Failure to Implement Individualized Behavioral Health Interventions for Suicidal Resident

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to follow up with psychiatric recommendations in a timely manner for one resident reviewed for mood and behavior. The resident was admitted with diagnoses including schizophrenia, depression, and muscle weakness. Hospital discharge instructions dated 01/02/26 directed follow-up with psychiatry in one week and documented that Oxcarbazepine was being down titrated to 30 mg and Lamotrigine 25 mg twice daily was started with slow up titration in the outpatient setting. The resident’s physician orders included Doxepin 75 mg at bedtime, Invega Sustenna 156 mg/mL IM every three weeks, Lamotrigine 25 mg twice daily, and Olanzapine 100 mg twice daily. The DON stated the psychiatric NP visited the resident in house on 01/30/26, but progress notes typically take about a month to obtain. The DON later provided the psychiatric progress note dated 01/30/26, which recommended obtaining Genesight testing if the resident and family were agreeable and obtaining records from the previous outpatient psychiatric provider to confirm diagnosis and prior medication trials. The DON verified these recommendations were not completed.

Penalty

Fine: $117,130

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide a safe environment free from drugs and alcohol and did not have an effective substance abuse program, as evidenced by multiple residents engaging in ongoing illicit drug and alcohol use while residing in the facility. Several residents with histories of substance use disorders, including opioid dependence, cocaine abuse, and alcohol abuse, were repeatedly found to be using illicit substances such as methamphetamine, cocaine, marijuana, and alcohol. Despite positive drug screens, observed drug paraphernalia, and admissions of ongoing use, the facility did not implement specific interventions to prevent or reduce illicit drug use, nor did it update care plans to address these issues. Staff interviews confirmed that drug access was a common problem and that the facility was not taking adequate action to address it. In one case, a resident with a history of opioid dependence and major depressive disorder tested positive for multiple illicit substances on several occasions, including methamphetamine, cocaine, and marijuana, without corresponding prescriptions. The resident's care plan lacked interventions specific to illicit drug use, and staff reported finding drug paraphernalia in the resident's room. The facility's behavioral health specialists stated that their recommendations for interventions were not implemented, and the administrator confirmed there was no policy addressing confirmed illicit substance use among residents. The facility's only response to suspected drug use was to notify the physician, as per their outdated policy. Other residents were also involved in incidents of drug use and related behaviors. Two residents sharing a room were found with an unknown visitor in possession of drugs, and one was observed performing sexual acts in exchange for substances. The facility failed to follow its own abuse and exploitation policies in response to this incident. Another resident with a history of alcohol and cocaine abuse was repeatedly found intoxicated, involved in altercations, and observed using marijuana in the facility, with no documented follow-up or interventions by staff. Interviews with staff and administrators confirmed a lack of cohesive care and policy regarding substance abuse, and that the facility had not taken effective steps to address the ongoing drug problem.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when the facility failed to implement a person-centered care plan to support the behavioral health care needs of a resident with multiple psychiatric and physical diagnoses, including borderline personality disorder, PTSD, generalized anxiety disorder, severe morbid obesity, and chronic pain conditions. The resident had documented care plans addressing pain management, behavioral symptoms, aggressive behaviors, and psychiatric/mood issues, with specific interventions such as timely medication administration, emotional support, and strategies to minimize behavioral triggers. Despite these plans, the resident did not receive scheduled medications at the prescribed time after requesting them during the night, resulting in a delay of care. On the night in question, the resident requested her scheduled medications at 4:00 A.M., but the assigned RN was on break. Upon returning, the RN did not attempt to administer the medications or seek assistance from other available nurses, despite the presence of additional licensed staff on duty. The RN reported feeling unsafe due to the resident's agitated and hostile behavior, which included yelling and making derogatory remarks. Instead of following up with the physician or nurse practitioner regarding the late medication request, the RN only contacted facility management via text and did not receive a timely response. The resident ultimately did not receive her medications until several hours later, after experiencing significant pain. Interviews and documentation confirmed that other nurses could have administered the medications, and that the RN's failure to do so was not in accordance with facility policy or standard nursing practice. The facility's medication administration policy required medications to be given as ordered, and the behavioral assessment policy emphasized individualized interventions to address residents' needs. The incident was substantiated by medical record review, staff interviews, and disciplinary action taken against the RN for failing to provide necessary care.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide necessary behavioral health care and services to a resident with a documented history of substance use disorder, resulting in neglect of the resident’s mental and psychosocial well-being. The resident, who had multiple diagnoses including paraplegia, anxiety disorder, depression, and chronic pain syndrome, was admitted with a known history of drug abuse, including the use of marijuana, methamphetamines, and cocaine. Despite this, the facility did not include substance use disorder in the resident’s diagnosis list or care plan, nor did it address his history of homelessness or trauma related to his accident and loss of his parents. The care plan lacked any mention of substance use triggers, interventions for substance use, or actions to take when the resident returned to the facility with altered mental status. Throughout the resident’s stay, there were multiple documented incidents of suspected substance use, including episodes where the resident returned to the facility with altered mental status, dilated pupils, lethargy, and abnormal behavior. Staff observed drug paraphernalia in the resident’s room, such as rolled-up dollar bills and pipes, and noted the presence of visitors at odd hours who were suspected of bringing in illicit substances. Despite these observations, the facility did not update the care plan to address substance use, did not consistently monitor or test for drug use, and failed to implement specific interventions to manage the resident’s behavioral health needs. Orders for naloxone (Narcan) and monitoring for adverse effects from substance use were absent, and staff responses were limited to holding narcotic medications and requesting drug screens, which the resident often refused. Interviews with staff revealed a lack of coordinated response and documentation regarding the resident’s substance use and related behaviors. The CNP acknowledged that the diagnosis of drug abuse should have been retained and that conversations about substance use disorder treatment were not documented. The DON confirmed that no care plan updates were made following a significant increase in the resident’s depression score. Staff expressed concerns about their safety and the impact of the resident’s behaviors on other residents and staff, but there was no evidence of supervision or restriction of visitors who may have contributed to the resident’s substance use. The facility’s failure to assess, care plan, and intervene appropriately for the resident’s behavioral health and substance use needs resulted in neglect as defined by facility policy.