Mission At Community Living Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Centerfield, Utah.
- Location
- 10 West 400 South, Centerfield, Utah 84622
- CMS Provider Number
- 465175
- Inspections on file
- 16
- Latest survey
- June 26, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Mission At Community Living Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors found that immunization histories were missing from the medical records of several residents with complex medical conditions. The DON reported that these records were kept separately in a pharmacy file rather than in the official medical records, and both the Administrator and DON were unsure about the process for accessing this information when needed.
The facility did not ensure proper infection control practices, as clean laundry was transported uncovered through hallways and sometimes delivered to incorrect resident rooms. Additionally, staff lacked knowledge and implementation of Enhanced Barrier Precautions for a resident with a wound vacuum, and no EBP signage was posted. Interviews confirmed that staff were unaware of EBP requirements and did not consistently use isolation signage.
Staff members were alleged to have consumed alcohol and transported residents while under the influence during an outing, but the incident was not documented in the medical records or reported to the State Survey Agency as required. The residents involved had complex medical conditions, and the facility administrator confirmed that the event should have been reported.
Allegations that a staff member drove residents while intoxicated were not investigated or documented by the facility. Despite policies prohibiting staff alcohol use during resident outings, no evidence of an investigation or reporting to the State Agency was found for three residents with complex medical needs.
Two residents did not have all required laboratory results filed in their medical records, including a missing urine culture and a missing urine microalbumin result. The ADON confirmed that these results were not present in the records and had to be obtained from external sources.
Surveyors found that chemicals were stored with food in the dry storage area, a freezer lacked a functional thermometer and backup temperature monitoring, and the Dietary Manager wore a hairnet that did not fully contain hair, all in violation of professional food service standards.
Following an incident where a staff member was arrested for drinking while transporting residents, the facility did not provide required training on dementia care, abuse, neglect, exploitation, or substance abuse to staff. Staff interviews confirmed a lack of formal education, audits, or checklists related to safe transportation and abuse prevention, despite facility policies mandating such training.
Incomplete Medical Records: Missing Immunization Documentation
Penalty
Summary
Surveyors determined that the facility failed to maintain complete and accurately documented medical records for four out of twenty-four sampled residents. Specifically, the immunization histories for these residents, who had various diagnoses including dementia, osteoporosis, macular degeneration, chronic pain, congestive heart failure, chronic kidney disease, morbid obesity, anxiety, type II diabetes, hyperkalemia, and neuropathy, were not found in their medical records. During interviews, the Administrator was unable to identify where the immunization records were stored if not in the medical record, and the DON stated that the records were kept in a pharmacy file in her office rather than in the residents' medical records. The DON also expressed uncertainty about what would happen if the immunization information was needed and not available in the medical record.
Failure to Implement Infection Control Measures and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement and maintain an effective infection prevention and control program, as evidenced by multiple observations and staff interviews. Laundry staff were seen transporting clean resident laundry throughout the facility without any covering, exposing the laundry to potential contamination as it was moved past residents and staff in the hallways. Additionally, the laundry staff sometimes carried laundered clothing on their shoulder and delivered bundles of clothing to multiple resident rooms, occasionally resulting in residents' clothing being placed in the wrong rooms. The supervisor of the laundry department confirmed that clean laundry was not covered during transport and was unaware of the requirement to do so. For one resident with significant medical conditions, including a stage 3 pressure ulcer and a wound vacuum, there was no evidence of Enhanced Barrier Precautions (EBP) being implemented or posted outside the resident's room. Staff interviews revealed a lack of knowledge about EBP among nursing and support staff, with some staff stating they did not know what EBP were and that isolation signage was not routinely used. The Director of Nursing also acknowledged unfamiliarity with EBP and recognized that some residents, including the one with a wound vacuum, would qualify for such precautions. No EBP signage was observed in the facility, and staff communication about precautions was inconsistent.
Failure to Timely Report Alleged Staff Misconduct Involving Alcohol Use During Resident Outing
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, were reported immediately, but not later than two hours after the allegation was made, to the State Survey Agency. Specifically, a staff member was arrested for driving under the influence (DUI) and had alcohol in the facility vehicle while transporting residents during a rafting trip. Additionally, it was alleged that maintenance, activities, and nursing staff consumed alcohol during the outing with residents. The incident was not documented in the medical records of the involved residents, and the State Survey Agency was not notified as required. The residents involved included individuals with significant medical conditions such as dementia, osteoporosis, macular degeneration, chronic pain, cerebral palsy, contracture, muscle weakness, cramp and spasm, major depressive disorder, Lupus, anxiety, and a history of falling. Despite the serious nature of the allegations and the vulnerability of the residents, there was no evidence in their records regarding the incident, and the required reporting procedures were not followed. The facility administrator confirmed that there was a zero-tolerance policy for alcohol and that the incident should have been reported, but acknowledged that it was not.
