Rocky Mountain Care - Logan
Inspection history, citations, penalties and survey trends for this long-term care facility in Logan, Utah.
- Location
- 1480 North 400 East, Logan, Utah 84341
- CMS Provider Number
- 465116
- Inspections on file
- 18
- Latest survey
- February 12, 2026
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Rocky Mountain Care - Logan during CMS and state inspections, most recent first.
Three residents did not receive timely assessment and treatment in response to serious changes in condition. One resident on anticoagulation with mobility issues fell in the bathroom, later developed headache, vomiting, lethargy, and unilateral weakness, and was not transferred to the ED for approximately 2.5 hours after these changes, where a large subdural hematoma was found and the resident later died. A second resident with Parkinsonism and mobility impairment fell, immediately complained of left hip pain, and remained in pain despite analgesics while staff awaited imaging; transfer to the hospital for a confirmed femoral neck fracture did not occur until about 10 hours after the fall. A third resident with muscular dystrophy, OSA, and dysphagia had multiple episodes of severely low O2 sats, including readings in the 40s and 50s with cyanosis, without consistent or prompt interventions, follow-up sats, or documentation, and staff described delays in notifying a nurse and initiating oxygen despite obvious hypoxia.
A resident admitted with surgical wounds and MASD, and identified as high risk for pressure sores by Braden Scale, did not receive pressure ulcer prevention and wound care consistent with professional standards. Initial wounds on the posterior left lower extremity related to a brace and coccyx MASD were documented without measurements or detailed descriptions, and an order for barrier cream with each incontinent episode lacked evidence of administration. Over time, the resident developed additional skin breakdown on the sacrum, left inner thigh, left great toe, left posterior calf, and hips, including multiple Stage 4 pressure ulcers, but documentation of wound onset, measurements, descriptions, and preventive interventions was incomplete or absent. A knee immobilizer was ordered twice daily without specific care instructions, and the resident later developed a Stage 4 ulcer on the calf where the immobilizer was applied. Physician notes identified Stage 4 ulcers on the left shin, left hip, right hip, and posterior left lower leg, yet corresponding wound treatments were not consistently reflected on the MAR, and the Administrator could not provide additional documentation of preventive measures beyond the existing record.
A resident with weakness and orthostatic hypotension fell and hit his head after being left alone in the shower, despite needing supervision or more assistance with bathing. Another resident with paraplegia was injured in a van crash when the wheelchair seatbelt was not secured properly, and the driver had no documented training on safely transporting residents. Surveyors also found multiple room sinks with water temperatures above 120 degrees, including readings up to 130.2 degrees.
Food was not stored and handled according to professional standards. Surveyors found undated drinks, frozen vegetables, buns, and refrigerated items, an opened bag of corndogs left exposed to air, expired evaporated milk in dry storage, and expired sandwiches and a snack pack in a resident refrigerator. On a follow-up tour, the sanitizer bucket tested at 75 ppm when the DM stated 100 ppm was required, and additional refrigerated items were still undated.
Failure to Thoroughly Investigate Abuse and Neglect Allegations: The facility did not have evidence of thorough investigations for multiple allegations involving resident injury, a van accident, staff misconduct, inadequate care, self-harm, and alleged spousal abuse. A resident with dementia and other diagnoses sustained a fracture after a fall, another resident reported being thrown from a wheelchair in a van crash with a drowsy driver, and several other residents reported CNA misconduct or neglect, but investigation records were not available.
The facility failed to maintain an infection prevention and control program. Staff handled a resident’s feeding tube without the full EBP described in the report, including not using gowns and leaving the tube uncapped when not in use. Another resident who was ordered EBP for a catheter and wounds had no EBP sign or supplies observed in or outside the room. During lunch service, a CNA touched a resident’s food bare handed and also handled another resident’s sandwich bare handed.
The facility failed to ensure that two residents’ discharges and non‑readmissions were justified, coordinated, and accurately documented. One resident with terminal liver cancer and on hospice, whose care plan called for continued LTC, showed clear clinical decline in provider and hospice notes with no mention of discharge, yet was discharged the same day using an outdated discharge summary from a prior stay that listed an incorrect date, an RV destination, and home health instead of hospice, while hospice staff were not informed in advance and social services was not involved. Another resident with TBI, paraplegia, major depression, antisocial personality disorder, and suicidal ideation was discharged after repeated episodes of severe aggression and self‑harm, but the record lacked physician documentation explaining why the facility could not meet the resident’s needs, what interventions were attempted, and why the resident was not readmitted, despite staff interviews describing blue‑sheeting, suicide attempts, and safety concerns. The facility also failed to care plan aggressive behaviors for one resident and did not document coordination with hospice or behavioral interventions before discharge.
Failure to report a transport accident involving resident injury: A resident with paraplegia and PTSD was injured when the facility van went off the road and through a fence, causing the resident to be thrown from the wheelchair after the seatbelt was not secured properly. The resident reported bruising to the ribs and said the driver appeared drowsy. Facility records showed no documentation of the incident and no evidence it was reported to the SSA; the VPPA said she investigated but did not report it, and the ADM said the only record was the physical asset investigation.
Improper Tube Feeding Handling and Incomplete Formula Labeling: A resident with a PEG tube had feeding stopped, disconnected, reconnected, and restarted by CNA and restorative staff even though nursing staff stated only nurses were allowed to handle tube feeds. The resident’s formula bag was also labeled incompletely, with staff noting that tube feed labels should include the date, time, and nurse initials, consistent with nursing procedure guidance.
Medication Given Despite Hold Parameters: A resident with hemiplegia/hemiparesis following CVA, acute kidney failure, and idiopathic hypotension had an order for furosemide 20 mg daily with hold parameters for low BP. The MAR showed the medication was administered multiple times when BP readings were below the ordered limits, and an RN and the ADON stated the medication should be held when parameters were not met.
A resident with hemiplegia and hemiparesis after a CVA did not have her call light within reach while in bed. During observation, the call light was clipped to the top of the bedsheet on the left side, out of the resident’s reach, even though the resident stated staff were supposed to clip it to her shirt so she could reach it with her right hand. Interviews and record review showed this had happened before, and staff acknowledged the call light needed to be within reach because of the resident’s left-sided paralysis.
The facility failed to provide necessary housekeeping and maintenance services, resulting in cracked and broken drywall, peeling paint, a sticking door handle, and a loose toilet in three residents' rooms. Despite being aware of the issues, the Maintenance Director did not address them in a timely manner, and the Administrator was unaware of the extent of the needed repairs.
The facility failed to ensure medication error rates were below five percent, with a 16% error rate observed. Medications meant to be taken before meals were given post-meal to four residents. RN 3 acknowledged the errors, and the DON confirmed the need to follow doctor's orders for medication administration.
The facility failed to ensure a resident was evaluated for self-administration of medications. Medications were found at the bedside of a resident with severe cognitive impairment and multiple diagnoses, without proper assessment or physician's order. Staff confirmed the resident was not authorized to have medications at their bedside.
The facility inaccurately coded a resident as having received insulin during the seven-day MDS observation period when no insulin was administered. The resident's medical record and Medication Administration Record confirmed the absence of insulin orders or administration, which was acknowledged by the MDS Coordinator.
