Aspen Ridge West Transitional Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Murray, Utah.
- Location
- 5323 South Murray Boulevard, Murray, Utah 84123
- CMS Provider Number
- 465166
- Inspections on file
- 15
- Latest survey
- January 14, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Aspen Ridge West Transitional Rehab during CMS and state inspections, most recent first.
Infection prevention and control was not maintained when EBP was inconsistently implemented for residents with PICC lines, an NG tube, a chronic wound, and an indwelling catheter. Staff were observed using gloves without gowns, one RN exited a room without hand hygiene after handling a PICC line, and there was no EBP signage for some residents. Clean linens were also observed on the laundry room floor.
A resident kept an unlabeled bottle of white tablets in the room, identified by the resident as digestive enzymes taken throughout the day, but there was no nursing assessment or MD order authorizing self-administration. Staff, including an LPN, NM, and DON, stated that a resident needed an assessment and order before medications could be stored in the room, and the resident’s record did not contain either document.
A resident with fractures and CKD missed multiple doses of ordered meds because the pharmacy did not have eszopiclone and dronabinol in stock. The MAR showed several consecutive days of non-administration for both meds due to unavailability. Interviews with an LPN, NM, and DON showed staff expected the floor nurse to contact the pharmacy and physician, but the NM was not aware the resident’s meds were unavailable.
Failure to Document Pneumococcal Immunization Offer or Declination: The facility did not document that two residents were offered the pneumococcal vaccine or that they refused it. One resident’s USIIS record showed no pneumococcal immunizations, and another resident’s USIIS record showed prior pneumococcal vaccines but indicated a current dose was due. Staff interviews confirmed that the admission nurse was responsible for reviewing immunizations, but the records did not show a declination or documentation of vaccine status for either resident.
A resident reported feeling threatened and scared for her safety due to a CNA's angry behavior during assistance with her bedtime routine. The facility did not report this allegation of mistreatment to the appropriate authorities, as required, instead treating it as a customer service issue.
A resident reported feeling threatened and unsafe due to a CNA's angry and rough behavior, but the facility did not conduct a thorough investigation into the abuse allegation as required by policy, instead treating the incident as poor customer service.
The facility failed to ensure safe self-administration of medications for two residents. One resident, with multiple diagnoses, had medications left at the bedside without authorization for self-administration. Another resident, with cognitive impairment and tremors, also had medications left unattended, despite lacking a self-administration assessment. Interviews revealed that leaving medications at the bedside was against facility policy.
Infection Prevention and Control Program Not Maintained
Penalty
Summary
The facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. During the initial tour, surveyors noted there was no Enhanced Barrier Precautions (EBP) signage for residents 3, 15, and 17. The Director of Nursing stated that residents requiring EBP should have a sign on their door and that gowns and gloves should be worn when staff spent over 15 minutes in a resident’s room, but the observations and interviews showed that this was not consistently occurring. Resident 15 had diagnoses that included sepsis and a cutaneous abscess of the buttock and had a physician order for EBP due to a right upper extremity PICC line. The resident was observed with the PICC line in place, stated that staff had only worn gloves when providing care, and there were no gowns in the room or EBP sign on the door. Later, two CNAs were observed weighing the resident with a Hoyer lift while wearing gloves and no gowns. Resident 55 had diagnoses that included osteomyelitis and left third toe resection and had an order for EBP due to a PICC line. The resident was observed receiving IV antibiotics through the PICC line, and the RN handling the line wore gloves but no gown and exited the room without performing hand hygiene. Resident 17 had diagnoses that included a left below-knee amputation and a stage 2 sacral pressure ulcer and was observed receiving NG tube feeding and having an indwelling catheter with a drainage bag. A physician order was created for EBP due to an NG tube and chronic wound to the left stump. Although an EBP sign and gowns were later observed in the room, staff interviews showed inconsistent understanding of EBP, with one CNA stating gowns were only for residents in isolation and an RN stating gowns were only needed for respiratory infections or not needed for PICC lines. In the laundry room, clean linens were observed on tables, with a blanket hanging off a table and touching the floor, and a pillowcase and towel on the floor; the housekeeper stated the items were clean and just needed to be folded.
