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:
A resident with impulse disorder, mood and anxiety diagnoses, and a history of escalating verbal and physical aggression had multiple documented incidents of threats, object throwing, and assault with a cane. Despite a psychiatric consult recommending PRN trazodone for agitation, anxiety, and insomnia, the provider order listed insomnia only, and the care plan was not updated with specific interventions to address the resident’s physically aggressive behaviors after several documented events. Subsequently, the resident struck another resident with a cane, causing a facial laceration that required wound closure and ongoing treatment.
A resident with a history of cerebral infarction and cognitive communication deficit was care planned as being at risk for elopement due to confusion, inability to express needs, and repeated statements about wanting to leave and go home. Interdisciplinary documentation described a consistent pattern of exit-seeking behaviors, including leaving on LOA with a family friend and not returning until the next day, requiring EMS assistance and hospital evaluation upon return, and later being found off facility grounds along a roadside. Despite these ongoing behaviors and the facility’s written Behavior Management Program requiring monitoring forms for residents with problematic behaviors, the clinical record contained no behavior tracking or monitoring specific to the resident’s exit-seeking behaviors, and staff acknowledged that such monitoring should have been in place.
A resident with schizophrenia, anxiety, and depression, who had a history of negative behaviors and identified triggers such as rude or "mouthy" people, became involved in a verbal argument with another cognitively intact resident in a dining area. Staff present were aware of this resident’s triggers and care-planned coping strategies but only reminded the other resident not to throw a drink and did not initiate the facility’s behavioral health response (Code [NAME]) or actively use non-pharmacological interventions at the start of the escalation. After repeated verbal warnings, the second resident threw a drink, prompting the first resident to get up and repeatedly strike the other in the face, causing visible bruising to the nose and forehead before staff separated them and called a Code [NAME].
The facility failed to provide necessary behavioral health care and services for two residents with known self-harm and aggressive behaviors. One resident with quadriplegia, depression, anxiety, and a documented history of self-mutilation by finger biting had repeated episodes of biting his/her fingers to the point of severe lacerations, bone exposure, and eventual amputation, often linked to frustration and delayed smoking. Despite multiple hospitalizations and clear documentation of chronic self-harm and disruptive behavior, the care plan initially lacked self-injury interventions, no specific safety plan or intensive/1:1 monitoring was implemented, and there was no documented ongoing notification of psychiatry or the primary physician about escalating behaviors. Staff interviews showed that many staff knew of the resident’s chronic self-mutilation and verbal aggression but were unaware of any special interventions or monitoring requirements, and the resident was left alone in the room, hall, and on the patio, where another finger was bitten off. Another resident with aggressive behavior and repeated pulling of the fire alarm also lacked documented individualized behavioral interventions or psychiatric follow-up, contrary to the facility’s own Behavioral Emergency and Intensive Monitoring policies.
The facility failed to provide necessary behavioral health services, including trauma evaluations and meaningful interventions, for several residents involved in physical altercations and with significant psychiatric histories. After two residents were physically assaulted by roommates and sustained injuries, psychiatric providers were notified but did not document trauma-focused evaluations or address contributing behaviors such as wandering. Two other residents with schizophrenia, schizoaffective disorder, violent behavior, and documented noncompliance with psychotropic medications were involved in repeated aggressive incidents toward peers and staff, yet records showed only routine refusals of medication without evidence of effective, individualized behavioral interventions. The facility acknowledged a high-behavior population and a pattern of resident altercations, along with dissatisfaction with the psychiatric NP’s limited and delayed evaluations.
A resident with major depressive disorder, anxiety, and multiple psychotropic medications had documented moderately severe depression on PHQ-9 and MDS assessments, along with care plans that listed psychiatrist consults and social services visits only "as indicated." Although the resident had signed consent for psychological services and family sent a text to the social worker reporting that the resident was very depressed, talking about making very bad decisions, and requesting therapy, no referral was made and there is no evidence the resident was ever seen by behavioral health providers. In the weeks before the event, the resident reported increased anxiety and received PRN Hydroxyzine on multiple days without clear documentation of the indication, and no behaviors were charted. The situation culminated when the resident ingested antifreeze in an apparent suicide attempt, telling staff he did not want to be alive anymore, demonstrating the facility’s failure to provide necessary behavioral health care and services.