A resident with severe cognitive impairment and asthma experienced a delay in receiving timely treatment for respiratory symptoms. Despite family concerns and low oxygen levels, the resident was only given nasal spray and Mucinex over the weekend. The physician assistant ordered appropriate interventions on Monday, highlighting a failure in timely care and communication among staff.
A resident with multiple diagnoses, including chronic inflammatory demyelinating polyneuritis and muscle weakness, did not receive recommended restorative nursing services to improve range of motion (ROM). Despite a care plan and physical therapy evaluation recommending PT and participation in a restorative nursing program, the facility failed to provide these services, and the resident was not offered alternative therapies or exercises.
A resident with multiple diagnoses and increased protein needs did not receive the recommended Liquacel supplement twice a day for wound healing. The Liquacel was unavailable for four administrations, and there were issues with ordering and stocking the supplement. Staff interviews revealed inconsistencies in following dietary recommendations and delays in receiving supplies.
A resident was not administered a prescribed protein supplement for wound healing due to it being unavailable. Staff interviews revealed issues in the ordering and stocking process, leading to missed doses and the resident receiving an alternative supplement instead.
The facility failed to act on a pharmacist's recommendation to discontinue atorvastatin during daptomycin therapy for a resident, resulting in the resident receiving both medications concurrently for an extended period. The delay was attributed to the DON being on vacation and the usual process for handling recommendations being disrupted.
Delayed Response to Falls and Hypoxia Resulting in Resident Harm
Penalty
Summary
The deficiency involves the facility’s failure to provide timely assessment and treatment in response to changes in condition after falls and episodes of hypoxia, resulting in harm to residents. One resident with paroxysmal atrial fibrillation, difficulty walking, muscle weakness, and on anticoagulant therapy with an elevated INR experienced an unwitnessed fall in the bathroom. She was found on the floor in soiled clothing, assisted back to the toilet, and then to a chair. Initial neuro checks and vital signs were documented as baseline, and she denied hitting her head with no signs of injury noted. Later neuro documentation showed elevated blood pressure and lethargy, with slow response to verbal stimuli, weakness in hand grasps, and slurred speech, but there was no documented immediate escalation of care at that time. Subsequently, the resident began complaining of a headache and then reported that she had hit her head at the time of the fall. Nursing notes documented nausea, vomiting, not following simple cues, and left-sided weakness in grip strength. Staff interviews indicated that a CNA reported the headache to the nurse, who administered medications including Tylenol and performed neuro checks, noting rising blood pressure but otherwise within normal limits at that time. When the resident vomited and her level of consciousness changed, with inability to open her eyes and no grip in the left hand, the nurse notified the wing nurse, who then initiated notifications and arranged for transfer. The resident was ultimately sent to the emergency department approximately 2.5 hours after the onset of significant change in condition, where a CT scan revealed a very large right subdural hematoma with midline shift and herniation. The facility later provided additional information but did not explain the 2.5-hour delay in sending her to the hospital after the change in condition, and the resident subsequently died. Another resident with Parkinsonism, muscle weakness, difficulty walking, and sepsis sustained an unwitnessed fall and was found lying on the floor next to the bed, complaining of left hip pain. The nurse documented no new bruising or redness at the time, initiated neuro and vital sign checks, administered pain medication, and notified management, the physician, and family. An order was placed for a left hip x-ray, and the resident continued to receive oxycodone for left hip pain, with one dose documented as ineffective. The resident was not discharged to the hospital until later that afternoon, when an x-ray confirmed a left femoral neck fracture, resulting in a delay of approximately 10 hours from the time of the fall and initial complaint of hip pain to hospital transfer. In a later interview, the LPN stated he did not know why the resident was not sent to the emergency room sooner and believed it was probably because he did not have a physician’s order, and that he had attempted to manage the pain at the facility. A third resident with muscular dystrophy, obstructive sleep apnea, and dysphagia experienced repeated episodes of low oxygen saturation without timely or consistent intervention. The resident had orders for cough assist every shift for airway management and BIPAP at night, though the BIPAP order was held for a period without documentation explaining why. Oxygen saturation readings showed multiple episodes of hypoxia, including values in the 80s, 70s, 60s, 50s, and as low as the 40s and 30s, often without documented follow-up saturations or immediate treatment. On one occasion, the resident’s sats were 80% and the provider ordered a chest x-ray and labs, but there was no documentation of treatment for low sats for four hours. On several other dates, low sats were recorded with no follow-up readings documented. Staff interviews revealed that CNAs routinely checked sats early in the morning and that this resident’s sats were often in the 70s and 80s at night. A CNA described a night when the resident was hot and cold, calling frequently, and reported difficulty breathing; the CNA found his sats in the 40s and observed him to be blue in the face and pale. She finished assisting him with a urinal and taking out the garbage before informing the nurse, after which oxygen was started and his sats increased above 90%. Another nurse stated that it was not standard to check sats on night shift, but that if sats were low, oxygen should be provided and saturations rechecked, and that sats below 80% should be reported to the DON, physician, and family. The DON reported receiving a call that this resident’s nurse did not act fast enough when the resident had oxygen issues, and administration initiated an investigation, but the administrator stated she did not review the resident’s prior oxygen levels. These events demonstrate repeated failures to promptly assess and treat significant changes in condition, including post-fall injuries and severe hypoxia, in accordance with professional standards, care plans, and resident needs.
Failure to Prevent and Manage Pressure Ulcers for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer prevention and wound care consistent with professional standards for one resident who was admitted with surgical wounds and Moisture Associated Skin Damage (MASD) and later discharged with a Stage 4 pressure ulcer. On admission, documentation noted breakdown on the proximal posterior left lower extremity related to a brace and MASD on the coccyx, but there were no measurements or detailed descriptions of these wounds. The resident was ordered to have a knee immobilizer applied twice daily, but the order did not specify what care was to be provided with the immobilizer, and nursing documentation only showed it was signed off on the MAR. A Braden Scale assessment identified the resident as high risk for pressure sores, and an order for barrier cream to the buttocks/peri-area with each incontinent episode was in place, but there were no signatures on the Treatment Administration Record to show the treatment was provided. Over the course of the stay, multiple new areas of skin breakdown developed, and documentation was inconsistent, incomplete, or missing. Care plans and nursing notes referenced skin impairment to the sacrum, left inner thigh, left great toe, and left posterior calf, but often lacked wound measurements, descriptions, or clear timelines of onset. A new wound to the left posterior calf was first noted by an aide after a shower, and subsequent notes described the area as black with surrounding pink skin, then later as open with yellow slough, moderate yellow drainage, and foul odor. Weekly skin assessments were delayed, with the first one dated months after admission, and when completed, they sometimes documented skin as pink, dry, warm, and intact at locations where other notes and physician documentation indicated the presence of Stage 4 ulcers. Physician notes later identified a Stage 4 ulcer of the left shin, a Stage 4 ulcer on the left hip, and a Stage 4 pressure ulcer of the right hip, in addition to the posterior left lower leg ulcer, but there were no corresponding wound treatment orders for the right or left hip on the MAR. The resident’s left hip surgical site, previously documented as a surgical wound, was later classified as a Stage 4 pressure ulcer without documentation of interventions to prevent further breakdown. There was also no documentation of when sacral skin breakdown developed. The resident had been admitted with a knee immobilizer and subsequently developed a Stage 4 pressure ulcer on the calf where the immobilizer was applied, and the record lacked documentation of interventions used to prevent skin breakdown. When surveyors requested additional information about preventive measures, the Administrator stated there was no documentation beyond what was in the medical record and was unable to provide further information.
