Maple Ridge Rehabilitation And Nursing
Inspection history, citations, penalties and survey trends for this long-term care facility in Salt Lake City, Utah.
- Location
- 455 South 900 East, Salt Lake City, Utah 84102
- CMS Provider Number
- 46A058
- Inspections on file
- 19
- Latest survey
- June 2, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Maple Ridge Rehabilitation And Nursing during CMS and state inspections, most recent first.
The facility did not employ a full-time clinically qualified dietitian or a certified dietary manager to direct nutrition services. The current DM had not completed required training or certifications and confirmed that the RD was not full-time. The ADM was aware of these deficiencies when the DM was moved into the position after the previous DM resigned.
The facility did not ensure that laboratory results for several residents were filed in their medical records as required. For four residents with complex medical conditions and multiple lab orders, the actual lab reports were missing from their clinical files, despite documentation that labs were ordered and sometimes reviewed. This deficiency was confirmed through record review and staff interviews, revealing a breakdown in the process for uploading lab results.
A resident with multiple complex medical conditions was documented as full code without a completed POLST or Advance Directive in the medical record. Required documentation and processes for determining and recording advance directive preferences were not followed, leaving the resident's code status and treatment wishes unclear.
A resident reported a missing wallet containing identification and Medicaid card and requested assistance from the Resident Advocate, who did not follow up or document the grievance investigation as required by facility policy. No evidence of prompt resolution or investigation was found in the grievance records.
A resident with a history of behavioral issues and multiple medical conditions was prescribed Trazodone and Depakote, but the facility failed to document a rationale for not attempting a gradual dose reduction (GDR) for Trazodone and did not attempt or document a GDR or clinical contraindication for Depakote. Staff interviews confirmed the medications were used for behaviors, but required documentation and rationale were missing.
Two residents were transferred to hospitals without proper documentation in their medical records of what information was sent to the receiving providers. Despite staff stating that they typically notify providers and send necessary paperwork, there was no record of transfer/discharge summaries or details such as practitioner contact, advanced directives, or care plan goals being communicated, resulting in incomplete transitions of care.
A resident with multiple chronic conditions experienced ongoing constipation, with documented periods of up to six days without a bowel movement. Although there were physician orders for Milk of Magnesia to treat constipation, the medication was not administered, and the care plan only addressed urinary elimination, omitting bowel elimination needs. The DON confirmed the care plan did not include interventions for constipation.
A resident with multiple chronic conditions experienced constipation that was not managed according to physician orders and the facility's bowel protocol. Despite documented periods of no bowel movement and standing orders for Milk of Magnesia (MOM) to be administered after three days without a BM, the medication was not given, and there was no documentation of administration, refusal, or follow-up interventions. Staff interviews revealed uncertainty about protocol implementation, and the resident's care plan did not address bowel management.
A resident with a history of heart disease and arthritis reported severe pain and requested more effective pain relief, but staff did not provide pain medication, alternative analgesics, or nonpharmaceutical interventions. Despite physician orders for acetaminophen and topical analgesics, there was no documentation that these were offered or administered, and the resident continued to report pain without relief. Documentation of pain assessments, interventions, and refusals was also lacking.
Surveyors found that an LPN and the DON did not ensure multi-use vials of Humalog and aplisol were properly labeled with open or discard dates. A resident's Humalog vial had an unclear date, and the aplisol vial lacked any labeling, both remaining available for use.
A resident with multiple complex diagnoses had a medication order incorrectly entered into the medical record, with hydroxyurea documented instead of hydroxyzine, and no corresponding diagnosis for sickle cell disease. Hydroxyzine was present in the medication cart, but there was no active order for it in the record. Interviews with an LPN and the DON confirmed that medication orders should be verified, but the error led to incomplete and inaccurate documentation.
A resident with multiple wounds and a PICC line did not have enhanced barrier precautions in place, and staff were unaware of the need for such precautions. During a meal, a plate guard that had fallen to the floor was reused without cleaning, contrary to facility expectations. These lapses resulted in a failure to maintain proper infection prevention and control practices.
