Provo Rehabilitation And Nursing
Inspection history, citations, penalties and survey trends for this long-term care facility in Provo, Utah.
- Location
- 1001 North 500 West, Provo, Utah 84604
- CMS Provider Number
- 465119
- Inspections on file
- 24
- Latest survey
- March 16, 2026
- Citations (last 12 mo.)
- 8 (1 serious)
Citation history
Health deficiencies cited at Provo Rehabilitation And Nursing during CMS and state inspections, most recent first.
Facility staff failed to provide safe tracheostomy and respiratory care for multiple residents, including not entering or following updated ENT recommendations for extended trach-change intervals, attempting trach changes without active orders, and proceeding with trach changes on a vented resident with known tracheal stenosis despite an "ENT only" limitation communicated outside the chart. In one case, an RT attempted to change a trach after a complaint of tightness, encountered resistance with two different tube sizes, and the resident developed acute respiratory distress and cardiac arrest, leading to death. In another case, an RT found a trach tube broken at the flange and dislodged, changed the trach, and repeated suctioning produced large amounts of blood while SpO2 remained low, culminating in a code and death. Staff interviews described awareness of broken trach flanges, concerns about ventilator alarms and inadequate pulse oximetry equipment, and additional events where a resident with a displaced BiPAP was found unresponsive and could not be resuscitated.
Two residents with chronic respiratory failure and tracheostomy status experienced neglect related to trach management and access to ENT care. For one resident, ENT had previously changed the trach and recommended three‑month changes, but this was never entered as an order, prior routine trach‑change orders had expired, and an ENT referral was not completed after the ENT office declined to schedule due to insurance concerns that were not escalated to the BOM. Despite verbal communication that the trach should be changed only by ENT, an RT attempted a trach change after the resident complained of tightness, encountered resistance with both the original and a smaller tube, and the resident developed acute respiratory distress, required a code blue, and died. For another comatose resident, an RT found a broken trach flange with the tube dislodged and not midline, changed the trach, and suctioned large amounts of frank blood while the resident’s O2 saturation remained low; the resident was found pulseless, CPR was initiated, and the resident could not be revived. The DON and RT staff interviews showed inconsistent documentation and communication of trach‑change orders and equipment issues, and both events resulted in resident death.
The facility failed to immediately report an alleged violation involving an injury of unknown source to the SSA and APS after a resident with a trach and respiratory failure was found with a broken trach flange and a dislodged trach tube. An RT discovered the broken trach during rounds, performed an urgent trach change with assistance, and noted significant bleeding, declining SpO2, and eventual loss of pulse, leading to a code blue, EMS involvement, and the resident’s death. Documentation confirmed the event and the resident’s unstable condition during the trach change, but SSA records showed no report was made. In interviews, the DON stated that she and the Administrator decided not to report the incident because they believed respiratory staff followed policy and there was no concern for negligence, and the DON was unsure how the trach broke or whether the RT director investigated the event.
A resident who was comatose, ventilator‑dependent, and had a tracheostomy with multiple respiratory diagnoses was found by respiratory staff with a broken trach flange and a dislodged trach tube that was shifted from midline. Respiratory staff notified nursing, called in another RT, and attempted a trach change and suctioning, during which they noted significant bleeding and continued blood accumulation. The resident’s O2 saturation dropped, manual ventilation was initiated without improvement, and nursing staff found no pulse, started CPR, and involved EMS, but the resident could not be revived. In a later interview, the DON acknowledged that while staff responded to the event, she had not investigated how the trach broke and was unsure if the RT director had done so, resulting in no evidence of a thorough investigation into the alleged violation.
A resident with chronic respiratory failure and tracheostomy status had prior orders for routine trach changes that were discontinued, and an ENT later recommended trach changes every three months, but this recommendation was never entered as an active order in the medical record. The RT Director reported receiving a VO that only ENT should change the trach unless emergent, but this VO was not documented in the chart and was only communicated verbally and on a whiteboard. Believing a trach change was appropriate, RT staff attempted what they considered a scheduled trach change when the resident complained the trach felt too tight, encountered resistance with reinsertion attempts, and the resident developed acute respiratory distress, leading to a Code Blue and subsequent death. Interviews showed RT staff were unaware that trach changes were restricted to ENT and that there was no active order for a trach change at the time, demonstrating a failure to ensure services met professional standards of quality.
A resident with chronic respiratory failure, tracheostomy status, pneumonia, anoxic brain damage, and documented subglottic/proximal tracheal stenosis had a provider order for an ENT referral and a subsequent NP note calling for ENT f/u. The Transportation Driver sent the referral to an ENT office, which refused to schedule due to the resident’s lack of active insurance and self-pay status, and the driver documented unsuccessful attempts to reach the family to confirm payment. The Business Office Manager later stated the resident was Medicaid pending and that the facility would have been responsible for payment if an outside provider would not accept that status, but she was never informed that the ENT would not see the resident for this reason. Consequently, the ordered ENT evaluation for the resident’s tracheostomy and tracheal stenosis was not obtained.
