Rocky Mountain Care - Cottage On Vine
Inspection history, citations, penalties and survey trends for this long-term care facility in Murray, Utah.
- Location
- 835 East Vine Street, Murray, Utah 84107
- CMS Provider Number
- 465125
- Inspections on file
- 21
- Latest survey
- November 5, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Rocky Mountain Care - Cottage On Vine during CMS and state inspections, most recent first.
A resident with a history of neurological and kidney conditions, who was cognitively intact, left the facility without signing out or notifying staff and remained unaccounted for over 18 hours. Multiple shifts, including agency CNAs and nurses unfamiliar with the resident, failed to notice or escalate his absence, and a nurse was found to have falsified documentation of resident checks. The facility's LOA protocol was not followed, leading to a significant lapse in supervision until the resident was eventually located and returned.
Surveyors found that kitchen staff failed to properly label and date multiple opened food items in both the refrigerator and freezer, did not consistently wear required hairnets, and did not maintain correct sanitizer levels in dish machines and cleaning buckets. These actions did not meet professional standards for food safety and sanitation.
Three residents experienced significant medication errors, including a dialysis patient not receiving phosphate binders with meals as ordered, a resident with chronic wounds missing scheduled IV antibiotics, and a resident with epilepsy not having seizure medication held as directed by the provider. These errors were linked to late or missed doses, lack of alignment with meal times, and inconsistent communication among staff and providers.
The facility did not ensure that laboratory reports were filed in the medical records for four residents who underwent diagnostic testing and received treatment for infections and other conditions. Despite orders and administration of antibiotics and other interventions, the required lab documentation was missing from the residents' records, as confirmed by staff interviews and record review.
Staff failed to provide correct portion sizes during meal service, as food was plated using tongs and incorrect scoops rather than the standardized utensils specified in the menu plan. The cook in training did not measure items as required, resulting in residents not receiving the appropriate portions needed to meet their nutritional requirements.
A resident with multiple medical conditions was found with a bottle of B-complex supplements in her closet, which she self-administered after her daughter brought them in. Although the resident had an intact BIMS score, staff interviews and documentation indicated she experienced confusion and memory deficits, and no assessment supported her ability to safely self-administer medications. Facility policy required staff to report and remove medications found in resident rooms, but this was not followed in this case.
The facility did not notify the physician when a resident's suprapubic catheter was changed to a different size due to supply issues, nor when two residents received intravenous antibiotics later than the ordered times. Staff interviews and record reviews confirmed that physician notification did not occur in these instances, despite facility policy requiring it when treatment orders could not be followed as prescribed.
A resident who was admitted with multiple medical conditions and later discharged home was not given a Notice of Medicare Non-coverage (NOMNC) when Medicare Part A services ended. Review of the medical record and interview with the ADM confirmed the absence of the required notice.
A resident's shower was repeatedly observed to have a bad odor, black substance on grout, white buildup on tiles, and red rings on the floor, despite daily cleaning and staff awareness. Interviews with LPN, housekeeping, and maintenance staff confirmed the ongoing presence of these issues, with explanations given for the stains but no resolution achieved after cleaning.
A resident with multiple medical and psychiatric conditions reported that a nurse used profane language in response to a care request. The resident informed the CNAC, who failed to report the allegation to the ADM or appropriate authorities as required. The incident was not investigated or reported to the SSA or APS within the mandated timeframe.
The facility did not provide evidence of thorough investigations or timely reporting to the SSA for two residents who alleged abuse or neglect by staff. In both cases, required investigation reports were missing, and there was no documentation that findings were submitted as mandated.
Two residents did not receive appropriate care: one was not placed on a scheduled toileting program despite being assessed as a candidate, and another with a suprapubic catheter did not receive the correct catheter size per physician orders, with the physician not notified of the change. Staff interviews confirmed lapses in toileting assistance and supply management, resulting in care that did not follow regulatory or clinical guidelines.
A resident with neuropathic pain and multiple comorbidities did not receive five consecutive doses of prescribed pregabalin because the medication was not available and pending delivery. Nursing staff documented the unavailability and described inconsistent backup procedures, with facility guidelines outlining steps that were not fully effective in ensuring timely medication administration.
A resident with a history of neurogenic bladder and frequent UTIs was prescribed Levaquin for suspected UTI symptoms without a urinalysis or urine culture, despite prior evidence of resistance to this antibiotic. Facility staff interviews revealed inconsistent adherence to protocols for obtaining necessary lab tests before prescribing antibiotics, and communication issues with lab reports further contributed to the failure to properly monitor antibiotic use as part of the facility's antibiotic stewardship program.
Two residents with complex medical histories did not have complete documentation regarding their pneumococcal vaccinations. One resident's consent form lacked details on administration, such as date, location, and lot number, while another's form did not indicate whether the vaccine was accepted or declined. Interviews with the DON and Corporate Nurse confirmed that required documentation was missing, contrary to facility policy.
A resident with psychological needs and a history of falls did not have a comprehensive care plan addressing mental health or fall prevention. Despite self-injurious behavior and multiple falls, no protocols were established, and the care plan was outdated. The DON acknowledged the absence of specific care plans and the lack of centralized information for staff.
A resident with severe cognitive impairment and a history of behavioral issues, including inappropriate sexual behavior and alleged drug use, did not have their care plan updated by the interdisciplinary team. Despite interventions such as one-on-one observation and medication evaluation, these were not documented in the care plan, highlighting a deficiency in the facility's care planning process.
A resident with a complex medical history experienced multiple falls in a facility, but required neurological assessments were not documented in the medical record. Despite staff initiating neuro checks after falls, interviews revealed that these were not consistently recorded, leading to a deficiency in supervision and care.
A resident with multiple psychological diagnoses, including suicidal ideations, did not receive necessary behavioral health care services in a LTC facility. Despite self-harming incidents and expressed suicidal thoughts, the facility failed to implement appropriate monitoring or mental health interventions. The care plan was not updated, and staff were unaware of the resident's mental health needs, compromising her well-being.
