Monument Healthcare Bountiful
Inspection history, citations, penalties and survey trends for this long-term care facility in Bountiful, Utah.
- Location
- 460 West 2600 South, Bountiful, Utah 84010
- CMS Provider Number
- 465112
- Inspections on file
- 19
- Latest survey
- November 6, 2025
- Citations (last 12 mo.)
- 3 (1 serious)
Citation history
Health deficiencies cited at Monument Healthcare Bountiful during CMS and state inspections, most recent first.
A resident with significant mobility limitations fell from a Hoyer lift during a transfer when only one CNA assisted, contrary to policy requiring two staff. The lift was missing required safety latches, and the sling was not properly secured, resulting in the resident sustaining a fracture. Staff interviews and observations confirmed lapses in following procedures and equipment checks.
A resident with multiple medical conditions sustained a fall from a Hoyer lift resulting in a fracture, but the incident was not reported to the SSA within the required timeframe, and APS was not notified. The DON confirmed the delay in reporting and lack of investigation for possible neglect, leading to a deficiency in mandated reporting.
A resident with multiple medical conditions fell from a Hoyer lift during a transfer, resulting in pain and injury. The facility's abuse investigation lacked documentation of interviews with the staff involved and the resident, and the incident date was recorded incorrectly. The DON confirmed that the investigation records were incomplete and did not demonstrate a thorough review to rule out neglect.
A resident with cerebral palsy and functional quadriplegia was being pushed in a wheelchair by a CNA without footrests in place, resulting in the resident's foot catching on the ground and a fall that caused facial abrasions, a lip laceration, and other minor injuries. The incident highlighted a failure to provide adequate supervision and accident prevention during wheelchair transport.
A nurse mistakenly administered a resident's roommate's medications, including acetaminophen, senna, trazodone, and extended release morphine. The error was promptly reported, the resident was monitored for adverse effects, and no changes in condition were observed during follow-up assessments.
A resident with cognitive impairment and mobility issues slid out of her wheelchair during transport, resulting in a femur fracture. The van driver did not call emergency services and continued to the appointment. Upon return, the incident was reported to the Admissions Coordinator and a nurse, but the resident was not assessed or documented in the medical record. The injury was discovered days later after the resident complained of pain, revealing a lack of supervision and communication within the facility.
A resident with multiple diagnoses, including chronic pain and pressure ulcers, did not receive adequate pain management during wound care. Despite having orders for Acetaminophen and Morphine, the resident was not premedicated, leading to significant discomfort. Staff interviews and observations confirmed the oversight, with the RN admitting to not administering pain relief as per protocol. The DON acknowledged the failure to follow pain management procedures, resulting in a deficiency in care.
A resident with multiple health conditions fell from a wheelchair during transportation, resulting in a fracture. The facility failed to report the incident to the SSA within the required timeframe. Despite the resident's ongoing pain and eventual diagnosis of a fracture, the incident was not reported, highlighting a communication breakdown between the DON and the Administrator.
Two residents' MDS assessments were inaccurately completed, failing to reflect hospice services and PASRR Level II status. A resident receiving hospice care was not coded as such, and another with a PASRR Level II indicating serious mental illness was incorrectly documented. The MDS Coordinator did not thoroughly verify these statuses, leading to documentation errors.
A resident with a complex medical history experienced knee and hip pain, prompting x-rays to be ordered. While reports for the left knee and hips were documented, the right knee x-ray report was missing from the medical record, despite a critical fracture being reported. The DON acknowledged the oversight, and the missing report was later provided by the Regional Clinical Operations Director.
A facility failed to maintain proper infection control during a wound care procedure for a resident with pressure ulcers. The RN did not perform hand hygiene between glove changes and handled sterile supplies with bare hands, contrary to facility policy. The resident, who had multiple medical conditions and was dependent on staff, expressed pain during the procedure. The DON confirmed the breach in protocol, highlighting a deficiency in the infection prevention and control program.