Failure to Implement Psychiatric Recommendations and Update Behavior Care Plan Leading to Resident Altercation
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary behavioral health services and care planning for a resident with a documented history of psychiatric conditions and aggressive behaviors. The resident was admitted in December 2024 with diagnoses including impulse disorder, adjustment disorder with mixed emotions and conduct, irritability and anger, restlessness and agitation, persistent mood disorder, and generalized anxiety. A Quarterly MDS showed intact cognition with a BIMS score of 13/15 and documented physical and verbal behaviors during the look-back period. Over time, multiple behavioral incidents were recorded, including threats to slit another resident’s throat during a smoking session, verbal disputes with name-calling and threats, and a statement to another resident that if touched again the resident would be killed. Further documentation showed escalating behaviors, including an incident where the resident attacked a roommate with a cane over television volume and required ER transfer for psychiatric evaluation, throwing poker chips and yelling when not winning at Bingo, causing the roommate to avoid the shared bathroom due to inappropriate comments and frustration over the light being turned on at night, and throwing a lunch plate across the nurses’ station at a nursing assistant over portion size. The care plan, initiated in January 2025 for verbal aggression and resident-to-resident altercations, did not contain added interventions to address the resident’s physically aggressive behaviors toward others after the incidents on 2/21/2026, 3/9/2026, and 4/10/2026. The DNS later could not provide evidence that the care plan had been updated with interventions to mitigate the risk of these physically aggressive behaviors or to guide staff in ensuring the safety of other residents. On 4/23/2026, a psychiatric evaluation recommended starting trazodone 25 mg twice daily as needed for agitation, anxiety, and insomnia, with monitoring of response and tolerability. However, the physician’s order dated 4/24/2026 implemented trazodone 25 mg twice daily as needed for insomnia only, and the record lacked evidence that agitation and anxiety were included as indications for use as recommended by the consulting psychiatrist. Both the RNP and the DNS stated it was their expectation that the trazodone order would have included agitation and anxiety. Following this incomplete implementation of the psychiatric recommendation and the lack of updated behavioral interventions in the care plan, a resident-to-resident altercation occurred on 4/27/2026 in which the resident struck another resident with a cane, causing a laceration to the left eyebrow that required closure with steri-strips and ongoing wound treatment.
Failure to Implement Behavior Monitoring for Exit-Seeking Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement behavior monitoring for a resident with known exit-seeking behaviors. Resident B’s clinical record showed diagnoses including cerebral infarction and cognitive communication deficit, and a care plan dated 4/24/26 identified the resident as being at risk for elopement due to periods of confusion, inability to verbally express needs, and verbal statements about wanting to leave and go home and not wanting to be at the facility. An IDT note dated 4/27/26 documented that the resident had a consistent pattern of expressing a desire to leave, with gesturing and behaviors indicative of exit-seeking. The note further described that on 4/19/26 the resident left the facility on a leave of absence with a family friend and did not return until the next day, and upon return initially refused to exit the vehicle, requiring assistance and EMS, and was sent to the hospital for evaluation before returning to the facility the following day. The IDT note also documented that the resident continued to express a desire to leave and exhibited ongoing exit-seeking behaviors, and that on 4/25/26 the resident was identified off facility grounds and located on the roadside at approximately 8:06 p.m. Despite these documented behaviors and events, the clinical record lacked documentation of the implementation of behavior tracking or monitoring for the resident’s exit-seeking behaviors. During the survey, a staff member indicated the resident had exit-seeking behaviors prior to the day of the elopement, and Social Services confirmed that the resident should have had behavior monitoring in place for exit-seeking behaviors. The facility’s Behavior Management Program policy, provided by the Regional Director of Operations, stated that residents exhibiting problematic behavior are to be observed to identify causal factors and appropriate interventions, and that each such resident should have a monitoring form listing behaviors and interventions specific to the resident, which was not in place for this resident.