A facility failed to maintain complete and timely medical records for a resident with complex diagnoses. Numerous late entries were made by the ADON, who documented information from floor nurses instead of the staff directly involved in the resident's care. Interviews revealed a lack of awareness and improper documentation practices, with the DON unaware of the ADON's actions and the ADON acknowledging the ethical concerns of her documentation approach.
Resident Unaccounted for Due to Inadequate Supervision and Communication Failures
Penalty
Summary
A deficiency occurred when a resident left the facility and was unaccounted for approximately 18 hours before management was alerted. The resident, who had a history of cerebral infection sequelae, left kidney injury, and right-sided hemiplegia and hemiparesis, was cognitively intact as indicated by a BIMS score of 15. The resident did not sign out or inform staff of his departure, and his absence went unnoticed by multiple shifts, including agency CNAs and nurses who were unfamiliar with the resident. The resident's television was left on and his dinner untouched, but these signs were not acted upon in a timely manner. Communication breakdowns occurred during shift changes, with staff assuming the resident was with family or that his absence was normal. Documentation in the medical record indicated the resident was not present, but this information was not escalated promptly. The night shift nurse was later found to have falsified documentation, indicating checks on the resident that did not occur. Agency staff, unfamiliar with the residents, contributed to the lack of awareness regarding the resident's whereabouts. The facility's procedures required residents to sign out in a Leave of Absence (LOA) book when leaving, but this protocol was not followed or enforced in this instance. The resident was eventually located after a pharmacy contacted the facility, and he was returned without injury. The incident revealed lapses in supervision, communication, and adherence to established protocols for monitoring resident whereabouts, particularly when agency staff were involved.
Deficient Food Storage, Sanitation, and Staff Practices in Kitchen
Penalty
Summary
Surveyors observed multiple failures in food storage, preparation, and sanitation practices within the facility's kitchen. Several food items in both the refrigerator and freezer, including mayonnaise, green peppers, whipped topping, sausage links, lettuce, churros, donuts, pork egg rolls, ice cream, and rolls, were found opened and undated. The Dietary Manager (DM) was observed working in the kitchen without a hairnet. During the inspection, the chemical dish machine was tested twice and failed to show the presence of sanitizer, as indicated by the test strips not changing color. Additionally, sanitizer buckets used for cleaning were found to have insufficient sanitizer levels, as confirmed by the DM using test strips. On a follow-up visit, some food items remained undated, and the dish machine, after being serviced, was found to have sanitizer levels below the required standard. The sanitizer buckets were also found to have excessively high sanitizer concentrations, which the DM acknowledged could result in chemical residue remaining on dishes. Interviews with the DM, Registered Dietitian (RD), and Director of Nursing (DON) confirmed that all food should be labeled and dated, proper head coverings are required, and sanitizer levels must be maintained within safe limits. These observations and interviews demonstrate that the facility did not consistently adhere to professional standards for food safety and sanitation.
Significant Medication Administration Errors Affect Multiple Residents
Penalty
Summary
Three residents experienced significant medication errors due to failures in medication administration practices. One resident with end stage renal disease and dependent on dialysis did not consistently receive his phosphate binder medication, Auryxia, with meals as ordered. The medication was often administered late or not at all, and administration times did not align with scheduled meal times. The resident reported the issue to the DON, who attempted to prioritize the medication in the electronic medical record, but the problem persisted, particularly when agency nurses were on duty. Documentation showed multiple missed or late doses, and the resident frequently had to remind staff to administer his medication. Another resident with chronic wounds, osteomyelitis, and a history of amputation did not receive scheduled intravenous antibiotics (Daptomycin and Micafungin) at the prescribed times. The MAR documented several instances where these antibiotics were administered hours late. Staff interviews confirmed that the antibiotics should be given within a 30-minute window of the scheduled time, and that delays should be reported to the physician. However, there was no evidence that the physician was notified of these delays, and the errors were not consistently documented as medication errors. A third resident with epilepsy and a history of seizures did not have her seizure medication, Lacosamide, held for the full duration ordered by the provider after a high serum level was reported. The provider ordered the medication to be held for two doses, but the MAR showed it was only held for one dose. Communication between nursing staff and providers was inconsistent, and the medication was resumed before the full hold period was completed. These events demonstrate failures in following physician orders and ensuring timely and accurate medication administration for multiple residents.
Failure to File Laboratory Reports in Resident Medical Records
Penalty
Summary
The facility failed to ensure that complete, dated laboratory records, including the name and address of the testing laboratory, were filed in the clinical records of four residents. For these residents, laboratory results such as urinalysis, urine culture and sensitivity, and other diagnostic tests were not documented in their medical records despite orders and treatments being administered based on these tests. In several cases, nursing notes and infection control logs referenced laboratory testing and subsequent medication administration for conditions such as urinary tract infections, but the corresponding laboratory reports were missing from the residents' records. Specifically, one resident with paraplegia and a neurogenic bladder received antibiotics for a urinary tract infection, but the urinalysis and culture results were not present in the record. Another resident with quadriplegia and bladder dysfunction was treated for a UTI, yet no urinalysis or culture report was found in the medical record. A third resident with diabetes and acute kidney failure was administered antibiotics for a UTI, but the relevant laboratory documentation was absent. The fourth resident, with osteomyelitis and MRSA infection, had multiple lab tests ordered and referenced in nursing notes, but none of the results were filed in the medical record.
Failure to Provide Correct Portion Sizes During Meal Service
Penalty
Summary
The facility failed to follow menus that met the nutritional needs of residents in accordance with established national guidelines, specifically by not providing correct portion sizes during meal service. During a lunch observation, the cook in training was seen plating food items such as meat, potatoes, and Brussels sprouts using tongs and an ice cream scoop, rather than the required measurement scoops. The gravy was served with a ladle that did not match the specified portion size. The cook in training admitted to attempting to give even amounts of food to fill the plate, rather than following the prescribed portion sizes listed on the menu spreadsheet. A review of the menu spreadsheet showed specific portion sizes for each food item, which were not adhered to during service. The Dietary Manager confirmed that the cook in training used incorrect serving utensils and did not measure the pot roast due to its crumbly texture. The Registered Dietitian stated that the menus were designed to meet residents' nutritional requirements and should be followed using standardized utensils. The Director of Nursing also expected kitchen staff to follow the menus correctly. These actions resulted in residents not receiving the appropriate portion sizes as outlined in the facility's menu plan.
