Millcreek Rehabilitation And Nursing
Inspection history, citations, penalties and survey trends for this long-term care facility in Salt Lake City, Utah.
- Location
- 3520 South Highland Drive, Salt Lake City, Utah 84106
- CMS Provider Number
- 465185
- Inspections on file
- 21
- Latest survey
- April 7, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Millcreek Rehabilitation And Nursing during CMS and state inspections, most recent first.
A resident reported to social services that another resident’s w/c had not been properly secured to the floor of a facility van during transport to an appointment, and this concern was documented and confirmed as a grievance. The ADM later explained that the facility used a group “trigger call” with corporate leadership and the DON to decide whether alleged abuse or neglect incidents should be reported, and they determined this event did not meet their criteria for neglect because no injury occurred. When provided the regulatory definition of neglect during interview, the ADM acknowledged the incident should have been reported, confirming the facility failed to immediately report an allegation of neglect to the State Survey Agency.
A deficiency occurred when a resident’s wheelchair was not secured during van transport between buildings on a medical campus. A resident reported, and video confirmed, that another resident’s wheelchair was not anchored to the van floor; instead, the driver was seen driving while holding the wheelchair base with one hand, and the resident was holding the back of the driver’s seat. The driver later admitted he did not apply the wheelchair straps because the distance was short and he was in a hurry, while the DON and ADM confirmed that the resident had not been properly secured despite usual practice of securing residents during transport.
A resident with multiple medical conditions fell backward in a wheelchair while being transported in a facility van, reportedly hitting his head and neck. The incident was not thoroughly investigated or reported to the State Survey Agency as required. Interviews revealed that staff did not follow proper procedures for incident assessment, documentation, or notification, and there was no evidence of an abuse investigation despite the resident's ongoing pain and concerns about the incident report's accuracy.
Two residents were not provided with adequate supervision or properly secured during transport, resulting in one resident falling backward in a facility van and sustaining a head and neck injury. Staff interviews revealed inconsistent and insufficient training on wheelchair securement and accident response, and the incident report did not accurately reflect the event. The deficiency was cited at the Immediate Jeopardy level due to the facility's failure to follow recommended safety practices.
A resident reported being sexually abused by another resident, with the facility failing to ensure separation or provide individualized interventions following the incident. Both residents had moderate cognitive impairment and psychiatric diagnoses. The capacity to consent to sexual activity was not assessed prior to the event, and care plan interventions addressing the altercation were delayed by several months. Staff interviews revealed a lack of timely communication and coordinated response to the abuse allegation.
Three residents with complex medical and psychosocial needs did not have comprehensive, individualized care plans addressing their specific conditions. One resident on dialysis lacked a care plan for fistula care and monitoring, another with repeated THC vape use had no substance use interventions in their care plan, and a third with frequent falls had care plan interventions that were not consistently implemented by staff, as observed and confirmed in interviews.
The facility did not consistently file laboratory reports in the clinical records for three residents, resulting in missing or misfiled lab results for routine and stat orders, including respiratory panels and metabolic panels. Staff interviews confirmed that some results were delayed, not uploaded, or placed in the wrong chart, leading to incomplete documentation.
Staff failed to maintain accurate and confidential medical records by documenting other residents' names in progress notes and misfiling discharge documentation, and did not ensure required physician rationale for ongoing PRN psychotropic medication was present in the chart. These actions resulted in incomplete, inaccurate, and insecure records for several residents with complex medical and psychiatric histories.
Staff failed to use proper infection control practices during snack distribution by handling food with bare hands, and did not implement Enhanced Barrier Precautions for two residents with indwelling medical devices or wounds. Staff interviews revealed a lack of awareness and adherence to required precautions, and there was no signage indicating EBP for affected residents.
Three handrails in resident corridors were found to be loose and not properly secured to the wall. The Maintenance and Housekeeping Supervisor reported that daily audits, including handrail inspections, were conducted but did not identify these deficiencies. The issue was confirmed during inspection with a State Surveyor.