Resident Fall Due to Improper Hoyer Lift Use and Missing Safety Latches
Penalty
Summary
A deficiency occurred when a resident, who was dependent on staff for all transfers and activities of daily living due to multiple medical conditions including hemiplegia, diabetes, and a history of stroke, sustained a fall from a Hoyer lift during a transfer from bed to wheelchair. The incident happened during a one-person assisted transfer, despite facility policy and manufacturer guidelines requiring at least two staff members for safe operation of the mechanical lift. The resident was found on the floor with pain in the hip and knee, and later diagnosed with a fracture after being transferred to the hospital due to persistent, severe pain. Investigation revealed that the Hoyer lift used during the incident was missing safety latches on the cradle hooks, which are required by the manufacturer to prevent sling straps from slipping off. Staff interviews confirmed that the sling was not properly secured, with one of the straps not attached to the lift, and that the CNA operating the lift did not request assistance or verify the secure placement of all straps. The CNA involved admitted to not being familiar with the sling and noted that the absence of safety latches made it easier for straps to come off the hooks. Another CNA present at the time also failed to inspect the sling for proper placement, assuming the other staff member had done so. Observations and interviews further confirmed that both Hoyer lifts in the facility were missing some or all of the required safety latches, and that staff were not consistently following procedures to ensure equipment was in good working condition and that transfers were performed with adequate supervision. The facility's own policy and the manufacturer's instructions both require thorough inspection of the lift and sling, proper attachment of all straps, and the presence of two trained staff during transfers. These requirements were not met at the time of the incident, directly leading to the resident's fall and injury.
Failure to Timely Report Suspected Neglect Following Resident Fall
Penalty
Summary
A deficiency occurred when the facility failed to report an alleged violation involving neglect within the required 24-hour timeframe. Specifically, a resident with multiple complex medical conditions, including type 2 diabetes mellitus, right femur fracture, hemiplegia, and respiratory failure, sustained a fall from a Hoyer lift during a one-person assisted transfer. The incident resulted in a fracture, and the event was documented by the Interdisciplinary Team as a fall from the lift. However, the State Survey Agency (SSA) was not notified of the incident until approximately seven days after it occurred, and there was no documentation indicating that Adult Protective Services (APS) had been notified at all. During an interview, the Director of Nursing (DON) acknowledged the regulatory requirement to report suspected abuse or neglect to the state within two hours and confirmed that the facility did not investigate the incident for possible neglect in a timely manner. The DON also stated that APS was not notified and could not provide a reason for this omission. The failure to report the incident as required and to notify the appropriate authorities constituted a violation of mandated reporting protocols.
Failure to Document Thorough Investigation After Resident Fall
Penalty
Summary
A deficiency was identified when the facility failed to provide evidence of a thorough investigation into an allegation of neglect following a fall incident involving a resident. The resident, who had multiple complex medical diagnoses including type 2 diabetes, right femur fracture, asthma, major depressive disorder, hemiplegia, respiratory failure, and cognitive communication deficit, sustained a fall from a Hoyer lift during a one-person assisted transfer. The incident resulted in complaints of pain and a visible injury, prompting an abuse investigation and notification to the State Survey Agency. The facility's abuse investigation documentation was incomplete, lacking records of interviews with the staff members involved in the transfer and the resident. Additionally, the investigation summary referenced an interview with the resident, but no documentation of this interview was found. The date of the incident was also incorrectly documented in the investigation. The Director of Nursing confirmed that the investigation records did not contain the necessary interviews to rule out neglect, and it was not evident from the documentation that a thorough investigation had been conducted.
Resident Fall Due to Lack of Wheelchair Footrests During Transport
Penalty
Summary
A deficiency occurred when a resident with a history of cerebral palsy, functional quadriplegia, contractures, and balance deficits was being transported in a wheelchair by a CNA without the use of footrests. The resident, who was able to self-propel using one foot, was being pushed by staff when her foot caught on the ground, causing her to fall forward out of the wheelchair. As a result, the resident sustained abrasions to her face and wrist, a skin tear, and a laceration to her lip. She also experienced pain in her back, mouth, face, and chest, and exhibited shallow breathing following the incident. Medical records indicated that the resident was unable to brace herself during the fall due to her physical limitations. The incident required emergency medical services, and the resident was transferred to a hospital for evaluation. Subsequent assessments confirmed no fractures, but superficial injuries were present. The deficiency was identified through observation, interviews, and record review, which confirmed that the resident did not have appropriate supervision and safety measures in place to prevent the accident during wheelchair transport.
