Sunshine Terrace Skilled Nursing
Inspection history, citations, penalties and survey trends for this long-term care facility in Logan, Utah.
- Location
- 248 West 300 North, Logan, Utah 84321
- CMS Provider Number
- 465079
- Inspections on file
- 15
- Latest survey
- April 13, 2026
- Citations (last 12 mo.)
- 16 (1 serious)
Citation history
Health deficiencies cited at Sunshine Terrace Skilled Nursing during CMS and state inspections, most recent first.
Food safety standards were not followed when the walk-in cooler was found at 50 degrees F and several refrigerated foods were measured above 41 degrees F. The kitchen also had multiple opened and undated items in the refrigerator, freezer, and dry storage. During tray line service, an aide handled food with the same gloves after touching her face and leaving the station, and the DM stated food should not be touched with bare or gloved hands.
The facility failed to provide ordered care for three residents. One resident with chronic pain and multiple diagnoses had limited BM documentation while receiving opioids, no documented offer or refusal of additional constipation treatment, and was later hospitalized with fecal impaction and constipation related to chronic opiate use. Another resident with MASD had red, non-intact skin on the buttocks/coccyx, but the wound was not evaluated by a wound provider and dressings were applied without a physician order. A third resident with incontinence and MS did not have weekly skin assessments completed as ordered, despite ongoing buttock wounds and conflicting staff descriptions of the areas.
Psychotropic meds were not properly supported or monitored for several residents. Records showed Seroquel, Haldol, clonazepam, hydroxyzine, sertraline, and trazodone being used without adequate indication, behavior tracking, non-pharm interventions, ASE monitoring, or documented GDRs/psychotropic reviews. One resident had PRN antipsychotic use without the required physician evaluation, and another had an open-ended PRN order that exceeded the 14-day limit without a documented rationale.
Failure to report abuse allegations and an elopement: the facility did not notify APS of injuries of unknown origin for two residents and did not report a resident’s elopement to the SSA. Another resident alleged rough care by a CNA, and the investigation record showed no other agencies were notified. The residents involved had significant cognitive and medical conditions, including dementia, Parkinson’s disease, and neurologic impairment.
The facility lacked thorough investigation documentation for multiple allegations involving bruising, rough CNA care, and an elopement. Residents with dementia and other significant diagnoses had unexplained bruises or reported rough handling, but the only records found were brief emails or incident forms, with no documented staff interviews or complete investigative findings. In one case, a resident with dementia was found missing from the unit, returned by law enforcement, and the ADM could not produce the investigation record.
Missing transfer documentation, Ombudsman notification, and bed-hold information. A resident with fluid overload and two other residents with significant medical issues were transferred to the hospital or ER, but the chart did not document what information was sent to the receiving provider. Staff also reported that transfer summaries were not completed, and the Ombudsman notification and bed-hold policy were not consistently included with resident transfers.
A facility failed to maintain infection prevention and control practices during resident care and dining. A resident with a central venous catheter had no EBP signage observed, staff gave conflicting information about whether EBP was required, hand hygiene was not performed between glove changes during wound care for a resident with buttock wounds, and a CNA touched a chair and then the resident's food with the same gloves during meal assistance.
Inadequate supervision and elopement prevention: One resident with dementia and multiple other diagnoses was repeatedly observed with the call light out of reach, the walker away from the bed, and the room door shut, despite a history of 15 falls and prior wandering. The record showed several falls with limited or no new interventions, and staff stated the resident needed close monitoring and reachable assistance devices. A second resident assessed as high risk for elopement wandered the unit, left the building after an alarm sounded, and was later found by police; the record noted no individualized care plan and no investigation into how the elopement occurred.
Failure to Evaluate Residents for Self-Administration of Medications: Two residents were observed with medications in their rooms, including Pepto-Bismol, nystatin powder, and mupirocin ointment, and both stated they used the products themselves. No documentation was found showing either resident had been evaluated for self-administration. RNs and the DON confirmed the items were medications and that there was no physician order or record of a self-administration evaluation.
Failure to Document and Retain Grievance Resolution: A resident’s family reported missing personal property, including a purse, wallet, glasses, driver’s license, and credit cards, but the facility did not maintain a written grievance or written resolution. Staff said they searched the resident’s room and the SSD spoke with the daughter, who was not concerned about the missing purse, but no grievance form or documented follow-up could be located. The resident had diagnoses including HF, Sjogren’s syndrome, and Non-Hodgkin lymphoma.