The facility did not ensure timely reporting of alleged abuse, neglect, or injury to the administrator, SSA, APS, or law enforcement. In multiple cases, including incidents of sexual abuse and an injury during transportation, notifications to required authorities were delayed beyond the mandated 2-hour window. Staff and leadership interviews confirmed delays and uncertainty regarding reporting requirements.
A resident with multiple medical conditions reported fecal matter on the bathroom wall that remained unaddressed for an extended period, despite daily cleaning routines and available reporting mechanisms. Observations confirmed the substance persisted, indicating a failure to provide a safe, clean, and homelike environment.
A resident with complex medical needs did not have required routine laboratory tests, including CBC, CMP, and HbA1c, completed and documented as ordered by the facility physician. The DON reported that some labs were obtained from a dialysis center, but not all required tests were included, and results were not consistently documented in the resident's medical record.
A resident with no teeth and moderate cognitive impairment, who had reported difficulty chewing and swallowing, was served a minced and moist diet without physician approval after the Dietary Manager downgraded the diet based on the resident's complaints. Staff interviews revealed confusion about the resident's prescribed diet, and the Speech-Language Pathologist had not yet evaluated the resident. The facility failed to provide food in a form consistent with the physician's order.
A resident assessed as safe to smoke independently was restricted from accessing the secured outside smoking patio after 9:00 PM, except during set supervised times, due to facility policy and staffing limitations. The resident reported being unable to go outside at night as desired, and staff confirmed the door was locked and only opened at specific times, despite the resident's independent status.
Failure to Report Alleged Neglect Related to Unsafe Van Transport
Penalty
Summary
The deficiency involves the facility’s failure to immediately report an allegation of neglect to the State Survey Agency after a resident grievance identified a safety concern during transportation in a facility van. A grievance dated 3/26/26 documented that a resident reported to social services/resident advocate that, during transport to an appointment earlier that week, another resident in the van was not strapped in appropriately. Specifically, the reporting resident observed that the other resident’s wheelchair was not anchored to the van floor with straps. The grievance was reviewed and confirmed through the facility’s grievance process. During an interview on 4/7/26, the Administrator explained that when there was an abuse or neglect allegation, a “trigger call” was held with the company president, a corporate representative, and the DON to determine if the incident met the level of abuse to report. The Administrator stated that neglect was defined as residents not receiving goods and services and that this incident was not reported to the State Survey Agency because they felt it did not meet the criteria, noting that the resident was not injured. After being provided the regulatory definition of neglect during the interview, the Administrator acknowledged that, under that definition, the incident should have been reported, confirming that the allegation of neglect was not reported immediately as required.
Unsecured Wheelchair During Resident Transport in Facility Van
Penalty
Summary
A deficiency occurred when a resident’s wheelchair was not secured during transport in the facility van, resulting in an environment that was not free from accident hazards. A grievance documented that during a transportation event earlier in the week, one resident observed that another resident’s wheelchair was not anchored to the van floor with straps. The grievance was confirmed. In an interview, the driver involved stated that he transported the resident to an appointment, realized they were at the wrong location, and then drove across the parking lot to the correct destination without securing the resident’s wheelchair with straps. The driver also sent a text message to the Administrator acknowledging that during this short transfer he did not secure the wheelchair, recognized this was not the correct procedure, and accepted responsibility. In a video provided by the reporting resident, the transported resident was seen in the facility van in a wheelchair that was not secured, while the driver was operating the vehicle and holding the base of the wheelchair with one hand. The transported resident was observed holding onto the back of the driver’s seat. In interviews, the transported resident reported that staff usually secured her wheelchair and ensured she was buckled, and that she had never been injured or had an incident in the van. The DON and Administrator both confirmed that the driver did not secure the resident’s wheelchair because the destination was within the same parking lot and the driver was in a hurry, and acknowledged that the resident was not secured as required.