Failure to Ensure Safe Self-Administration of Medications
Penalty
Summary
A resident with diagnoses including osteomyelitis of the vertebra, MRSA infection, paraplegia, and encephalopathy was found to have a large bottle of B-complex supplement in her closet. The resident reported that her doctor approved her taking supplements and that her daughter brought them in to save money. Review of the resident's medical record showed that she had previously indicated she did not wish to self-administer medications, and her care plan did not address self-administration. The resident's BIMS score indicated intact cognition, but nursing notes and staff interviews revealed concerns about her memory and ability to safely self-administer medications. Staff interviews confirmed that medications or supplements found in resident rooms should be reported to nursing staff, and that residents were not allowed to have medications at the bedside. A nurse stated that the resident had episodes of confusion, needed reminders, and was not safe to self-administer medications due to short-term memory deficits and a tendency to forget if she had already taken her medication. The DON acknowledged the resident's cognitive score but noted that the self-administration assessment did not support allowing the resident to keep medications at the bedside.
Failure to Notify Physician of Changes in Treatment and Delays in Medication Administration
Penalty
Summary
The facility failed to notify and consult with the physician when there was a need to alter the treatment for two residents. For one resident with quadriplegia and a history of neuromuscular bladder dysfunction, the physician's order specified the use of a 24 French suprapubic catheter. However, due to the unavailability of the correct catheter size in stock, a 22 French catheter was inserted without notifying the physician or obtaining a new order. Interviews with staff confirmed that the physician was not informed of the change, and documentation did not reflect any physician notification or updated order for the different catheter size. For another resident with multiple diagnoses including polyneuropathy, diabetes, osteomyelitis, and chronic ulcers, intravenous antibiotics were ordered to be administered at specific times. The medication administration records showed that both Daptomycin and Micafungin were given late on several occasions, outside the 30-minute window allowed by facility policy. There was no documentation indicating that the physician was notified of these late administrations, despite staff acknowledging that such notification was required when medications were not given as scheduled. These deficiencies were identified through interviews with the residents, nursing staff, and the Director of Nursing, as well as a review of medical records and treatment administration logs. The lack of timely physician notification and consultation occurred in both cases when treatment orders could not be followed as prescribed, either due to supply issues or delays in medication administration.
Failure to Provide Notice of Medicare Non-Coverage
Penalty
Summary
The facility failed to inform a resident of the termination of Medicare Part A services by not providing a Notice of Medicare Non-coverage (NOMNC) as required. Specifically, a resident admitted with diagnoses including pneumonia, septicemia, renal insufficiency, and diabetes mellitus was discharged home, but a review of the medical record did not find a signed NOMNC form. Upon request, the Administrator was unable to locate the NOMNC for this resident, confirming that the required notice was not issued during the resident's stay.
Persistent Unsanitary Conditions in Resident Shower
Penalty
Summary
A deficiency was identified when a resident's shower was observed to have a persistent bad odor, black substance along the grout lines, white buildup on tile surfaces, and circular red rings on the shower floor. These conditions were first noted during an observation and remained unchanged during subsequent inspections, even after daily cleaning was reportedly completed. The resident involved had multiple medical diagnoses, including atherosclerosis, malnutrition, rhabdomyolysis, and osteoarthritis. Staff interviews confirmed that the resident's bathroom was supposed to be cleaned daily, with specific cleaning products and procedures described, but the visible issues in the shower persisted after cleaning. Further interviews with housekeeping and maintenance staff revealed that the black substance might be dirt, the red rings were identified as rust marks from shower chair feet, and the white buildup was not specifically addressed. The maintenance director stated that visual inspections of resident rooms and bathrooms were conducted weekly, and maintenance needs were to be reported in a binder at the nursing station. Despite these protocols, the unsanitary conditions in the resident's shower were not resolved, as confirmed by multiple staff members and direct observation.
Failure to Timely Report Alleged Verbal Abuse
Penalty
Summary
A resident with multiple diagnoses, including chronic kidney disease, morbid obesity, type 2 diabetes mellitus, borderline personality disorder, PTSD, bipolar disorder, anxiety disorder, and hypertension, reported an incident of verbal abuse by a male nurse. The resident, who was assessed as cognitively intact, stated that when she requested her blood sugar be checked early, the nurse responded with profanity. The resident reported this incident to the Certified Nursing Assistant Coordinator (CNAC) during incontinence care. Despite being informed of the incident, the CNAC did not report the allegation to nursing management or the facility Administrator (ADM) as required. The CNAC acknowledged knowing that all allegations of abuse should be reported immediately to the ADM but failed to do so, stating uncertainty about whether the incident constituted abuse. The ADM only became aware of the incident days later and confirmed that no abuse investigation had been initiated or reported to the State Survey Agency (SSA) or Adult Protective Services (APS) within the required timeframe.
Failure to Investigate and Report Alleged Abuse and Neglect
Penalty
Summary
The facility failed to provide evidence that all alleged violations of abuse, neglect, exploitation, or mistreatment were thoroughly investigated and failed to report the results of all investigations to the State Survey Agency (SSA) within 5 working days of the incident. For two sampled residents, allegations of abuse or neglect by staff members were not fully investigated, and required documentation was missing. In the first case, a resident with multiple diagnoses including atrial fibrillation, chronic kidney disease, bipolar disorder, type 2 diabetes, and morbid obesity alleged that a CNA told her to go to the bathroom in her pants and pulled up her shirt without permission. While the CNA was placed on administrative leave and APS was notified, the investigation report could not be found, and the information provided was limited to an email summary from a previous administrator. There was no evidence of a thorough investigation or submission of findings to the SSA. In the second case, an anonymous report alleged that another resident was left soiled due to lack of care or neglect. The facility notified APS and the SSA, but the investigation report was missing from the abuse binder and no additional documentation was provided. The DON described the facility's general process for handling such allegations, but there was no evidence that a complete investigation was conducted or that findings were reported as required. Both cases lacked documentation of thorough investigations and timely reporting to the SSA.