Failure to Initiate Behavioral Health Response During Verbal Escalation Leading to Resident Assault
Penalty
Summary
The deficiency involves the facility’s failure to follow its behavioral health response procedures, specifically not initiating a Code [NAME] at the start of a verbal escalation involving a resident with known behavioral health diagnoses. Facility policy required that residents receive necessary behavioral health services, including person-centered, non-pharmacological interventions and staff education to recognize and respond to behavioral triggers and escalating behaviors. Resident #2 had documented diagnoses of schizophrenia, anxiety disorder, and major depressive disorder, with a care plan noting prior physical altercations, negative behaviors such as yelling, threatening to hurt people, and throwing objects, and triggers including rude people, yelling, cursing, and people not listening. Interventions in the care plan included closely monitoring for signs of anxiety, acting before the resident lost control, avoiding power struggles, respecting personal space, and using coping skills and meaningful activities to reduce anxiety and prevent escalation. On the day of the incident, Resident #1 and Resident #2 were seated at a table and became involved in a verbal argument. According to interviews and witness statements, the conversation included comments about Resident #1’s child and led to mutual name-calling. Resident #2 warned Resident #1 multiple times not to throw a drink and stated that he/she would “whoop” Resident #1’s “ass” if the drink was thrown. Staff present, including CNAs, were aware that Resident #2 had triggers related to “mouthy people” and boredom and that he/she escalated quickly to anger. One CNA reported checking in with Resident #2 when the argument started but did not actively intervene, instead only reminding Resident #1 not to throw the water. Another staff member was heard shouting for the residents to stop just before the altercation became physical. Staff interviews later indicated that they recognized there had been an opportunity to intervene earlier using Resident #2’s coping strategies, such as talking, walking, or engaging in activities, but these interventions were not implemented at the onset of the verbal escalation. The situation escalated when Resident #1 threw a cup of juice or water at Resident #2, after which Resident #2 got up and began hitting Resident #1 in the face. Witnesses observed Resident #2 punching Resident #1, and staff then called a Code [NAME] and physically separated the residents. Resident #1 sustained yellow and purple bruising to the nose and left eyebrow/forehead area and reported pain in those areas. Resident #2 was later observed in his/her room breathing heavily and appearing anxious, with superficial scratches to the upper chest, and reported that he/she had “blacked out” during the incident and continued punching until staff pulled him/her away. Multiple staff, including CNAs, a CMT, the ADON, the NP, and the DON, acknowledged that the altercation was triggered behavior and that earlier, more active behavioral intervention at the start of the verbal escalation could possibly have prevented the physical assault. The failure to utilize the facility’s behavioral health practices and procedures, including calling a Code [NAME] at the start of the verbal escalation and implementing care-planned non-pharmacological interventions, led to Resident #2 striking Resident #1 in the face and causing bruising. Resident #1, who was cognitively intact and had no documented behavioral symptoms in the MDS look-back period, was later care planned for involvement in a physical altercation with emotional distress and bruising to the nose. Resident #2, also cognitively intact with no behavioral symptoms noted in the most recent MDS look-back period, nonetheless had an existing care plan documenting significant behavioral risks, triggers, and required interventions. Staff interviews consistently reflected awareness of Resident #2’s behavioral history, triggers, and need for meaningful activities and coping support, yet during the incident they did not fully implement these interventions or initiate the behavioral health response at the onset of the verbal conflict. This sequence of inaction in the face of known risk factors and escalating verbal aggression directly preceded the physical altercation and resulting injury to Resident #1.