The facility failed to use its QAPI process to identify, investigate, and analyze three respiratory‑related deaths and did not document corrective actions. Two residents on ventilators experienced critical tracheostomy events—an inappropriate trach change by respiratory staff and a broken trach flange causing dislodgement—leading to cardiac arrest and death. Two residents did not receive access to outside provider appointments for trach care, and verbal orders for trach changes were not followed. For one comatose resident in a vegetative state whose trach flange broke and who later died, the SSA and APS were not notified within the required timeframe. The ADM reported that only two of the deaths were reviewed in QAPI, was not informed of one death and its circumstances until the next morning, and stated that a contracted respiratory company, which had not reported equipment issues, was responsible for respiratory equipment.
A ventilator-dependent resident with a tracheostomy and respiratory failure experienced a broken trach flange and significant tube displacement, yet the ventilator and continuous pulse oximeter did not alarm despite low O2 saturation and visible cyanosis. During suctioning, staff noted substantial bleeding and the resident’s oxygen level continued to drop, leading to manual ventilation, a pulseless state, CPR, EMS involvement, and the resident’s death. A RT later reported prior concerns about broken ventilator alarm cables that could prevent alarms from reaching the call system and non-functioning pulse oximeters, while the Administrator stated that a contracted respiratory company supplied the equipment and had not reported any equipment issues.
The facility failed to protect residents from abuse and neglect, particularly in cases involving consensual relationships where residents lacked the capacity to consent. Residents with cognitive impairments were involved in inappropriate interactions, which were not properly assessed or reported. The facility relied on family consent without consulting medical professionals, leading to multiple incidents of potential abuse and exploitation.
The facility failed to maintain cleanliness and proper maintenance in the kitchen, with observations of a soiled steam table, dusty hood vents, a soiled wall behind the dish machine, missing grout, and a dusty fan. The Dietary Manager acknowledged these issues, noting that the vents were cleaned quarterly and the fan was a personal item. The steam table shelf was cleaned daily but was stained, and a work order was to be sent for the wall behind the dish machine.
Two residents with cognitive impairments were found in compromising situations, but the facility failed to report these incidents to the SSA and APS, citing them as consensual relationships. Despite the lack of documented capacity to consent, the facility relied on family input and staff observations, leading to a deficiency in compliance with reporting requirements.
A resident with COPD and other health issues did not have an active physician's order for oxygen therapy upon returning from the hospital, despite requiring it. Nursing staff acknowledged the need for such orders, but none were documented, leading to a deficiency in providing appropriate respiratory care.
A resident with multiple diagnoses, including anoxic brain damage and mental health disorders, experienced chronic mouth pain for ten months without adequate pain management. Despite a care plan and various prescribed medications, the resident's pain was not effectively addressed, leading to ongoing distress. Delays in dental care and specialist referrals further contributed to the deficiency in pain management.
A resident with multiple diagnoses, including depression and anxiety, did not receive prescribed medications like Zoloft, busPIRone, traMADol, TEGretol-XR, and Depakote due to unavailability. Despite refill requests, the facility's emergency medication system and pharmacy coordination failed, leading to unmanaged pain and agitation for the resident. Interviews revealed ongoing issues with medication supply and a recent pharmacy change.
A resident with a history of diabetes, hypertension, and atrial fibrillation self-administered medications brought by a family member, which were not documented by the nursing staff. The MAR indicated the medications were administered, but interviews revealed inconsistencies in the administration process. The DON was not informed until the next day, highlighting procedural lapses in medication management.
Two residents with cognitive impairments eloped from a memory care unit due to inadequate supervision. One resident, initially assessed as low risk, was allowed to leave unsupervised and was found outside after a fall. Another resident, assessed as high risk, was moved off the secured unit and later eloped, being found by emergency services. These incidents highlight failures in risk assessment and supervision processes.