Unapproved Self-Administration of Medications
Penalty
Summary
The facility did not ensure the right to self-administer medications when clinically appropriate because Resident 2 had medications kept in the room without a nursing assessment or physician order authorizing self-administration. Resident 2 was admitted with diagnoses including displaced transverse fracture of the shaft of the right fibula, displaced fracture of the lateral malleolus of the left fibula, age-related osteoarthritis, and diverticulitis of the large intestine. During an interview and observations, surveyors found an unlabeled prescription bottle containing white tablets on the resident’s bedside table, and the resident stated the tablets were digestive enzymes taken throughout the day. A later observation again found an unlabeled medication bottle on the bedside table, halfway filled with white tablets. Staff interviews confirmed that medications in a resident’s room required a nursing assessment and a physician’s order for self-administration. A CNA stated she would notify the nurse if she saw medications in a room and was not aware of any residents currently keeping medications in their rooms. An LPN stated that if a resident requested to self-administer medications, the admissions nurse would assess the resident and obtain a physician order before medications could be stored in the room, and she acknowledged that Resident 2 kept medication in the room. The NM and DON both stated that a resident needed a nursing assessment and physician order before medications could be kept in the room, and both were unable to locate either document in Resident 2’s record.
Unavailability of Ordered Medications
Penalty
Summary
The facility failed to provide routine and emergency drugs and biologicals to meet resident needs when Resident 3 did not receive multiple ordered medications because they were out of stock and unavailable from the pharmacy. Resident 3 was admitted with diagnoses including fracture of the first lumbar vertebra, nondisplaced zone II fracture of the sacrum, and chronic kidney disease. A physician’s order for eszopiclone at bedtime was started on 12/12/25, but the December 2025 MAR showed the medication was not administered on 12/12/25, 12/13/25, 12/14/25, and 12/15/25 because it was unavailable. A physician’s order for dronabinol once daily was started on 12/24/25, and the MAR showed it was not administered on 12/25/25, 12/26/25, 12/27/25, 12/28/25, 12/29/25, and 12/30/25 because it was unavailable. Staff interviews showed that an LPN would contact the pharmacy and notify the NM if a medication was unavailable, and the NM stated he would contact the pharmacy, family, and physician if needed, but he was not made aware that Resident 3 had unavailable medications. The DON stated that the floor nurse was expected to contact the pharmacy and inform the physician, and that a resident’s medication should not be unavailable for any period of time, especially more than a day or longer.
Failure to Document Pneumococcal Immunization Offer or Declination
Penalty
Summary
The facility did not ensure that residents were offered the pneumococcal immunization and that the medical record documented either receipt of the vaccine or a valid reason for not receiving it, such as medical contraindication or refusal. For 2 of 5 sampled residents, Resident 15 and Resident 55, there was no documentation that the pneumococcal immunization was offered or declined. Resident 15’s record contained a PNA/FLU/COVID/RSV Immunizations, Medication Consent form signed on 12/30/25, and a USIIS record showing no pneumococcal immunizations, but the record did not show that she was offered or declined the vaccine. Resident 55’s record contained a similar signed immunization consent form and a USIIS record showing prior pneumococcal vaccines, including PCV-13 on 8/7/17 and PPSV 23 on 10/13/97 and 1/1/06. The USIIS record indicated that Resident 55 was due for a pneumococcal immunization and required PCV 20 or PCV 21 per CDC timing, but the medical record did not show that she was offered or declined the immunization. During interviews, the Nurse Manager stated he reviewed USIIS for new admissions, notified the DON when residents were not current, and documented refusals in a progress note, while the DON stated the admission nurse was responsible for discussing immunizations but did not have access to USIIS and should have verified immunization status and documented either administration or declination.