A resident with multiple medical conditions experienced two incidents—elopement and an allegation of sexual abuse—where facility documentation failed to include the date APS was notified, despite forms indicating notification occurred. The administrator confirmed no further documentation was available to verify timely reporting.
A resident with severe cognitive impairment and a high risk for elopement was able to leave the facility unsupervised on two occasions due to inadequate supervision and unsecured exit points. Despite orders for a wander guard and frequent monitoring, the resident exited through a gate left open by visitors and, in another instance, through a side gate while the wander guard was attached to a wheelchair. Staff did not consistently check all areas when alarms sounded, and exit points were not always secured, resulting in the resident being found off facility grounds by police.
Failure to Employ Qualified Nutrition Services Director
Penalty
Summary
The facility failed to employ a clinically qualified full-time dietitian or another clinically qualified nutrition professional to serve as the director of nutrition services. During an initial walk-through of the kitchen, the Dietary Manager (DM) stated that he had not completed the required training to serve in his role and had only been working as DM for two months. The DM also confirmed that the Registered Dietitian (RD) did not work at the facility full-time and that he was in the process of obtaining necessary certifications. In a follow-up interview, the DM reiterated that he was scheduled to take his ServSafe test and would soon begin the Certified Dietary Manager course. The Administrator acknowledged awareness that the DM was not certified and had assumed the position after the previous DM resigned.
Failure to Maintain Complete Laboratory Records in Resident Files
Penalty
Summary
The facility failed to maintain complete, dated laboratory records in the clinical records of several residents. For four out of fourteen sampled residents, laboratory results for ordered tests were not filed in their medical records. Specifically, one resident with a history of cerebral infarction, hemiplegia, dysphagia, and hypertension had a physician order for a Prothrombin Time (PT) and International Normalized Ratio (INR) lab draw, but the results were not present in the medical record. The laboratory results were only provided later upon request. The Administrator confirmed that the process required the DON to upload lab results into the medical record within a week, but this was not done for the resident in question. Additional residents were also affected by this deficiency. One resident with respiratory failure, dementia, and muscle weakness had orders for a Vitamin B12, Folate, and Iron panel, but no results were found in the record. Another resident with diabetes, chronic kidney disease, and a history of traumatic amputation had orders for a Basic Metabolic Panel and magnesium level, but again, no results were present. A fourth resident with intracranial injury, diabetes, and mood disorders had multiple lab orders, including a complete blood count and metabolic panels, with no corresponding results in the medical record. In each case, documentation indicated that labs were ordered and sometimes reviewed, but the actual laboratory reports were missing from the residents' clinical records.
Failure to Document Advance Directive and POLST Status
Penalty
Summary
A deficiency occurred when a resident was documented as full code in their medical record without having a completed Physician Orders for Life-Sustaining Treatment (POLST) or Advance Directive on file. The resident, who had multiple significant diagnoses including acute respiratory failure with hypoxia, chest pain, pleural effusion, COPD, asthma, atrial fibrillation, type 2 diabetes with complications, secondary hypertension, and shortness of breath, was admitted and readmitted to the facility. Despite the facility's policy requiring determination and documentation of advance directives upon admission, the resident's medical record lacked both a POLST and an Advance Directive, and the POLST status was left blank in the admission progress note. Interviews with the DON and Administrator confirmed that the required POLST form could not be located in the resident's record. The DON stated that completed POLST forms are to be turned in to her and then given to the Medical Director for signature, with monthly audits by the Resident Advocate. However, for this resident, the process was not completed as required, resulting in the absence of critical documentation regarding the resident's code status and advance directive preferences.