Failure to Investigate Alleged Staff Intoxication During Resident Outing
Penalty
Summary
The facility failed to provide evidence that all alleged violations of abuse, neglect, or mistreatment were thoroughly investigated for three residents. Specifically, allegations were made that a staff member drove residents while being intoxicated, but there was no documentation in the medical records of the involved residents regarding the incident, nor was there any investigation provided by the facility. The residents involved had significant medical conditions, including dementia, osteoporosis, macular degeneration, chronic pain, cerebral palsy, muscle weakness, major depressive disorder, Lupus, anxiety, and a history of falling. Interviews with the Administrator and CEO revealed that the incident involved a staff member being stopped by authorities due to alcohol containers found in the facility vehicle while transporting residents on an outing. Both the Administrator and CEO confirmed that staff are not permitted to consume alcohol or have alcohol in facility vehicles while on duty. Despite these policies, the incident was not reported to the State Agency, and no investigation was conducted or documented by the facility.
Incomplete Filing of Laboratory Results in Resident Records
Penalty
Summary
The facility failed to maintain complete, dated laboratory records in the clinical records of two residents. For one resident with diagnoses including Lupus, major depressive disorder, dementia, anxiety, and a history of falls, a physician's order was placed for a urine analysis with culture. While the urine analysis result was present in the medical record, the urine culture result was missing. The Assistant Director of Nursing (ADON) confirmed that the culture results had not been filed in the medical record and had to be obtained by calling the laboratory. Similarly, another resident with Alzheimer's disease, type 2 diabetes, major depressive disorder, and anxiety disorder had a physician's order for multiple laboratory tests, including a urine microalbumin. Although most test results were documented, the urine microalbumin result was not found in the medical record. The ADON stated that she had to request the hospital to send the missing result so it could be attached to the medical record. In both cases, the required laboratory reports were not filed in the residents' clinical records as required.
Food Safety Deficiencies in Kitchen Storage, Temperature Monitoring, and Staff Hygiene
Penalty
Summary
Surveyors observed multiple failures to adhere to professional standards for food service safety within the facility's kitchen. Chemicals, including peroxide, multi-surface cleaner, glass cleaner, mop cleaner, table top cleaner, vinegar, and mop heads, were stored in the dry storage room alongside food items. Specifically, a mop handle was found touching an open bag of tortilla chips, which was also in contact with a bottle of vinegar. The Dietary Manager confirmed that some frequently used chemicals were kept in the dry storage room, despite most being stored elsewhere. Additionally, the freezer's temperature monitoring was inadequate. The external display for the freezer temperature was not functioning, and there was no backup thermometer inside the freezer to verify the temperature. Although temperature logs indicated a consistent reading, the accuracy could not be confirmed due to the lack of a working thermometer. Furthermore, the Dietary Manager was observed wearing a hairnet that did not fully contain all hair, with several strands exposed, contrary to professional standards for food safety.
Failure to Provide Required Staff Training After Substance Abuse Incident
Penalty
Summary
The facility failed to provide staff training on dementia care, abuse, neglect, exploitation, and the procedures for reporting such incidents, as well as ongoing substance abuse training following a significant event. Specifically, after a staff member was arrested for drinking while driving residents in the facility van, there was no formal training or education provided to staff regarding substance abuse, safe transportation, or abuse prevention. Multiple staff interviews confirmed that no additional training or audits were conducted after the incident, and staff were only verbally informed that drinking while working would result in termination. The facility's own policies require education on abuse, neglect, and exploitation during orientation and periodically thereafter, but this was not followed after the incident. Record review and staff interviews revealed that staff involved in resident transportation did not receive formal training on safe transport or abuse prevention, and there were no checklists, audits, or ongoing education provided. The administration could not recall any specific training or follow-up after the alcohol-related incident, and the only action taken was the removal of driving privileges from the involved staff member. Facility policies reviewed indicated a requirement for ongoing education on abuse prevention and a drug-free workplace, but these were not implemented as required.
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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