Failure to Provide Safe Tracheostomy and Respiratory Care Resulting in Resident Deaths
Penalty
Summary
The deficiency involves the facility’s failure to provide safe and appropriate respiratory and tracheostomy care in accordance with physician orders, professional standards, and resident-specific limitations. For one ventilator-dependent resident with chronic respiratory failure, tracheostomy status, pneumonia, anoxic brain damage, and documented subglottic and proximal tracheal stenosis, hospital records indicated that ENT had changed the trach in the OR and recommended trach changes every three months instead of monthly, and advised against trialing a Passy Muir Valve. A nurse practitioner note directed continued trach care per RT protocol with ENT follow-up for the stenosis. The DON reported seeing a provider note indicating the trach should be changed every three months, but this order was never entered into the medical record. The prior standing order to change the trach every 45 days had been converted to every 30 days by the contracted respiratory company, and then the trach change order dropped off the MAR in January, leaving no active order for trach changes at the time of the resident’s death. On the day of the event, RT documentation earlier in the day described the resident as alert and oriented, on a ventilator with an XLT cuffed, non-fenestrated size 7 trach, with the trach midline, secure, and patent, and no signs of respiratory distress. Later, an RT note documented that the RT performed a trach change because the resident reported the trach was too tight that morning. The RT pre-oxygenated the resident and recorded stable SpO2 and HR before the attempt. During removal and reinsertion of the trach tube, resistance was encountered and insertion was unsuccessful; a smaller trach was then attempted and also could not be inserted. The resident developed acute respiratory distress with pallor and cyanosis, oxygen saturation dropped, and a code blue was initiated. Nursing documentation corroborated that during the attempted trach change, resistance was met twice, the resident became cyanotic with decreasing oxygen saturation, and CPR was initiated after the resident was found unresponsive, apneic, and pulseless. EMS continued resuscitative efforts, and the resident was pronounced dead. Interviews revealed that RT 1 believed the resident’s complaint of tightness meant the trach needed to be changed immediately, pushed a partially dislodged trach back in earlier that morning, and then proceeded with a trach change despite the resident not being in distress and the trach being described as secure, patent, and midline. RT 2 stated he was unaware the trach was not supposed to be changed and had never changed a vented patient’s trach before. RT 3 stated there were instructions that the resident’s trach was not to be changed until seen by ENT, and that he had seen the resident’s name on a whiteboard with an “ENT only” notation. The RT Director stated she had received a verbal order that the trach should be changed only by ENT unless emergent, but this was not entered into the chart and was only communicated verbally and on a whiteboard. A second resident with anoxic brain damage, acute and chronic respiratory failure, tracheostomy status, and pneumonia due to pseudomonas experienced a fatal event related to a broken trach flange and trach displacement. A late-entry RT note documented that during first rounds at night, the RT found the trach tube broken and dislodged from the flange, with the tube about 1.5 inches out of position and deviated from midline. The RT called a nurse and another RT to assist, removed the old tube, and inserted a new Shiley XLT 6 that had been tested and lubricated. During suctioning, a significant amount of blood was observed, and repeated suction passes continued to remove blood. The SpO2 alarm indicated low oxygen saturation, the resident was disconnected from the ventilator for manual bagging, and SpO2 did not improve. A pulse check revealed no pulse, the resident was transferred to the floor, a smaller XLT 5 trach was placed without resistance, and manual ventilation and chest compressions continued until EMS arrived, but the resident could not be revived. A nursing late entry confirmed that the RT showed the nurse the broken trach, that vital signs were stable before the change, and that copious bleeding occurred during the trach change, followed by code blue and unsuccessful resuscitation. RT 4 reported that the trach was broken at the flange and deviated at a 45-degree angle, that the ventilator was not alarming despite the deviation, that the resident’s lips appeared cyanotic with SpO2 below 90%, and that he changed the trach to restore a patent airway. He described large amounts of frank blood and mucus on suctioning and believed the airway was filled with blood. RT 4 also reported concerns about ventilator alarms, pulse oximeters, alarm cables, and lack of needed supplies prior to the current RT Director’s tenure, and stated he had asked repeatedly for alarms, pulse oximeters, and cables. A third resident with quadriplegia, anoxic brain damage, and chronic respiratory failure with hypoxia and hypercapnia had orders related to BiPAP/ventilator use, including checking body positioning, nasal cannula placement, and BiPAP vent settings with humidity. The overall deficiency cited that staff did not follow physician orders for changing tracheostomies, did not obtain needed consultations with outside providers, did not accurately document resident condition prior to trach changes, and did not initiate hospital transfer when there were concerns about trach integrity. Staff interviews revealed knowledge of faulty trach equipment, including broken flanges that caused trach dislodgement, and that one resident with a broken flange and dislodged trach went into cardiac arrest and died. Additionally, another resident with displaced BiPAP was found unresponsive, CPR was initiated, and the resident could not be resuscitated and died. These failures in respiratory and tracheostomy care for multiple residents resulted in findings of immediate jeopardy for two of the residents.