Failure to Provide Behavioral Health Services for Residents With Self-Harm and Aggressive Behaviors
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary behavioral health care and services for residents with known self-harm and aggressive behaviors, specifically failing to develop and implement appropriate care plan interventions, safety planning, and timely psychiatric referrals. One resident with quadriplegia, depression, anxiety, and a documented history of self-mutilation by biting his/her fingers was admitted with prior PASRR documentation noting routine self-harm by biting the middle or index finger, prior hospitalization for a bite wound infection, and staff reports that mental health follow-up would be arranged. The admission MDS identified self-directed behavioral symptoms occurring several days and placing the resident at significant risk for physical injury and interference with care. Despite this, the care plan initially contained no interventions for self-injury in January or February, and there were no behavioral monitoring orders or documented safety plan specific to the resident’s finger-biting behavior. Following admission, multiple episodes of self-harm occurred, with staff repeatedly observing the resident biting his/her right-hand fingers, causing bleeding, open lacerations, and progressive damage to the bone, resulting in repeated transfers to the hospital. Progress notes document that the resident bit his/her middle finger shortly after admission, leading to hospital transfer for a self-inflicted wound, and later reopened the wound by biting, again requiring hospital care. Subsequent notes describe the resident biting his/her finger to obtain a cigarette, biting to the point of bone exposure, and stating an intention to continue biting until the finger fell off. Staff documented ongoing verbal abuse, yelling, cursing, and difficulty redirecting the resident, but there was no consistent documentation of behavioral interventions, no evidence of intensive monitoring or 1:1 observation in the facility record, and no documented safety plan addressing triggers such as smoking delays or frustration. Although the care plan was later updated to include a generic focus on risk for self-directed violence and listed interventions such as assessing self-harm thoughts, developing a written safety plan, and referring to psychiatric services, the electronic medical record contained no actual safety plan or specific, implemented interventions related to the resident’s finger-biting behavior. The facility also failed to ensure timely and ongoing psychiatric involvement despite repeated self-harm episodes. A psychiatry NP completed an initial assessment noting the resident’s history of self-harm by finger biting, verbal aggression, and irritability, and directed staff to monitor and promptly report any self-harm behaviors. However, after this encounter there were no further psychiatry notes, and the record contained no documentation that psychiatry or the primary care physician were notified of the resident’s ongoing and escalating self-mutilation. Hospital documentation later identified psychiatric diagnoses including delirium and antisocial personality disorder, with associated complications of agitation, violence, self-injurious behavior, impulse control problems, and poor insight and judgment, and specifically indicated that continuous 1:1 observation was required due to risk of harm to self. When the resident returned from the hospital with a surgical dressing and a recent history of finger amputation, staff interviews revealed that no 1:1 or enhanced monitoring was implemented, staff were unaware of any special interventions, and the resident was left alone in his/her room or in the hall and on the patio. During a supervised smoking period, the resident became agitated about delays in smoking, was briefly left unattended, and bit off another finger. Multiple CNAs, a restorative aide, an activities aide, a CMT, and nursing staff stated that everyone knew about the resident’s chronic self-mutilation and disruptive behaviors, yet they were not aware of any specific interventions, 1:1 monitoring, or safety plan in place to prevent further self-harm. In addition, the facility failed to address another resident’s aggressive behavior and repeated pulling of the facility fire alarm. This resident’s behavior included aggressive actions and multiple instances of activating the fire alarm, but the report does not describe any individualized behavioral interventions, monitoring plans, or psychiatric referrals implemented to address these behaviors. The facility’s own Behavioral Emergency and Intensive Monitoring policies require early non-physical interventions, assessment of residents in behavioral crisis, notification of physicians or psychiatrists, updating care plans, and use of intensive or 1:1 monitoring for residents with poor impulse control, self-harm, or aggressive behaviors. Despite these policies, the documented actions and staff interviews show that these processes were not effectively carried out for the residents in question, leading to repeated self-mutilation events for one resident and unaddressed aggressive and alarm-pulling behavior for another. The Administrator was notified that an Immediate Jeopardy situation existed related to these failures, beginning on 4/21/26, based on the facility’s failure to provide necessary behavioral health services, to implement care plan interventions and safety planning for known self-harm behaviors, and to timely involve psychiatric services, resulting in repeated episodes of self-mutilation by finger biting and unaddressed aggressive and alarm-pulling behavior.