Care plan not updated after repeated falls. A resident with Parkinson's disease, arthritis, psychotic disorder with hallucinations, major depressive disorder, and dementia with psychotic disturbance had multiple falls, but the care plan was not updated with new interventions after several of them. During observation, the resident's call light and walker were out of reach, the room door was shut, and the resident stated he used the button for help or went to the office to call for someone when needed.
A resident with chronic pain, CKD, PVD, MDD, and anxiety reported severe back and right leg pain, with pain medication helping only somewhat and leaving pain above the resident’s acceptable level. The MAR documented multiple hydrocodone doses as semi-effective, but there was no documentation of additional pain-relief measures or notification to the MD or pain clinic when the medication did not fully relieve the pain. The resident’s care plan included pain assessment, PRN pain meds, repositioning, and other non-pharmacologic interventions, and the RN and DON both described pain-relief measures that were not consistently documented.
A resident with ESRD on hemodialysis had no physician order for dialysis, missing communication notes with the dialysis center, and no physician orders for fistula monitoring. Staff documented a left arm shunt/fistula with thrill and bruit on several occasions, but there was no ongoing pre- or post-dialysis assessment or immediate documentation of fistula status after treatments. RN and DON interviews confirmed gaps in dialysis orders, post-dialysis assessment, and coordination with the dialysis center.
A nurse aide was hired and continued working without completing the required training and competency evaluation program within 4 months of hire. HR stated the aide was told how to obtain certification and that certification was required within 4 months, but no verification of completion was in the file, and the DON acknowledged the aide had worked longer than 4 months without certification.
Failure to Document Pain Interventions and Side Effect Monitoring: Two residents had PRN pain regimens that were not fully monitored for non-pharmacological interventions or adverse side effects. One resident with dementia, insomnia, a femur fracture, and pain received acetaminophen, tramadol, and Tylenol PM for low or no pain scores, with no MAR documentation of non-pharm pain measures or ASE monitoring. Another resident with fluid overload had PRN acetaminophen, hydrocodone-acetaminophen, and a lidocaine patch, but the MAR showed no non-pharm interventions offered; the DON and nursing staff confirmed this was not documented.
Nurse aides did not receive the required annual in-service training for continued competency, and the documented training did not include dementia management or abuse prevention. HR and the DON stated that training was handled through monthly in-services, unit-based discussions, and on-the-job instruction, but there was no evidence that all aides received the required yearly education.
Food Storage Temperature and Handling Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. During an initial kitchen tour, the walk-in refrigerator was observed at 50 degrees Fahrenheit, and multiple food items inside were measured above 41 degrees Fahrenheit, including ground beef, cooked deli ham, and tartar sauce. The Dietary Manager stated that the refrigerator should be at 42 degrees Fahrenheit or below and that food above that range could pose a foodborne illness issue, requiring the items to be removed and placed in another refrigerator. The kitchen also contained multiple opened and undated food items in storage areas. Observations included an opened jar of pickles with a date on the lid, opened and undated bags of hamburger buns and wheat bread in the reach-in refrigerator, opened and undated bags of fries, crinkle fries, and mixed vegetables in the freezer, and an opened and undated bag of raisin bran in dry storage. On a later kitchen tour, additional opened and undated freezer items were found, including corn dogs, peas and carrots, salmon, and tater tots open to air. During lunch tray line service, dietary staff were observed handling food and surfaces with gloved hands. One staff member touched mixed vegetables and chicken with gloved hands, wiped her cheek with a gloved hand, continued touching food, used scissors to cut chicken, and left the station to get lids while wearing the same gloves throughout service. When interviewed, the staff member stated she was not sure whether she should touch food with gloved hands. The Dietary Manager stated that food should not be touched with bare hands or gloved hands and that all foods in the freezer should have opened dates and should never be opened to air.