Failure to Coordinate Tracheostomy Care and Specialty Access Resulting in Harm and Death
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from neglect related to tracheostomy management and access to necessary outside specialty care, resulting in harm to two residents. One resident with chronic respiratory failure, tracheostomy status, pneumonia, and anoxic brain damage had physician orders for routine tracheostomy changes that were later discontinued, with no active order for trach changes at the time of death. An ENT referral was ordered due to subglottic and proximal tracheal stenosis, and the hospital H&P documented that ENT had changed the trach in the OR and recommended trach changes every three months instead of monthly, and against use of a Passy Muir Valve. A nurse practitioner note referenced continued trach care per RT protocol and follow-up with ENT, but the ENT appointment was never obtained. The transportation driver later documented that the ENT office would not schedule because the resident had no insurance and would be self-pay, and that repeated attempts to reach the family were unsuccessful; however, the business office manager stated that the resident was Medicaid pending and that, if an outside provider would not accept that status, the facility would be responsible for payment, and she was not informed of any barrier to the ENT visit. On the day of the first resident’s death, RT documentation earlier in the day showed the trach as midline, secure, and patent, with stable vital signs and no respiratory distress. Later, RT 1 documented attempting a scheduled trach change after the resident complained the trach was too tight, pre-oxygenating the resident, and then encountering resistance when removing and reinserting the trach tube; a smaller size trach was also unsuccessfully attempted. The resident developed acute respiratory distress with pallor and cyanosis, and a code blue was initiated. Nursing documentation described that during the attempted trach change, resistance was met twice, the resident exhibited respiratory distress with decreasing oxygen saturation and cyanosis, and manual ventilation and CPR were initiated, but the resident was ultimately pronounced dead by EMS. RT 1 reported that the resident had complained of tightness, that the trach appeared dislodged about 1.5 inches from the stoma earlier, and that she pushed it back in; she stated that complaints of tightness could indicate the trach was dirty and needed immediate change, and that she attempted the change with RT 2 assisting, met resistance with both the original and a smaller trach, and then the resident’s oxygen saturation dropped significantly before cardiac arrest. RT 2 stated he did not know the trach was not supposed to be changed and had never changed a vented patient’s trach before; he also noted that he learned only after the death that the physician was supposed to change the trach and that prior monthly trach-change orders had expired. Additional interviews revealed conflicting and incomplete communication about trach-change orders and ENT-only status. RT 3 stated that due to tracheal stenosis, the resident’s trach was not to be changed until seen by ENT, that he had seen the resident’s name on a whiteboard with a note stating “ENT only,” and that he would not change an ENT-only trach if it was patent, midline, and secure. The RT Director reported receiving a verbal order from the provider in early February that the resident’s trach should be changed only by ENT unless in an emergent situation, but acknowledged this order was never entered into the resident’s chart; she said it was communicated verbally to staff and written on a whiteboard as “trach change on hold until otherwise notified.” The DON stated she had seen a provider note indicating the trach should be changed every three months, but that this order was never placed in the medical record, and that the prior 45-day trach-change order had been changed to every 30 days by the contracted respiratory company and then dropped off the MAR in January, leaving no active trach-change order. The facility’s trach-change policy required changes per doctor’s orders or every 30 days, including emergency changes for damaged or non-patent tubes, and outlined steps for managing inadequate airflow and failed reinsertion, including manual ventilation and calling emergency services. The second resident involved in the deficiency had anoxic brain damage, acute and chronic respiratory failure, tracheostomy status, and pneumonia due to pseudomonas, and was comatose and in a vegetative state. Respiratory staff entered the resident’s room in the evening and found the trach flange broken, with the trach tube dislodged about 1.5 inches out of position, shifted to the right, and not midline. RT 4 stated that trachs should be centered and midline to avoid airway obstruction or bleeding, and that the ventilator was not alarming despite every breath being pressurized. The resident’s lips appeared cyanotic, and when the oxygen sensor was repositioned, the saturation was below 90%. RT 4 called for another RT and a nurse, determined the trach needed to be changed to ensure a patent airway, and changed the trach and suctioned the airway. On the first suction pass, a large amount of frank blood and mucus was removed, and two additional passes continued to yield large amounts of blood. The resident’s oxygen remained low, a nurse checked for a pulse and found none, the resident was lowered to the floor, and CPR was initiated while RT 4 continued suctioning large amounts of blood, stating he believed the airway was filled with blood. EMS arrived, but the resident could not be revived and died. The DON confirmed that respiratory staff had identified a broken trach and decided to change it, that there was increased bleeding, and that the resident went into cardiac arrest and passed away, and stated she did not know how the flange broke and was unaware of other residents with broken trach flanges.
Failure to Report Tracheostomy-Related Injury and Death to SSA and APS
Penalty
Summary
The facility failed to ensure that an alleged violation involving an injury of unknown source was reported immediately, but no later than 2 hours after the allegation was made, to the administrator, State Survey Agency (SSA), and Adult Protective Services (APS). For one resident with anoxic brain damage, acute and chronic respiratory failure, tracheostomy status, and pneumonia due to pseudomonas, the tracheostomy flange was found broken and the tracheostomy tube dislodged. A respiratory therapist documented that around 9:00 PM, during first rounds, the tracheostomy tube was observed broken and approximately 1.5 inches out of position, requiring immediate replacement. During the trach change, significant bleeding was noted, multiple suction passes were performed, the resident’s SpO2 alarmed low, and manual bagging was initiated. Despite these interventions, the resident’s SpO2 did not improve, no pulse was detected, chest compressions were started, and EMS later took over. A nursing late entry note documented that the RT called the nurse into the room, showed that the trach was broken and needed replacement, and that another RT was called to assist. At that time, the resident’s oxygen and other vital signs were stable. The RTs then alerted the nurse to copious bleeding during the trach change, after which the resident became unstable, a code blue was initiated, additional staff arrived, 911 was called, and the resident could not be revived, with time of death pronounced. Review of SSA records showed the incident was not reported. In interviews, the DON stated that night shift respiratory staff identified the broken trach and changed it, that there was increased bleeding and the resident went into cardiac arrest, and that the incident was not reported to the SSA because it was believed staff followed policy and there was no concern for negligence. The DON also stated she was unsure how the trach broke and was unsure if the respiratory director investigated the incident, and that she and the Administrator decided not to report the event because they believed respiratory staff followed policy when changing the broken trach.