Failure to Report Resident Allegation of Threatening Behavior by CNA
Penalty
Summary
The facility failed to report an allegation of abuse, neglect, exploitation, or mistreatment as required. A resident submitted a grievance stating that a CNA appeared angry while assisting her with her bedtime routine, threw her belongings onto a chair, and made her feel threatened and scared for her safety. The resident requested a different CNA, but her request was denied, and the CNA continued to act angrily when asked to assist further. The resident documented her fear and sense of being threatened in the grievance report. The Administrator reviewed the grievance the following day and spoke with the resident, who described the CNA as angry and rude. The Administrator determined that the incident was a matter of poor customer service rather than abuse, and did not report the allegation to the appropriate authorities. The facility's failure to report the resident's allegation of feeling threatened and unsafe constituted a deficiency in meeting the requirement to report all allegations of abuse, neglect, exploitation, or mistreatment.
Failure to Thoroughly Investigate Allegation of Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a resident who reported feeling threatened and unsafe due to the actions and demeanor of a CNA. The resident documented that the CNA appeared upset, was angry when corrected, handled her belongings roughly, and denied her request for another CNA to assist. The resident expressed feeling scared and threatened by the CNA's behavior. The grievance was documented, and the administrator spoke with the resident the following day. Despite the resident's report of feeling threatened and unsafe, the administrator determined the incident was a matter of poor customer service rather than abuse, based on the resident's statement that she did not feel it was abuse. The administrator did not conduct a thorough investigation as required by the facility's abuse policy, which mandates a written summary of findings within five working days. The documentation lacked evidence of a comprehensive investigation into the allegation of abuse.
Failure to Ensure Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that the right of residents to self-administer medications was clinically appropriate and safe. For Resident 20, who was admitted with multiple diagnoses including a wedge compression fracture and cardiac arrhythmia, medications were left on the bedside table without confirming if the resident was authorized to self-administer. During a morning medication pass, Resident 20 expressed nausea, prompting RN 1 to leave the medication at the bedside, despite not knowing if there were orders permitting self-administration. Resident 27, who had significant cognitive impairment and essential tremors, was also observed with medications left at the bedside. Despite a BIMS score indicating cognitive impairment, RN 1 left medications for Resident 27, who was unable to confirm if she self-administered her medications. The resident's medical records lacked a Self Administration Assessment, and RN 1 acknowledged that Resident 27 sometimes forgot to take her medications or had difficulty due to tremors. Interviews with RN 2 and the Director of Nursing (DON) revealed that leaving medications at the bedside was against facility policy. RN 2 stated that medications should not be left unattended due to the risk of other residents taking them. The DON confirmed that medications should be locked up if a resident refused them, and a self-medication assessment should be conducted before allowing residents to have medications in their rooms.
Latest citations in Utah
Surveyors found that the facility did not ensure residents or their representatives were informed of and able to participate in decisions about psychotropic medications. Several residents with conditions such as dementia, early-onset Alzheimer’s disease, major depressive disorder, psychotic disorder, and Parkinson’s disease were started on drugs including haloperidol, donepezil, buspirone, quetiapine, zaleplon, and sertraline without documentation that risks, benefits, or alternative treatments were discussed in advance. The DON reported that staff notify families when medications are started or changed but do not review risks and benefits, offer alternative options, or obtain signed consent, resulting in no evidence of informed decision-making for these psychotropic treatments.
Surveyors determined that the facility failed to consistently manage psychotropic medications for three residents. Two residents with dementia and psychiatric conditions had only one documented psychotropic medication review and gradual dose reduction (GDR) attempt, completed in January, with no evidence of quarterly reviews or additional GDR efforts. Another resident with hemiplegia, psychotic disorder, dementia, and major depressive disorder had a PRN IM haloperidol order written without an end date, which remained active and was administered on multiple occasions beyond 14 days, and the DON confirmed there was no physician documentation justifying the extended PRN antipsychotic order.