Failure to Maintain Continence Services and Provide Proper Catheter Care
Penalty
Summary
The facility failed to ensure that residents who were continent of bladder received services and assistance to maintain continence, and did not provide appropriate catheter care in accordance with physician orders. For one resident, who had a history of urinary tract infections (UTIs), anxiety, and mobility limitations, the care plan identified the need for assistance with toileting and scheduled toileting interventions. Despite being assessed as a candidate for scheduled toileting, the resident was not placed on a toileting program. The resident reported that staff did not respond promptly to requests for toileting assistance and was told to use incontinence briefs instead, which she believed contributed to her UTIs. Staff interviews confirmed that the resident should have been on a toileting program and that some staff, particularly agency staff, encouraged residents to use briefs rather than assist with toileting. Another resident with quadriplegia and a suprapubic catheter did not receive catheter care in accordance with physician orders. The resident required a specific size (24 French) suprapubic catheter, but the facility ran out of this size and inserted a smaller (22 French) catheter without notifying the physician or obtaining a new order. The care plan for this resident was not updated to reflect the current physician orders for catheter size. The resident also reported concerns about the cleanliness of the catheter change procedure, stating that the nurse did not change gloves or use antiseptic during the last catheter change. Staff interviews revealed that supply management issues led to the unavailability of the correct catheter size, and the Director of Nursing confirmed that the physician was not notified of the change in catheter size. These deficiencies demonstrate that the facility did not provide services to maintain continence for a resident who was a candidate for scheduled toileting, and did not ensure that catheter care was provided according to physician orders for another resident. The lack of timely toileting assistance and failure to maintain appropriate catheter supplies and procedures resulted in care that did not meet regulatory requirements for these residents.
Failure to Provide Prescribed Medication Due to Unavailability
Penalty
Summary
The facility failed to provide routine and emergency pharmaceutical services to meet the needs of a resident who was prescribed pregabalin for neuropathic pain. The resident, who had multiple diagnoses including neuropathy, osteomyelitis, diabetes mellitus, and amputations, did not receive five consecutive doses of pregabalin as prescribed. Documentation in the Medication Administration Record (MAR) indicated that the medication was not available during the scheduled administration times, and nursing notes confirmed the medication was either unable to be located or pending delivery. Interviews with nursing staff revealed inconsistent practices regarding the management of out-of-stock medications. One RN stated that there was no backup supply of prescription medications in the facility, while another indicated that some prescription medications were available in the emergency medication system. The facility's guidelines required staff to take specific steps when medications were unavailable, such as contacting the pharmacy, checking the emergency kit, and notifying the provider, but the documentation showed that the medication remained unavailable for multiple doses, resulting in missed administrations for the resident.
Failure to Monitor Antibiotic Use and Obtain Required Testing
Penalty
Summary
The facility failed to implement an infection prevention and control program that included a system to monitor antibiotic use as part of its antibiotic stewardship program. Specifically, for one resident with a history of paraplegia, neurogenic bladder, and neuromuscular dysfunction of the bladder, a urinalysis and urine culture and sensitivity were not completed prior to prescribing antibiotics for suspected urinary tract infection (UTI) symptoms. The resident reported symptoms consistent with a UTI, and the physician prescribed Levaquin based on the resident's history and preference, without obtaining a urinalysis or culture. Nursing documentation confirmed the new order for Levaquin, and the responsible party was notified. However, a previous urinalysis and culture had shown resistance to Levaquin in this resident. Interviews with facility staff, including the DON, NP, and Infection Preventionist, revealed that while there were protocols in place for nurses to notify medical staff of suspected infections and for typically obtaining urinalysis and cultures, these were not consistently followed. The NP acknowledged prescribing antibiotics without obtaining a urinalysis or culture in at least one instance. The Infection Preventionist also noted challenges with lab report communication and recognized the need for more vigilant monitoring of antibiotic use and lab results. The lack of a consistent system to monitor antibiotic use and ensure appropriate testing contributed to the deficiency identified during the survey.
Deficient Documentation of Flu and Pneumonia Vaccinations
Penalty
Summary
The facility failed to ensure that each resident was properly offered and documented for influenza and pneumococcal immunizations, as required by policy. For two out of five sampled residents, there were deficiencies in the documentation process. One resident, with a history of quadriplegia, type 2 diabetes mellitus, dysphagia, anemia, antiphospholipid syndrome, pressure ulcer, and hypertension, had signed a consent form for the pneumococcal vaccine, but the form lacked documentation regarding whether the vaccine was administered, the location of administration, the lot number, or the date of administration. Another resident, with diagnoses including osteomyelitis, type 2 diabetes mellitus, polyneuropathy, anemia, hypothyroidism, and pain, had a signed consent form for the pneumococcal vaccine, but the form did not indicate whether the resident consented or declined the vaccination, nor did it contain any additional information. Interviews with the Director of Nursing and the Corporate Nurse confirmed that the expected documentation for immunization administration should include the date, medication, time, manufacturer, lot number, and location of administration. However, in these cases, such documentation was missing. The facility's policy required that residents be offered the vaccines annually, be provided education on the benefits and potential side effects, have the opportunity to refuse, and that documentation reflect education and immunization status, but these requirements were not met for the two residents in question.
Failure to Develop Comprehensive Care Plan for Resident with Psychological Needs and Falls
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with significant psychological needs and a history of multiple falls. The resident, who had been admitted and readmitted with various diagnoses including suicide attempt, dissociative identity disorder, and bipolar disorder, did not have a care plan addressing mental health or fall prevention. Despite a complaint indicating self-injurious behavior and a subsequent incident where the resident inflicted a wound on herself, no protocol for self-harm or suicidal ideation was established. The care plan had not been updated since its initial entry, and a psychotropic care plan was marked as completed but was not found in the medical record. Additionally, the resident experienced multiple falls over a period of time, yet no fall care plan was documented in the medical record. The Director of Nursing acknowledged the absence of specific care plans for the resident's behaviors and falls, noting that while staff had a checklist for post-fall procedures, there was no centralized location for information on previous interventions. The DON also recognized that the resident's behaviors were not being managed, despite medication management being in place. Staff were expected to use various resources to understand resident care needs, but the lack of a comprehensive care plan hindered effective management of the resident's conditions.
