Failure to Address Behavioral Health Needs Leads to Resident's Suicide
Summary
The facility failed to ensure that staff members, including the Social Service Director, Registered Nurses, Licensed Vocational Nurses, and Certified Nursing Assistants, possessed the necessary competencies to care for residents with mental and psychosocial disorders. This deficiency was highlighted by the case of a resident who was observed sobbing and accusing a CNA of poisoning his water. Despite these signs of distress, the staff did not intervene appropriately, resulting in a lack of care plan interventions to address the resident's symptoms of depression. The resident, who had a history of depression and was on antidepressant medication, did not receive the necessary care and services to address his emotional and psychosocial needs. The resident's condition deteriorated, and he was found to have committed suicide by hanging himself in the bathroom. Interviews with staff revealed that there was a failure to report and assess the resident's change in behavior adequately. The CNA and LVN involved did not notify the resident's physician or implement one-to-one monitoring, despite the resident exhibiting delusional thoughts and anxiety. The LVN admitted to not conducting a Change of Condition (COC) assessment, which could have led to better monitoring and intervention. The Social Service Director also failed to review the resident's previous records and did not complete necessary assessments in a timely manner. The Director of Nursing acknowledged that the staff should have reviewed the resident's past medical history and care plan interventions. The facility's policies and procedures emphasized the importance of staff competency and resident safety, but these were not effectively implemented in this case, leading to the tragic outcome.
Penalty
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Staff failed to use appropriate behavioral interventions for a resident with cerebral palsy, severe intellectual disability, and muscular dystrophy whose care plan identified behaviors such as hitting, kicking, and spitting during care. Instead of following the care-planned approach to postpone care and re-approach when the resident became resistive or combative, two CNAs attempted a bed-to-wheelchair transfer while the resident’s face was covered with a pillowcase to avoid being spit on. Leadership later stated that the CNAs had access to the resident’s cardex with the correct interventions and should have followed those person-centered strategies in accordance with the facility’s behavior management policy.
The facility failed to employ a qualified Psychiatric Rehabilitation Services Director (PRSD) for its locked mental illness behavioral unit, despite state requirements for this role and for provision of community reintegration groups. A resident with multiple serious mental health diagnoses, who was generally independent in ADLs and had a documented goal to return to the community, reported concerns about being forced to leave. The DON, Administrator, and a PRSC all confirmed there was no current PRSD, the position had been vacant for months, and community reintegration groups were not being provided. The Administrator stated an LPN had unsuccessfully attempted to fill the role and that the PRSC was qualified but not selected, and staff indicated that needed reintegration services would instead be provided at another facility.
Two residents with behavioral health diagnoses were left unsupervised on a locked unit when a CMT left to retrieve medication records during an internet outage. In the absence of staff, a verbal and physical altercation occurred between the residents over delayed medication administration. Staff interviews confirmed that the unit was left unattended, and facility leadership acknowledged that supervision should have been maintained at all times.
Staff failed to receive adequate training on behavioral health competencies and resident-specific interventions, resulting in multiple incidents where residents with mental health diagnoses engaged in verbal and physical altercations without timely or appropriate staff intervention. Staff were unsure how to access care plans or when to call behavioral crisis codes, and documentation of incidents was lacking. Residents and staff reported feeling unsafe due to the lack of effective behavioral health management.
Three residents with behavioral health needs, including exit-seeking and aggression, were not consistently provided with one-on-one supervision by facility staff. Instead, the facility relied on family members or outside agency sitters to supervise these residents, and only provided staff supervision temporarily when family was unavailable. This resulted in a failure to ensure sufficient staff with the necessary competencies and skills to meet the behavioral health needs of these residents.
Staff interviews and record reviews revealed that employees, including LPNs, CNAs, and an RN, had not received adequate training in dementia care or behavioral management, despite caring for a significant population of residents with Alzheimer's and dementia. Staff reported witnessing aggressive behaviors and resident-to-resident incidents, and expressed fear and uncertainty in managing these situations. The DON confirmed the lack of training in behavioral health for staff.