The facility failed to ensure that alleged abuse and serious injuries were reported to the State Survey Agency as required, instead either reporting only to a state patient safety system or not reporting at all. One resident with severe cognitive impairment sustained bilateral femur fractures after a fall, another cognitively impaired resident with Parkinson’s disease was later found to have a femur fracture after being discovered on the floor, and a third cognitively impaired resident required ORIF surgery for fractures following a fall; none of these incidents were reported through the State Survey Agency’s incident reporting website, per the ADM. In addition, an allegation that a resident with dementia and sensory impairments may have been molested was documented in the abuse binder but not in the medical record, and the ADM did not report the allegation to agencies or law enforcement after deeming it not credible, despite interviewing the resident and family. These actions and omissions resulted in multiple unreported events that met criteria for immediate reporting of alleged abuse and injuries of unknown source.
The facility failed to investigate multiple major injuries and an allegation of sexual abuse involving three residents with severe cognitive impairment and significant medical conditions. One resident, dependent for transfers, was found on the floor after attempting to get out of bed and was later found to have bilateral femur fractures. Another resident with Parkinson’s disease was found on the floor after a wheelchair alarm sounded and was later diagnosed with a femur fracture following complaints of leg pain. A third resident, described as very independent, triggered a bed alarm and was found kneeling by a recliner, later requiring ORIF for fractures of the right 4th and 5th metacarpals. In each case, the ADM acknowledged awareness of the fractures, stated there was no belief of neglect or abuse, and confirmed that no investigation into the cause of the injuries or the alleged abuse was initiated or documented.
Surveyors found that the facility failed to ensure monthly pharmacist drug regimen reviews were completed and documented for several residents with conditions such as Parkinson’s disease, dementia, and Alzheimer’s disease, with no pharmacist notes present for at least two consecutive months. Additionally, a pharmacist’s recommendation to add a low-dose daytime antipsychotic for a resident with dementia, psychotic disorder, and behavioral symptoms was not communicated to the physician or implemented for several months, despite documented behavioral concerns. An LPN reported not relaying the pharmacist’s recommendation because PRN Haldol had not been needed at that time, and the DON confirmed that the pharmacist reviews for the missing months were not done and that she did not have time to monitor follow-through on such recommendations.
Surveyors identified a failure to properly label medications when two open insulin pens were found in a medication refrigerator bin marked only with a resident’s first name, with no labels directly on the pens. During an observation, an RN confirmed the pens belonged to a resident and acknowledged that pens are supposed to be labeled with the resident’s name but could not explain why these were not labeled. In a subsequent interview, the DON confirmed the pens had been unlabeled and stated they should have been labeled in accordance with professional standards.
The facility failed to sustain effective QAPI processes related to pharmacist medication regimen reviews, resulting in repeated noncompliance with F756. Surveyors found that medical records for four residents lacked documentation showing that a pharmacist had reviewed medications, identified potential irregularities, or made recommendations to attending physicians, an issue previously cited. The DON reported she did not have time to maintain this documentation, and the Administrator acknowledged there was no formal performance improvement project in place, though some plans were noted in QAPI minutes, and no supporting documents were produced to demonstrate ongoing compliance.
Staff failed to follow infection control practices during medication administration and did not maintain organized infection surveillance documentation. An LPN was observed handling an oral medication with bare hands before administering it to a resident, contrary to the DON’s stated expectation that pills be dispensed directly into medication cups without hand contact and that any contaminated dose be discarded. Additionally, the DON, who also served as the Infection Preventionist, reported that several residents had influenza during a past holiday season but had no list of affected residents or rooms, and the requested infection control surveillance logs and a formal tracking system were not available.