Failure to Investigate and Report Resident Fall During Transport
Penalty
Summary
The facility failed to thoroughly investigate and report an incident involving a resident who sustained a fall while being transported in a facility van. The incident occurred when the resident, who had a history of heart failure, type 2 diabetes, osteomyelitis, and diarrhea, was being taken to a cardiology appointment. During the transport, the resident fell backward in his wheelchair, reportedly hitting his head and neck. The resident stated that his wheelchair was strapped in, but he was unsure about the seatbelt placement. Upon returning to the facility, the resident reported the accident and was provided an x-ray the following day. The resident also expressed concerns about the accuracy of the incident report and the timeliness of his medical assessment and follow-up care. Interviews and record reviews revealed that the facility did not conduct a thorough investigation of the incident or report it to the State Survey Agency (SSA) within the required five working days. The Director of Nursing (DON) and the Administrator (ADM) both acknowledged that the incident was not investigated as potential abuse or neglect, and there was no documentation of an abuse investigation. The ADM admitted that the process for handling such incidents, including immediate notification and assessment, was not followed. The transportation driver reported the incident after returning to the facility, but the ADM did not document the event or initiate an investigation, relying instead on the driver's account that no injuries occurred and that the wheelchair was secured. Further interviews with another resident who witnessed the incident indicated that the wheelchair may not have been properly secured, as something in the front came undone, causing the wheelchair to fall backward rapidly. The witness could not confirm if the resident hit his head but noted that the resident complained of neck pain and requested an x-ray. The facility's lack of investigation, failure to assess the resident immediately upon return, and omission of timely reporting to the SSA constituted a deficiency at the Immediate Jeopardy level.
Failure to Ensure Safe Resident Transport and Adequate Supervision
Penalty
Summary
Surveyors identified a deficiency in the facility's failure to ensure adequate supervision and the use of appropriate assistive devices to prevent accidents for two of 43 sampled residents. One resident, who had a history of heart failure, diabetes, bilateral below-knee amputations, and multiple wounds, fell backward while being transported in a facility van. The resident was not properly secured, resulting in a fall that caused injury to the head and neck. The incident was witnessed by another resident, and both the resident and the witness reported that the wheelchair tipped backward while the van was in motion. The transportation driver was unable to clearly recall or demonstrate the correct securement of the wheelchair and seatbelt, and there was inconsistency in staff training and understanding of proper transport procedures. The resident reported pain and symptoms consistent with a neck injury following the incident, including pain at the base of the skull and cracking sounds when turning the neck. Medical records confirmed that the resident received a cervical spine x-ray and was later referred for orthopedic evaluation, where a diagnosis of cervical spondylosis and whiplash injury was made. The resident and the witness both stated that the incident report provided by the facility was inaccurate, and the resident expressed dissatisfaction with the lack of immediate assessment upon return to the facility. The transportation driver and other staff interviews revealed gaps in training, inconsistent practices regarding the securement of wheelchairs and seatbelts, and a lack of clear protocols for responding to accidents during transport. Additionally, the facility failed to ensure that all staff involved in resident transport were adequately trained in safety procedures, including the proper securement of wheelchair-dependent residents and the appropriate response to accidents. Staff interviews indicated that training was often verbal, lacked documentation, and did not always include return demonstrations or specific guidance on accident protocols. The deficiency was determined to be at the Immediate Jeopardy level due to the facility's failure to implement CMS-recommended practices for hazard identification, risk evaluation, intervention implementation, and monitoring for effectiveness.