Improper Use of Pillowcase to Manage Resident Behavioral Symptoms
Penalty
Summary
The deficiency involves staff failing to demonstrate appropriate skills and competencies to meet a resident’s behavioral health needs. Resident B had diagnoses including cerebral palsy, severe intellectual disability, and muscular dystrophy, and a care plan dated 11/4/25 documented behavioral symptoms of hitting, kicking, and spitting at staff during care. The care plan interventions, initiated 11/4/24, directed staff that if the resident became resistive to care or combative, they were to postpone care and re-approach rather than continue in a confrontational manner. During an observation described by the Social Service Director (SSD), she entered Resident B’s room and saw CNA 2 and CNA 3 preparing to transfer the resident from bed to wheelchair while the resident’s entire face was covered with a pillowcase, though the head was not in the pillowcase. The SSD instructed the CNAs to stop and remove the pillowcase, after which they completed the transfer. CNA 2 told the SSD that the resident had spit at staff and she did not want to be spit on. The DON stated that CNA 2 and CNA 3 had access to the resident’s cardex with the appropriate interventions and should have known to use those interventions instead of covering the resident’s face with a pillowcase, contrary to the facility’s Behavior Management policy that calls for supportive, person-centered interventions for behavioral needs.
Failure to Employ Required Psychiatric Rehabilitation Services Director
Penalty
Summary
The facility failed to employ a qualified Psychiatric Rehabilitation Services Director (PRSD) as required for its locked mental illness behavioral unit, resulting in insufficient staffing with appropriate competencies to meet residents' behavioral health needs. A resident on the locked unit, diagnosed with Borderline Personality Disorder, Suicidal Ideation, Anxiety, Bipolar Disorder, Major Recurrent Depression, Post-Traumatic Stress Disorder, Cocaine Abuse, and Nicotine Dependence, reported that staff wanted to "kick him out" and expressed a desire to speak with the Administrator for clarification. The resident’s care plans documented that he was generally independent in emotional, intellectual, physical, and social needs, usually able to perform ADLs independently or with supervision, and had a goal to return home or to the community, with interventions including evaluation for appropriate living environment, coordination with community support resources, and provision of written instructions. During the survey, the DON, a Psychiatric Rehabilitation Services Counselor (PRSC), and the Administrator each confirmed that the facility did not currently employ a PRSD and had not done so since November 2025. The Administrator stated that an LPN had attempted to fill the PRSD position but it was not a good fit, and that although the PRSC was qualified, the Administrator believed her personality was too timid for the role. The Administrator acknowledged that having a PRSD and providing community reintegration groups are state requirements for a mental illness behavioral unit. A staff member reported that the resident was not being discharged involuntarily but that the facility was not providing community reintegration groups and that these services could be provided at another nursing facility, which she believed would be more beneficial for the resident. The staff roster did not list a PRSD, and throughout the survey the mental illness unit Director’s office remained closed and unoccupied, further evidencing the absence of a functioning PRSD.
Failure to Maintain Supervision on Behavioral Health Unit Leads to Resident Altercation
Penalty
Summary
The facility failed to ensure adequate staffing coverage and supervision on the secure behavioral locked unit, resulting in an altercation between two residents. On the evening in question, a Certified Medication Technician (CMT) left the behavioral unit unsupervised to retrieve printed Medication Administration Records (MARs) due to an internet outage, leaving no staff present on the unit. During this period, two residents engaged in a verbal and physical altercation in the hallway, with one resident striking the other in the upper arm after a dispute over delayed medication administration. The residents involved had significant behavioral health diagnoses, including paranoid schizophrenia, schizoaffective disorder, bipolar disorder, and major depression. One resident was moderately cognitively impaired, while the other was cognitively intact but had a history of agitation when routines or medication schedules were disrupted. The incident occurred after one resident became upset about not receiving medication on time, leading to a confrontation and subsequent physical contact. Interviews with staff and residents confirmed that the behavioral unit was left without staff supervision at the time of the incident. Multiple staff members, including the CMT, LPNs, CNAs, the Administrator, and the DON, acknowledged that the behavioral unit should never be left unattended and that at least one staff member should always be present. The facility was unable to provide a staffing policy at the time of the survey exit.