Unsafe Supervision, Transportation, and Hot Water Temperatures
Penalty
Summary
The facility did not ensure that the environment remained free of accident hazards and that residents received adequate supervision and assistance devices to prevent accidents. One resident with diagnoses including malignant neoplasm of the large intestine and rectum, muscle weakness, orthostatic hypotension, and moderate protein-calorie malnutrition sustained an unwitnessed fall in the shower room and hit his head after being left unattended. The resident’s record showed that his bathing needs had changed from set-up assist to requiring supervision or partial to moderate assistance, but staff were not aware of the change in condition at the time of the incident. The resident stated that he slipped while taking a shower and that the CNA was not in the room with him. The nurse documented that the resident walked out of the shower room stating he had fallen, was lethargic, had no footwear, and reported that he slipped on water and hit his head. The first responder report documented that the resident was placed in the shower and was last checked on 20 minutes later, and identified contributing factors as being left alone in the shower, no supervision, and no use of the call light. The resident’s care plan addressed fall risk, but the interventions listed before the fall focused on call light use, bed position, and clutter reduction rather than supervision in the shower. A second resident, who had paraplegia, a thoracic spinal injury, and PTSD, was involved in a motor vehicle accident while being transported in the facility van and reported being thrown from the wheelchair because the seatbelt was not secured properly. The resident reported bruising to the ribs and that the driver was drowsy. Records documented injuries and emergency evaluation after the crash, and the facility’s transportation records did not identify which driver transported each resident. The personnel file for the driver contained no documentation of training on safely securing a resident during transportation or education on transporting residents, and the administrator stated that the driver had not received education for driving the facility van. The survey also found resident room sink water temperatures as high as 130.2 degrees, with multiple rooms measuring above 120 degrees. Residents reported that the water could get hot quickly and that staff sometimes had to turn down the hot water. The maintenance director stated that the water heaters were set slightly above 120 degrees, that some rooms were running high, and that mixing valves were on order, while the observed north water heater was set at 130 and had no mixing valve.
Food Storage and Sanitizer Monitoring Deficiencies
Penalty
Summary
Food was not stored, prepared, distributed, and served in accordance with professional standards for food service safety. During an initial kitchen tour, surveyors observed multiple cups with different liquids in the refrigerator that were not dated, an opened bag of frozen vegetables and an opened bag of buns in the freezer that were not dated, and an opened bag of corndogs that was left open to air. In dry storage, cans of evaporated milk were found past their expiration date. In the resident refrigerator, three sandwiches were found past their use-by date and a pepperoni and cheese snack pack was also expired. On a follow-up kitchen tour, the sanitizer bucket tested at 75 parts per million, and the Dietary Manager stated the required level was 100 parts per million and that surfaces were not being sanitized correctly at 75 parts per million. The same tour also found fresh vegetables, potato salad, and ranch cups inside the refrigerator that were not dated. During interviews, the Dietary Manager acknowledged that drinks in the refrigerator should be dated, the frozen vegetables had been placed in a box without a date, the corndogs should have been closed, expired evaporated milk should be discarded, and items in the resident refrigerator were the responsibility of kitchen staff and should have been thrown out when expired.
Failure to Thoroughly Investigate Abuse and Neglect Allegations
Penalty
Summary
The facility did not have evidence of a thorough investigation in response to allegations of abuse, neglect, exploitation, or mistreatment for 9 of 46 sampled residents. The allegations involved residents with fractures, a motor vehicle accident involving a resident, staff-related allegations concerning care and abuse, a resident who self-harmed, and an allegation of abuse by a spouse. The survey findings identified that the facility could not provide investigation documentation for residents 32, 38, 86, 87, 88, 91, 92, 93, and 95. Resident 86 was admitted and later readmitted with diagnoses including dementia, major depressive disorder, epilepsy, and unsteadiness on feet. The facility reported that the resident sustained a fall, complained of pain, and was found by x-ray to have a fracture, but no investigation was provided to determine whether abuse or neglect occurred. Resident 32, who had paraplegia, a T7-T10 injury, and PTSD, reported that a facility van went off the road and through a fence, that the resident was thrown from the wheelchair because the seatbelt was not secured properly, and that the transportation driver appeared drowsy; the facility had no abuse or neglect investigation documentation for the incident beyond a physical asset report about the vehicle. For the remaining residents, the facility reported allegations but did not provide investigations to determine whether abuse or neglect occurred. Resident 38 reported that a brief was not being changed when asked; resident 87 reported that a CNA hit the resident in the calf and tossed a remote control; resident 88 reported that a CNA hit the resident's hand away during a brief change; resident 91's daughter reported the resident's wound was not being cared for according to physician orders; resident 92 reported a CNA asked inappropriate questions during peri-care; resident 93 was found with blood on the sheets and stated he had intentionally cut himself; and resident 95 reported that her husband hit her arm during an argument while visiting. The Administrator and ADM 2 stated they were unable to locate investigation records for these allegations.
Infection Prevention and Control Program Deficiency
Penalty
Summary
The facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infections. For a resident with a feeding tube, staff repeatedly handled the tube without using the full Enhanced Barrier Precautions (EBP) described in the report. The resident was admitted with diagnoses including aphasia following cerebrovascular disease, cerebral infarction, and COPD, and observations showed the feeding tube hanging uncapped around the IV pole or pump when not in use. When CNA 5 and the restorative therapy aide connected the resident to the feeding tube, both were observed wearing gloves but not a gown. For another resident with diagnoses including anorexia, gastrointestinal hemorrhage, abscess of lung with pneumonia, severe sepsis, and a stage three sacral pressure ulcer, EBP signage and supplies were not observed in or outside the room during observations. The resident had orders initiated to ensure EBP were implemented every shift for the catheter and wounds. During interview, RN 7 stated that EBP required a sign on the door and supplies in a hanging caddy within the room, and also stated the resident should be on EBP due to the catheter. However, the room was observed without the sign or supplies at the time of the survey observation. During meal service in the dining room, a CNA assisted a resident with lunch and touched the resident’s food bare handed. The CNA picked up and handed the resident a French dip sandwich, then touched the resident’s plate, lid, wheelchair armrest, and a ham and cheese sandwich bare handed. In interview, another CNA stated staff should never touch a resident’s food bare handed, and the ADON stated staff should not be touching resident food items bare handed and should use utensils instead.