Failure to Provide Ordered Constipation and Wound Care
Penalty
Summary
The facility did not ensure that residents received treatment and care according to orders, resident preferences and goals, and professional standards of practice. For one resident with chronic pain and multiple neurologic and medical diagnoses, bowel monitoring showed a medium bowel movement on 2/2/26 and then no further documented bowel movements until a small bowel movement on 2/11/26. The resident received multiple doses of oxycodone during that period, but there was no documentation that additional constipation medication was offered or refused, and no documentation that the physician was notified. The resident was later transferred to the hospital with nausea and blood in the brief, and the hospital documented constipation likely related to chronic opiate use and significant fecal impaction. For another resident with diagnoses including lymphedema, chronic pain, peripheral vascular disease, CHF, diabetes, and CKD, the record showed skin assessments that only documented the presence of a preexisting wound without wound characteristics or interventions. The resident had an order for wound provider consultation and weekly skin assessments, but the wound was not evaluated by a wound care provider, and staff applied barrier cream and foam dressings without a physician order. During observation, the resident had red, non-intact skin on the coccyx, right buttock, and left gluteal fold, and RN and DON statements reflected disagreement about whether the areas were open wounds, flaky skin, or sloughing skin. The DON stated the facility had been without a wound care provider for months and that if nurses applied a dressing they would need a doctor’s order. A third resident with mixed incontinence, neuromuscular bladder dysfunction, and multiple sclerosis had an order for weekly skin assessments and an order for barrier cream and covering the left buttock wound with a brief. The last documented skin assessment showed a preexisting heat and moisture sore with scant exudate and erythematous surrounding tissue, but weekly skin assessments were not consistently completed as ordered. During interviews, staff described open sores on the buttocks, a wound near the coccyx, and a new wound on the lower left buttock, while the DON stated he was unsure whether the wound had been assessed by a physician or nurse practitioner and did not know why weekly skin checks were not documented.
Psychotropic medications lacked indication, monitoring, and required review
Penalty
Summary
The facility did not ensure that psychotropic medications were supported by an adequate indication for use, monitored for behaviors and adverse side effects, or managed with gradual dose reduction attempts or documented clinical contraindications. Surveyors identified that for 5 of 32 sampled residents, the record did not show appropriate indication, behavior monitoring, non-pharmacological interventions, adverse side effect monitoring, or required psychotropic review documentation. The cited residents included individuals with diagnoses such as dementia, insomnia, anxiety, major depressive disorder, delirium, Parkinson’s disease, and generalized anxiety disorder. For one resident with dementia, insomnia, a right femur fracture, and pain, the record showed scheduled and PRN Seroquel orders and PRN Tylenol PM use. The PRN Seroquel was given for anxiety and crying, including administration shortly before a scheduled dose, and Tylenol PM was given multiple times for pain and sleep, including several administrations before bedtime and not as ordered. No documentation was found for behavior monitoring, non-pharmacological interventions, or adverse side effect monitoring for Seroquel. The psychotropic review form listed Seroquel for anxiety but did not contain an individualized rationale, and the DON stated the resident did not have a diagnosis such as schizophrenia, bipolar disorder, or major depressive disorder to support the antipsychotic use. For another resident with insomnia, major depressive disorder, and generalized anxiety disorder, the record showed clonazepam, sertraline, trazodone, and a prior Seroquel review, but no documentation was found for behavior monitoring, non-pharmacological interventions, or adverse side effect monitoring for the psychotropic medications. The psychotropic review dated in 2024 recommended continuing the same doses, but no additional psychotropic review was found afterward and no attempted GDR was documented. The DON stated the GDR was not found in the chart. A resident with Parkinson’s disease, dementia, anxiety, delirium, and hypersomnia had multiple benzodiazepine and Seroquel orders, but no additional psychotropic medication reviews or GDRs were located after the November 2024 review, which had recommended decreasing Seroquel at bedtime. A resident with Alzheimer’s disease, anxiety, and dementia had orders for haloperidol PRN for anxiety, hydroxyzine PRN for restlessness, scheduled Seroquel for anxiety disorder due to known physiological condition, and additional Seroquel without a diagnosis listed. The record did not contain behavior monitoring, psychotropic meetings, or physician rationales for the antipsychotic use, and the DON stated the resident did not have a psychotropic meeting documented. Another resident with major depressive disorder, generalized anxiety, and insomnia had an open-ended hydroxyzine PRN order that was not limited to 14 days and lacked a documented clinical rationale to extend it. The record also lacked behavior monitoring, sleep tracking, and adverse side effect monitoring for clonazepam, sertraline, and trazodone, and the DON stated he could not find a justification to continue the hydroxyzine.
