Stonehenge Of Richfield
Inspection history, citations, penalties and survey trends for this long-term care facility in Richfield, Utah.
- Location
- 125 East 600 North, Richfield, Utah 84701
- CMS Provider Number
- 465173
- Inspections on file
- 13
- Latest survey
- May 29, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Stonehenge Of Richfield during CMS and state inspections, most recent first.
Three residents did not receive appropriate management of psychotropic medications, including lack of gradual dose reduction, missing physician rationale for continued PRN anti-anxiety medication, and failure to implement a recommended dose reduction for an antidepressant. Documentation gaps and confusion over medication orders contributed to the deficiencies, as confirmed by staff interviews and record review.
The facility did not employ a full-time, qualified Director of Food and Nutrition Services, as the full-time Dietary Manager in Training was not certified and the certified Dietary Manager worked only part-time, with oversight from a Corporate Dietitian who visited quarterly.
Surveyors found that multiple food items in the kitchen, including frozen and dry goods, were left open to air and several items were past their use by or best used by dates. Despite regular audits and ongoing staff education, the facility did not maintain proper food storage practices, leading to deficiencies in food service safety standards.
Staff failed to follow infection control protocols during meal and medication passes, including delivering uncovered food and beverages to residents and a nurse placing her bare thumb inside medication cups before administering medications. Both dietary and nursing staff acknowledged these practices were not sanitary.
A resident with a history of joint replacement surgery was discharged AMA, but the facility did not notify the LTC Ombudsman as required. Interviews with the RA, BOM, and DON revealed inconsistent understanding and practice regarding Ombudsman notification, with staff only notifying in select cases rather than for all discharges.
Two residents receiving oxygen therapy were inaccurately documented in their MDS assessments as not using oxygen, despite physician orders, care plans, and staff interviews confirming regular oxygen use. The MDS Coordinator acknowledged the error after reviewing the records and discussing with surveyors.
A resident with neurological and respiratory conditions did not have a comprehensive care plan addressing oral hygiene, despite requiring setup or cleanup assistance. Staff provided reminders and occasional help, but there was no specific care plan with measurable objectives or timeframes for oral care, and communication between shifts about oral hygiene completion was lacking.
A resident with neurological and respiratory conditions was found with significant buildup on his teeth, despite requiring setup or cleanup assistance for oral hygiene. Staff provided reminders and occasional assistance, but there was no consistent documentation or communication between shifts to ensure oral care was completed, resulting in inadequate support for the resident's ADL needs.
Failure to Ensure Proper Psychotropic Medication Management and Documentation
Penalty
Summary
The facility failed to ensure appropriate management of psychotropic medications for three residents, specifically regarding gradual dose reduction (GDR), behavioral interventions, and proper documentation for continued use of PRN (as needed) medications. For one resident with severe cognitive impairment and a history of depression and anxiety, the facility continued PRN Ativan orders beyond the initial 90-day period without documented physician rationale for its ongoing use. The medication was administered multiple times over several months, and staff interviews confirmed the absence of required documentation supporting the continued PRN order. Another resident with diagnoses including dysthymic disorder and anxiety was maintained on two antidepressant medications, Citalopram and Bupropion, with dose adjustments over time. However, the medical record lacked documentation of a physician's response to a rationale for duplicative therapy and did not include evidence of a second GDR or justification for not reducing the medications further, as required by regulations. The DON acknowledged confusion regarding the medication orders and confirmed the absence of necessary documentation for dose reduction or rationale. A third resident with neurological and respiratory conditions was prescribed Trazodone for insomnia. Although a GDR was recommended and discussed in a psychotropic review meeting, the order to reduce the dose was not correctly implemented in the medical record. The DON admitted to documenting the recommendation in a progress note but failing to update the physician order for signature, resulting in the GDR not being carried out as intended.
Lack of Qualified Full-Time Dietary Manager
Penalty
Summary
The facility failed to employ a full-time Director of Food and Nutrition Services with the required qualifications, as mandated by regulations. The full-time Dietary Manager in Training (DMT) was not certified and was in the process of preparing for certification, while the previous certified Dietary Manager (DM) was only working part-time, approximately 20 hours per week or less, and was available by phone. The DM was training the DMT to take the necessary courses for certification. Additionally, the Corporate Dietitian (CD) provided remote assessments and only visited the facility quarterly for one day to review resident charts, documentation, and conduct audits. These actions resulted in the facility not having a full-time, qualified individual overseeing the food and nutrition service as required.
Improper Food Storage and Expired Items in Kitchen
Penalty
Summary
Surveyors observed that the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. During two separate walk-throughs of the kitchen, multiple food items in the walk-in freezer, walk-in refrigerator, and dry food storage room were found open to the air, including boxes of bulk frozen peas, omelet replacements, omelets, dried mashed potatoes, and baking soda. Additionally, several food items in the dry storage room were found to be past their use by or best used by dates, such as apple cider vinegar, baking powder, yeast, Worcestershire sauce, and Maltomeal. During an interview, the Dietary Manager confirmed that the Corporate Dietitian conducted quarterly kitchen audits, which included inspections of the refrigerator and dry storage areas. The findings from these audits were shared with the Dietary Manager, the Administrator, and the Director of Nursing, and were used to educate kitchen staff about sanitation and proper food storage. Despite ongoing education, the facility did not ensure that all food items were properly stored and within their use by dates, resulting in the observed deficiencies.