Failure to Properly Justify, Plan, and Document Resident Discharges and Non‑Readmissions
Penalty
Summary
The deficiency involves the facility’s failure to ensure that transfers and discharges were only carried out under permissible conditions, were properly planned and coordinated, and were supported by complete and accurate documentation. For one resident with liver cell carcinoma, heart failure, and a terminal prognosis who had been admitted for comfort management and hospice, the care plan and social services documentation identified a discharge plan of continued LTC with skilled nursing and hospice. Subsequent provider and hospice notes documented clinical decline, including dizziness, severe abdominal pain, weakness, nausea, vomiting, jaundice, and markedly reduced oral intake, without any indication of an upcoming discharge. Despite this, the resident was discharged on the same day a hospice nurse documented further decline, and the first mention of discharge in the record appeared in a hospice chaplain note stating the resident was being asked to leave and did not know where he was going. The facility’s discharge documentation for this resident was incomplete and inaccurate. A Transition of Care/Discharge Summary was printed on the day of discharge using an incorrect discharge date from a prior year and listing the discharge destination as the resident’s RV with home health services, with a goal that he would continue to get stronger with home health. The document omitted any reference to hospice services. All signatures were dated later that afternoon, after the hospice chaplain note, and a nursing progress note recorded that discharge teaching was done and the resident left in a private vehicle with a three‑day supply of medications. Hospice records later showed the resident was actually on LOA and staying at his ex‑wife’s home, and the Social Services Director stated she did not complete the discharge summary, was not involved in the discharge process, and that this lack of involvement was not normal. The Regional Social Work Director determined that staff had reused a prior discharge summary from a previous discharge to the RV, and the hospice director confirmed there was no prior hospice documentation of a planned facility discharge. For a second resident with diffuse TBI, spastic hemiplegia, major depressive disorder, paraplegia, antisocial personality disorder, and suicidal ideations, the facility discharged the resident following episodes of severe aggression and self‑harm behaviors without required physician documentation supporting the discharge and non‑readmission. A nursing progress note described escalating verbal aggression, vulgar language, physical aggression toward staff, attempts to tip the wheelchair, and throwing objects at staff. A discharge summary later characterized the resident as having physical and verbal aggression that staff were unable to manage and a history of suicidal ideation, but there was no physician documentation explaining why the facility was unable to care for the resident, what interventions had been attempted, or why the resident was not readmitted after hospital transfer. Interviews with the Restorative Therapy Aide, ADON, SSD, and Administrator described multiple aggressive incidents, blue‑sheeting to the hospital, suicide attempts, and the facility’s decision not to readmit the resident due to safety concerns, but these details were not supported by corresponding physician documentation in the medical record. Additionally, for the first resident, there was no care plan addressing aggressive behaviors despite multiple progress notes documenting such behaviors, and no documentation of hospice being contacted about behavioral concerns, medication adjustments, or room changes prior to discharge.
Failure to Report Transport Accident Involving Resident Injury
Penalty
Summary
The facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately to the State Survey Agency. For one sampled resident, Resident 32, the record and interviews showed that the resident was involved in a motor vehicle accident while being transported in the facility van and the incident was not reported to the SSA. Resident 32 was admitted with diagnoses including paraplegia, unspecified injury of T7-T10, and post traumatic stress disorder. During interview, Resident 32 stated that the Transportation Driver was late, drove off the road and through a fence, and that she was thrown from her wheelchair because her seatbelt was not secured properly. She stated that she hit the armrest, sustained bruising to her ribs, and landed on the floor of the van, and that the driver appeared drowsy while driving. Review of the facility abuse investigations found no documentation of the incident and no documentation that it was reported to the SSA. The VPPA stated she investigated the accident but did not report it to the SSA and was unsure whether the DON or Administrator had done so. The Administrator stated that the only documentation available was the physical asset investigation from the VPPA and that it did not appear the incident had been reported to the SSA.
Improper Tube Feeding Handling and Incomplete Formula Labeling
Penalty
Summary
The facility did not ensure that enteral tube feeding services met professional standards of quality for one resident with a PEG tube. Resident 47 was admitted with diagnoses including aphasia following cerebrovascular disease, cerebral infarction, and chronic obstructive pulmonary disease. During observation, a CNA stopped the resident’s tube feeding, disconnected the tube, and took the resident to the bathroom, then later reconnected the tube and restarted the feeding pump. On another observation, a Restorative Therapist Assistant assisted the resident back into bed, connected the feeding tube, and restarted the tube feed. Interviews with nursing staff and facility staff indicated that only nurses were supposed to stop or start tube feedings and connect or disconnect the tube from the resident. The resident’s tube feed labeling was also incomplete. The formula bag was observed labeled only with the date on one occasion and later with a date and time that did not match the observed administration time. Nursing staff stated that tube feeds should be labeled with the date, time of administration, and the initials of the nurse who started the tube feed, while the ADON stated that tube feeds should be labeled when opened but was unsure of the additional required information. Review of Lippincott Nursing Procedures showed that enteral formula containers should be labeled with patient identifiers, formula name, date and time of preparation, date and time hung, route, rate, duration if applicable, initials of who prepared, hung, and checked the formula, expiration date and time, dosing weight if appropriate, and the notation ENTERAL USE ONLY-NOT FOR IV USE.
Medication Given Despite Hold Parameters
Penalty
Summary
The facility did not ensure that each resident's drug regimen was free from unnecessary drugs when Resident 2's furosemide was administered despite physician-ordered hold parameters. Resident 2 was admitted with diagnoses including hemiplegia and hemiparesis following a cerebral vascular accident, acute kidney failure, and idiopathic hypotension. The physician ordered furosemide 20 mg by mouth daily with instructions to hold the medication for systolic blood pressure less than 110 or diastolic blood pressure less than 60. The MAR documented that the medication was given on multiple dates when the resident's blood pressure was below the ordered parameters, including readings such as 96/64, 105/65, 106/68, 94/58, 109/85, 105/70, 92/60, 100/69, and 107/68. During interview, RN 1 stated she would hold the medication for blood pressures outside the ordered ranges, and the ADON stated nurses should hold medications based on the parameters documented in the MAR.
Call Light Not Kept Within Reach for Resident With Left-Sided Paralysis
Penalty
Summary
A resident with hemiplegia and hemiparesis following a cerebral infarction affecting the left non-dominant side did not have a call light accessible while in bed. During observation, the resident’s call light was clipped to the top of the bedsheet on the left side, out of reach of the resident’s right hand. The resident stated that staff were supposed to clip the call light to her shirt on the left side so she could reach it, and stated that she had left-sided paralysis. The resident also pointed out signs in the room instructing staff to clip the call light to her left chest. Record review showed prior grievances from the resident’s spouse reporting that the call light had been out of reach during visits, and interviews confirmed that this had occurred at times. The Social Service Director stated she had found times when the call light was not within the resident’s reach, and the CNA and ADON both stated that the call light needed to be within reach because of the resident’s left-sided paralysis and need to use her right arm.
Failure to Maintain Sanitary and Comfortable Environment
Penalty
Summary
The facility did not provide the necessary housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable environment for its residents. Specifically, three residents experienced issues with their rooms, including cracked and broken drywall, peeling paint, a door handle that sticks, and a loose toilet. Resident 37 reported having to tape a large hole in the wall, a wobbly toilet, and a door handle that was difficult to use. Despite informing the Maintenance Director, no repairs were made. Resident 24's room had chipped and peeling paint and drywall near the bathroom door. Resident 18's room had peeling paint and drywall near the sink and bathroom, a main door missing pieces of Formica, and chipped cabinets, which were reportedly caused by his roommate's behavior. The Maintenance Director acknowledged being aware of the issues in the residents' rooms but had not addressed them in a timely manner. He mentioned that he was still figuring out what products were required for the repairs and was unsure of the timeframe for completing them. The Administrator was unaware of the multiple repairs needed in Resident 37's room and stated that there was no specific timeframe for maintenance items to be completed unless they were emergent issues. The Administrator also mentioned that repairs related to fixing or painting walls could take up to a week, but nothing should take over a month to be addressed and fixed by maintenance.