Failure to Report Abuse Allegations and Elopement
Penalty
Summary
The facility did not ensure that allegations of abuse and neglect were reported immediately to the State Survey Agency and other agencies. Survey findings identified that for 4 of 32 sampled residents, the facility did not report allegations of abuse to Adult Protective Services, and the facility did not report a resident elopement to the State Survey Agency. The deficiencies involved residents 3, 41, 47, and 58. Resident 41 had diagnoses including Alzheimer's disease, chronic venous hypertension, and dementia, and an incident report described a contusion with multiple possible causes being evaluated; no documentation was found that APS was notified of the injury of unknown origin. Resident 47 had diagnoses including Parkinson's disease, arthritis, psychotic disorder with hallucinations, major depressive disorder, and dementia with psychotic disturbance; the record documented that the resident wandered out of the facility and was later located by police, but the elopement was not reported to the SSA. Resident 58 had diagnoses including dementia, insomnia, fracture of the right femur, and pain; the facility reported a bruise on the inner right thigh, but no documentation was found that APS was notified of the injury of unknown origin. Resident 3 had diagnoses including cerebral infarction, left nondominant hemiplegia, pseudobulbar affect, epilepsy, and chronic pain; the resident reported that a CNA had provided rough care during a brief change, and the investigation documentation showed no other agencies were notified.
Incomplete investigations of abuse allegations and elopement
Penalty
Summary
The facility did not have evidence of thorough investigations into allegations of abuse, neglect, exploitation, or mistreatment for four sampled residents. For Resident 41, who had Alzheimer’s disease, chronic venous hypertension, and dementia, an incident report stated that a contusion was identified and that possible causes were being evaluated, but the only additional documentation located was an email from the DON stating the resident moved his bed and scratched his abdomen on the headboard. The Administrator stated she relied on the DON’s email and the NP’s assessment, but there was no additional documentation of interviews or a completed investigation. For Resident 58, who had dementia, insomnia, a right femur fracture, and pain, the facility reported a large bruise on the inner right thigh after the family member noticed it during a care conference. The resident denied knowing how the bruise occurred, and the NP documented a large dark contusion to the posterior right thigh that appeared consistent with a hard sit-down or transfer to the toilet. The only investigation documentation located was an email from the DON to the ADM referencing the NP’s assessment, and the Administrator stated she interviewed nurses but had no documentation of those interviews. For Resident 3, who had cerebral infarction, left-sided hemiplegia, pseudobulbar affect, epilepsy, and chronic pain, the facility reported an allegation that a CNA was rough during brief care and caused pain when changing the resident. The investigation form documented the resident’s statement that the CNA was impatient and threw her left leg onto her right foot, but it also stated there were no visible injuries and no witnesses. No additional investigation documentation was located. For Resident 72, who had vascular dementia and dementia with anxiety, the facility documented that the resident was found missing during medication administration, 911 was called, law enforcement located and returned him, and he was unharmed. The Administrator stated she could not locate the investigation form and did not have documentation of the investigation or of the interventions put in place after the elopement.
Missing Transfer Documentation, Ombudsman Notification, and Bed-Hold Information
Penalty
Summary
The facility did not ensure that when residents were transferred to the hospital, the medical record documented the information provided to the receiving provider, and it did not document notification to the Ombudsman or provide the bed-hold policy for transferred residents. This was identified for 3 of 32 sampled residents: residents 3, 6, and 50. The report states that the required transfer-related documentation was missing from the residents’ records, including what information was sent to the receiving provider, and that the Ombudsman notification and bed-hold policy were not found for these transfers. Resident 50 was readmitted after a hospital stay with diagnoses including fluid overload. After returning from dialysis, the resident became upset, cried, received NORCO and hydroxyzine, called EMS on his personal phone, and attempted to wheel himself out the door while refusing help. EMS transported him to the hospital, and his daughter was notified. The nursing progress note did not document what information was sent to the receiving provider. The Social Services Director stated she could not find the Ombudsman notification form for this resident and believed the notification was missed. Resident 6 had multiple transfers to the hospital or ER for conditions including shortness of breath after dialysis, low oxygen saturation, nausea and vomiting, GI bleed concerns, critical lab values, and low blood pressure. Notes documented EMS activation or facility transport and, in some instances, that report was given to the ER nurse or EMS. However, the notes did not document what information was sent to the receiving provider. Resident 3, who had diagnoses including cerebral infarction, epilepsy, Parkinsonism, diabetes, hypertension, and left-sided hemiplegia, was transferred to the ER after blood was found in her brief and she experienced nausea; the progress note also did not document what information was sent to the receiving provider. Staff interviews confirmed that transfer summaries were not completed, that the information sent was not documented in the medical record, and that the bed-hold policy and Ombudsman notification were not consistently handled as part of the transfer process.