Failure to Update Care Plan for Resident with Behavioral Issues
Penalty
Summary
The facility failed to ensure that the care plan for a resident with severe cognitive impairment was revised by the interdisciplinary team to address repeated behaviors. The resident, who had a history of substance use disorder, schizoaffective disorder, anxiety, and traumatic brain injury, exhibited behaviors such as engaging in sexual activity with another cognitively impaired resident, entering other residents' rooms, and alleged drug use. Despite these incidents, the resident's behavior care plan, dated several months prior, was not updated to include interventions to prevent and address these behaviors. The facility's Director of Nursing (DON) confirmed that the care plan should have been updated following these incidents. The DON mentioned that the resident had been placed on one-on-one and line of sight observation, and the facility had been purchasing cigarettes for the resident, suspecting the behaviors might be transactional. Additionally, the resident's medications were evaluated. However, these interventions were not documented in the care plan, indicating a deficiency in the facility's care planning process.
Inadequate Supervision and Documentation of Falls
Penalty
Summary
The report identifies a deficiency in the supervision and care provided to a resident who experienced multiple falls without adequate neurological assessments being completed. The resident, who has a complex medical history including conditions such as morbid obesity, obstructive sleep apnea, and bipolar disorder, was admitted and readmitted to the facility with a history of falls. Despite several incidents where the resident fell, including unwitnessed falls and instances where the resident hit their head, the facility failed to document the required neurological assessments in the medical record. Interviews with facility staff, including a CNA, RN, and the DON, revealed that while neuro checks were initiated following falls, they were not consistently documented in the resident's medical record. The staff indicated that neuro checks were supposed to be completed and then scanned into the medical record, but this process was not followed, leading to a lack of documentation. This oversight in documentation and supervision contributed to the deficiency noted in the report.
Failure to Provide Behavioral Health Care Services
Penalty
Summary
The facility failed to provide necessary behavioral health care services to a resident, identified as Resident 10, who was admitted with multiple psychological diagnoses, including suicidal ideations and a history of self-harm. Despite these significant mental health concerns, the facility did not implement a protocol for self-harm or suicidal ideation after the resident inflicted a wound on herself. The only action taken was the application of bacitracin to the wound, without any further mental health interventions or monitoring. Interviews and record reviews revealed that Resident 10 had expressed suicidal thoughts and self-harming behaviors on multiple occasions. The resident had a history of cutting and had used a plastic spoon to harm herself. Despite these incidents, there was no documentation of 15-minute checks or 1:1 observation in the medical record. The care plan for Resident 10 was not updated to reflect her specific behaviors and needs, and there was no evidence of mental health services being arranged for her. Staff interviews indicated a lack of awareness and communication regarding Resident 10's mental health needs. The Director of Nursing acknowledged that the resident's behaviors were not being managed appropriately, and there was no centralized location in the medical record for staff to access information about the resident's mental health status. The facility's failure to provide adequate behavioral health care services compromised Resident 10's quality of life and well-being.
Incomplete and Late Documentation in Resident's Medical Records
Penalty
Summary
The facility failed to maintain complete, accurately documented, and readily accessible medical records for one of the sampled residents. The deficiency was identified through a review of the medical records of a resident who had been admitted and readmitted with multiple complex diagnoses, including suicide attempt, morbid obesity, and bipolar disorder. The review revealed numerous instances of late entries in the resident's progress notes, with delays ranging from several days to over a month. These late entries were not documented by the staff directly involved in the resident's care, but rather by the Assistant Director of Nursing (ADON), who recorded information obtained from floor nurses. Interviews with the Director of Nursing (DON) and the ADON highlighted a lack of awareness and improper documentation practices. The DON was unaware that the ADON was entering late notes into the medical records, and acknowledged that late charting could lead to inaccuracies. The ADON admitted to documenting information based on recollections from floor nurses, regardless of the time elapsed since the events occurred. The ADON also recognized that it would be more ethical for the floor nurses, who were directly involved with the residents, to document the information themselves.
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Surveyors found that the facility did not ensure residents or their representatives were informed of and able to participate in decisions about psychotropic medications. Several residents with conditions such as dementia, early-onset Alzheimer’s disease, major depressive disorder, psychotic disorder, and Parkinson’s disease were started on drugs including haloperidol, donepezil, buspirone, quetiapine, zaleplon, and sertraline without documentation that risks, benefits, or alternative treatments were discussed in advance. The DON reported that staff notify families when medications are started or changed but do not review risks and benefits, offer alternative options, or obtain signed consent, resulting in no evidence of informed decision-making for these psychotropic treatments.
Surveyors determined that the facility failed to consistently manage psychotropic medications for three residents. Two residents with dementia and psychiatric conditions had only one documented psychotropic medication review and gradual dose reduction (GDR) attempt, completed in January, with no evidence of quarterly reviews or additional GDR efforts. Another resident with hemiplegia, psychotic disorder, dementia, and major depressive disorder had a PRN IM haloperidol order written without an end date, which remained active and was administered on multiple occasions beyond 14 days, and the DON confirmed there was no physician documentation justifying the extended PRN antipsychotic order.
The facility failed to ensure that alleged abuse and serious injuries were reported to the State Survey Agency as required, instead either reporting only to a state patient safety system or not reporting at all. One resident with severe cognitive impairment sustained bilateral femur fractures after a fall, another cognitively impaired resident with Parkinson’s disease was later found to have a femur fracture after being discovered on the floor, and a third cognitively impaired resident required ORIF surgery for fractures following a fall; none of these incidents were reported through the State Survey Agency’s incident reporting website, per the ADM. In addition, an allegation that a resident with dementia and sensory impairments may have been molested was documented in the abuse binder but not in the medical record, and the ADM did not report the allegation to agencies or law enforcement after deeming it not credible, despite interviewing the resident and family. These actions and omissions resulted in multiple unreported events that met criteria for immediate reporting of alleged abuse and injuries of unknown source.