Medication Administration Errors
Penalty
Summary
The facility did not ensure that medication error rates were not five percent or greater. During observations of 25 medication opportunities, four medication errors were identified, resulting in a 16% medication error rate. Specifically, for four out of 28 sampled residents, medications that were supposed to be taken at least 30 minutes before meals were given to the residents after they had consumed a meal. The residents involved were identified as 23, 33, 51, and 69. The errors included pantoprazole, gabapentin, metoclopramide, and omeprazole being administered post-meal instead of pre-meal as per the doctor's orders. RN 3 was observed administering these medications incorrectly and acknowledged the errors during interviews. RN 3 stated that resident 23 preferred taking medications after breakfast, and resident 51 was often hard to locate in the mornings, leading to the medication being given after meals. The Director of Nursing (DON) confirmed that there was no documentation of residents' medication preferences in the medical records and emphasized that all nurses need to follow the doctor's orders for medication administration. The DON stated that medications ordered to be given before meals must be administered before meals, and if this is not feasible, the doctor's orders need to be updated accordingly.
Failure to Evaluate Resident for Self-Administration of Medications
Penalty
Summary
The facility did not ensure that the interdisciplinary team had evaluated and determined that a resident's right to self-administer medications was clinically appropriate. Specifically, medications were found at the bedside of a resident who had not been assessed for self-administration. The resident, identified as having severe cognitive impairment and multiple diagnoses including polyneuropathy, dementia, and major depressive disorder, had Tums at their bedside, which they took as needed without proper evaluation or physician's order. Interviews with staff, including an LPN, RN, and the DON, revealed that the facility's policy required a self-administration assessment and a physician's order for residents to keep medications at their bedside. The staff confirmed that resident 43 had not been assessed for self-administration and was not authorized to have medications at their bedside. The DON emphasized that the purpose of the assessment was to ensure the resident's safety in self-administering medications, and resident 43 was not among those permitted to do so.
Inaccurate Resident Assessment for Insulin Administration
Penalty
Summary
The facility did not ensure that the resident assessment accurately reflected the resident's status. Specifically, for one resident, the facility coded the resident as having received insulin during the seven-day Minimum Data Set (MDS) observation period when the resident had not received any insulin. The resident was admitted with diagnoses including infection and inflammatory reaction due to internal left knee prosthesis, type 2 diabetes mellitus with hyperglycemia, and type 2 diabetes mellitus without complications. A review of the resident's medical record and Medication Administration Record showed no orders or documentation of insulin administration since admission. The MDS Coordinator confirmed that the MDS assessment had been miscoded.
Delay in Treatment for Respiratory Illness
Penalty
Summary
The facility failed to ensure that a resident with a respiratory illness received timely treatment and care in accordance with professional standards of practice and the resident's comprehensive person-centered care plan. Resident 43, who had severe cognitive impairment and multiple diagnoses including asthma, experienced a delay in receiving appropriate medical intervention for their respiratory symptoms. Despite the resident's family member notifying the Director of Nursing (DON) about the resident's condition over the weekend, the resident was only given nasal spray and Mucinex until the physician assistant saw them on Monday and ordered a chest x-ray, breathing treatment, and oxygen therapy. The medical record review revealed that the resident's oxygen saturation was documented to be 89% on one occasion and 80% on another, yet no immediate interventions were put in place to address these low oxygen levels. Interviews with the nursing staff indicated that although the resident had been complaining of respiratory symptoms and had received some as-needed medications, there was a lack of timely and appropriate response to the resident's deteriorating condition. The DON acknowledged that the nurses should have followed standing orders for oxygen and notified the physician and DON about the resident's low oxygen saturation. The deficiency was further highlighted by the fact that the resident's condition was not adequately monitored or addressed over the weekend, leading to a delay in receiving necessary medical treatment. The DON and nursing staff provided inconsistent accounts of the events and actions taken, indicating a breakdown in communication and adherence to protocols. The resident's family member expressed concern that the resident's condition should have been treated sooner, underscoring the facility's failure to provide timely and appropriate care.
Failure to Provide Recommended Restorative Nursing Services for Resident with Limited ROM
Penalty
Summary
The facility did not ensure that a resident with limited range of motion (ROM) received appropriate treatment and services to increase ROM and prevent further decline. Specifically, for one resident with chronic inflammatory demyelinating polyneuritis, diabetes mellitus, difficulty walking, hypertension, chronic pain syndrome, and muscle weakness, the facility failed to provide restorative nursing services recommended by physical therapy. The resident expressed a desire for physical or occupational therapy due to perceived loss of mobility and ROM, but was informed that his insurance would not cover these services and was not offered alternative therapies or exercises by the facility. The resident's care plan included encouraging PT/OT services and assisting with ADL tasks. An orthopedic note and a physical therapy evaluation recommended PT for the resident's right knee and participation in the restorative nursing program for upper and lower extremity ROM. However, the Director of Rehab was unaware of the therapy needs, and the Minimum Data Set Coordinator could not locate a referral for the restorative nursing program. The Director of Nursing acknowledged the resident's ongoing ROM issues but was unsure if there had been a decline since admission. The Administrator was also unaware of the resident's desire for therapy services and believed the resident was already receiving restorative nursing assistance.
Failure to Provide Adequate Nutritional Supplements
Penalty
Summary
The facility failed to ensure that a resident maintained acceptable parameters of nutritional status. Specifically, a resident with a recommendation for Liquacel twice a day for wound healing and increased protein needs had the Liquacel order implemented daily, and the Liquacel was unavailable for four administrations. The resident had multiple diagnoses, including infection and inflammatory reaction due to internal left knee prosthesis, type 2 diabetes mellitus, and peripheral vascular disease. The care plan included offering supplements and double portions, providing diet and snacks as prescribed, and weight monitoring, among other interventions. The resident's medical record indicated that the resident was at moderate risk for malnutrition due to poor medical history, poor mobility, and inadequate oral intake. Despite the dietary recommendation for Liquacel 30 mL twice a day, the order was implemented as once a day. The resident expressed concerns about not getting enough protein and the dietary recommendations were not consistently followed. The April and May Medication Administration Records showed that the Liquacel was not administered on four occasions due to unavailability. Interviews with staff revealed that there were issues with ordering and stocking the Liquacel. The Registered Nurse stated that the Liquacel was ordered with over-the-counter medications and that Central Supply was responsible for ordering it. The Transportation Director, who had just started working in Central Supply, confirmed that the Liquacel was ordered weekly and that there were sometimes delays in receiving items. The Registered Dietician and Dietary Director confirmed that the Liquacel was recommended for wound healing and that the order should have been twice a day. The Director of Nursing stated that dietary recommendations were discussed in meetings and that the Unit Manager was responsible for inputting the orders.