Infection Control Lapses During EBP, Wound Care, and Dining Assistance
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 diseases and infections. For a resident with end stage renal disease, dependence on renal dialysis, and type 2 diabetes with diabetic chronic kidney disease, staff observed a central venous catheter used for dialysis, but no Enhanced Barrier Precautions (EBP) signage was posted. During interviews, staff gave conflicting information about whether the resident had an indwelling medical device and whether EBP was required, and the DON initially stated he was not sure if the resident required EBP before later stating the resident did have a central line and was placed on EBP. For a resident with mixed incontinence, neuromuscular dysfunction of the bladder, and multiple sclerosis, wound care was observed on buttock wounds. The RN donned a gown and gloves, cleansed the wounds, and then removed a bandage and gloves, walked to the cabinet in the resident's room to retrieve more bandages, donned gloves again, and continued care without performing hand hygiene between glove removal and putting on new gloves. The RN later stated that best practice would be to wash or sanitize hands before applying new gloves, and the DON stated that hand hygiene should be performed after removing gloves and before applying new gloves. During lunch meal service, a CNA assisting a resident with spastic quadriplegic cerebral palsy, dysphagia, and borderline intellectual functioning donned gloves, pulled out a chair with the gloved hands, and then touched the resident's chicken nuggets with the same gloves. The CNA stated gloves should be changed anytime something with potential for cross contamination was touched and that she should have changed gloves after touching the chair and before touching the resident's food. The DON stated that dining assistance staff were to sanitize in between touching a resident and resident items and before handling utensils and cups, and that the CNA should have sanitized hands before touching the resident's food.
Inadequate supervision and elopement prevention
Penalty
Summary
The facility did not ensure adequate supervision and assistance devices to prevent accidents for two sampled residents. One resident with Parkinson’s disease, arthritis, psychotic disorder with hallucinations, major depressive disorder, and dementia with psychotic disturbance was observed with the call light out of reach, the walker placed about two steps from the bed, and the room door shut. On another observation, the same resident was lying in bed with the call light under the bedspread and stated that if he needed help he went down to the office to call for someone. He was also observed trying to locate the call light but was unable to find it. That resident had a history of repeated falls, with 15 falls documented over the review period. The record showed multiple falls with limited or no new interventions after several of the incidents. Examples included being educated to call for assistance, being told to keep the walker close, being encouraged to leave a light on, and having the area checked for tripping hazards. The DON stated there were no interventions after one fall and also stated the resident did not have interventions after each fall. Staff interviews indicated the resident was sometimes kept in activities for supervision, that his door should be kept open so staff could peek in, and that his call light should be reachable, but these conditions were not consistently observed. The same resident also had a prior elopement event documented in the record. Staff notes showed he was not in his room, a code green was initiated, authorities were notified, and he was later located safely. The DON stated the resident had been wandering prior to the elopement, staff reviewed camera footage, and the resident was later moved to the secured unit. The DON also stated there was no incident report available for that elopement and did not know where police located the resident. A second resident with vascular dementia and dementia in other diseases classified elsewhere, mild, with anxiety, was identified as high risk for elopement on an assessment that documented multiple interventions, including wander detection systems, 15-minute checks, and moving the resident closer to the nurses’ desk as appropriate. However, an individualized care plan was not initiated. Nursing notes documented wandering in the unit, repeated redirection, and an incident in which the resident left the building after an alarm sounded and was later found by police. The facility report stated staff searched for the resident, called 911 within minutes, and the resident was returned unharmed. The record also stated that no investigation was conducted to determine how the resident eloped from the facility.
Failure to Evaluate Residents for Self-Administration of Medications
Penalty
Summary
The facility did not ensure that residents’ right to self-administer medications was clinically appropriate and safe for 2 of 32 sampled residents. Resident 6 was admitted and readmitted with diagnoses including acute posthemorrhagic anemia, constipation, and gastrointestinal hemorrhage. During observation on 4/6/26, an opened bottle of Pepto-Bismol was seen on the resident’s dresser, and during interview on 4/7/26, the resident stated he had given himself Pepto-Bismol for an upset stomach and had last taken it about one week earlier. No documentation was found in the medical record showing that Resident 6 had been evaluated to self-administer medication. Resident 28 was admitted and readmitted with diagnoses including mixed incontinence, neuromuscular dysfunction of the bladder, and multiple sclerosis. During observation and interview on 4/6/26, nystatin powder and a tube of mupirocin ointment were found on a table in the resident’s room, and the resident stated she applied the nystatin powder or mupirocin to wounds on her buttocks, with a CNA applying the nystatin powder during brief changes. No documentation was found in the medical record showing that Resident 28 had been evaluated to self-administer medication. Interviews with RN 1, RN 2, and the DON confirmed that these products were medications, that residents generally should not keep them at bedside without a physician order, and that the DON’s self-administration form was not kept in the medical record.