Failure to Train Staff on Behavioral Health Needs and Resident-Specific Interventions
Penalty
Summary
Facility staff failed to ensure that staff members possessed the necessary competencies and skills to meet the behavioral health needs of residents, as evidenced by multiple incidents involving residents with behavioral health diagnoses. Staff did not receive adequate training on resident-specific behaviors and interventions, and there was a lack of education on how to access and implement individualized care plans. This deficiency was observed through staff inaction during escalating resident-to-resident altercations, where staff did not intervene or utilize care planned interventions to de-escalate situations, resulting in physical altercations between residents. Additionally, staff interviews revealed uncertainty and lack of knowledge regarding when to call behavioral crisis codes and how to access or apply resident-specific interventions. Several residents with complex behavioral health needs, including diagnoses such as schizophrenia, bipolar disorder, PTSD, and impulse disorders, were involved in repeated incidents of aggression, verbal altercations, and physical assaults. In one instance, two residents engaged in a verbal and physical altercation while staff failed to intervene according to care plan interventions or call a behavioral crisis code in a timely manner. Staff members supervising the residents did not implement de-escalation techniques or follow the individualized interventions outlined in the residents' care plans. Documentation of these incidents was also lacking, with no investigation or nursing notes reflecting the altercations. Interviews with staff and residents further highlighted the deficiency, with staff expressing fear and lack of preparedness to manage residents with severe behavioral health needs. Staff reported not being trained on mental health interventions, de-escalation techniques, or how to access and apply care plan interventions. Residents reported feeling unsafe and stated that staff did not intervene until altercations became physical. The facility's failure to provide adequate training and education for staff on behavioral health needs and individualized interventions contributed directly to the incidents and ongoing unsafe environment for both residents and staff.
Failure to Provide Sufficient Staff for Behavioral Health Supervision
Penalty
Summary
The facility failed to ensure that sufficient staff with appropriate competencies and skills were available to meet the behavioral health needs of residents requiring one-on-one supervision. For three residents with exit-seeking behaviors and other behavioral health concerns, the facility relied on family members or outside agency sitters to provide necessary supervision, rather than consistently providing this care through facility staff. In several instances, the facility contacted family members to sit with residents or to arrange for private sitters, and when family could not provide supervision, the facility considered alternate placement for the residents. One resident with dementia and a history of exit-seeking was observed wandering without required safety devices and was only provided one-on-one supervision when family or an outside agency sitter was available. Another resident with multiple medical and behavioral diagnoses, including agitation and aggression, required one-on-one supervision due to exit-seeking and aggressive behaviors. The facility communicated to the family that it could not provide ongoing one-on-one care and that the family would need to arrange supervision or consider alternate placement. During periods when family members were unavailable, staff provided one-on-one care only temporarily, and the facility continued to seek alternate placement. A third resident with dementia and a history of falls was admitted and subsequently found outside the facility attempting to leave. The care plan called for one-on-one supervision until alternate placement could be found, but the facility again relied on family to provide this supervision. The facility's approach to residents requiring intensive behavioral supervision was to request family or outside agencies to provide care, and only provided staff supervision for short periods, indicating a lack of sufficient staff to meet these residents' behavioral health needs as required.
Failure to Provide Staff Training in Dementia and Behavioral Health Management
Penalty
Summary
The facility failed to ensure that staff members were adequately trained to manage residents with dementia and challenging behaviors. Multiple staff interviews revealed that both new and long-term employees had not received training from the facility on dementia care or behavioral management. Staff reported witnessing resident-to-resident incidents and aggressive behaviors from residents with dementia, expressing fear and uncertainty about how to handle such situations. Employee record reviews confirmed a lack of documented training in dementia management and behavioral health for the staff reviewed. Staff members, including LPNs, CNAs, and an RN, described situations where they felt unprepared to manage aggressive or challenging behaviors, sometimes requiring additional staff to provide care safely. The Director of Nursing acknowledged the deficiency, stating that there was a recognized lack of training for staff in behavioral health. The facility had a census of 34 residents, many with Alzheimer's and dementia, yet staff consistently reported insufficient training in managing these residents' behavioral health needs.
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