Failure to Provide Prescribed Supplement
Penalty
Summary
The facility failed to provide routine and emergency drugs and biologicals to a resident, specifically a protein supplement necessary for wound healing. Resident 18, who had multiple diagnoses including infection due to a knee prosthesis, diabetes, and muscle weakness, was not administered Liquacel as ordered by the physician. The resident's medical record indicated that the supplement was recommended by the dietitian and agreed upon by the resident, but it was not available on several occasions, leading to missed doses on 4/25/24, 5/5/24, 5/6/24, and 5/7/24. Interviews with staff revealed a breakdown in the ordering and stocking process for the supplement. The Registered Nurse (RN) responsible for medication refills stated that the Liquacel was ordered through Central Supply and should have been available in the medication room. However, the Transportation Director, who had recently taken over central supply duties, indicated that she had not yet ordered Liquacel and was unaware of its shortage until it was too late. The process for ordering over-the-counter medications involved a weekly review and order, which led to delays in obtaining the necessary supplement. Further interviews with the Registered Dietician (RD) and the Director of Nursing (DON) confirmed that the dietary recommendations were communicated during Nutrition At Risk (NAR) meetings and should have been followed up with appropriate orders. Despite these procedures, the supplement was not available when needed, and the resident was given an alternative (Metamucil) when the Liquacel was out of stock. This deficiency highlights a failure in the facility's system to ensure timely availability of prescribed supplements for resident care.
Failure to Act on Pharmacist's Medication Recommendation
Penalty
Summary
The facility did not ensure that the pharmacist's recommendation to discontinue atorvastatin during daptomycin therapy was acted upon in a timely manner. Specifically, for one resident, the recommendation to discontinue atorvastatin to avoid potential myopathy and rhabdomyolysis was accepted by the Physician Assistant on 3/15/24 but was not implemented until 4/2/24. During this period, the resident continued to receive atorvastatin daily while also being administered daptomycin, contrary to the pharmacist's recommendation. The delay in implementing the recommendation was attributed to the Director of Nursing (DON) being on vacation and the process of handling the pharmacist's recommendations being disrupted. The DON stated that the pharmacist's reports were usually reviewed and acted upon within 24 to 48 hours, but due to her absence, the recommendations were not updated and noted in a timely manner. This lapse resulted in the resident receiving potentially harmful medication concurrently for an extended period.
Latest citations in Utah
Surveyors found that the facility did not ensure residents or their representatives were informed of and able to participate in decisions about psychotropic medications. Several residents with conditions such as dementia, early-onset Alzheimer’s disease, major depressive disorder, psychotic disorder, and Parkinson’s disease were started on drugs including haloperidol, donepezil, buspirone, quetiapine, zaleplon, and sertraline without documentation that risks, benefits, or alternative treatments were discussed in advance. The DON reported that staff notify families when medications are started or changed but do not review risks and benefits, offer alternative options, or obtain signed consent, resulting in no evidence of informed decision-making for these psychotropic treatments.
Surveyors determined that the facility failed to consistently manage psychotropic medications for three residents. Two residents with dementia and psychiatric conditions had only one documented psychotropic medication review and gradual dose reduction (GDR) attempt, completed in January, with no evidence of quarterly reviews or additional GDR efforts. Another resident with hemiplegia, psychotic disorder, dementia, and major depressive disorder had a PRN IM haloperidol order written without an end date, which remained active and was administered on multiple occasions beyond 14 days, and the DON confirmed there was no physician documentation justifying the extended PRN antipsychotic order.
The facility failed to ensure that alleged abuse and serious injuries were reported to the State Survey Agency as required, instead either reporting only to a state patient safety system or not reporting at all. One resident with severe cognitive impairment sustained bilateral femur fractures after a fall, another cognitively impaired resident with Parkinson’s disease was later found to have a femur fracture after being discovered on the floor, and a third cognitively impaired resident required ORIF surgery for fractures following a fall; none of these incidents were reported through the State Survey Agency’s incident reporting website, per the ADM. In addition, an allegation that a resident with dementia and sensory impairments may have been molested was documented in the abuse binder but not in the medical record, and the ADM did not report the allegation to agencies or law enforcement after deeming it not credible, despite interviewing the resident and family. These actions and omissions resulted in multiple unreported events that met criteria for immediate reporting of alleged abuse and injuries of unknown source.
The facility failed to investigate multiple major injuries and an allegation of sexual abuse involving three residents with severe cognitive impairment and significant medical conditions. One resident, dependent for transfers, was found on the floor after attempting to get out of bed and was later found to have bilateral femur fractures. Another resident with Parkinson’s disease was found on the floor after a wheelchair alarm sounded and was later diagnosed with a femur fracture following complaints of leg pain. A third resident, described as very independent, triggered a bed alarm and was found kneeling by a recliner, later requiring ORIF for fractures of the right 4th and 5th metacarpals. In each case, the ADM acknowledged awareness of the fractures, stated there was no belief of neglect or abuse, and confirmed that no investigation into the cause of the injuries or the alleged abuse was initiated or documented.
Surveyors found that the facility failed to ensure monthly pharmacist drug regimen reviews were completed and documented for several residents with conditions such as Parkinson’s disease, dementia, and Alzheimer’s disease, with no pharmacist notes present for at least two consecutive months. Additionally, a pharmacist’s recommendation to add a low-dose daytime antipsychotic for a resident with dementia, psychotic disorder, and behavioral symptoms was not communicated to the physician or implemented for several months, despite documented behavioral concerns. An LPN reported not relaying the pharmacist’s recommendation because PRN Haldol had not been needed at that time, and the DON confirmed that the pharmacist reviews for the missing months were not done and that she did not have time to monitor follow-through on such recommendations.
Surveyors identified a failure to properly label medications when two open insulin pens were found in a medication refrigerator bin marked only with a resident’s first name, with no labels directly on the pens. During an observation, an RN confirmed the pens belonged to a resident and acknowledged that pens are supposed to be labeled with the resident’s name but could not explain why these were not labeled. In a subsequent interview, the DON confirmed the pens had been unlabeled and stated they should have been labeled in accordance with professional standards.
The facility failed to sustain effective QAPI processes related to pharmacist medication regimen reviews, resulting in repeated noncompliance with F756. Surveyors found that medical records for four residents lacked documentation showing that a pharmacist had reviewed medications, identified potential irregularities, or made recommendations to attending physicians, an issue previously cited. The DON reported she did not have time to maintain this documentation, and the Administrator acknowledged there was no formal performance improvement project in place, though some plans were noted in QAPI minutes, and no supporting documents were produced to demonstrate ongoing compliance.
Staff failed to follow infection control practices during medication administration and did not maintain organized infection surveillance documentation. An LPN was observed handling an oral medication with bare hands before administering it to a resident, contrary to the DON’s stated expectation that pills be dispensed directly into medication cups without hand contact and that any contaminated dose be discarded. Additionally, the DON, who also served as the Infection Preventionist, reported that several residents had influenza during a past holiday season but had no list of affected residents or rooms, and the requested infection control surveillance logs and a formal tracking system were not available.
The facility lacked an antibiotic stewardship program, with no protocols to ensure appropriate indication, dose, and duration of antibiotic prescriptions and no system to monitor antibiotic use or resistance patterns. When surveyors requested Infection Control Surveillance Logs, including antibiotic tracking information, the logs were not available. In an interview, the DON, who also functioned as the Infection Preventionist, acknowledged that she did not track resident antibiotic utilization, clinical indications, or treatment durations.
A resident with multiple chronic conditions, including DM, HTN, anxiety, major depressive disorder, and PTSD, reported that a CNA on night shift failed to hold open a smoking-area door, leading the resident to grab the door and sustain a finger cut that bled. The resident completed a grievance with the RA, who documented that the CNA swung the door open and walked away and that no abuse or neglect allegation was initially identified. However, the grievance lacked documentation of investigative steps, a summary of findings, a conclusion on whether the grievance was confirmed, and any decision date or required signatures, and leadership later reported they had not been informed of the incident, demonstrating the grievance was not promptly resolved or fully tracked through conclusion.