Failure to Document and Retain Grievance Resolution
Penalty
Summary
The facility did not maintain evidence showing the results of all grievances for at least three years from the grievance decision. For one sampled resident, Resident 5, the resident’s family member reported that the resident lost a purse, wallet, glasses, driver’s license, and credit cards when first admitted to the facility, and the family member stated the purse was never located. Resident 5 was admitted and later readmitted with diagnoses including heart failure, Sjogren’s syndrome, and Non-Hodgkin lymphoma. During interviews, CNA 2 stated that missing property would be looked for in the resident’s room and reported to the DON or ADON. RN 2 stated she would look around the resident’s room if missing items were reported and believed the social worker had grievance forms, but was not sure. The SSD stated the missing purse had occurred a while back, the facility searched for it, and she spoke with the resident’s daughter, who was not worried about the purse. The SSD later stated she did not have the resident complete a grievance form and could not locate a form or written resolution. She later found a spreadsheet showing that on 6/15/25 the family member reported the purse, wallet, and glasses missing and believed they were stolen, but she still could not locate a written resolution. The Administrator stated grievances were usually brought up in resident council or verbally, that the SSD contacted the daughter and ended the investigation, and that there was not a written grievance or written resolution.
Care Plan Not Updated After Repeated Falls
Penalty
Summary
Resident 47, who was admitted with diagnoses including Parkinson's disease, arthritis, pain, psychotic disorder with hallucinations, major depressive disorder, and dementia with psychotic disturbance, had repeated falls and was not consistently updated with new care plan interventions after those events. The resident sustained 15 falls from 7/6/25 through 4/13/26, and the record review identified multiple falls in which no new intervention was added to the care plan, including falls on 12/6/25, 1/22/26, 2/5/26, 3/11/26, and 3/20/26. The Director of Nursing stated that after a fall, staff were to assess for injury, complete an incident report, review the reason for the fall, add a new intervention to the care plan if there was no injury, and monitor the resident for 72 hours, but acknowledged that Resident 47 did not have interventions added after those falls. During observation and interview, Resident 47 was found in bed with the door shut, the walker placed about 2 steps away from the bed, and the call light not within reach. On one occasion the call light was wrapped around the headboard and the resident could not find it; on another, it was under the bedspread while the resident was lying on top of the bedspread. The resident stated he used the button for help and later stated he went down to the office to call for someone when needed. The DON had no additional information to add when notified that the resident's door was shut and both the call light and walker were out of reach.
Pain Medication Documented as Semi-Effective Without Documented Follow-Up Relief Measures
Penalty
Summary
Safe, appropriate pain management was not provided for Resident 63 when pain medication was documented as semi-effective and no other pain-relief interventions were documented. Resident 63 was admitted and re-admitted with diagnoses including chronic pain, peripheral vascular disease, chronic kidney disease, major depressive disorder, and generalized anxiety disorder. During an interview, the resident reported pain in the right leg and back, stated the pain medication helped only somewhat, and rated current pain as 8/10 with an acceptable level of 5/10. Resident 63 had physician orders for acetaminophen 1000 mg every 8 hours PRN, hydrocodone-acetaminophen 10-325 mg every 4 hours PRN, and ibuprofen 800 mg every 8 hours PRN. The March 2026 MAR documented 20 doses of hydrocodone as semi-effective. The record review found no documentation of what other treatments were provided to relieve the resident’s pain when the medication was only partially effective. The resident also had a pain care plan with interventions including distraction, pain assessment, pain medications as ordered, notification of the MD if medication was not managing pain adequately, and repositioning as needed. An RN stated that non-pharmacological interventions for pain included repositioning, ice, heat, pillows, and elevating the feet, and that if pain medication was documented as semi-effective, repositioning would be offered. The RN stated she did not notify the MD when the resident’s pain medication was semi-effective and said the pain clinic managed the resident’s pain medications, but no documentation was found that the pain clinic was notified. The DON stated that staff should document medication effectiveness, assess whether pain was tolerable, and notify the MD if alternate pain relief options were not effective; however, the DON also stated these interventions were not documented in the MAR prior to the day before the interview and were not currently documented in progress notes.