Failure to Promptly Resolve and Document Resident Grievance Regarding Missing Property
Penalty
Summary
A resident with a history of schizophrenia, tremor, stimulant abuse, COPD, peripheral vascular disease, and hypertension reported that his wallet containing identification and Medicaid card was missing. The resident informed the Resident Advocate (RA) and was told assistance would be provided to obtain new identification, but the resident stated that the RA never followed up. Review of the resident's personal inventory confirmed the wallet was previously documented, but the contents were not listed. Progress notes indicated the wallet was reported stolen, and the RA acknowledged the need to replace the wallet and obtain a new ID, but there was no documentation that this was completed. Further review of the facility's grievance binder revealed no record of a grievance or investigation related to the missing wallet and identification cards for this resident. The facility's grievance policy requires prompt efforts to resolve grievances and mandates documentation of the investigation and resolution, but no such evidence was maintained. The RA confirmed that a grievance investigation should have been initiated and documented, but none was found for this incident.
Failure to Document and Attempt Gradual Dose Reduction for Psychotropic Medications
Penalty
Summary
A deficiency was identified when a resident with multiple diagnoses, including cerebral infarction, cognitive communication deficit, hemiplegia, hemiparesis, dysphagia, aphasia, and hypertension, was not provided with appropriate gradual dose reductions (GDR) or behavioral interventions for psychotropic medications as required. The resident had physician orders for Trazodone for insomnia and Divalproex Sodium (Depakote) for increased behaviors. Documentation showed that a clinical contraindication form for GDR of Trazodone was completed, but the section specifying the reason for the contraindication was left blank. There was no documentation of an attempted GDR or a clinical contraindication for the use of Divalproex Sodium. Interviews with staff revealed that the resident exhibited behaviors such as impatience, yelling, and a history of physical and verbal aggression, which were being monitored. The Divalproex was reportedly used for these behaviors, but no GDR attempt or clinical contraindication was documented. The process for GDR and documentation was discussed among staff, but the required rationale for not attempting a GDR, particularly for Divalproex, was not provided in the resident's record.
Failure to Document and Communicate Required Information During Resident Transfers
Penalty
Summary
The facility failed to ensure that the transfer or discharge of two residents was properly documented in their medical records, and that all required information was communicated to the receiving provider. For both residents, there was no documentation of a transfer or discharge summary, nor was there evidence of what information was sent to the receiving provider at the time of transfer. This included missing details such as contact information for the practitioner responsible for the resident's care, resident representative contact information, advanced directive information, special instructions or precautions for ongoing care, comprehensive care plan goals, and other necessary information to ensure a safe and effective transition. One resident with diagnoses including HIV, anxiety disorder, schizophrenia, and hepatitis C was transferred to a hospital after calling 911 due to complaints of brain pain, but the medical record lacked documentation of what information was provided to the hospital. Another resident with multiple complex conditions, including diabetes, chronic kidney disease, traumatic amputation, bipolar disorder, and suicidal ideations, was transferred to the hospital on two occasions due to acute medical changes, but again, the medical record did not contain documentation of a transfer/discharge summary or what information was sent to the receiving provider. Interviews with staff confirmed that while there was a process for notifying providers and sending documentation, it was not consistently documented in the residents' records.
Failure to Address Bowel Elimination in Resident Care Plan
Penalty
Summary
A deficiency was identified when the facility failed to develop and implement a comprehensive, person-centered care plan that addressed all of a resident's needs, specifically regarding bowel elimination. The resident, who had multiple diagnoses including schizophrenia, Parkinsonism, generalized anxiety disorder, obsessive-compulsive disorder, major depressive disorder, congestive heart failure, and peripheral vascular disease, reported experiencing constipation over the previous two months, with extended periods without a bowel movement. Medical records confirmed physician orders for Milk of Magnesia to treat constipation, but the medication was not administered during the month reviewed. Documentation showed the resident went up to six days without a bowel movement on one occasion and three days on another within a 30-day period. The resident's care plan, initially created for ADL self-care performance deficits related to schizophrenia, only addressed urinary elimination and did not include any interventions or monitoring for bowel elimination or constipation. The care plan's toileting focus area had not been updated to reflect the resident's bowel elimination needs, despite evidence of ongoing constipation and physician orders for treatment. The DON confirmed that the care plan only addressed urinary elimination and not bowel elimination.