Failure to Inform Residents of Risks, Benefits, and Alternatives Before Starting Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents, or their representatives, were informed of and allowed to participate in decisions regarding psychotropic medication treatment, including being informed in advance of the risks, benefits, and treatment alternatives. For four sampled residents, medical record review showed new orders for multiple psychotropic medications without any documentation that the resident or representative had been informed of these elements prior to initiation. Resident 8, with diagnoses including hemiplegia and hemiparesis following cerebral infarction, psychotic disorder with delusions, dementia, and major depressive disorder, was started on haloperidol lactate, donepezil, buspirone, quetiapine, and sertraline on various dates, with no documentation of informed discussion or consent. Resident 4, with unspecified dementia and anxiety disorder, was started on zaleplon, quetiapine, and buspirone, again with no record that risks, benefits, or alternatives were discussed in advance. Resident 54, diagnosed with early-onset Alzheimer’s disease and dementia in other diseases classified elsewhere, was started on sertraline and quetiapine, and Resident 6, diagnosed with Parkinson’s disease without dyskinesia, was started on buspirone, quetiapine (Seroquel), and sertraline, with no documentation that either resident or their representative had been informed of the risks and benefits or treatment options before these psychotropic medications were initiated. During an interview, the DON stated that the facility notifies families when medications are started or doses are changed but does not discuss risks and benefits, provide alternative options, or obtain signed consent. This practice contributed to the lack of documented evidence that residents or their representatives were fully informed and able to participate in treatment decisions regarding psychotropic medications.
Failure to Perform Regular GDR and Limit PRN Antipsychotic Orders
Penalty
Summary
Surveyors found that the facility did not ensure appropriate management of psychotropic medications for three sampled residents. For two residents with dementia and related psychiatric diagnoses, the medical records from late April 2026 showed only one documented psychotropic medication review and gradual dose reduction (GDR) attempt, completed in January 2026. There was no documentation of any GDR attempts or psychotropic reviews prior to January 2026, despite the DON stating that such reviews and GDRs should be completed quarterly. The records for these residents did not contain additional GDR attempts beyond the January 2026 review. For a third resident with hemiplegia following cerebral infarction, psychotic disorder with delusions, dementia, and major depressive disorder, a physician’s order dated February 8, 2026, prescribed PRN intramuscular haloperidol lactate every 12 hours for delusions, hallucinations, paranoia, and agitation, without an end date. Review of the MARs for February through April 2026 showed that this PRN antipsychotic was administered on two occasions, and no end date was documented on the MAR. In an interview, the DON acknowledged that the PRN haloperidol order extended beyond 14 days and that the physician had not documented a reason for continuing the order beyond that period.
Failure to Report Alleged Abuse and Serious Injuries to State Survey Agency
Penalty
Summary
The deficiency involves the facility’s failure to ensure that all alleged violations of abuse, including injuries of unknown source and incidents involving major injuries, were reported immediately to the State Survey Agency and other officials as required by state law. For four sampled residents, the Administrator acknowledged that incidents were reported only to the state’s patient safety website and not to the State Survey Agency’s incident reporting website. This omission meant that the State Survey Agency did not receive timely notice of serious events, including an allegation of sexual abuse and multiple incidents resulting in significant fractures and surgery. For one resident with severely impaired cognition and diagnoses including hemiplegia and hemiparesis, nursing notes documented that the resident was found on the floor after attempting to get out of bed, was sent to the ER, and returned with immobilizing braces on both legs due to bilateral femur fractures. The resident’s bones were not strong enough for surgery, and he was placed on comfort care. Despite the seriousness of the injuries and the requirement to treat such events as potential abuse or neglect until ruled out, the Administrator stated that this incident was reported only to the state’s patient safety website and not to the State Survey Agency’s incident reporting system. Another resident with Parkinson’s disease and severely impaired cognition was found on the floor after a wheelchair alarm sounded, initially with no visible injury and able to bear weight. A few days later, staff documented complaints of left leg pain, tenderness, and wincing with movement, leading to an order for x‑rays and transfer for imaging. X‑ray results revealed a femur fracture, and surgery was not pursued. The Administrator reported this incident to the state’s patient safety website but not to the State Survey Agency’s incident reporting website. A third resident with severe cognitive impairment experienced a fall with complaints of pain in the left knee, left elbow, and fingers, and later underwent ORIF surgery for fractures of the right fourth and fifth metacarpals; this incident also was not reported to the State Survey Agency’s incident reporting system, according to the Administrator. For another resident with dementia, adjustment disorder with anxiety, hearing and visual loss, and age‑related debility, a document in the facility’s abuse binder described a possible molestation allegation originating from a phone call by the resident’s nephew. The nephew reported that his mother, the resident’s sister and then‑POA, was emotionally unstable and had stated she felt the resident had reported being molested. The Administrator documented that the nephew did not believe the allegation was credible, that the sister had dementia and emotional issues, and that the Administrator considered the report “not a viable allegation.” The Administrator noted that he interviewed the resident, who denied being touched, and that the sister could not provide more details beyond stating that a man had groped the resident’s breast. The Administrator concluded the allegation was not credible and did not report it to any agencies or law enforcement. The incident was not documented in the resident’s medical record, and the Administrator confirmed in interview that he did not report this sexual abuse allegation to the State Survey Agency’s incident reporting website. Across these four residents, the common deficiency was the facility’s failure to treat serious injuries and a sexual abuse allegation as reportable events to the State Survey Agency, as required. Instead, the Administrator limited reporting to the state’s patient safety website or chose not to report at all when he personally judged an allegation as not credible. This pattern of inaction regarding mandated reporting requirements formed the basis of the cited deficiency.
Failure to Investigate Major Injuries and Alleged Abuse
Penalty
Summary
The deficiency involves the facility’s failure to initiate and document investigations into multiple major injuries and an allegation of sexual abuse, as required for all alleged violations involving abuse and injuries of unknown source. For one resident with hemiplegia, hemiparesis, and severely impaired cognition (BIMS score of 6), nursing notes documented that his roommate activated the call bell after the resident fell while attempting to get out of bed by himself. He was found on the floor between his bed and the window, reported knee pain with a popping sensation, and was sent to the ER. On return from the hospital, he was noted to have bilateral femur fractures, immobilizing braces on both legs, and was placed on comfort care due to bones not being strong enough for surgery. The Administrator acknowledged awareness of the bilateral femur fractures, stated he did not believe neglect or abuse caused the injury, and confirmed he did not investigate the cause of this major injury. Another resident with Parkinson’s disease and a BIMS score of 0 (rarely/never understood) was documented in an incident note as sitting in a wheelchair in the dining room when his alarm sounded; he was found supine on the floor, denied hitting his head or injury, and was assisted back into the chair with no signs of injury noted. Several days later, nursing notes recorded that CNAs reported the resident complaining of left leg pain when getting him out of bed. On assessment, he had tenderness and wincing with movement of the left leg but was able to bear weight. The MD was notified, an x-ray was ordered, and the resident was transported for imaging, which revealed a femur fracture for which surgery was not pursued. The Administrator stated he was aware of the femur fracture, did not feel neglect or abuse caused the major injury, and did not investigate the cause of the injury. A third resident with COPD, scoliosis, and severely impaired cognition (BIMS score of 7) had an incident note documenting that her bed alarm sounded and staff found her in a kneeling position leaning into her recliner after she attempted to get up from bed to go to the bathroom, stating her walker “didn't go where she was going.” She complained of left knee, left elbow, and right pinky pain, with no visible injury except an abrasion on the right ring finger. A later nursing note documented that she underwent ORIF of fractures of the right fourth and fifth metacarpals at a hospital and returned from surgery the same day. The Administrator reported being aware of the fractures, described the resident as very independent and wanting to wander the facility, stated he did not feel neglect or abuse caused the major injury, and confirmed he did not investigate the cause of the injury. Across these three residents, the facility did not initiate or document investigations into the causes of the major injuries or the related allegation of sexual abuse, nor did it determine causation or responsible parties as required.