The facility lacked an antibiotic stewardship program, with no protocols to ensure appropriate indication, dose, and duration of antibiotic prescriptions and no system to monitor antibiotic use or resistance patterns. When surveyors requested Infection Control Surveillance Logs, including antibiotic tracking information, the logs were not available. In an interview, the DON, who also functioned as the Infection Preventionist, acknowledged that she did not track resident antibiotic utilization, clinical indications, or treatment durations.
A resident with multiple chronic conditions, including DM, HTN, anxiety, major depressive disorder, and PTSD, reported that a CNA on night shift failed to hold open a smoking-area door, leading the resident to grab the door and sustain a finger cut that bled. The resident completed a grievance with the RA, who documented that the CNA swung the door open and walked away and that no abuse or neglect allegation was initially identified. However, the grievance lacked documentation of investigative steps, a summary of findings, a conclusion on whether the grievance was confirmed, and any decision date or required signatures, and leadership later reported they had not been informed of the incident, demonstrating the grievance was not promptly resolved or fully tracked through conclusion.
Failure to Inform Residents of Risks, Benefits, and Alternatives Before Starting Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents, or their representatives, were informed of and allowed to participate in decisions regarding psychotropic medication treatment, including being informed in advance of the risks, benefits, and treatment alternatives. For four sampled residents, medical record review showed new orders for multiple psychotropic medications without any documentation that the resident or representative had been informed of these elements prior to initiation. Resident 8, with diagnoses including hemiplegia and hemiparesis following cerebral infarction, psychotic disorder with delusions, dementia, and major depressive disorder, was started on haloperidol lactate, donepezil, buspirone, quetiapine, and sertraline on various dates, with no documentation of informed discussion or consent. Resident 4, with unspecified dementia and anxiety disorder, was started on zaleplon, quetiapine, and buspirone, again with no record that risks, benefits, or alternatives were discussed in advance. Resident 54, diagnosed with early-onset Alzheimer’s disease and dementia in other diseases classified elsewhere, was started on sertraline and quetiapine, and Resident 6, diagnosed with Parkinson’s disease without dyskinesia, was started on buspirone, quetiapine (Seroquel), and sertraline, with no documentation that either resident or their representative had been informed of the risks and benefits or treatment options before these psychotropic medications were initiated. During an interview, the DON stated that the facility notifies families when medications are started or doses are changed but does not discuss risks and benefits, provide alternative options, or obtain signed consent. This practice contributed to the lack of documented evidence that residents or their representatives were fully informed and able to participate in treatment decisions regarding psychotropic medications.
Failure to Perform Regular GDR and Limit PRN Antipsychotic Orders
Penalty
Summary
Surveyors found that the facility did not ensure appropriate management of psychotropic medications for three sampled residents. For two residents with dementia and related psychiatric diagnoses, the medical records from late April 2026 showed only one documented psychotropic medication review and gradual dose reduction (GDR) attempt, completed in January 2026. There was no documentation of any GDR attempts or psychotropic reviews prior to January 2026, despite the DON stating that such reviews and GDRs should be completed quarterly. The records for these residents did not contain additional GDR attempts beyond the January 2026 review. For a third resident with hemiplegia following cerebral infarction, psychotic disorder with delusions, dementia, and major depressive disorder, a physician’s order dated February 8, 2026, prescribed PRN intramuscular haloperidol lactate every 12 hours for delusions, hallucinations, paranoia, and agitation, without an end date. Review of the MARs for February through April 2026 showed that this PRN antipsychotic was administered on two occasions, and no end date was documented on the MAR. In an interview, the DON acknowledged that the PRN haloperidol order extended beyond 14 days and that the physician had not documented a reason for continuing the order beyond that period.