Missing dialysis orders, communication, and fistula monitoring
Penalty
Summary
Safe, appropriate dialysis care/services were not provided for a resident receiving hemodialysis. Resident 50 was admitted with diagnoses including end stage renal disease, dependence on renal dialysis, fluid overload, chronic diastolic heart failure, hypotension, hypertensive heart and chronic kidney disease, and type 2 diabetes mellitus with diabetic chronic kidney disease. The resident stated he went to dialysis on Monday, Wednesday, and Friday, and was observed with white coban on his left forearm during the survey observations. The medical record did not contain a physician order for dialysis three times a week, and communication notes with the dialysis center were missing on 18 occasions. The record also did not show ongoing assessments of the resident’s condition before and after dialysis treatments, and there was no immediate monitoring and documentation of the status of the resident’s fistula upon return from dialysis. Staff documented that the resident had a left arm shunt or fistula with patent thrill and bruit on several dates, but there was no other monitoring of the fistula documented in the record. There were no physician orders for monitoring the dialysis fistula. RN 2 stated staff would assess the fistula, remove the dressing when appropriate, and communicate with the dialysis center, but also stated there were no orders for the resident’s dialysis in the system and was not sure what to assess post dialysis. The DON stated there should be orders for dialysis and that staff should assess the fistula for signs and symptoms of infection, pain, and bleeding, but also stated staff would not assess the fistula for bruit or thrill. The facility’s dialysis coordination agreement stated the dialysis center would provide dialysis services in accordance with the resident’s treating physician’s orders and that the facility would provide a plan of care and maintain appropriate medical records for continuity of care.
Nurse Aide Worked Beyond Required Training Period Without Certification
Penalty
Summary
The facility did not ensure that a nurse aide who had worked more than 4 months had completed a training and competency evaluation program within the required timeframe. Record review showed that Nurse Aide 1 was hired on 5/19/25 and, as of the personnel file review on 4/13/26, there was no verification on file of a completed nurse aide competency and certification course. During interview, Human Resources stated that the nurse aide was given information on how to obtain certification and how to be reimbursed by the facility, and that the nurse aide had been working without certification since being hired in May 2025. Human Resources also stated that the nurse aide signed a form acknowledging the education and the requirement to obtain certification within 4 months of hire, but that form was not provided to the State Survey Agency. The Director of Nursing stated he was aware that the nurse aide had been working longer than 4 months without obtaining certification.
Failure to Document Pain Interventions and Side Effect Monitoring
Penalty
Summary
The facility did not ensure that each resident’s drug regimen was free from unnecessary drugs because it did not monitor pain management for non-pharmacological interventions and adverse side effects for 2 of 32 sampled residents. The deficiency involved residents 50 and 58, both of whom had physician-ordered pain medications and related treatments, but the record did not show documentation of non-pharmacological pain interventions or monitoring for adverse side effects as required by the facility’s pain management policy. Resident 58 was admitted and later readmitted with diagnoses including dementia, insomnia, fracture of the right femur, and pain. The resident had orders for tramadol 50 mg every 6 hours PRN, acetaminophen 650 mg every 6 hours PRN, and Tylenol PM Extra Strength at bedtime PRN. The March 2026 MAR showed acetaminophen given 10 times for pain scores of 2, including one administration when the pain score was 0, tramadol given 15 times for pain scores ranging from 2 to 4, including one administration when the pain score was 0, and Tylenol PM given 8 times with the reason documented as pain. Tylenol PM was also administered after acetaminophen on two occasions within about 5 hours. No documentation was found on the MAR for non-pharmacological pain interventions or for adverse side effect monitoring. RN 4 stated that non-pharmacological interventions such as repositioning and ambulation were attempted before pain medication and would be documented in a nurse’s note, but no such documentation was found. The DON stated staff were not documenting non-pharmacological interventions on the MAR and there was no way to determine whether they were provided before pain medication. Resident 50 was readmitted after a hospital stay with diagnoses including fluid overload and had orders for acetaminophen 500 mg every 6 hours PRN, hydrocodone-acetaminophen 7.5-325 mg every 6 hours PRN for pain, and a lidocaine 4% patch daily. Review of the January through April 2026 MAR showed that non-pharmacological pain interventions were not offered. RN 1 stated that nursing staff assessed pain each shift but non-pharmacological interventions were not on her charting, CNA 1 stated she would only provide non-pharmacological interventions if asked by the nurse, and the DON stated that resident 50 did not have non-pharmacological interventions for pain. The facility policy stated that pain management includes assessing pain, implementing approaches to pain management, monitoring effectiveness, and, when opioids are used, monitoring for medication effectiveness, adverse effects, and potential overdose.
