Maple Springs Senior Living
Inspection history, citations, penalties and survey trends for this long-term care facility in North Logan, Utah.
- Location
- 350 East 2200 North, North Logan, Utah 84341
- CMS Provider Number
- 465186
- Inspections on file
- 16
- Latest survey
- February 25, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Maple Springs Senior Living during CMS and state inspections, most recent first.
Food items were found undated in the refrigerator and freezer, including opened whipped topping, meatballs, dijon honey mustard, and frozen rolls. The DM was observed without a hairnet, and sanitizer buckets tested at 150 PPM when the DM stated they should be 200 PPM. The dishwasher and DM gave differing accounts of when the sanitizer solution was changed, and the dishwasher said he had not changed it that morning because dishes had piled up.
A resident with fractures, dysphagia, and a history of choking was admitted with SLP recommendations and physician orders specifying that medications be crushed in puree due to choking risk. Facility diet and medication orders reflected the need for crushed meds, and nurses documented administration on the MAR. However, after the family reported the resident was receiving whole pills, an internal review found that multiple medications that could not be crushed, including capsules and certain tablets, had been administered in that form instead of being provided in an appropriate crushable or alternative formulation, contrary to the physician’s crush order.
A resident with multiple medical conditions was transported in a facility van when the wheelchair was only secured with rear straps and the front straps were not attached, causing the chair to tip backward and the resident to strike her head on the vehicle. The driver repositioned and fully secured the wheelchair and continued to the appointment without calling EMS. The resident later reported the incident at an urgent care visit and was diagnosed with a closed head injury. Facility interviews confirmed that the van used required manual attachment of front straps and that these had been forgotten, and the incident was not documented in the resident’s medical record, although neuro checks were completed afterward.
Improper Storage of a Controlled Medication: A Schedule II narcotic prescribed for a resident was found in a medication cart blister pack with 1 tablet taped into an opened blister cell. RN and DON stated that a medication not administered should be wasted, and that taping a tablet back into the blister pack was not secure and could lead to cross contamination and medication errors.
The facility failed to maintain infection control practices for two residents. One resident with a Foley catheter had the catheter bag observed on the floor instead of kept below the bladder and off the floor in a privacy bag, despite staff stating it should not be placed on the floor. A second resident receiving wound care had dressing removal followed by continued wound care without the LPN doffing dirty gloves, performing hand hygiene, and donning clean gloves before cleaning the wounds.
A resident with diabetes and dementia, who had a physician's order for a minced and moist diet due to swallowing difficulties, was given inappropriate snacks by nursing staff who were unaware of the updated diet order. The nurse relied on outdated report sheets that did not include diet texture information, leading to the resident choking and passing away after consuming the food.
Food Storage and Sanitation Deficiencies in Kitchen
Penalty
Summary
Food items were not stored, prepared, distributed, and served in accordance with professional standards for food service safety. During an initial kitchen tour, the Dietary Manager was observed behind the preparation table without a hairnet. In the refrigerator, an opened bag of whipped topping and a pan of meatballs were undated, and in the freezer an opened bag of frozen rolls was also undated. At the preparation table, the sanitation bucket tested at 150 parts per million (PPM), while the Dietary Manager stated the level should be 200 PPM and that the bucket needed to be emptied and restarted. On a follow-up kitchen tour, the sanitation bucket at the front end of the kitchen again tested at 150 PPM, and the Dietary Manager stated it should be 200 PPM. The Dietary Manager stated the dishwasher was responsible for changing the sanitation buckets and said he had changed the bucket that morning, while the dishwasher later stated he had not changed the sanitation buckets because dishes had started to pile up and he needed to wash them. On a later follow-up tour, an opened dijon honey mustard and an opened bag of frozen rolls were again found undated in the refrigerator and freezer. The Dietary Manager stated that all items in the refrigerator and freezer should have dates on them, that staff should wear a hairnet while in the kitchen, and that the sanitation buckets should be at the correct sanitation levels.
Failure to Administer Medications in Accordance With Crush Orders for Resident With Dysphagia
Penalty
Summary
A resident with fractures of the right and left pubis, sacrum fracture, dysphagia, and age-related osteoporosis was admitted with a history of choking episodes, including a documented choking event on toast during a recent hospital stay. A hospital SLP evaluation identified severe dysphagia with pills/medications, including difficulty initiating the oral stage, coughing after swallow, and watery eyes, and outlined swallow strategies such as upright positioning, small bites and sips, slow rate, head turn for solids, adding moisture, and chasing with liquid. Subsequent facility diet and communication orders specified a regular diet with thin liquids and an order that medications were to be crushed in puree, and a physician order directed that medications be crushed every shift due to choking risk, with nurses documenting administration on the MAR twice daily. Despite these orders, the facility’s own investigation, initiated after the resident’s family reported the resident was receiving whole pills instead of crushed medications, revealed that several prescribed medications were not able to be crushed and had nonetheless been administered in that form until the end of the month. These medications included Align capsules, cholecalciferol tablets, celecoxib capsules, vitamin E tablets, tamsulosin capsules, and PreserVision AREDS 2 capsules. The Administrator later stated that the facility had a process for SLP evaluation of medication swallowing after admission and that the physician was responsible for specifying whether medications should be crushed, but the record review and interviews showed that, for this resident, medications that could not be crushed were still given contrary to the physician’s order for crushed medications related to choking risk.