Medication Error: Resident Administered Roommate's Medications
Penalty
Summary
A nurse administered the incorrect medications to a resident by giving her the medications intended for her roommate. The medications given in error included acetaminophen 325mg, senna 8.6mg, trazodone 50mg, and extended release morphine 15mg. The incident was documented in the resident's medical record, and the nurse notified the physician, who provided instructions to hold the resident's scheduled Tylenol, senna, and trazodone. The nurse also contacted the resident's emergency contact and initiated monitoring for any adverse effects. Following the medication error, nursing staff conducted additional assessments each shift to monitor the resident for any changes in condition. Throughout the monitoring period, the resident's condition remained at baseline with no noted changes. The nurse involved reported the error to the nurse manager and followed instructions to check for allergies and perform neurological checks. The incident was the only medication error reported in the facility within the past 60 days.
Resident Injury Due to Inadequate Supervision During Transport
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices to prevent accidents for a resident, who slid out of her wheelchair during transport and sustained a femur fracture. The resident, who had a history of hemiplegia, hemiparesis, and moderate cognitive impairment, was being transported to a medical appointment when the incident occurred. The van driver reported that the resident informed him she was sliding out of her wheelchair, prompting him to stop and seek assistance from a nearby school. Despite the resident being partially suspended by the seatbelt, the driver did not call emergency services, as per company policy, and continued to the appointment. Upon returning to the facility, the van driver informed the Admissions Coordinator and a nurse about the incident. However, the nurse did not assess the resident or document the occurrence in the medical record. The resident later complained of pain, leading to x-rays that revealed a fracture. The facility's staff, including the DON and ADON, were not immediately informed of the incident, and the resident's condition was not promptly addressed, resulting in a delay in identifying the injury. Interviews with facility staff revealed communication breakdowns and a lack of proper documentation and assessment following the incident. The SLP was informed by the resident about the fall and reported it to the DON, but did not document this communication. The RN on duty at the time of the incident did not perform an assessment or document the event, contributing to the oversight. The facility's failure to ensure proper supervision and communication led to the resident's injury going unaddressed for several days.
Inadequate Pain Management for Resident During Wound Care
Penalty
Summary
The facility failed to provide adequate pain management for a resident, identified as Resident 42, who required such services. Resident 42 was admitted with multiple diagnoses, including chronic pain and pressure ulcers. Despite having physician orders for pain management, including Acetaminophen and Morphine, the resident did not receive pain medication prior to or after wound care treatments. The resident reported a pain level of 8 out of 10, yet the medication administration record showed inconsistent documentation of pain scores and administration of pain relief. During an observation, Resident 42 expressed pain during wound care, moaning and vocalizing discomfort, yet was not premedicated with pain relief as per the facility's protocol. The Registered Nurse (RN) involved acknowledged the oversight and admitted to not administering pain medication before or after the wound care session. The Director of Nursing (DON) confirmed that pain medication should be administered 30 to 40 minutes prior to wound care, but this protocol was not followed. Interviews with staff revealed that Resident 42 was dependent on staff for care and experienced pain with movement, particularly in the right knee and heels. Despite having orders for pain evaluations every shift and the availability of Morphine for severe pain, the resident's pain management was inadequate, leading to unnecessary suffering during wound care procedures. The facility's failure to adhere to pain management protocols and physician orders resulted in a deficiency in providing appropriate care for Resident 42.