Failure to Provide Trauma Evaluations and Effective Behavioral Health Interventions
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary behavioral health care and services, including trauma evaluations, following resident-to-resident physical abuse incidents. One resident with psychosis, schizophrenia, and major depressive disorder was found on the floor with a bleeding nose, a skin tear, and forehead redness after being pushed and kicked by another resident. A psychiatry progress note documented that the psychiatric NP saw the resident per staff request, but the record lacked documentation that the altercation or physical abuse incident was discussed or that the resident’s newly identified wandering behavior, which led to the altercation, was addressed. Another resident with COPD, heart failure, and schizoaffective disorder was punched by a roommate, resulting in discoloration around the eye, a nose bridge abrasion, and a forehead skin tear. Although the care plan for emotional distress included a psychiatry evaluation and the NP was informed of the incident, there was no documented evidence that a psychiatric trauma evaluation was completed. The facility also failed to implement meaningful behavioral health interventions for residents with psychiatric histories, aggressive behaviors, and refusal of psychotropic medications. One resident with schizophrenia and paranoid personality disorder, intact cognition, and a history of violent behavior and homicidal ideation, including chasing a person with a knife and threatening police, was involved in multiple physical altercations. This resident punched another resident in the smoking area and later admitted to pushing and kicking a different resident who entered the room. The care plan identified behavioral problems such as irritability, anger, violent behavior, homicidal ideations, mood swings, and a tendency to push and kick other residents, with interventions including attempts to identify underlying causes. However, the medical record showed the resident routinely refused medications, and there was no documentation of effective, meaningful interventions addressing this ongoing refusal and associated behaviors. Another resident with neuroleptic-induced Parkinsonism, schizoaffective bipolar type, and psychosis, recently transferred from a psychiatric hospital after an exacerbation of schizophrenia symptoms and noncompliance with psychotropic medications, was also involved in a physical altercation. Progress notes documented that this resident punched a roommate, was screaming violently, hostile, physically aggressive, and non-redirectable toward residents and staff. A social services note indicated that when staff attempted to discuss the altercation, the resident became agitated, screamed, yelled, and used inappropriate language, preventing further information gathering. A refusal of treatment form showed the resident had declined medications after being informed that refusal could affect mood stabilization and worsen behaviors. Despite the facility’s acknowledgment of a high-behavior population and multiple resident altercations, the report describes a pattern of inadequate psychiatric support and lack of thorough evaluations and timely, effective behavioral interventions for these residents.
Failure to Provide Behavioral Health Services for Depressed Resident Leading to Suicide Attempt
Penalty
Summary
The deficiency involves the facility’s failure to ensure that necessary behavioral health services were provided to a resident with significant mental health diagnoses and documented depressive symptoms. The resident was admitted with multiple medical and psychiatric diagnoses, including major depressive disorder, generalized anxiety disorder, and alcohol abuse, and had signed a supplemental admission agreement granting permission to receive psychological services. Physician orders included multiple psychotropic medications for depression, anxiety, and agitation, as well as an order for staff to record behavior monitoring each shift using a defined numerical behavior scale. A PHQ-9 assessment in early January showed a score of 15, indicating moderately severe depression with recommended treatment actions including pharmacotherapy with psychotherapy, and the quarterly MDS documented a total mood severity score of 15 with little interest in activities and poor appetite over most of the lookback period. Despite these findings and the resident’s psychiatric diagnoses, the care plan only listed psychiatrist consults and social services visits as "as indicated" and there is no evidence in the record that psychological or psychiatric services were actually provided during the resident’s stay. The DON confirmed that the resident had signed permission to receive psychological services and that the resident did not receive such services while in the facility. The social worker acknowledged receiving a text message from the resident’s son reporting increased depression and requesting some kind of therapy, stating the resident was very depressed and talking about making very bad decisions, and asking if someone could talk him through continuing therapy. The social worker did not make a referral for psychological services and could not provide evidence that the resident was ever seen or evaluated by behavioral health providers. In the weeks preceding the incident, the resident reported increased anxiety related to financial worries, leading to a 14-day PRN order for Hydroxyzine, which was administered on eight days during that period. Nursing documentation did not specify whether the Hydroxyzine was given for anxiety or itching, and no behaviors were documented on the MAR or in corresponding progress notes. On the day of the incident, the resident’s son called the facility after receiving a goodbye call from the resident. Staff found the resident alert with a bright yellow substance on his gown and bedding, an open bottle of antifreeze on the bedside table in an open Amazon box, and the resident admitted to putting antifreeze in a coffee cup and drinking it, stating he could not get a gun and that he did not want to be alive anymore. The resident and his son both reported prior expressions of wanting to harm himself and worsening depression in the weeks leading up to the suicide attempt. The facility’s own behavioral health services policy stated that residents exhibiting signs of emotional or psychosocial distress would receive services and support to address their needs, but the resident did not receive behavioral health services despite documented depression, anxiety, and family-reported concerns.
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