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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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.
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.
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.
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.
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