Failure to Report Resident Fracture Incident
Penalty
Summary
The facility failed to report an incident involving a resident who sustained a fracture during transportation. Resident 20, who has a medical history including hemiplegia, heart disease, diabetes, and cognitive deficits, fell out of a wheelchair while being transported to an appointment. The incident was initially noted by a speech language pathologist and later by the Assistant Director of Nursing (ADON), who observed an abrasion on the resident's knee. Despite these observations, the incident was not reported to the State Survey Agency (SSA) as required. The resident continued to experience pain, leading to further assessments and x-rays. Initially, x-rays of the left knee and hips showed normal results, but subsequent x-rays revealed a critical fracture in the right leg/knee. The resident was then sent to the emergency room for treatment. Despite the discovery of the fracture, the facility did not report the incident to the SSA within the required timeframe. Interviews with the Director of Nursing (DON) and the Administrator revealed a lack of communication and understanding regarding the reporting requirements. The DON believed the incident was not reportable until the fracture was confirmed, and the Administrator acknowledged that no report was filed with the SSA. The Administrator stated that the incident should have been reported within 24 hours once the fracture was identified, but this did not occur.
Inaccurate MDS Assessments for Hospice and PASRR Status
Penalty
Summary
The facility failed to accurately reflect the status of two residents in their Minimum Data Set (MDS) assessments, leading to deficiencies in the documentation of hospice services and Preadmission Screening and Resident Review (PASRR) Level II status. Resident 22, who was receiving hospice services, was not coded as such on two quarterly MDS assessments and an annual MDS assessment. Despite the hospice start of care date being documented in the resident's medical record, the MDS Coordinator did not identify this in the daily census or the resident's medical record, where the resident was listed as private pay. Resident 27, who had a PASRR Level II assessment indicating serious mental illness, was not accurately coded in the MDS assessment. The MDS Coordinator relied solely on the PASRR Letter of Determination, which did not explicitly state the presence of a serious mental illness, rather than reviewing the full PASRR Level II evaluation. This led to an incorrect 'No' response in the MDS assessment regarding the resident's PASRR status, despite the evaluation documenting a serious mental illness. The MDS Coordinator's process for completing assessments involved a schedule distributed to department heads, with various sections of the MDS being completed by different staff members. However, the MDS Coordinator did not verify the hospice status or PASRR Level II status through comprehensive review of the residents' medical records, leading to inaccuracies in the MDS assessments for both residents.
Missing X-ray Report in Resident's Medical Record
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for a resident, specifically by not filing a signed and dated x-ray report for the resident's right knee. The resident, who had a complex medical history including hemiplegia, atherosclerotic heart disease, and type 2 diabetes, was experiencing bilateral knee and hip pain. An x-ray was ordered for both knees and hips, and while the results for the left knee and hips were documented, the report for the right knee was missing from the medical record. The deficiency was identified during a review of the resident's medical records, which revealed that the x-ray report for the right knee was not present, despite a critical fracture being reported to the facility. The Director of Nursing acknowledged the oversight, stating that the facility had not received a printed report for the right knee, although the Regional Clinical Operations Director later provided a copy of the missing report. This lapse in documentation highlights a failure in the facility's process for ensuring all diagnostic reports are properly filed in the resident's medical record.
Infection Control Deficiency in Wound Care Procedure
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by improper hand hygiene and PPE usage during a wound care treatment for a resident. The resident, who had multiple medical conditions including dementia and pressure ulcers on both heels, was observed receiving wound care from a registered nurse (RN). During the procedure, the RN did not adhere to proper hand hygiene protocols, such as failing to perform hand hygiene between glove changes and handling sterile supplies with bare hands. The resident, who was dependent on staff for care and had a moderate cognitive impairment, expressed pain during the wound care procedure. The RN was observed to don and doff gloves without performing hand hygiene in between, and handled sterile gauze with bare hands, which compromised the sterility of the supplies. The RN acknowledged the need for hand hygiene between glove changes but did not follow through during the procedure. The Director of Nursing (DON) confirmed that the facility's policy required hand hygiene before donning gloves and between glove changes, especially when moving from a dirty to a clean area. The facility's policy on hand hygiene, which was last revised in February 2024, was not adhered to during the observed wound care, leading to a deficiency in the infection prevention and control program.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
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