Failure to Report Alleged Abuse and Serious Injuries to State Survey Agency
Penalty
Summary
The deficiency involves the facility’s failure to ensure that all alleged violations of abuse, including injuries of unknown source and incidents involving major injuries, were reported immediately to the State Survey Agency and other officials as required by state law. For four sampled residents, the Administrator acknowledged that incidents were reported only to the state’s patient safety website and not to the State Survey Agency’s incident reporting website. This omission meant that the State Survey Agency did not receive timely notice of serious events, including an allegation of sexual abuse and multiple incidents resulting in significant fractures and surgery. For one resident with severely impaired cognition and diagnoses including hemiplegia and hemiparesis, nursing notes documented that the resident was found on the floor after attempting to get out of bed, was sent to the ER, and returned with immobilizing braces on both legs due to bilateral femur fractures. The resident’s bones were not strong enough for surgery, and he was placed on comfort care. Despite the seriousness of the injuries and the requirement to treat such events as potential abuse or neglect until ruled out, the Administrator stated that this incident was reported only to the state’s patient safety website and not to the State Survey Agency’s incident reporting system. Another resident with Parkinson’s disease and severely impaired cognition was found on the floor after a wheelchair alarm sounded, initially with no visible injury and able to bear weight. A few days later, staff documented complaints of left leg pain, tenderness, and wincing with movement, leading to an order for x‑rays and transfer for imaging. X‑ray results revealed a femur fracture, and surgery was not pursued. The Administrator reported this incident to the state’s patient safety website but not to the State Survey Agency’s incident reporting website. A third resident with severe cognitive impairment experienced a fall with complaints of pain in the left knee, left elbow, and fingers, and later underwent ORIF surgery for fractures of the right fourth and fifth metacarpals; this incident also was not reported to the State Survey Agency’s incident reporting system, according to the Administrator. For another resident with dementia, adjustment disorder with anxiety, hearing and visual loss, and age‑related debility, a document in the facility’s abuse binder described a possible molestation allegation originating from a phone call by the resident’s nephew. The nephew reported that his mother, the resident’s sister and then‑POA, was emotionally unstable and had stated she felt the resident had reported being molested. The Administrator documented that the nephew did not believe the allegation was credible, that the sister had dementia and emotional issues, and that the Administrator considered the report “not a viable allegation.” The Administrator noted that he interviewed the resident, who denied being touched, and that the sister could not provide more details beyond stating that a man had groped the resident’s breast. The Administrator concluded the allegation was not credible and did not report it to any agencies or law enforcement. The incident was not documented in the resident’s medical record, and the Administrator confirmed in interview that he did not report this sexual abuse allegation to the State Survey Agency’s incident reporting website. Across these four residents, the common deficiency was the facility’s failure to treat serious injuries and a sexual abuse allegation as reportable events to the State Survey Agency, as required. Instead, the Administrator limited reporting to the state’s patient safety website or chose not to report at all when he personally judged an allegation as not credible. This pattern of inaction regarding mandated reporting requirements formed the basis of the cited deficiency.
Failure to Investigate Major Injuries and Alleged Abuse
Penalty
Summary
The deficiency involves the facility’s failure to initiate and document investigations into multiple major injuries and an allegation of sexual abuse, as required for all alleged violations involving abuse and injuries of unknown source. For one resident with hemiplegia, hemiparesis, and severely impaired cognition (BIMS score of 6), nursing notes documented that his roommate activated the call bell after the resident fell while attempting to get out of bed by himself. He was found on the floor between his bed and the window, reported knee pain with a popping sensation, and was sent to the ER. On return from the hospital, he was noted to have bilateral femur fractures, immobilizing braces on both legs, and was placed on comfort care due to bones not being strong enough for surgery. The Administrator acknowledged awareness of the bilateral femur fractures, stated he did not believe neglect or abuse caused the injury, and confirmed he did not investigate the cause of this major