Failure to Maintain Infection Control During Meal and Medication Passes
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple observations during meal and medication passes. During several meal services, food and beverages such as lemonade, milk, juice, soup, and cold cereal were transported and delivered to residents while uncovered, exposing them to potential environmental contaminants. Additionally, a dietary aide was observed returning to a resident's room with uncovered drinks, and water condensate from a milk bottle was observed splashing into a resident's soup. These actions occurred repeatedly during both breakfast and lunch meal services in the resident hallways. During medication administration, a registered nurse was observed placing her bare thumb inside medication cups before placing medications in them and administering them to residents. This practice was repeated for multiple residents during the morning medication pass. Both the nurse and the Director of Nursing acknowledged during interviews that touching the inside of medication cups with bare hands is not sanitary and should not occur. These observations demonstrate a lack of adherence to basic infection control protocols during both meal and medication administration.
Failure to Notify Ombudsman of Resident Discharge
Penalty
Summary
A deficiency was identified when the facility failed to send a copy of the notice of transfer or discharge to the representative of the Office of the State Long-Term Care (LTC) Ombudsman for one resident. The resident, who had been admitted with diagnoses including aftercare following joint replacement surgery and the presence of a right artificial knee joint, was discharged against medical advice (AMA) to home. Documentation in the nurse's note confirmed the discharge event. Interviews with facility staff revealed a lack of consistent practice and training regarding notification of the Ombudsman. The Resident Advocate (RA) and Business Office Manager (BOM) both stated that they did not notify the Ombudsman for every discharge, only in cases they considered difficult or when there were concerns for the resident's safety. The Director of Nursing (DON) was unaware that all discharges required notification, and the Regional Nurse Consultant (RNC) clarified that notification should occur for every discharge, typically via a monthly summary. This inconsistency led to the failure to notify the Ombudsman about the resident's discharge.
Inaccurate MDS Assessment of Oxygen Use
Penalty
Summary
Two residents with physician orders for oxygen therapy were not accurately assessed in their Minimum Data Set (MDS) documentation. Both residents had medical records, treatment administration records, and care plans indicating the use of oxygen, either at night or as needed, with specific instructions for oxygen administration and equipment maintenance. Despite this, their quarterly MDS assessments indicated that they were not using oxygen while in the facility. Interviews with staff, including a CNA and the DON, confirmed that both residents used oxygen at night and occasionally during the day. The MDS Coordinator, responsible for completing the assessments, acknowledged that the MDS entries for these residents were incorrect after reviewing the documentation and discussing the findings with the surveyor. The deficiency was identified through a combination of record review and staff interviews.
Failure to Develop and Implement Comprehensive Oral Hygiene Care Plan
Penalty
Summary
A deficiency was identified when a resident with neurological conditions, respiratory failure, and seizure disorder did not have a comprehensive, person-centered care plan addressing oral hygiene needs. The resident was observed with white buildup on his teeth and reported brushing his own teeth, but had not seen a dentist during his stay. The Minimum Data Set (MDS) assessment indicated the resident required setup or cleanup assistance with oral hygiene, yet the care plan only generally addressed assistance with activities of daily living (ADLs) and did not specifically include measurable objectives or timeframes for oral hygiene care. Certified Nursing Assistant (CNA) documentation showed the resident received oral care assistance only 8 times in 14 days, and there were no documented concerns about teeth or gums in the nursing progress notes. Interviews with staff revealed that reminders and encouragement were provided, but there was no consistent communication between shifts regarding whether the resident completed oral hygiene. The Director of Nursing confirmed that a care plan should have been developed to address the resident's need for more assistance with oral hygiene.
Failure to Ensure Consistent Oral Hygiene Assistance
Penalty
Summary
A deficiency was identified when a resident with neurological conditions, respiratory failure, and seizure disorder was observed to have white buildup on his teeth, indicating inadequate oral hygiene. The resident reported brushing his own teeth but had not seen a dentist either in or out of the facility. Review of the resident's medical record showed he required setup or cleanup assistance with oral hygiene, and the care plan directed staff to assist with activities of daily living (ADLs) as needed, encouraging independence and providing adaptive equipment if necessary. However, CNA documentation indicated that oral care assistance was only provided 8 times in the last 14 days, and there were no nursing notes documenting concerns with the resident's oral health during the review period. Interviews with staff revealed that reminders to brush teeth were given, but there was no consistent follow-up or communication between shifts to ensure the resident completed oral hygiene. The CNA stated that the resident often postponed brushing his teeth and that it was not routinely communicated between shifts whether he had completed this task. The DON was unaware of where oral hygiene was documented and did not know if reminders were passed along during shift changes. These actions and inactions led to the resident not receiving appropriate treatment and services to maintain or improve his ability to carry out ADLs, specifically oral hygiene.
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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