The facility failed to investigate multiple major injuries and an allegation of sexual abuse involving three residents with severe cognitive impairment and significant medical conditions. One resident, dependent for transfers, was found on the floor after attempting to get out of bed and was later found to have bilateral femur fractures. Another resident with Parkinson’s disease was found on the floor after a wheelchair alarm sounded and was later diagnosed with a femur fracture following complaints of leg pain. A third resident, described as very independent, triggered a bed alarm and was found kneeling by a recliner, later requiring ORIF for fractures of the right 4th and 5th metacarpals. In each case, the ADM acknowledged awareness of the fractures, stated there was no belief of neglect or abuse, and confirmed that no investigation into the cause of the injuries or the alleged abuse was initiated or documented.
Surveyors found that the facility failed to ensure monthly pharmacist drug regimen reviews were completed and documented for several residents with conditions such as Parkinson’s disease, dementia, and Alzheimer’s disease, with no pharmacist notes present for at least two consecutive months. Additionally, a pharmacist’s recommendation to add a low-dose daytime antipsychotic for a resident with dementia, psychotic disorder, and behavioral symptoms was not communicated to the physician or implemented for several months, despite documented behavioral concerns. An LPN reported not relaying the pharmacist’s recommendation because PRN Haldol had not been needed at that time, and the DON confirmed that the pharmacist reviews for the missing months were not done and that she did not have time to monitor follow-through on such recommendations.
Surveyors identified a failure to properly label medications when two open insulin pens were found in a medication refrigerator bin marked only with a resident’s first name, with no labels directly on the pens. During an observation, an RN confirmed the pens belonged to a resident and acknowledged that pens are supposed to be labeled with the resident’s name but could not explain why these were not labeled. In a subsequent interview, the DON confirmed the pens had been unlabeled and stated they should have been labeled in accordance with professional standards.
The facility failed to sustain effective QAPI processes related to pharmacist medication regimen reviews, resulting in repeated noncompliance with F756. Surveyors found that medical records for four residents lacked documentation showing that a pharmacist had reviewed medications, identified potential irregularities, or made recommendations to attending physicians, an issue previously cited. The DON reported she did not have time to maintain this documentation, and the Administrator acknowledged there was no formal performance improvement project in place, though some plans were noted in QAPI minutes, and no supporting documents were produced to demonstrate ongoing compliance.
Staff failed to follow infection control practices during medication administration and did not maintain organized infection surveillance documentation. An LPN was observed handling an oral medication with bare hands before administering it to a resident, contrary to the DON’s stated expectation that pills be dispensed directly into medication cups without hand contact and that any contaminated dose be discarded. Additionally, the DON, who also served as the Infection Preventionist, reported that several residents had influenza during a past holiday season but had no list of affected residents or rooms, and the requested infection control surveillance logs and a formal tracking system were not available.
The facility lacked an antibiotic stewardship program, with no protocols to ensure appropriate indication, dose, and duration of antibiotic prescriptions and no system to monitor antibiotic use or resistance patterns. When surveyors requested Infection Control Surveillance Logs, including antibiotic tracking information, the logs were not available. In an interview, the DON, who also functioned as the Infection Preventionist, acknowledged that she did not track resident antibiotic utilization, clinical indications, or treatment durations.
A resident with multiple chronic conditions, including DM, HTN, anxiety, major depressive disorder, and PTSD, reported that a CNA on night shift failed to hold open a smoking-area door, leading the resident to grab the door and sustain a finger cut that bled. The resident completed a grievance with the RA, who documented that the CNA swung the door open and walked away and that no abuse or neglect allegation was initially identified. However, the grievance lacked documentation of investigative steps, a summary of findings, a conclusion on whether the grievance was confirmed, and any decision date or required signatures, and leadership later reported they had not been informed of the incident, demonstrating the grievance was not promptly resolved or fully tracked through conclusion.
Failure to Inform Residents of Risks, Benefits, and Alternatives Before Starting Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents, or their representatives, were informed of and allowed to participate in decisions regarding psychotropic medication treatment, including being informed in advance of the risks, benefits, and treatment alternatives. For four sampled residents, medical record review showed new orders for multiple psychotropic medications without any documentation that the resident or representative had been informed of these elements prior to initiation. Resident 8, with diagnoses including hemiplegia and hemiparesis following cerebral infarction, psychotic disorder with delusions, dementia, and major depressive disorder, was started on haloperidol lactate, donepezil, buspirone, quetiapine, and sertraline on various dates, with no documentation of informed discussion or consent. Resident 4, with unspecified dementia and anxiety disorder, was started on zaleplon, quetiapine, and buspirone, again with no record that risks, benefits, or alternatives were discussed in advance. Resident 54, diagnosed with early-onset Alzheimer’s disease and dementia in other diseases classified elsewhere, was started on sertraline and quetiapine, and Resident 6, diagnosed with Parkinson’s disease without dyskinesia, was started on buspirone, quetiapine (Seroquel), and sertraline, with no documentation that either resident or their representative had been informed of the risks and benefits or treatment options before these psychotropic medications were initiated. During an interview, the DON stated that the facility notifies families when medications are started or doses are changed but does not discuss risks and benefits, provide alternative options, or obtain signed consent. This practice contributed to the lack of documented evidence that residents or their representatives were fully informed and able to participate in treatment decisions regarding psychotropic medications.
Failure to Perform Regular GDR and Limit PRN Antipsychotic Orders
Penalty
Summary
Surveyors found that the facility did not ensure appropriate management of psychotropic medications for three sampled residents. For two residents with dementia and related psychiatric diagnoses, the medical records from late April 2026 showed only one documented psychotropic medication review and gradual dose reduction (GDR) attempt, completed in January 2026. There was no documentation of any GDR attempts or psychotropic reviews prior to January 2026, despite the DON stating that such reviews and GDRs should be completed quarterly. The records for these residents did not contain additional GDR attempts beyond the January 2026 review. For a third resident with hemiplegia following cerebral infarction, psychotic disorder with delusions, dementia, and major depressive disorder, a physician’s order dated February 8, 2026, prescribed PRN intramuscular haloperidol lactate every 12 hours for delusions, hallucinations, paranoia, and agitation, without an end date. Review of the MARs for February through April 2026 showed that this PRN antipsychotic was administered on two occasions, and no end date was documented on the MAR. In an interview, the DON acknowledged that the PRN haloperidol order extended beyond 14 days and that the physician had not documented a reason for continuing the order beyond that period.