Failure to Protect Residents from Sexual Abuse and Inadequate Response to Allegation
Penalty
Summary
The facility failed to ensure that residents were protected from abuse, specifically sexual abuse, as evidenced by an incident involving inappropriate sexual contact between two residents. One resident reported waking up to another resident touching his genitals and attempting to penetrate his anus without consent. The incident was reported to the Resident Advocate and the police were contacted, but the alleged perpetrator was not arrested. The victim expressed ongoing anger and anxiety related to the incident and reported that the facility did not take sufficient action to keep the residents separated following the event. Documentation shows that the alleged perpetrator remained in the facility for several months after the incident, and the victim felt unsupported by staff in the aftermath. Medical records and interviews revealed that both residents involved had moderate cognitive impairments and significant psychiatric histories, including schizoaffective disorder, PTSD, and histories of trauma. The victim's care plan included trauma-informed care, but did not identify interventions specific to the sexual abuse incident. Additionally, the assessment of the resident's capacity to consent to sexual activity was not completed prior to the incident, and the care plan interventions addressing the altercation were not initiated until four months after the event. The facility's investigation was ultimately deemed inconclusive, with no conclusive evidence to verify the allegation, and the only interventions documented were the relocation of the alleged perpetrator and general monitoring. Interviews with facility staff, including the Resident Advocate, social worker, and administrator, indicated a lack of timely and coordinated response to the incident. The social worker was not informed of the sexual abuse allegation and did not address it in therapy or care planning. The administrator and Resident Advocate both acknowledged the incident and the subsequent anger and anxiety experienced by the victim, but could not recall or document any new or specific interventions implemented to support the resident or prevent further contact. The facility's failure to promptly assess capacity for consent, implement individualized interventions, and ensure separation of the residents contributed to the deficiency.
Failure to Develop and Implement Comprehensive Care Plans for Residents with Complex Needs
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for three residents with significant medical and psychosocial needs. One resident with end stage renal disease and an arteriovenous fistula for dialysis did not have a care plan addressing dialysis care, monitoring of the fistula, or interventions for potential complications. Despite regular assessments and communication with the dialysis center, there were no documented care plan focus areas or interventions specific to dialysis or fistula management in the resident's medical record. Another resident with a history of substance use, including repeated possession and use of THC vape devices, did not have a care plan addressing substance use or interventions to manage the associated risks. Multiple incidents were documented where the resident was found with THC vapes, and staff, including the DON and ADON, acknowledged awareness of the resident's substance use and the need for a care plan. However, no goals or interventions related to substance use were present in the care plan, despite ongoing issues and the potential impact on other residents. A third resident with a history of falls, cognitive impairment, and physical limitations had a care plan that included several interventions, such as the use of a Gerihip hip protector, pressure alarm mat, and education on using the call light. However, observations and staff interviews revealed that these interventions were not consistently implemented. The resident was repeatedly observed without the hip protector, and some staff were unaware of the intervention or its purpose. The pressure alarm mat was not always positioned correctly, and the resident was seen ambulating in socks, increasing fall risk. These lapses contributed to the facility's failure to ensure that care plan interventions were effectively carried out to meet the resident's needs.
Failure to Maintain Complete Laboratory Records in Resident Charts
Penalty
Summary
The facility failed to maintain complete, dated laboratory records in the clinical records of three residents. For one resident with multiple chronic conditions, including diabetes, end stage renal disease, and hypertension, there was no documentation in the medical record for the results of a respiratory panel ordered due to influenza A exposure, nor for routine labs (CBC, CMP, HbA1c) ordered for a specific month. The Assistant Director of Nursing (ADON) indicated that the resident only allowed the dialysis center to obtain labs, and the results were not present in the facility's records until much later. The Director of Nursing (DON) confirmed that the laboratory results for the routine labs were only recently obtained from the dialysis center. Another resident with psychiatric and substance use diagnoses also had a respiratory panel ordered due to influenza A exposure, but the results were not found in the medical record. Staff interviews revealed that while lab results were typically faxed to the facility and uploaded into the medical record, the respiratory panel result remained in the fax queue and had not been uploaded. For a third resident with cardiac and renal diagnoses, a one-time basic metabolic panel was ordered, but the results were not present in the medical record; the DON later stated that the results had been uploaded to the wrong resident's chart. These findings demonstrate that laboratory reports were not consistently filed in the correct resident records as required.