Failure to Follow Bowel Protocol for Resident with Constipation
Penalty
Summary
A deficiency was identified when a resident with multiple medical diagnoses, including schizophrenia, Parkinsonism, generalized anxiety disorder, obsessive-compulsive disorder, major depressive disorder, congestive heart failure, and peripheral vascular disease, experienced episodes of constipation that were not managed according to the facility's established bowel protocol. The resident reported experiencing constipation over the previous two months and indicated that he had gone extended periods without a bowel movement. Despite having physician orders for Milk of Magnesia (MOM) to be administered as needed for constipation, and a specific order to administer MOM on the third day without a bowel movement, the medication was not given during the month in question, as documented in the Medication Administration Record (MAR). Review of the resident's bowel elimination records showed multiple instances where the resident went three or more days without a bowel movement, including a six-day period and a three-day period. The facility's bowel protocol required staff to initiate treatment with MOM after three days without a bowel movement, followed by additional interventions if the initial treatment was ineffective. However, there was no documentation that the protocol was followed, that MOM was administered or refused, or that subsequent steps were taken as required by the protocol. Interviews with facility staff, including an LPN, a CNA, and the DON, revealed a lack of clarity regarding the location and implementation of the bowel protocol. The DON confirmed that the protocol should have been initiated and that documentation of administration or refusal should have been present in the MAR or nurse progress notes. The resident's care plan also did not address bowel elimination patterns or treatment for constipation, and there was no evidence that the required interventions were provided or documented during the periods of constipation.
Failure to Provide Timely and Appropriate Pain Management
Penalty
Summary
A deficiency was identified when a resident with a history of atherosclerotic heart disease, arthritis, and a childhood neck injury reported significant pain to facility staff. The resident expressed that he was experiencing severe neck and back pain, requested to go to the hospital, and stated that his current pain management regimen of two Tylenol was ineffective. Despite these complaints, the resident was not provided with any pain medication, alternative pain relievers, or nonpharmaceutical pain interventions at the time of his request. Staff responses included relaying the complaint to a nurse, who indicated she would contact the Medical Director, and instructing the resident to rest, but no immediate pain relief measures were implemented. Review of the resident's care plan revealed it was focused on headache pain and included interventions such as medication and rest, anticipating pain relief needs, and documenting pain history and management. The care plan also noted the resident's preference for Tylenol, but did not address his arthritis or neck pain specifically. The resident's recent pain assessment documented frequent pain, with significant interference in sleep and activities, and a high pain score. Orders for acetaminophen and topical analgesics were present, but there was no documentation that these were offered or administered during the pain episode in question, nor was there documentation of refusal. Interviews with the resident confirmed that he had not received any pain relief or intervention following his complaints. The DON stated that the Medical Director was contacted, but the response was delayed by several hours, and there was no evidence of alternative pain management strategies being discussed or implemented. Documentation was lacking regarding pain assessments, interventions offered, and resident refusals, contributing to the failure to provide appropriate pain management as required.
Failure to Properly Label Multi-Use Medication Vials
Penalty
Summary
Surveyors observed that the facility failed to ensure drugs and biologicals were labeled in accordance with accepted professional principles, specifically regarding the inclusion of expiration, open, or discard dates. During an inspection of the medication fridge at the nurses station with an LPN, an open multi-use vial of Humalog was found with a date on the box, but the LPN was unsure if it represented the open or discard date. This vial was available for use and belonged to a resident. Additionally, an open multi-use vial of aplisol was present in the fridge without any open or discard date labeled. The DON confirmed that multi-use vials are typically labeled with an open date and that both Humalog and aplisol are considered good for 30 days after opening, but this practice was not followed for the vials in question.