Failure to Report Alleged Abuse and Serious Injuries to State Survey Agency
Penalty
Summary
The deficiency involves the facility’s failure to ensure that all alleged violations of abuse, including injuries of unknown source and incidents involving major injuries, were reported immediately to the State Survey Agency and other officials as required by state law. For four sampled residents, the Administrator acknowledged that incidents were reported only to the state’s patient safety website and not to the State Survey Agency’s incident reporting website. This omission meant that the State Survey Agency did not receive timely notice of serious events, including an allegation of sexual abuse and multiple incidents resulting in significant fractures and surgery. For one resident with severely impaired cognition and diagnoses including hemiplegia and hemiparesis, nursing notes documented that the resident was found on the floor after attempting to get out of bed, was sent to the ER, and returned with immobilizing braces on both legs due to bilateral femur fractures. The resident’s bones were not strong enough for surgery, and he was placed on comfort care. Despite the seriousness of the injuries and the requirement to treat such events as potential abuse or neglect until ruled out, the Administrator stated that this incident was reported only to the state’s patient safety website and not to the State Survey Agency’s incident reporting system. Another resident with Parkinson’s disease and severely impaired cognition was found on the floor after a wheelchair alarm sounded, initially with no visible injury and able to bear weight. A few days later, staff documented complaints of left leg pain, tenderness, and wincing with movement, leading to an order for x‑rays and transfer for imaging. X‑ray results revealed a femur fracture, and surgery was not pursued. The Administrator reported this incident to the state’s patient safety website but not to the State Survey Agency’s incident reporting website. A third resident with severe cognitive impairment experienced a fall with complaints of pain in the left knee, left elbow, and fingers, and later underwent ORIF surgery for fractures of the right fourth and fifth metacarpals; this incident also was not reported to the State Survey Agency’s incident reporting system, according to the Administrator. For another resident with dementia, adjustment disorder with anxiety, hearing and visual loss, and age‑related debility, a document in the facility’s abuse binder described a possible molestation allegation originating from a phone call by the resident’s nephew. The nephew reported that his mother, the resident’s sister and then‑POA, was emotionally unstable and had stated she felt the resident had reported being molested. The Administrator documented that the nephew did not believe the allegation was credible, that the sister had dementia and emotional issues, and that the Administrator considered the report “not a viable allegation.” The Administrator noted that he interviewed the resident, who denied being touched, and that the sister could not provide more details beyond stating that a man had groped the resident’s breast. The Administrator concluded the allegation was not credible and did not report it to any agencies or law enforcement. The incident was not documented in the resident’s medical record, and the Administrator confirmed in interview that he did not report this sexual abuse allegation to the State Survey Agency’s incident reporting website. Across these four residents, the common deficiency was the facility’s failure to treat serious injuries and a sexual abuse allegation as reportable events to the State Survey Agency, as required. Instead, the Administrator limited reporting to the state’s patient safety website or chose not to report at all when he personally judged an allegation as not credible. This pattern of inaction regarding mandated reporting requirements formed the basis of the cited deficiency.
Failure to Investigate Major Injuries and Alleged Abuse
Penalty
Summary
The deficiency involves the facility’s failure to initiate and document investigations into multiple major injuries and an allegation of sexual abuse, as required for all alleged violations involving abuse and injuries of unknown source. For one resident with hemiplegia, hemiparesis, and severely impaired cognition (BIMS score of 6), nursing notes documented that his roommate activated the call bell after the resident fell while attempting to get out of bed by himself. He was found on the floor between his bed and the window, reported knee pain with a popping sensation, and was sent to the ER. On return from the hospital, he was noted to have bilateral femur fractures, immobilizing braces on both legs, and was placed on comfort care due to bones not being strong enough for surgery. The Administrator acknowledged awareness of the bilateral femur fractures, stated he did not believe neglect or abuse caused the injury, and confirmed he did not investigate the cause of this major injury. Another resident with Parkinson’s disease and a BIMS score of 0 (rarely/never understood) was documented in an incident note as sitting in a wheelchair in the dining room when his alarm sounded; he was found supine on the floor, denied hitting his head or injury, and was assisted back into the chair with no signs of injury noted. Several days later, nursing notes recorded that CNAs reported the resident complaining of left leg pain when getting him out of bed. On assessment, he had tenderness and wincing with movement of the left leg but was able to bear weight. The MD was notified, an x-ray was ordered, and the resident was transported for imaging, which revealed a femur fracture for which surgery was not pursued. The Administrator stated he was aware of the femur fracture, did not feel neglect or abuse caused the major injury, and did not investigate the cause of the injury. A third resident with COPD, scoliosis, and severely impaired cognition (BIMS score of 7) had an incident note documenting that her bed alarm sounded and staff found her in a kneeling position leaning into her recliner after she attempted to get up from bed to go to the bathroom, stating her walker “didn't go where she was going.” She complained of left knee, left elbow, and right pinky pain, with no visible injury except an abrasion on the right ring finger. A later nursing note documented that she underwent ORIF of fractures of the right fourth and fifth metacarpals at a hospital and returned from surgery the same day. The Administrator reported being aware of the fractures, described the resident as very independent and wanting to wander the facility, stated he did not feel neglect or abuse caused the major injury, and confirmed he did not investigate the cause of the injury. Across these three residents, the facility did not initiate or document investigations into the causes of the major injuries or the related allegation of sexual abuse, nor did it determine causation or responsible parties as required.
