Health Needs
Penalty
Summary
The facility failed to ensure staff had the basic competencies and skill sets needed to meet residents’ behavioral health needs, despite identifying in its Facility Assessment that it cared for residents with dementia, mental health conditions, trauma history, Level II PASRRs, and intellectual disabilities. The assessment stated the facility provided assistance with behavioral symptoms for 28 residents and described staffing and training expectations that included orientation, ongoing education, and competencies for all staff. However, surveyors found the facility did not provide the requested staff competency assessments, and the facility did not produce a Staff Competency Assessment policy during the survey. The facility also failed to provide the education it had identified in its own assessment as necessary for staff competency. The 2026 education calendar listed monthly topics including Dementia and Behavior Management, Caring for Residents with Mental/Psychosocial Disorders, Person Centered Care, and other resident-care subjects. When surveyors requested the 2025 Education Calendar, attendance records for the March 2026 education program, the competency policy, the outline of the March 2026 material, and the credentials of the speaker, the facility did not provide the 2025 calendar, attendance records, or the competency policy. The facility provided an outline for Resident Rights presented by the Long-Term Care Ombudsman, but did not provide documentation for the scheduled Dementia and Behavior Management education. It also provided a documentation training sign-in sheet and an undated LTC staff training handout on Schizophrenia and Bipolar Disorders, but there was no validation of when the information was presented, who provided it, or copies of completed post-education quizzes. Staff interviews reflected that education specific to managing behavioral symptoms and psychiatric conditions was limited or inconsistent. An LPN stated staff had to be reactive and flexible to keep residents safe and learned mostly from practice. Another LPN said staff were not really educated with specifics for managing resident behaviors and that the only option for aggressive and threatening behaviors was often to send the resident to the ER. An RN stated staff were not really educated to manage complex conditions and aggressive behaviors, and that there was not a plan to ensure staff had the knowledge needed. CNAs stated they were unsure whether behavior or psychiatric education was covered in staff meetings and could only recall general approaches such as trying a different staff member when a resident was difficult. Another RN stated the facility now had a more diverse population with younger, more mobile residents with psychiatric problems and that staff did the best they could with what they had.
Inadequate 1:1 Staffing Assignment
Penalty
Summary
The facility failed to provide adequate staffing to meet the behavioral safety needs of all residents, affecting one resident reviewed for behavior management. The resident was admitted with diagnoses including major depressive disorder, borderline personality disorder, suicidal ideations, conversion disorder, anxiety disorder, bipolar disorder, post-traumatic stress disorder, insomnia, and other medical and behavioral conditions. Her MDS assessment dated 04/29/26 indicated she was cognitively intact, and progress notes dated 04/21/26 showed she was placed on facility-issued one-on-one staff supervision on that date. As of 05/13/26, there was no documentation showing she had been removed from one-on-one supervision. Interview with a CNA confirmed that on 05/01/26 she was scheduled as one-on-one staff, but the schedule did not identify which resident she was assigned to. The CNA stated she initially went into the resident’s room, but was later pulled to work on the back of the 100 hall because staff there were needed, and about 40 to 45 minutes later a night shift nurse supervisor told her she needed to be in the resident’s room because that was where she was assigned. The CNA confirmed she was not aware of anyone being in the resident’s room during the time she was away, and the night shift nurse supervisor stated no one had been in the room. The Administrator and VPCS confirmed the CNA was listed as one-on-one on the schedule while also assigned to the back of the 100 hall, and the facility schedule for 05/01/26 showed the CNA scheduled for the back of the 100 hall with 1:1 noted next to her name.
Failure to Address Ongoing Behavioral and Smoking Safety Issues
Penalty
Summary
The facility failed to ensure sufficient staff competencies and behavioral health interventions for a resident with bipolar disorder, anxiety, depression, PTSD, psychoactive substance abuse, opioid dependence, and tobacco use. The resident had repeated documented behaviors including smoking in the room despite oxygen safety concerns, arguing with staff, refusing education, manipulating staff, repeatedly requesting medications, hiding cigarettes, refusing pulmonary rehabilitation, refusing showers, and attempting to leave the facility outside approved smoking times. The resident also required oxygen at 3 liters per nasal cannula and was documented attempting to light a cigarette near an oxygen tank and smoking near the staff entrance/vending area while refusing to extinguish the cigarette. The resident’s care plan addressed smoking safety, impaired safety awareness, depression, anxiety, and mood monitoring, but did not include individualized interventions for the resident’s ongoing verbally aggressive and disruptive behaviors toward residents and staff. The record also did not show changes to fire safety interventions after repeated re-education documented in the notes. Facility staff repeatedly documented the behaviors and provided education about smoking and oxygen safety, but the resident continued the same behaviors, including attempting to sign out another resident to smoke, encouraging another resident to pull the exit door handle and activate the alarm, and pushing a resident in a wheelchair outside to smoke. During observation, the resident was verbally aggressive toward another resident at the nurse’s station, loudly argued with a CMT about pain medication in front of others, and encouraged another resident to repeatedly pull the exit door handle while demanding residents be taken outside to smoke. The DON, CMT, CNA, and Administrator were present during these events and did not redirect, intervene, or de-escalate the behavior. Interviews with the Administrator, DON, CMT, SSD, RNC, and other staff confirmed the resident’s aggressive and disruptive behavior was considered baseline, that there were no interventions that worked, and that staff were unaware of any activity plan or redirection interventions in place.
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