injury. Another resident with Parkinson’s disease and a BIMS score of 0 (rarely/never understood) was documented in an incident note as sitting in a wheelchair in the dining room when his alarm sounded; he was found supine on the floor, denied hitting his head or injury, and was assisted back into the chair with no signs of injury noted. Several days later, nursing notes recorded that CNAs reported the resident complaining of left leg pain when getting him out of bed. On assessment, he had tenderness and wincing with movement of the left leg but was able to bear weight. The MD was notified, an x-ray was ordered, and the resident was transported for imaging, which revealed a femur fracture for which surgery was not pursued. The Administrator stated he was aware of the femur fracture, did not feel neglect or abuse caused the major injury, and did not investigate the cause of the injury. A third resident with COPD, scoliosis, and severely impaired cognition (BIMS score of 7) had an incident note documenting that her bed alarm sounded and staff found her in a kneeling position leaning into her recliner after she attempted to get up from bed to go to the bathroom, stating her walker “didn't go where she was going.” She complained of left knee, left elbow, and right pinky pain, with no visible injury except an abrasion on the right ring finger. A later nursing note documented that she underwent ORIF of fractures of the right fourth and fifth metacarpals at a hospital and returned from surgery the same day. The Administrator reported being aware of the fractures, described the resident as very independent and wanting to wander the facility, stated he did not feel neglect or abuse caused the major injury, and confirmed he did not investigate the cause of the injury. Across these three residents, the facility did not initiate or document investigations into the causes of the major injuries or the related allegation of sexual abuse, nor did it determine causation or responsible parties as required.
Failure to Complete Monthly Pharmacist Reviews and Timely Act on Medication Recommendations
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a licensed pharmacist conducted and documented monthly drug regimen reviews for multiple residents and to ensure that identified medication irregularities were acted upon by the attending physician. For four sampled residents, the medical records lacked monthly pharmacist medication regimen review notes for at least two consecutive months. Specifically, residents with diagnoses including Parkinson’s disease, unspecified dementia, Alzheimer’s disease with early onset, and dementia related to other diseases had no documented pharmacist review notes for March and April 2026. The DON confirmed that the pharmacist had not completed pharmacy reviews for those months and that the notes, which should have been uploaded into each resident’s electronic medical record, were absent. In addition, the facility failed to act promptly on a pharmacist’s recommendation for a resident receiving psychotropic medications. One resident with hemiplegia following cerebral infarction, psychotic disorder with delusions, dementia, and major depressive disorder had a pharmacist recommendation in November 2025 to add a low-dose daytime Seroquel due to behavioral issues and afternoon anxiety. Nursing documentation showed that the pharmacist discussed the resident’s response to Seroquel versus Abilify and suggested a low-dose daytime Seroquel, but this recommendation was not communicated to the physician at that time. The LPN later stated she did not speak to the physician about the pharmacist’s recommendation because the resident had not needed PRN Haldol around that time. The physician did not write the order for daytime Seroquel until early February 2026, after a nurse raised concerns about the resident’s behaviors and reminded the physician of the prior pharmacist recommendation. The DON acknowledged that the pharmacist’s November 2025 recommendation was not completed until February 2026 and stated she did not have time to stay on top of such issues.
Unlabeled Insulin Pens Found in Medication Refrigerator
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled in accordance with accepted professional principles when two open insulin pens belonging to resident 56 were found without the resident’s name on them. During an observation of the south medication refrigerator on 4/29/26 at 10:50 AM, surveyors noted a plastic bin labeled only with resident 56’s first name, containing two loose, open insulin pens that had no resident identification labels affixed directly to the pens. In a concurrent interview, RN 1 confirmed that the two insulin pens belonged to resident 56 and stated that staff always put residents’ names on insulin pens, but was unsure why these pens had not been labeled. Later that day at 2:17 PM, the DON stated in an interview that the two insulin pens in question had been unlabeled and acknowledged that the insulin pens should have been labeled with the resident’s information.
