Failure to Implement Substance Use Disorder Program and Safety Measures for Resident on Stepping Stones Consent
Summary
The deficiency involves the facility’s failure to provide necessary behavioral health care and services for a resident with a known substance use disorder, in accordance with the resident’s assessment, hospital history, and the facility’s own Substance Use Disorder/Stepping Stones program consent and care plan. Prior to admission, the resident signed a Substance Use Disorder Program consent that outlined specific safety measures and monitoring, including supervised visits, restricted visitation hours, random room and package searches, random drug screens, and no LOA without collaboration among the counselor, IDT, and physician. Hospital discharge paperwork documented that the resident had tested positive for amphetamines and cannabinoids and was discharged with a PICC line for IV antibiotics after toe amputations. The resident’s admission MDS showed intact cognition (BIMS 15), and the care plan identified a substance abuse disorder with interventions requiring participation in Stepping Stones activities and adherence to the Stepping Stones protocol. Despite these documented needs and the signed consent, the facility did not actually provide the Stepping Stones program or its associated behavioral health services. There was no documented evidence that the resident received Stepping Stones activities, homework, counseling sessions, or follow-up with a counselor. Multiple staff, including the Admission Director, Regional Director of Clinical Services, and Social Service Director, acknowledged that the facility did not have a functioning substance abuse program, had no counselor, and that no one was doing weekly check-ins on residents who were supposedly in the program. The Regional Director of Clinical Services confirmed there were no policies, procedures, or admission information for the Stepping Stones program other than the consent form, and the physician reported he was only made aware that the facility did not have a substance abuse program after the resident’s admission. The lack of implemented behavioral health interventions and safety measures contributed to repeated unsupervised departures from the facility by the resident, who had a history of substance use and was admitted under a program that was not actually in place. On one occasion, the resident signed himself out for an LOA, obtained access to the LOA book without clear staff oversight, and left in a friend’s car to retrieve his power wheelchair, traveling through the community and stopping at various locations before returning later that night. Staff interviews revealed confusion about whether the resident had privileges to leave, uncertainty about his destination, and acknowledgment that he was supposed to have limited LOA access under the Stepping Stones program. On another occasion, after a medical appointment, the resident left the facility without notifying staff, was later found at a grocery store with alcohol, and was observed back at the facility smelling of alcohol and upset. The resident himself confirmed he had been admitted on a substance abuse program, knew he was not allowed to leave, and had not received any services related to the program, demonstrating the facility’s failure to deliver the behavioral health care and safety interventions it had identified and consented to provide.
Plan Of Correction
Resident #2 no longer resides at the facility. On 4/23/2026 Director of nursing /designee reviewed program policy and contract to discover any like residents, no qualifying residents for the program as of 4/23/2026. On 4/17/2026 new counselor/therapist started to be available to provide services. As of 4/23/2026 there are currently no residents on the program. To ensure the deficit practice does not recur the Administrator/designee will assess new referrals/admission to the facility if they meet criteria to participate in the substance use disorder program. Regional Director of Operations will educate facility program director and facility administrator on substance use disorder program. This will be completed by 4/27/2026. On 4/23/2026 Administrator/designee will educate all staff on program guidelines and contract. Audits will be completed weekly by the Administrator/designee with any residents on the program to ensure program is being compliant if not compliant, physician notified. Administrator/designee will add any new candidates to the audit upon admission x 4 weeks.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Failure to address a resident’s alcohol use and substance use disorder concerns. A cognitively intact resident with stroke, malnutrition, a G-tube, and an NPO diet was observed with signs of intoxication, and staff found alcohol in the room and documented that the resident admitted sneaking alcohol into the facility daily. The care plan did not include the resident’s alcohol use or any interventions, and multiple staff reported there were no documented interventions related to monitoring for intoxication or substance use.
A resident with schizoaffective disorder, PTSD, depression, anxiety, and an intellectual disability repeatedly manipulated his colostomy bag and ate feces, while staff also observed him adding excessive salt to food and becoming tearful or aggressive when redirected. The care plan did not address the feces-eating behavior, trauma history, or triggers, and social services did not follow through on a physician’s guardianship recommendation. The resident later developed nausea, hypoxia, and respiratory distress, and hospital records showed pneumonia likely related to aspiration.