Failure to Maintain Accurate and Confidential Medical Records
Penalty
Summary
The facility failed to maintain complete, accurate, and secure medical records for multiple residents. In several instances, staff documented other residents' names within a resident's medical record, rather than using appropriate identifiers such as room numbers. For example, in the medical record of a resident with schizoaffective disorder, PTSD, and other psychiatric diagnoses, progress notes included the full names of other residents involved in an altercation, contrary to facility policy and accepted standards. Additionally, another resident's discharge documentation was found in the wrong resident's medical record, and similar issues were identified in the records of other residents, where names of unrelated residents appeared in progress and event notes. Furthermore, the facility did not ensure that required physician documentation was present in the medical record for the ongoing use of a PRN psychotropic medication. In one case, a resident with PTSD and schizoaffective disorder had a PRN order for clonazepam extended, but the physician's rationale for this extension was not found in the medical record as required. The DON later located the missing document outside of the resident's chart, indicating a lapse in maintaining complete and accessible records. These deficiencies were identified through record review, staff interviews, and observation.
Failure to Implement Infection Control Practices and Enhanced Barrier Precautions
Penalty
Summary
A deficiency was identified when a Certified Nurse Assistant (CNA) was observed distributing snacks to residents in the hallway using bare hands, without the use of tongs or hand hygiene between residents. The Director of Nursing (DON) confirmed that staff are expected to use tongs and perform hand hygiene between each resident when handling food. This failure to follow proper infection control practices resulted in direct hand-to-food contact during snack distribution. Additionally, two residents with indwelling medical devices or wounds did not have Enhanced Barrier Precautions (EBP) in place as required. One resident with a wound vac for a right elbow wound and another with a foley catheter were not on EBP, and there was no signage indicating such precautions outside their rooms. Interviews with staff revealed a lack of awareness and implementation of EBP for residents with invasive devices, despite physician orders and care plans indicating the presence of these devices and associated infection risks.
Loose Handrails in Resident Corridors
Penalty
Summary
The facility failed to ensure that all corridors were equipped with firmly secured handrails, as required. During observations on multiple occasions, three separate handrails in resident corridors were found to be loose and not properly secured to the wall. These deficiencies were identified outside and between various resident rooms. In an interview, the Maintenance and Housekeeping Supervisor (MHS) stated that daily audits were conducted, including inspection of handrails, but acknowledged that the loose handrails had not been noticed during these audits. The MHS further confirmed during inspection with the State Surveyor that the handrails were loose and needed tightening or possible replacement. No information was provided regarding specific residents affected, their medical history, or their condition at the time of the deficiency.
Failure to Timely Report Alleged Abuse, Neglect, or Injury
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, or theft were reported immediately, but not later than 2 hours after the allegation was made, to the administrator, State Survey Agency (SSA), Adult Protective Services (APS), and local law enforcement. In several instances, staff did not notify the administrator or external agencies within the required timeframe after becoming aware of incidents involving residents. For example, after a resident reported being touched inappropriately by another resident, staff became aware of the incident at 5:51 AM, but the administrator was not notified until over 3 hours later, and notifications to SSA, APS, and law enforcement were delayed by more than 4 to 5 hours. In another case, two residents were found engaging in a sexual act in a bathroom. While the SSA was notified within an hour, notifications to APS and law enforcement were not made until four days after the facility became aware of the incident. The documentation did not include the exact time of these notifications, further indicating a lack of timely reporting as required by regulations. Additionally, a resident sustained an injury after falling in a transportation van. The incident was not reported to the SSA until several days later, and other agencies were not notified at the time of the incident. Interviews with the Director of Nursing and the administrator revealed uncertainty about whether the incident constituted neglect and acknowledged that the incident should have been reported. These failures demonstrate that the facility did not consistently follow required protocols for timely reporting of alleged abuse, neglect, or theft.