Failure to Investigate Broken Tracheostomy Incident Leading to Resident Death
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate an alleged violation related to a serious incident involving a ventilator‑dependent, comatose resident with a tracheostomy. The resident had diagnoses including anoxic brain damage, acute and chronic respiratory failure, tracheostomy status, and pneumonia due to pseudomonas. On the evening in question at 9:00 PM, respiratory staff entered the resident’s room and found the tracheostomy flange broken, with the tracheostomy tube dislodged and approximately 1.5 inches out of position, shifted to the right and not midline. Respiratory therapy staff notified nursing and called a second respiratory therapist to assist with a tracheostomy tube change. During suctioning, respiratory staff observed a significant amount of blood and performed additional suction passes due to continued accumulation of blood. As the event progressed, the resident’s oxygen saturation dropped, and respiratory staff initiated manual ventilation, but oxygen levels did not improve. Nursing staff performed a pulse check, found no pulse, and the resident was lowered to the floor where CPR was initiated. EMS arrived, but the resident could not be revived and died. In a subsequent interview, the DON stated that staff had identified the broken tracheostomy and decided to change it, that increased bleeding occurred, and that the resident went into cardiac arrest, leading to CPR and EMS involvement. The DON further stated she had not investigated how the tracheostomy broke and was unsure whether the respiratory therapy director at the time had conducted any investigation, demonstrating that the facility did not have evidence that the alleged violation was thoroughly investigated.
Failure to Enter and Follow Tracheostomy Orders Leading to Improper Trach Change
Penalty
Summary
The deficiency involves the facility’s failure to ensure that respiratory services met professional standards of practice for a resident with chronic respiratory failure, tracheostomy status, pneumonia, and anoxic brain damage. The resident had prior physician orders for tracheostomy tube changes every 45 days and then every 30 days, but these orders were discontinued and no new order to change the tracheostomy tube was entered after a certain date. A hospital H&P documented that the resident’s tracheostomy had been exchanged by ENT due to hemoptysis, that the resident had experienced a dislodged trach with respiratory arrest and PEA, and that ENT recommended against PMV trials and advised trach changes every three months instead of monthly. Despite this, the ENT recommendation was not converted into an active physician order in the resident’s medical record. On the day of the incident, an RT note documented that the RT performed a trach change because the resident reported that the trach felt too tight. During removal and attempted reinsertion of the trach tube, resistance was encountered and insertion was unsuccessful, even with a smaller size trach. The resident then developed acute respiratory distress with pallor and cyanosis, leading to a Code Blue. A nursing note corroborated that the RTs initiated what they described as a scheduled trach tube change, encountered resistance with two insertion attempts, and that the resident became cyanotic with decreasing oxygen saturation, prompting immediate resuscitative efforts including manual ventilation, CPR, AED application, and EMS involvement, after which the resident was pronounced dead. Interviews revealed that RT staff and leadership were operating under inconsistent and undocumented directives. RT 1 stated that trach changes were done if the trach was dislodged or if the resident complained, and otherwise the MD changed the trach. RT 3 stated that, due to tracheal stenosis, the resident’s trach was not to be changed until seen by ENT and recalled seeing the resident’s name on a whiteboard labeled “ENT only.” RT 2 stated he was not informed that the trach was not supposed to be changed and believed there were monthly trach change orders, not realizing those orders had expired. The RT Director reported receiving a VO from the provider that the resident’s trach should be changed only by ENT unless emergent, but this VO was never entered into the resident’s chart; instead, it was only communicated verbally and noted on a whiteboard. The DON confirmed that the ENT recommendation for trach changes every three months was never entered as an order and that the prior standing trach change order had dropped off the MAR, leaving the resident without an active trach change order at the time of the event.