Incorrect Medication Order Entry and Incomplete Medical Record Documentation
Penalty
Summary
A deficiency was identified when a resident's medication order was incorrectly entered into the medical record. The resident, who had a complex medical history including type 1 diabetes mellitus, generalized anxiety disorder, chronic kidney disease stage 3, traumatic amputation of toes, bipolar disorder, and suicidal ideations, was admitted and readmitted to the facility. During a review of the resident's records, it was found that a physician's order for Hydroxyurea 25 mg by mouth every 12 hours as needed for anti-anxiety was documented, despite no diagnosis of sickle cell disease being present in the resident's record. Additionally, a nursing progress note indicated a verbal order to restart hydroxyzine 25 mg by mouth twice a day and as needed, but there was no active order for hydroxyzine in the medical record. Upon observation, hydroxyzine 25 mg was found in the medication cart for the resident, while hydroxyurea was not present. Interviews with an LPN revealed that medication orders were supposed to be double-checked and verified against the medication card, and the DON confirmed that nurses were expected to verify the correct medication was entered into the medical record. The incorrect entry of the medication order resulted in incomplete and inaccurate documentation in the resident's medical record.
Failure to Implement Enhanced Barrier Precautions and Maintain Infection Control
Penalty
Summary
A deficiency was identified when a resident with multiple wounds and a peripherally inserted central catheter (PICC) line did not have enhanced barrier precautions (EBP) implemented as required. Despite physician orders for wound care and PICC line monitoring, there was no EBP signage or supplies outside the resident's room. Interviews with staff, including a CNA, LPN, and the Director of Nursing, revealed a lack of awareness and implementation of EBP for residents with wounds and indwelling catheters, including PICC lines. Staff reported not using gowns during care and were unsure about the need for EBP in such cases. Additionally, during a meal service, a plate guard that had fallen to the floor was picked up and placed back on the resident's plate by a CNA, without being cleaned or replaced. The CNA was unaware that the plate guard had been on the floor, and the Administrator later confirmed that the expectation was for dropped items to be replaced with clean ones and not reused. These actions demonstrated a failure to maintain proper infection prevention and control practices for the resident.
Failure to Document Timely APS Notification for Abuse and Neglect Allegations
Penalty
Summary
A deficiency was identified when the facility failed to ensure that all alleged violations involving abuse and neglect were reported immediately, but not later than two hours after the allegation was made, to the administrator, State Survey Agency (SSA), and Adult Protective Services (APS). Specifically, for one resident with a history of anoxic brain damage, unspecified convulsions, diabetes mellitus, asthma, hypothyroidism, restless leg syndrome, and dysphagia, the facility's documentation of two separate incidents—an elopement and an allegation of sexual abuse—did not include a documented date that APS was notified. In the first incident, the local police found the resident wandering outside the facility and transported him to a hospital; the facility's form indicated APS was notified, but no date was recorded. In the second incident, the resident reported rectal pain and alleged rape to a nurse, but again, while the form stated APS was notified, no date was documented. The current administrator confirmed that there was no additional documentation available to verify the timing of APS notification for either event.
Failure to Prevent Resident Elopement Due to Inadequate Supervision and Unsecured Exit
Penalty
Summary
A deficiency occurred when a resident with a known history of elopement risk and severe cognitive impairment was not adequately supervised, resulting in two separate elopement incidents. The resident, who had diagnoses including anoxic brain damage, unspecified convulsions, diabetes mellitus, asthma, hypothyroidism, restless leg syndrome, and dysphagia, was assessed as high risk for wandering and elopement. Physician orders and care plans specified the use of a wander guard device, frequent monitoring, and supervision, especially during exit-seeking behaviors. Despite these interventions, the resident was able to leave the facility unsupervised on two occasions. On one occasion, the resident exited through a gate that was left slightly open by visitors who had attended a church service at the facility. The gate, which required a code to enter, was not properly secured after the visitors left. The resident was found by local police wandering on a street near the facility and was transported to a hospital for evaluation. Staff interviews and documentation revealed that the wander guard alarm system was in place, but staff did not check the entire courtyard when the alarm sounded, and the gate was not secured as required. In another incident, the resident was able to leave the facility through the side gate of the courtyard. At the time, the wander guard was attached to the resident's wheelchair rather than his person, as he had previously removed the device from his leg. Documentation indicated that the resident was exit-seeking, and staff were aware of his behaviors, but the supervision and monitoring in place were insufficient to prevent his elopement. These lapses in supervision and failure to secure exit points directly contributed to the resident's ability to leave the facility unsupervised.
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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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