Failure to Provide Behavioral Health Care for Resident Grief: A resident with Lewy body dementia and severe cognitive impairment developed grief-related behaviors after learning of her sister’s death, including yelling at staff and attempting to hit staff. The record contained only a RD note linking poor intake to grief, with no social work or psych notes and no care plan addressing grief or the resident’s psychosocial symptoms.
Failure to Manage Unsafe Behaviors and Behavioral Health Needs: A resident with dementia, schizophrenia, and a history of fire-setting repeatedly smoked in undesignated areas and in the building, while another resident with mood disorder, nicotine dependence, and TBI repeatedly smoked in the room and bathroom and kept smoking paraphernalia in the room. The facility also failed to monitor residents with elopement risk, allowing one resident to wander unsupervised and elope, another to leave the building unsupervised multiple times and nearly be struck by a vehicle, and a third resident with a history of aggression to physically assault other residents.
Failure to Identify and Monitor Behavioral Health Needs Related to Substance Use: The facility did not adequately assess or monitor residents with known SUD histories and recent signs of relapse. A resident with opioid withdrawal, fentanyl use disorder, and polysubstance use disorder showed erratic behavior, withdrawal signs, and self-injury, while staff documented concerns but did not clearly communicate withdrawal from illegal drugs to the physician. Another resident with psychoactive substance abuse was found unresponsive with labored respirations, required Narcan and CPR, and was later on a Narcan drip. The record also showed narcotics found in a resident’s purse and room, with police involvement after the resident admitted recent fentanyl and methamphetamine use.
Failure to Individualize Behavioral Health Care Plan: A resident with agitation, verbal aggression, and loud outbursts had repeated behavioral issues documented in psych, psychosocial, and nursing notes, including distress when needs were not met right away. The care plan did not address his behaviors, cultural background from Honduras, preferences, or refusal of outside psychiatric services, and the ADM and DON confirmed these items were not care planned.
Failure to Address Resident Alcohol Use and Substance Use Disorder
Penalty
Summary
The facility failed to implement interventions related to substance use disorder for a resident who was admitted with diagnoses including stroke and malnutrition and who was receiving tube feeding through a gastrostomy tube with a current NPO diet order. The resident had a BIMS of 15 and was cognitively intact. On 4/14/26, an RN observed the resident ambulating with an unsteady gait, red/glossy eyes, increased drooling from baseline, and an odor of alcohol, and found a bottle of whiskey that was about 60% gone in the resident’s room. The resident admitted to sneaking alcohol every day since admission and refused transfer to the hospital for further evaluation, so hourly monitoring was initiated. A physician progress note on 4/15/26 documented that the resident admitted being an alcoholic and sneaking alcohol into the facility daily despite the NPO order and facility policies, and the risks of aspiration were reviewed. The care plan contained no information related to the resident’s noncompliance with the NPO diet order and alcohol consumption, and no interventions were implemented, including monitoring for signs and symptoms of substance use disorder. Multiple staff members later stated they found empty alcohol containers or observed signs consistent with alcohol use, but reported there were no interventions in place related to the resident’s alcohol use, and the DNS acknowledged the medical record needed to include interventions such as signs and symptoms of intoxication.
