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 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.
Staff lacked training on caring for residents with SUDs, and a resident with polysubstance abuse history had no SUD care plan or related interventions. Interviews showed CNAs, an LPN, the Social Services Director, the RNCM, and the DNS had not received SUD-specific training, and several staff were unaware of the resident's full substance abuse history or how to respond when the resident was excessively drowsy and hard to arouse.
Inadequate behavioral documentation, supervision, and staffing on the secured unit. A resident with TBI, schizophrenia, depression, anxiety, and psychosis was observed yelling that a CNA hit him, but the nurse did not assess him for marks and the resident was left alone with the CNA in the shower room. His chart showed repeated behaviors such as yelling, accusations, agitation, and self-injury, yet the behavior task documented no behaviors observed. Two other residents were observed with limited supervision during meals, including one resident who was dependent for eating but was seen feeding herself, while staff reported the unit was short an aide and lunch care was challenging.
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.
Lack of SUD Training and Care Planning for Resident with Polysubstance Abuse History
Penalty
Summary
The facility failed to ensure staff had the competencies and skills needed to meet the behavioral health needs of residents with substance use disorders. Survey review found no evidence that annual nursing department training included substance use disorder education, and staff interviews showed multiple employees, including CNAs, an LPN, the Social Services Director, the RNCM, and the DNS, had not received training related to working with residents with SUDs or identifying the signs and symptoms of substance use. Resident 9 was admitted with diagnoses including psychoactive substance dependence, other stimulant use, and sedative, hypnotic or anxiolytic abuse. The hospital history and physical documented polysubstance abuse disorder involving opioids, benzodiazepines, and methamphetamine, with the resident reporting daily use of each prior to hospitalization. The resident's care plan did not include a diagnosis of SUD or interventions for staff to identify or manage substance use, and staff interviews showed several were unaware of the resident's full substance abuse history or what to do when the resident was excessively drowsy and difficult to arouse.
Inadequate behavioral documentation, supervision, and staffing on secured unit
Penalty
Summary
The facility failed to ensure nursing staff were competent to meet the behavioral health needs of residents on the secured unit. During observation, Resident #80 was heard yelling from a closed shower room after Staff F, CNA, was observed behind him in a wheelchair with a pink substance on his clothing. Resident #80 stated that Staff F slapped him, while Staff F denied hitting him and said the resident had slapped himself. The Activities Director observed the resident being pushed in a rough manner and aggressively by Staff F, and the resident was not assessed by the nurse for markings or skin changes that could indicate a slap or hit. Staff J, LPN briefly came to the shower room, but the resident and CNA were left together in the shower room without other staff present. The resident continued yelling that he had been hit. Resident #80 had diagnoses including traumatic brain injury, schizophrenia, psychotic disorder, major depressive disorder, generalized anxiety disorder, and cerebral infarction. His record showed an order for side effect monitoring every shift, and his care plan included behavioral interventions such as documenting episodes of behavior and reviewing their effectiveness. However, the behavior task for the last 30 days showed daily documentation of no behaviors observed. The record also showed multiple notes describing yelling, accusations, agitation, and impulsive verbalizations, and staff interviews confirmed that he frequently accused staff and residents of hitting him, yelled, picked at and ate his scabs, and bit himself. The DON stated that behaviors such as agitation, hitting, kicking, or biting could be documented in behavior monitoring or progress notes, and that documentation was important for psychiatry to know when evaluating medications and side effects. The deficiency also involved supervision and staffing on the secured unit. During observations, Resident #62 was seen in a room with the door closed, moving around slowly and opening drawers, while staff were observed in the dining room and at the nurse’s station. Resident #34 was observed in the dining room scooping food off his plate and dropping it on the table, and Resident #61 was observed feeding herself even though her MDS showed she was dependent for eating and her care plan indicated she required assistance. Staff interviews stated that the unit normally had three aides and one nurse, but on the day of observation there were only two aides and a nurse because one aide had been sent home, making lunch time challenging because residents needing assistance had to wait while trays were passed. Staff also stated that behaviors were not documented if they were considered usual for the resident, and that only certain behaviors such as resident-to-resident or sexual behaviors were documented.
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