Failure to Complete Monthly Pharmacist Reviews and Timely Act on Medication Recommendations
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a licensed pharmacist conducted and documented monthly drug regimen reviews for multiple residents and to ensure that identified medication irregularities were acted upon by the attending physician. For four sampled residents, the medical records lacked monthly pharmacist medication regimen review notes for at least two consecutive months. Specifically, residents with diagnoses including Parkinson’s disease, unspecified dementia, Alzheimer’s disease with early onset, and dementia related to other diseases had no documented pharmacist review notes for March and April 2026. The DON confirmed that the pharmacist had not completed pharmacy reviews for those months and that the notes, which should have been uploaded into each resident’s electronic medical record, were absent. In addition, the facility failed to act promptly on a pharmacist’s recommendation for a resident receiving psychotropic medications. One resident with hemiplegia following cerebral infarction, psychotic disorder with delusions, dementia, and major depressive disorder had a pharmacist recommendation in November 2025 to add a low-dose daytime Seroquel due to behavioral issues and afternoon anxiety. Nursing documentation showed that the pharmacist discussed the resident’s response to Seroquel versus Abilify and suggested a low-dose daytime Seroquel, but this recommendation was not communicated to the physician at that time. The LPN later stated she did not speak to the physician about the pharmacist’s recommendation because the resident had not needed PRN Haldol around that time. The physician did not write the order for daytime Seroquel until early February 2026, after a nurse raised concerns about the resident’s behaviors and reminded the physician of the prior pharmacist recommendation. The DON acknowledged that the pharmacist’s November 2025 recommendation was not completed until February 2026 and stated she did not have time to stay on top of such issues.
Unlabeled Insulin Pens Found in Medication Refrigerator
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled in accordance with accepted professional principles when two open insulin pens belonging to resident 56 were found without the resident’s name on them. During an observation of the south medication refrigerator on 4/29/26 at 10:50 AM, surveyors noted a plastic bin labeled only with resident 56’s first name, containing two loose, open insulin pens that had no resident identification labels affixed directly to the pens. In a concurrent interview, RN 1 confirmed that the two insulin pens belonged to resident 56 and stated that staff always put residents’ names on insulin pens, but was unsure why these pens had not been labeled. Later that day at 2:17 PM, the DON stated in an interview that the two insulin pens in question had been unlabeled and acknowledged that the insulin pens should have been labeled with the resident’s information.
Failure to Sustain QAPI Actions and Documentation for Pharmacist Medication Reviews
Penalty
Summary
The deficiency involves the facility’s failure, as part of its performance improvement activities, to take actions aimed at performance improvement, measure the success of those actions, and track performance to ensure that improvements were realized and sustained, specifically related to F756. Record review and interviews showed that the facility did not maintain documentation in the medical records to demonstrate that a pharmacist reviewed residents’ medications, identified potential irregularities, or provided recommendations to the attending physician for four sampled residents, despite this same issue having been cited in the previous health survey in 2024. During an interview, the DON stated she did not have time to maintain this required documentation. In a separate interview, the Administrator stated he did not have a performance improvement project, though he had QAPI minutes that captured some improvement plans, and he believed the facility had achieved compliance with F756, which had been cited previously, but no documents demonstrating compliance were provided when requested by surveyors.
Failure in Medication Handling and Infection Surveillance Documentation
Penalty
Summary
The facility failed to ensure a safe and sanitary environment during medication administration and infection surveillance. During an observation of medication pass for resident 23, an LPN was seen popping an oral pill directly from a blister pack into her bare hand and then placing it into a medication cup, after which the medication was administered to the resident. In a subsequent interview, the DON stated that staff were expected to pop pills directly into medication cups and never touch medications with bare hands, and that any medication contacting a staff member’s bare hand was to be discarded and replaced, indicating that the observed practice did not follow facility expectations. The facility also failed to maintain infection control surveillance documentation and an organized tracking system for infections. When Infection Control Surveillance Logs were requested, the DON reported that several residents had contracted influenza during the 2025 holiday season, attributed to an increased number of visitors, and that symptomatic residents were kept in their rooms. However, the DON stated she did not have a list of affected residents or rooms, and the requested surveillance logs were unavailable for review. In a later interview, the DON, who also served as the facility’s Infection Preventionist, confirmed that the facility lacked an infection control surveillance manual or organized system for tracking infections.
Failure to Implement and Monitor an Antibiotic Stewardship Program
Penalty
Summary
The facility failed to develop and implement an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use. There was no established facility-wide system to ensure appropriate indication, dose, and duration for antibiotic prescriptions, and no process for monitoring antibiotic usage or resistance data. On 4/29/26 at 8:20 AM, when surveyors requested the facility’s Infection Control Surveillance Logs, including any prescribed antibiotic tracking information, these logs were unavailable. On 4/30/26 at 12:28 PM, during an interview, the DON, who also served as the facility’s designated Infection Preventionist, stated that she did not track resident antibiotic utilization, including the specific clinical indications for the medications or the prescribed durations of treatment. No specific residents, their medical histories, or clinical conditions at the time of the deficiency were described in the report.
Failure to Promptly Resolve and Document Resident Grievance Regarding Door Injury
Penalty
Summary
The deficiency involves the facility’s failure to promptly resolve and properly document a resident grievance in accordance with its grievance policy. A resident with type II DM, HTN, anxiety disorder, major depressive disorder, and PTSD reported that a CNA on night shift did not hold open the smoking door for her and another resident, and that when she went to grab the door, it slammed on or closed against her finger, causing a cut to bleed. The resident stated she reported this to the Resident Advocate (RA) and completed a grievance form, and that nursing staff applied Neosporin and a bandage to the finger. The resident did not know the CNA’s name but identified that the CNA worked nights and stated that no one should be treating residents that way. The grievance form dated 4/10/26 documented the concern that the CNA on night shift did not hold the smoking door open and instead swung the door open and walked away, and that upon initial interview no allegation of abuse or neglect was identified. However, the grievance form contained no documentation of investigative steps taken, no summary of findings or conclusion, and no indication whether the grievance was confirmed or not. The form also lacked a written decision date, resident signature, grievance officer signature, and Administrator signature. The RA reported that the resident told her the door incident caused a small cut to reopen and that the CNA seemed in a hurry, but did not state that the CNA acted intentionally or purposefully toward her. The Administrator and DON later stated they had not been informed of the incident, and the Regional Nurse Consultant noted that nothing was filled out on the back of the grievance form, indicating it remained incomplete despite having been initiated several days earlier.
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