Failure to Secure ENT Evaluation for Resident With Tracheostomy and Tracheal Stenosis
Penalty
Summary
The facility failed to obtain outside professional ENT services for a resident when it did not employ a qualified professional to provide the required service. The resident was admitted with chronic respiratory failure, tracheostomy status, pneumonia, and anoxic brain damage. Hospital records documented that the resident previously had a tracheostomy exchange by ENT due to hemoptysis, experienced a respiratory arrest with a dislodged trach, and had significant subglottic and proximal tracheal stenosis. ENT had recommended against trialing a Passy Muir Valve and advised changing the trach every three months. A physician order for an ENT referral related to stenosis and tracheostomy status was initiated, and a later nurse practitioner note documented the need for follow-up with ENT for subglottic and tracheal stenosis. The Transportation Driver documented that an order for the ENT visit was received and sent to the ENT office, but the office reported the resident did not have insurance and would require self-pay, and therefore would not schedule the appointment without confirmation from the family. The Transportation Driver reported multiple unsuccessful attempts to contact the family and did not secure an appointment. The Business Office Manager stated the resident was Medicaid pending, that she had been in contact with Medicaid since admission, and that if an outside provider would not accept a Medicaid pending resident, the facility would be responsible for payment. The Business Office Manager also stated she was not informed that the ENT provider would not see the resident due to Medicaid pending status and that, had she known, she would have discussed payment with the Administrator so the resident could be seen by ENT. As a result, the resident did not receive the ordered ENT evaluation for tracheostomy and tracheal stenosis.
Failure to Integrate Respiratory-Related Deaths and Tracheostomy Incidents into QAPI and Required Reporting
Penalty
Summary
The deficiency involves the facility’s failure to use its QAPI and QAA processes to identify, report, investigate, analyze, and prevent adverse events related to three respiratory‑related resident deaths, and to document corrective actions. Surveyors found that the facility did not include all three deaths, particularly one resident’s death, in its QAPI review despite the events involving serious clinical issues with ventilators and tracheostomies. Two residents on ventilators experienced critical tracheostomy events: in one case, respiratory staff changed a tracheostomy when they were not supposed to, and in another, a tracheostomy flange broke, causing the tracheostomy to become dislodged. Both residents went into cardiac arrest and died. The facility also failed to ensure residents had access to outside provider appointments for tracheostomy care and did not follow verbal orders for tracheostomy changes. The report further notes that the facility did not ensure residents were free from neglect and did not meet reporting requirements for incidents involving serious bodily injury. For two residents, the facility did not provide access to outside tracheostomy care as ordered, and verbal orders for tracheostomy changes were not followed. One comatose resident in a vegetative state experienced a broken tracheostomy flange, resulting in a dislodged tracheostomy, cardiac arrest, and death. For this same resident, the State Survey Agency and Adult Protective Services were not notified when the tracheostomy flange broke and the resident died, despite the requirement to report such events within two hours. During interview, the Administrator stated that deaths were reviewed in QAPI with a focus on staff adherence to procedure and reported that residents associated with the immediate jeopardy events had been addressed in QAPI, but one resident’s death had not been reviewed. The Administrator also stated he was not informed of one resident’s death and the broken flange until the following morning and indicated that the contracted respiratory company was responsible for respiratory equipment and had not reported any equipment issues.
Ventilator and Monitoring Equipment Alarms Failed During Tracheostomy Dislodgement
Penalty
Summary
Failure to maintain mechanical, electrical, and patient care equipment in safe operating condition resulted in a ventilator not alarming when a resident’s tracheostomy tube flange broke and the tube became dislodged. The resident had diagnoses including anoxic brain damage, acute and chronic respiratory failure, tracheostomy status, and pneumonia due to pseudomonas, and was ventilator-dependent. On the evening in question, a respiratory therapist (RT 4) entered the resident’s room and found the tracheostomy flange broken, the tracheostomy tube deviated approximately 45 degrees to the right, partially out of the stoma, and about 1.5 inches out of position, with the resident’s lips noted to be blue. Despite this significant displacement, the ventilator was not alarming, and the continuous pulse oximeter alarm was also not sounding even though the resident’s oxygen saturation was below 90%, requiring RT 4 to move the sensor to a different location. During subsequent suctioning, respiratory staff observed a significant amount of blood and performed additional suction passes due to continued blood accumulation. The resident’s oxygen saturation dropped further, prompting initiation of manual ventilation, but oxygen levels did not improve. Nursing staff checked for a pulse, found none, and the resident was lowered to the floor where CPR was performed until EMS arrived; the resident could not be revived and died. RT 4 later reported that he checked all ventilators after the event because the ventilator had not alarmed, and he had previously expressed concerns to the interim respiratory supervisor that some ventilator alarm cables were breaking, which could prevent alarms from signaling to the call system, and that some pulse oximeters were not working, leaving him at times without needed monitoring equipment. The Administrator stated that the contracted respiratory company was responsible for supplying all respiratory equipment and that no equipment issues had been reported to him.