Resident Injury Due to Incomplete Wheelchair Securement During Transport
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and safe transport, resulting in a resident not being fully secured in a facility van and sustaining a closed head injury. One resident, admitted with diagnoses including UTI, acute respiratory failure with hypoxia, CKD, HTN, diastolic heart failure, and anxiety, was being transported to an appointment when her wheelchair was not properly secured in the transport van. The back straps of the wheelchair were attached, but the front straps were not secured, allowing the wheelchair to tip backward during transport. During the incident, the transport driver reported that the resident’s wheelchair tipped backward to about a 45-degree angle, and the resident struck her head on the back door or ramp of the van. The driver asked the resident if she was okay, and when she responded yes, he repositioned the wheelchair upright and then secured all four straps before continuing to the scheduled appointment. The driver did not contact emergency medical services at the time of the incident and proceeded with the transport after securing the wheelchair. Subsequently, the resident was evaluated at an urgent care clinic for a head injury that occurred earlier that day. The urgent care documentation indicated that the resident reported her wheelchair had not been secured, rolled back, and caused her to strike her head on the back door of the vehicle. She denied loss of consciousness, pain, headache, neck pain, or back pain at the time of evaluation, but was diagnosed with a closed head injury. Review of the resident’s medical record showed no documentation of the incident itself, although neurological checks were completed afterward. Interviews with the Transportation Director, the transport driver, and the Administrator confirmed that the resident had been transported in a van without built-in front retention straps and that the front straps had been forgotten, leading to the tipping event and resulting injury.
Improper Storage of a Controlled Medication
Penalty
Summary
The facility did not ensure that drugs and biologicals were stored and labeled in accordance with accepted professional principles, including proper storage of controlled drugs. During observation of the medication carts, a blister pack containing Percocet 10-325 mg tablets was found with 1 tablet taped into an opened blister cell for Resident 21. The Percocet was a Schedule II narcotic prescribed for this resident, and the tablet had been left taped in place rather than being handled through the facility’s controlled-substance process. At the time of the observation, RN 2 stated that medication tablets should not be taped back into blister cells because this could allow the wrong medication to be replaced in the cell. RN 2 also stated that if a narcotic tablet was removed from the blister cell and not administered, it needed to be wasted with another nurse as witness. Later, the DON stated that if a medication was not administered, it should have been wasted in the drug disposal system on the medication carts, and that controlled substances required wasting with another nurse witnessing and documentation in the narcotic log. The DON further stated that medications would not be securely stored if taped into blister cells and could unintentionally fall out, and that this practice increased the risk of cross contamination and medication errors.
Infection Control Lapses During Catheter Care and Wound Care
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 disease and infections. For one resident with diagnoses including hemiplegia and hemiparesis following cerebral infarction, retention of urine, and obstructive and reflexive uropathy, the physician’s order required the Foley bag to be kept below the bladder and off the floor in a privacy bag. During observations, the resident’s urinary catheter bag was seen on the floor of the room and not in a privacy bag while the resident sat in a recliner. The resident stated staff placed the urinary catheter bag on the floor anytime he was out of his wheelchair. Multiple staff members, including CNAs, an RN, the PTA, and the DON, stated the catheter bag should not be on the floor and should be kept in a basin or hanging off the floor. For a second resident receiving wound care for a left heel pressure sore and left foot surgical wounds, an LPN was observed performing hand hygiene and donning gown, gloves, and mask before starting care, then removing the old dressing. The LPN did not remove the dirty gloves, perform hand hygiene, and don new clean gloves before continuing wound care. The LPN then used a sterile gauze pad soaked in normal saline to clean the left foot dorsum surgical incision, left lateral foot surgical incision, and left heel pressure ulcer. The LPN stated she should have doffed the dirty gloves and performed hand hygiene after removing the old dressing and before cleaning the wound bed. The DON stated staff should reduce the risk of infection with wound care by performing hand hygiene, having equipment prepped prior to initiation, and following wound care orders.
Failure to Provide Diet Consistent with Physician Orders Results in Resident Harm
Penalty
Summary
A resident with diagnoses including type 2 diabetes and vascular dementia, and a Brief Interview for Mental Status (BIMS) score indicating moderately impaired cognition, had a physician's order for a minced and moist texture diet with thin consistency due to recent swallowing complications such as coughing and vomiting up food. Despite this order, the resident was provided with a cheese stick and pretzels as a snack after a low blood sugar reading. Both food items were not appropriate for the prescribed diet texture. The nurse, who was training a new nurse at the time, was unaware of the resident's updated diet order. The nurse report sheet only documented how residents took their pills and did not include information about diet texture. The updated diet order was present only in the primary care provider's orders and was not reflected in the nurse report sheet or the treatment/medication administration records. The nurse did not receive any information during shift report about changes to the resident's diet or new swallowing difficulties. After the resident consumed some of the provided snack, staff found the resident choking and unresponsive. Despite attempts to clear the airway and perform the Heimlich maneuver, the resident passed away. The facility's investigation determined that the incident occurred because the nurse did not have access to the resident's texture restrictions at the point of care, as this information was not readily available or communicated to nursing staff.
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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