Failure to Address Recurrent Coprophagia and Behavioral Health Needs
Penalty
Summary
The facility failed to facilitate guardianship and appropriate behavioral health services for a resident with schizoaffective disorder, PTSD, depression, anxiety, and an intellectual disability, while the resident continued to display behaviors that were detrimental to his psychosocial and physical well-being. The resident also had paraplegia, diabetes, chronic kidney disease, dysphagia, and a colostomy. Care plans addressed elimination needs and psychosocial/mood concerns, but the record did not include interventions for the resident opening his colostomy bag, eating feces, or what staff should do when that behavior was observed or suspected. The social services director confirmed there was no care plan mention of the resident’s trauma history or triggers and no evidence that a PASRR had been filed regarding his intellectual disability, psychiatric diagnoses, and acute respiratory illness with hypoxia. The record showed repeated episodes of the resident manipulating his colostomy bag and ingesting stool. A nurse documented witnessing the resident eating bowel movements from a leaking colostomy bag, and the resident became yelling and hit the nurse when educated. A provider note later described the behavior as consistent with pica and documented that staff had seen the behavior multiple times. Additional notes and staff interviews described the resident putting multiple salt packets into food, crying when redirected, picking at his colostomy bag, and eating his own scabs. Several staff members stated they had seen the resident eat feces or touch and lick stool from the colostomy bag, but some said they did not document the behavior or did not think it was a big deal. The resident’s behavior escalated to a hospital transfer after he was found to have gotten into his colostomy bag and eaten stool, followed by nausea, dry heaves, minimal intake, sudden hypoxia, tachycardia, sweating, and low-grade fever. Hospital records documented pneumonia, likely aspiration, and acute respiratory failure with hypoxia. The physician later noted the resident lacked decision-making capacity for surgery and recommended expediting guardianship, but the medical record contained no follow-up documentation related to that recommendation. Interviews also confirmed the social services director had not followed up on the guardianship request and did not know the resident’s triggers, while staff and providers described the resident as childlike, tearful, and unable to understand the impact of his behaviors.
Failure to Provide Behavioral Health Care for Resident Grief
Penalty
Summary
The facility failed to ensure that Resident 41 received necessary behavioral health care in a timely manner to attain or maintain the highest practicable mental and psychosocial well-being. Resident 41 was admitted with diagnoses including neurocognitive disorder with Lewy body dementia and was severely cognitively impaired on the Quarterly MDS, with a BIMS score of 3. The record showed that the resident experienced grief after learning of her sister’s death, and a roommate reported that Resident 41 had been exhibiting new behaviors, including attempting to hit staff and yelling at staff, related to that loss. The clinical record contained only one note addressing the resident’s loss, which was a nursing progress note by the Registered Dietician stating that the resident’s recent poor intake could potentially be related to grief. There was no documented evidence that behavioral health services were provided for the grief, no social service notes, no psychological services notes, and no care plan for grief. The resident’s care plan did not address the specific mental health concern or psychosocial symptoms, and the NHA was unable to provide evidence that Resident 41 was receiving psychological services to maintain the highest practicable level of mental and psychosocial well-being.
Failure to Manage Unsafe Behaviors and Provide Behavioral Health Services
Penalty
Summary
The facility failed to ensure behavioral health care and services were provided for residents with known unsafe behaviors, including unsafe smoking, wandering, elopement risk, and physical aggression toward other residents. The report states the facility did not implement a behavior management process to identify, evaluate, and address behaviors affecting resident safety, and did not recognize the need for adequate supervision and monitoring of residents with unsafe behaviors. The Immediate Jeopardy was cited under F740 Behavioral Health Services and was identified as beginning on 03/30/2024. Resident #33 had diagnoses including Dementia with Moderate Mood Disturbance, Insomnia due to other mental disorders, Mental Disorder NOS, and Paranoid Schizophrenia, and had a BIMS score of 15 of 15. The resident’s behavior management care plan addressed noncompliance with smoking and setting fires, with interventions including 1:1 supervision, re-education on smoking policy, observation and documentation of target behaviors, diversional activities, and behavior medications as ordered. Progress notes and staff interviews documented repeated unsafe smoking-related behaviors, including smoking in undesignated areas, smoking in the building, possession of cigarettes and lighters, and a history of starting fires. Staff described that when cigarettes or lighters were found, they were taken away, and the medical director stated she was aware of the smoking and aggression but not that the resident was a fire starter. Resident #109 had diagnoses including Mood Disorder due to Psychological Condition with Depressive Features, Paraplegia, Nicotine Dependence, and Personal History of Traumatic Brain Injury, and also had a BIMS score of 15 of 15. The resident was care planned for verbal behavioral symptoms, nicotine addiction, and smoking outside designated areas, with an approach to observe for need for 1:1 smoking supervision. Progress notes documented repeated smoking in the room and bathroom, strong cigarette odor, cigarette butts and smoking paraphernalia in the room, and marijuana odor in the room. Staff interviews confirmed that the resident continued to smoke in the room and that no new interventions were put in place beyond education on the smoking policy. Resident #106, who had a history of elopement risk, wandered the facility unsupervised during the day and at night and eloped on 04/14/2026 without the facility being aware. Resident #121, who had a history of elopement risk, noncompliance with care/treatment, and confusion, left the building unsupervised on 04/05/2026 and 04/10/2026, and eloped again on 04/11/2026, nearly being struck by an employee’s vehicle. The facility was aware of the earlier instances because the resident was allowed to leave unsupervised. The report also states the facility failed to manage Resident #116’s pattern of abusive behavior toward other residents, including swinging at, hitting, and pulling other residents to the floor when wheelchairs bumped into each other. Investigative files documented physically abusive incidents involving multiple residents on several dates, and the deficiency affected five sampled residents.