Failure to Protect Residents from Abuse and Inadequate Consent Assessment
Penalty
Summary
The facility failed to ensure that residents were protected from abuse, neglect, and exploitation, particularly in cases involving consensual relationships where residents lacked the capacity to consent. For instance, Resident 70, who had moderate cognitive impairment, was involved in a relationship with Resident 208, who was unable to complete a mental status interview. Despite family consent, the facility did not assess the residents' capacity to consent, leading to inappropriate interactions that were not reported as abuse. The Director of Nursing (DON) and staff considered the relationship consensual based on family input, without consulting medical professionals to evaluate the residents' cognitive abilities. Another incident involved Resident 409, who had severe cognitive impairment, and Resident 209, who had a history of violent behavior and moderate cognitive impairment. Resident 209 was found inappropriately touching Resident 409, an act that was later confirmed as non-consensual. Despite Resident 209's known history of aggression and inappropriate behavior, the facility failed to prevent the incident, which was only addressed after it occurred. The facility's documentation revealed that Resident 409 expressed sadness and discomfort following the incident, indicating a failure to protect him from abuse. The facility's approach to managing resident interactions, particularly those with potential sexual implications, was inadequate. The staff relied heavily on family consent and did not consistently involve medical professionals to assess residents' capacity to consent. This lack of proper assessment and intervention led to multiple incidents where residents were exposed to potential abuse and exploitation, highlighting significant deficiencies in the facility's safeguarding practices.
Deficiencies in Kitchen Cleanliness and Maintenance
Penalty
Summary
The facility failed to maintain food service areas in accordance with professional standards for food safety. During an initial tour of the kitchen, several deficiencies were observed, including a soiled steam table, dusty hood vents, a soiled wall behind the dish machine, missing grout in the tile, and a fan with dust buildup. The steam table was noted to be soiled under the shelf above the food, and the hood vents, which were due for cleaning, were dusty. The wall behind the dish machine was soiled with a yellow/brown substance and had a hole, while the tile in the dish machine room was missing grout. A follow-up tour revealed that the hood vents remained dusty, and the fan, which was pointed toward the food preparation area, had dust buildup. The wall behind the dish machine was still soiled, and the grout was still missing in the dish machine room. The Dietary Manager acknowledged these issues, stating that the vents were cleaned quarterly by an external company and that the fan was a personal item from an employee. The manager also noted that the steam table shelf was cleaned daily but was stained, not soiled, and had not noticed the missing grout. A work order was to be sent to the Maintenance department for the wall behind the dish machine.
Failure to Report Alleged Abuse and Assess Consent Capacity
Penalty
Summary
The facility failed to report alleged violations involving abuse, neglect, exploitation, or mistreatment to the State Survey Agency (SSA) and Adult Protective Services (APS) within the required timeframe. Specifically, the facility did not report an incident involving two residents with cognitive impairments who were found in a compromising situation. Resident 70, who had a BIMS score indicating moderate cognitive impairment, was found disrobed in his room with Resident 208, who was unable to complete a BIMS interview due to severe cognitive impairment. Despite the potential for non-consensual interaction, the facility did not report the incident, citing it as a consensual relationship. Resident 70 was admitted with multiple diagnoses, including dementia and cognitive communication deficit, and was found on multiple occasions in situations that suggested inappropriate or potentially non-consensual interactions with Resident 208. Nursing progress notes documented these interactions, and the facility's response was to separate the residents and monitor their interactions. However, the facility did not consult the Medical Director or other professionals to assess the capacity to consent, nor did they report the incidents to the appropriate authorities. Resident 208, diagnosed with Alzheimer's disease and unable to complete a BIMS interview, was involved in similar incidents with Resident 70. Despite the lack of documented capacity to consent, the facility relied on family input and staff observations to determine the interactions as consensual. The Director of Nursing stated that the interactions were considered companionship, and thus, the incidents were not reported as abuse. This oversight in reporting and assessing the capacity to consent led to a deficiency in the facility's compliance with reporting requirements.
Deficiency in Respiratory Care Due to Lack of Physician's Orders
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident who required oxygen therapy, as there were no active physician's orders specifying the type of oxygen delivery system, when to administer the oxygen, and the equipment settings for the prescribed flow rates. The resident, who had a history of chronic obstructive pulmonary disease (COPD) and other serious health conditions, was observed using oxygen without a current order upon returning from the hospital. Despite previous orders for oxygen therapy, these were discontinued after hospital discharges, and no new orders were documented upon the resident's return to the facility. Observations and interviews revealed that nursing staff, including a Registered Nurse (RN) and the Director of Nursing (DON), acknowledged the necessity of having an active order for oxygen therapy. The RN mentioned using nursing judgment to adjust oxygen levels based on the resident's condition, but confirmed that an active order should be in place. The DON also stated that oxygen therapy should be documented in the resident's medical record, even if standing orders were present. This lack of documentation and adherence to professional standards of practice led to the deficiency in providing safe and appropriate respiratory care for the resident.