Failure to Maintain Clean and Homelike Resident Bathroom Environment
Penalty
Summary
A resident with a history of heart failure, type 2 diabetes, osteomyelitis, and diarrhea reported the presence of fecal matter on the wall next to the toilet in their bathroom, which had been there since admission. Multiple observations by the State Surveyor confirmed the presence of a brown substance on the wall near the toilet paper dispenser over several days, indicating the issue persisted throughout the survey period. Housekeeping staff interviewed stated that they cleaned the bathrooms daily, including the walls if needed, but did not notice the substance until it was pointed out. The Maintenance and Housekeeping Supervisor reported monitoring staff and addressing complaints as they arose, but was unaware of this specific issue until shown. Despite daily cleaning routines and available reporting mechanisms, the brown substance remained on the wall for an extended period, demonstrating a failure to maintain a safe, clean, and homelike environment for the resident.
Failure to Obtain and Document Required Laboratory Tests
Penalty
Summary
A deficiency was identified when a resident with multiple complex diagnoses, including type II diabetes mellitus, end stage renal disease, and hypertension, did not have required laboratory tests completed as ordered. The resident had physician orders for routine laboratory tests, specifically a Complete Blood Count (CBC), Comprehensive Metabolic Panel (CMP), and hemoglobin A1c (HbA1c) to be performed every six months in February and August. Upon review of the resident's medical records, there was no documentation of the CBC, CMP, or HbA1c results for the required periods. Interviews with the Director of Nursing (DON) revealed that while some laboratory results for CBC and CMP were eventually obtained from the dialysis center, the HbA1c was not included. The DON further explained that the dialysis center was conducting its own lab tests based on orders from their Nurse Practitioner, not the facility's physician orders, and that these results were not consistently communicated to or documented in the facility's medical records. Additionally, it was unclear if the facility's physician had access to the dialysis center's lab results, and the required lab results were not present in the resident's records.
Failure to Provide Physician-Ordered Diet Texture for Resident with Chewing and Swallowing Difficulties
Penalty
Summary
A deficiency occurred when a resident with no teeth, moderate cognitive impairment, and documented swallowing difficulties was served a modified diet that was not approved by the physician. The resident was observed eating chopped Lo Mein, chicken, vegetables, and whole French fries, despite a physician's order for a soft and bite-sized diet. The resident had previously reported difficulty chewing large chunks of food, prompting the Dietary Manager (DM) to downgrade the diet to minced and moist and notify the Speech-Language Pathologist (SLP) and the clinical team. However, this change was not approved by the physician, and the SLP had not yet evaluated the resident. Staff interviews revealed confusion regarding the resident's prescribed diet, with CNAs unsure of the current order and the DM stating that the meal card had been updated to minced and moist without physician approval. The Director of Nursing (DON) acknowledged being notified of the resident's difficulties and the dietary change but confirmed that any diet downgrade required provider approval and SLP evaluation, which had not occurred at the time of the survey. As a result, the facility failed to ensure that food was prepared and provided in a form designed to meet the resident's individual needs as ordered by the physician.
Failure to Support Resident Choice for Independent Smoking Access After Hours
Penalty
Summary
A deficiency was identified when a resident, who had been assessed as safe to smoke without supervision, was not allowed access to the secured outside smoking patio after 9:00 PM except during designated supervised smoking times at 11:00 PM and 3:00 AM. The resident expressed a desire to sit outside on the patio at night but was informed by staff that he had to be inside by 9:00 PM. The resident reported feeling treated like a child and unable to leave when he wanted. Review of the resident's smoking evaluations confirmed that he was considered safe to smoke independently. Facility staff, including the ADON, stated that the back interior door to the patio locked automatically at 9:00 PM and reopened at 6:00 AM, and that the policy required residents to wait for supervised smoking times at night, even if they were independent smokers. The ADON cited staffing limitations as the reason for this policy, noting that staff could not accommodate letting residents in and out at will during the night. The Administrator indicated that independent smokers should be allowed access as they pleased, but acknowledged there was no way for residents to alert staff to be let back in except by knocking, as the patio door lacked a doorbell.
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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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