Failure to Complete Monthly Pharmacist Reviews and Timely Act on Medication Recommendations
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a licensed pharmacist conducted and documented monthly drug regimen reviews for multiple residents and to ensure that identified medication irregularities were acted upon by the attending physician. For four sampled residents, the medical records lacked monthly pharmacist medication regimen review notes for at least two consecutive months. Specifically, residents with diagnoses including Parkinson’s disease, unspecified dementia, Alzheimer’s disease with early onset, and dementia related to other diseases had no documented pharmacist review notes for March and April 2026. The DON confirmed that the pharmacist had not completed pharmacy reviews for those months and that the notes, which should have been uploaded into each resident’s electronic medical record, were absent. In addition, the facility failed to act promptly on a pharmacist’s recommendation for a resident receiving psychotropic medications. One resident with hemiplegia following cerebral infarction, psychotic disorder with delusions, dementia, and major depressive disorder had a pharmacist recommendation in November 2025 to add a low-dose daytime Seroquel due to behavioral issues and afternoon anxiety. Nursing documentation showed that the pharmacist discussed the resident’s response to Seroquel versus Abilify and suggested a low-dose daytime Seroquel, but this recommendation was not communicated to the physician at that time. The LPN later stated she did not speak to the physician about the pharmacist’s recommendation because the resident had not needed PRN Haldol around that time. The physician did not write the order for daytime Seroquel until early February 2026, after a nurse raised concerns about the resident’s behaviors and reminded the physician of the prior pharmacist recommendation. The DON acknowledged that the pharmacist’s November 2025 recommendation was not completed until February 2026 and stated she did not have time to stay on top of such issues.
Unlabeled Insulin Pens Found in Medication Refrigerator
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled in accordance with accepted professional principles when two open insulin pens belonging to resident 56 were found without the resident’s name on them. During an observation of the south medication refrigerator on 4/29/26 at 10:50 AM, surveyors noted a plastic bin labeled only with resident 56’s first name, containing two loose, open insulin pens that had no resident identification labels affixed directly to the pens. In a concurrent interview, RN 1 confirmed that the two insulin pens belonged to resident 56 and stated that staff always put residents’ names on insulin pens, but was unsure why these pens had not been labeled. Later that day at 2:17 PM, the DON stated in an interview that the two insulin pens in question had been unlabeled and acknowledged that the insulin pens should have been labeled with the resident’s information.
Failure to Sustain QAPI Actions and Documentation for Pharmacist Medication Reviews
Penalty
Summary
The deficiency involves the facility’s failure, as part of its performance improvement activities, to take actions aimed at performance improvement, measure the success of those actions, and track performance to ensure that improvements were realized and sustained, specifically related to F756. Record review and interviews showed that the facility did not maintain documentation in the medical records to demonstrate that a pharmacist reviewed residents’ medications, identified potential irregularities, or provided recommendations to the attending physician for four sampled residents, despite this same issue having been cited in the previous health survey in 2024. During an interview, the DON stated she did not have time to maintain this required documentation. In a separate interview, the Administrator stated he did not have a performance improvement project, though he had QAPI minutes that captured some improvement plans, and he believed the facility had achieved compliance with F756, which had been cited previously, but no documents demonstrating compliance were provided when requested by surveyors.
Failure in Medication Handling and Infection Surveillance Documentation
Penalty
Summary
The facility failed to ensure a safe and sanitary environment during medication administration and infection surveillance. During an observation of medication pass for resident 23, an LPN was seen popping an oral pill directly from a blister pack into her bare hand and then placing it into a medication cup, after which the medication was administered to the resident. In a subsequent interview, the DON stated that staff were expected to pop pills directly into medication cups and never touch medications with bare hands, and that any medication contacting a staff member’s bare hand was to be discarded and replaced, indicating that the observed practice did not follow facility expectations. The facility also failed to maintain infection control surveillance documentation and an organized tracking system for infections. When Infection Control Surveillance Logs were requested, the DON reported that several residents had contracted influenza during the 2025 holiday season, attributed to an increased number of visitors, and that symptomatic residents were kept in their rooms. However, the DON stated she did not have a list of affected residents or rooms, and the requested surveillance logs were unavailable for review. In a later interview, the DON, who also served as the facility’s Infection Preventionist, confirmed that the facility lacked an infection control surveillance manual or organized system for tracking infections.
Failure to Implement and Monitor an Antibiotic Stewardship Program
Penalty
Summary
The facility failed to develop and implement an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use. There was no established facility-wide system to ensure appropriate indication, dose, and duration for antibiotic prescriptions, and no process for monitoring antibiotic usage or resistance data. On 4/29/26 at 8:20 AM, when surveyors requested the facility’s Infection Control Surveillance Logs, including any prescribed antibiotic tracking information, these logs were unavailable. On 4/30/26 at 12:28 PM, during an interview, the DON, who also served as the facility’s designated Infection Preventionist, stated that she did not track resident antibiotic utilization, including the specific clinical indications for the medications or the prescribed durations of treatment. No specific residents, their medical histories, or clinical conditions at the time of the deficiency were described in the report.
Failure to Promptly Resolve and Document Resident Grievance Regarding Door Injury
Penalty
Summary
The deficiency involves the facility’s failure to promptly resolve and properly document a resident grievance in accordance with its grievance policy. A resident with type II DM, HTN, anxiety disorder, major depressive disorder, and PTSD reported that a CNA on night shift did not hold open the smoking door for her and another resident, and that when she went to grab the door, it slammed on or closed against her finger, causing a cut to bleed. The resident stated she reported this to the Resident Advocate (RA) and completed a grievance form, and that nursing staff applied Neosporin and a bandage to the finger. The resident did not know the CNA’s name but identified that the CNA worked nights and stated that no one should be treating residents that way. The grievance form dated 4/10/26 documented the concern that the CNA on night shift did not hold the smoking door open and instead swung the door open and walked away, and that upon initial interview no allegation of abuse or neglect was identified. However, the grievance form contained no documentation of investigative steps taken, no summary of findings or conclusion, and no indication whether the grievance was confirmed or not. The form also lacked a written decision date, resident signature, grievance officer signature, and Administrator signature. The RA reported that the resident told her the door incident caused a small cut to reopen and that the CNA seemed in a hurry, but did not state that the CNA acted intentionally or purposefully toward her. The Administrator and DON later stated they had not been informed of the incident, and the Regional Nurse Consultant noted that nothing was filled out on the back of the grievance form, indicating it remained incomplete despite having been initiated several days earlier.
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