Inadequate Pain Management for Resident with Chronic Mouth Pain
Penalty
Summary
The facility failed to provide timely and appropriate pain management for a resident who had been experiencing mouth pain for approximately ten months. The resident, who was admitted with multiple diagnoses including anoxic brain damage and various mental health disorders, consistently reported mouth and gum pain. Despite having a care plan in place that included interventions such as pain assessments every shift and the use of non-pharmacological interventions, the resident's pain was not adequately addressed. The resident's medical records indicate that various medications were prescribed for pain management, including acetaminophen, benzocaine gel, celecoxib, gabapentin, and lidocaine patches. However, the documentation shows that these interventions were often ineffective, and the resident continued to report significant pain. Nursing notes frequently documented the resident's complaints of pain and requests for additional pain relief, yet there were delays in adjusting the pain management plan or seeking further medical evaluation. The resident's condition was further complicated by the lack of timely dental care and the potential impact of smoking on their oral health. Despite multiple notes indicating the need for dental evaluation and potential concerns for conditions such as TMJ, there were significant delays in coordinating appropriate dental and specialist care. This lack of timely intervention and effective pain management resulted in ongoing distress and discomfort for the resident, highlighting a deficiency in the facility's pain management practices.
Medication Unavailability for Resident in Pain
Penalty
Summary
The facility failed to provide routine and emergency medications to a resident, identified as Resident 64, who was experiencing pain, agitation, and depression. The resident was admitted with multiple diagnoses, including anoxic brain damage, antisocial personality disorder, and major depressive disorder. The medical records revealed that the resident did not receive prescribed medications such as Zoloft, busPIRone, traMADol, TEGretol-XR, and Depakote on several occasions due to unavailability, despite refill requests being sent to the pharmacy. Interviews with the resident and staff highlighted the ongoing issues with medication availability. Resident 64 expressed experiencing severe mouth pain and dissatisfaction with the lack of timely dental care and oral pain relief. The resident reported that the staff frequently ran out of oral gel, which was used to alleviate gum pain. Interviews with LPN 4 and the Director of Nursing (DON) revealed that the facility had an emergency medication system, but it primarily contained narcotics and antibiotics. The staff had to reorder medications through the eMAR system, and there were delays in receiving refills from the pharmacy. The DON mentioned that the facility had changed pharmacies six to eight months prior, which may have contributed to the medication supply issues. Despite having a system in place to reorder medications, the facility failed to ensure that Resident 64 received their prescribed medications consistently. This deficiency in pharmaceutical services resulted in the resident experiencing unmanaged pain and agitation, highlighting a significant lapse in the facility's ability to meet the medication needs of its residents.
Resident Self-Administers Medications Brought by Family
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs, as evidenced by an incident involving Resident 160. The resident, who had a medical history including diabetes mellitus, hypertension, and atrial fibrillation, was found to have self-administered medications brought in by a family member. These medications included Metformin, a blood pressure medication, and a blood thinner, which were not documented by the nursing staff. The resident reported having to chase down nurses to receive his medications, and his family member confirmed bringing the medications to him. The Medication Administration Record (MAR) indicated that the medications were administered at 8:25 AM, but there was no documentation of the resident self-administering the medications. Interviews with nursing staff revealed inconsistencies in the administration process. RN 1 mentioned a flex time for medication administration, while LPN 1 initially denied administering the medications but later acknowledged her initials on the MAR. LPN 1 admitted that the resident refused the medications she offered and that she failed to document the refusal properly. Further interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) highlighted procedural lapses. The ADON noted that the nurse did not document the family member's involvement, and the DON emphasized that medications should not be provided by family members. The DON was not informed of the incident until the following day, delaying communication with the physician. The Regional Nurse Consultant (RNC) suggested that an Interdisciplinary Team Meeting was necessary to address the issue, but this was not documented in the report.
Inadequate Supervision Leads to Resident Elopement
Penalty
Summary
The facility failed to ensure adequate supervision to prevent accidents for two residents with cognitive impairments, leading to their elopement from the memory care unit. Resident 70, who had a history of dementia and cognitive impairment, was initially assessed as a low risk for elopement. Despite this, the resident exhibited wandering behaviors and was eventually moved to a locked memory care unit. However, on one occasion, a CNA allowed Resident 70 to leave the unit unsupervised, resulting in the resident being found outside the facility by a bystander after falling. Resident 50, diagnosed with dementia and assessed as a high risk for elopement, was moved off the secured unit due to a perceived lack of exit-seeking behavior. This decision was made despite the resident's history of wandering. Subsequently, Resident 50 eloped from the facility and was found by emergency services after a fall. The resident was returned to the facility with only minor injuries. The incidents highlight a failure in the facility's risk assessment and supervision processes, as both residents were able to leave the secured areas unsupervised. The staff's actions, such as allowing a resident to exit without proper authorization and moving a high-risk resident off a secured unit, contributed to these deficiencies.
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.
Trusted by long-term care providers and associations.