Failure to Sustain QAPI Actions and Documentation for Pharmacist Medication Reviews
Penalty
Summary
The deficiency involves the facility’s failure, as part of its performance improvement activities, to take actions aimed at performance improvement, measure the success of those actions, and track performance to ensure that improvements were realized and sustained, specifically related to F756. Record review and interviews showed that the facility did not maintain documentation in the medical records to demonstrate that a pharmacist reviewed residents’ medications, identified potential irregularities, or provided recommendations to the attending physician for four sampled residents, despite this same issue having been cited in the previous health survey in 2024. During an interview, the DON stated she did not have time to maintain this required documentation. In a separate interview, the Administrator stated he did not have a performance improvement project, though he had QAPI minutes that captured some improvement plans, and he believed the facility had achieved compliance with F756, which had been cited previously, but no documents demonstrating compliance were provided when requested by surveyors.
Failure in Medication Handling and Infection Surveillance Documentation
Penalty
Summary
The facility failed to ensure a safe and sanitary environment during medication administration and infection surveillance. During an observation of medication pass for resident 23, an LPN was seen popping an oral pill directly from a blister pack into her bare hand and then placing it into a medication cup, after which the medication was administered to the resident. In a subsequent interview, the DON stated that staff were expected to pop pills directly into medication cups and never touch medications with bare hands, and that any medication contacting a staff member’s bare hand was to be discarded and replaced, indicating that the observed practice did not follow facility expectations. The facility also failed to maintain infection control surveillance documentation and an organized tracking system for infections. When Infection Control Surveillance Logs were requested, the DON reported that several residents had contracted influenza during the 2025 holiday season, attributed to an increased number of visitors, and that symptomatic residents were kept in their rooms. However, the DON stated she did not have a list of affected residents or rooms, and the requested surveillance logs were unavailable for review. In a later interview, the DON, who also served as the facility’s Infection Preventionist, confirmed that the facility lacked an infection control surveillance manual or organized system for tracking infections.
Failure to Implement and Monitor an Antibiotic Stewardship Program
Penalty
Summary
The facility failed to develop and implement an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use. There was no established facility-wide system to ensure appropriate indication, dose, and duration for antibiotic prescriptions, and no process for monitoring antibiotic usage or resistance data. On 4/29/26 at 8:20 AM, when surveyors requested the facility’s Infection Control Surveillance Logs, including any prescribed antibiotic tracking information, these logs were unavailable. On 4/30/26 at 12:28 PM, during an interview, the DON, who also served as the facility’s designated Infection Preventionist, stated that she did not track resident antibiotic utilization, including the specific clinical indications for the medications or the prescribed durations of treatment. No specific residents, their medical histories, or clinical conditions at the time of the deficiency were described in the report.
Failure to Promptly Resolve and Document Resident Grievance Regarding Door Injury
Penalty
Summary
The deficiency involves the facility’s failure to promptly resolve and properly document a resident grievance in accordance with its grievance policy. A resident with type II DM, HTN, anxiety disorder, major depressive disorder, and PTSD reported that a CNA on night shift did not hold open the smoking door for her and another resident, and that when she went to grab the door, it slammed on or closed against her finger, causing a cut to bleed. The resident stated she reported this to the Resident Advocate (RA) and completed a grievance form, and that nursing staff applied Neosporin and a bandage to the finger. The resident did not know the CNA’s name but identified that the CNA worked nights and stated that no one should be treating residents that way. The grievance form dated 4/10/26 documented the concern that the CNA on night shift did not hold the smoking door open and instead swung the door open and walked away, and that upon initial interview no allegation of abuse or neglect was identified. However, the grievance form contained no documentation of investigative steps taken, no summary of findings or conclusion, and no indication whether the grievance was confirmed or not. The form also lacked a written decision date, resident signature, grievance officer signature, and Administrator signature. The RA reported that the resident told her the door incident caused a small cut to reopen and that the CNA seemed in a hurry, but did not state that the CNA acted intentionally or purposefully toward her. The Administrator and DON later stated they had not been informed of the incident, and the Regional Nurse Consultant noted that nothing was filled out on the back of the grievance form, indicating it remained incomplete despite having been initiated several days earlier.
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