Failure to Identify and Monitor Behavioral Health Needs Related to Substance Use
Penalty
Summary
The facility failed to identify, assess, monitor, and address behavioral health needs related to substance use disorder for residents with known histories of substance abuse. The report states that the facility did not thoroughly review referral information that identified recent substance use and positive toxicology results, and it did not implement appropriate behavioral health interventions, monitoring, and services during a period when social services staff were unavailable. As a result, warning signs of relapse and ongoing substance use were not identified or addressed for Residents #104, #105, and #101. Resident #104 had a hospital history that included opioid withdrawal, fentanyl use disorder, and polysubstance use disorder. The resident’s psychosocial history listed substance abuse, increased anxiety, and a past history of suicidal ideations/attempts. The care plan identified risk for polysubstance abuse and overdose, with interventions to monitor for substance abuse, intoxication, withdrawal, and items brought into the facility. Progress notes described erratic behavior, signs of withdrawal, repeated sliding out of a wheelchair, and self-picking that caused a sore on the face. Staff documented that the resident refused clinical evaluation and a telehealth visit, and the physician was notified of behavior and refusal of care, but the notes did not show staff spoke with the physician specifically about withdrawal from illegal substances. Interviews showed staff believed the resident was withdrawing from street drugs, had a history of opioid abuse, and was later found with fentanyl, methamphetamine, and other substances in the resident’s purse and room. Resident #105 had diagnoses including other psychoactive substance abuse and homelessness. The resident experienced an acute change in condition and was found slumped over in a wheelchair, unresponsive, with labored and irregular respirations and oxygen saturation of 82% on 5 liters of oxygen. Narcan was administered twice, CPR was initiated, EMS transported the resident to the hospital, and the resident was later documented as being on a Narcan drip. The record also showed a care plan addressing overdose risk, substance-seeking behavior, monitoring for intoxication and withdrawal, and room checks. The report further described that Resident #104 and Resident #105 spent time together before the overdose event, and police later reported that Resident #104 admitted obtaining narcotics from an outside source and that narcotics were found in the resident’s room and purse.
Failure to Individualize Behavioral Health Care Plan
Penalty
Summary
The facility failed to develop an individualized behavioral health care plan to address one resident’s behavioral health needs. Resident #1’s psychiatric consult note documented increased agitation, verbal aggression when needs were not met right away, defensiveness and irritability during conversation, and statements about talking loudly so people would understand him. The note also recorded that he said he had been a slave in Honduras and did not like being disrespected or labeled as something he was not. Nursing notes documented multiple dates when behaviors were present, including an incident in which he was observed yelling in the hallway for a pillowcase and continued to yell and act irate even after staff promptly provided it. The resident’s psychosocial note also documented increased agitation when his needs or preferences were not met immediately. Review of the care plan showed no plan addressing his behaviors, cultural background and preferences, or refusal of outside services. Staff interviews confirmed he was verbally aggressive, difficult to calm when he did not get his way, and had loud outbursts when things did not go as he wanted. Social services and nursing staff stated he refused all therapeutic psychiatric services except the consulting psychiatric group, and the administrator and DON confirmed that his behaviors, cultural background, and refusal of services should have been care planned but were not.
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