Nurse Aide Training Deficiencies
Penalty
Summary
The facility did not ensure that nurse aides received in-service training for continued competency of at least 12 hours per year, and the documented training did not include dementia management or abuse prevention. On 4/13/26, the personnel files for CNA 1 and NA 1 were reviewed. CNA 1 had a hire date of 11/10/25 and NA 1 had a hire date of 5/19/25, but neither file contained evidence of continued competency training meeting the 12-hour yearly requirement. The staff training schedule provided by HR 1 showed that CNA 1 had not received any of the 3 in-service training opportunities since hire, and NA 1 had not received any of the 6 in-service training opportunities since hire. During interviews, the DON stated that dementia care training consisted of the nurse on the unit talking to aides about individual resident needs, and that at the last staff meeting they discussed behaviors and how to interact with residents. The DON also stated that new hire orientation did not include dementia care training. HR 1 stated that the facility had monthly in-service training, but did not view annual education as necessary and relied on monthly in-service and on-the-job training. HR 1 further stated that there was no evidence that all staff received the required yearly training for dementia and abuse.
Latest citations in Utah
Surveyors found that the facility did not ensure residents or their representatives were informed of and able to participate in decisions about psychotropic medications. Several residents with conditions such as dementia, early-onset Alzheimer’s disease, major depressive disorder, psychotic disorder, and Parkinson’s disease were started on drugs including haloperidol, donepezil, buspirone, quetiapine, zaleplon, and sertraline without documentation that risks, benefits, or alternative treatments were discussed in advance. The DON reported that staff notify families when medications are started or changed but do not review risks and benefits, offer alternative options, or obtain signed consent, resulting in no evidence of informed decision-making for these psychotropic treatments.
Surveyors determined that the facility failed to consistently manage psychotropic medications for three residents. Two residents with dementia and psychiatric conditions had only one documented psychotropic medication review and gradual dose reduction (GDR) attempt, completed in January, with no evidence of quarterly reviews or additional GDR efforts. Another resident with hemiplegia, psychotic disorder, dementia, and major depressive disorder had a PRN IM haloperidol order written without an end date, which remained active and was administered on multiple occasions beyond 14 days, and the DON confirmed there was no physician documentation justifying the extended PRN antipsychotic order.
The facility failed to ensure that alleged abuse and serious injuries were reported to the State Survey Agency as required, instead either reporting only to a state patient safety system or not reporting at all. One resident with severe cognitive impairment sustained bilateral femur fractures after a fall, another cognitively impaired resident with Parkinson’s disease was later found to have a femur fracture after being discovered on the floor, and a third cognitively impaired resident required ORIF surgery for fractures following a fall; none of these incidents were reported through the State Survey Agency’s incident reporting website, per the ADM. In addition, an allegation that a resident with dementia and sensory impairments may have been molested was documented in the abuse binder but not in the medical record, and the ADM did not report the allegation to agencies or law enforcement after deeming it not credible, despite interviewing the resident and family. These actions and omissions resulted in multiple unreported events that met criteria for immediate reporting of alleged abuse and injuries of unknown source.
The facility failed to investigate multiple major injuries and an allegation of sexual abuse involving three residents with severe cognitive impairment and significant medical conditions. One resident, dependent for transfers, was found on the floor after attempting to get out of bed and was later found to have bilateral femur fractures. Another resident with Parkinson’s disease was found on the floor after a wheelchair alarm sounded and was later diagnosed with a femur fracture following complaints of leg pain. A third resident, described as very independent, triggered a bed alarm and was found kneeling by a recliner, later requiring ORIF for fractures of the right 4th and 5th metacarpals. In each case, the ADM acknowledged awareness of the fractures, stated there was no belief of neglect or abuse, and confirmed that no investigation into the cause of the injuries or the alleged abuse was initiated or documented.
Surveyors found that the facility failed to ensure monthly pharmacist drug regimen reviews were completed and documented for several residents with conditions such as Parkinson’s disease, dementia, and Alzheimer’s disease, with no pharmacist notes present for at least two consecutive months. Additionally, a pharmacist’s recommendation to add a low-dose daytime antipsychotic for a resident with dementia, psychotic disorder, and behavioral symptoms was not communicated to the physician or implemented for several months, despite documented behavioral concerns. An LPN reported not relaying the pharmacist’s recommendation because PRN Haldol had not been needed at that time, and the DON confirmed that the pharmacist reviews for the missing months were not done and that she did not have time to monitor follow-through on such recommendations.
Surveyors identified a failure to properly label medications when two open insulin pens were found in a medication refrigerator bin marked only with a resident’s first name, with no labels directly on the pens. During an observation, an RN confirmed the pens belonged to a resident and acknowledged that pens are supposed to be labeled with the resident’s name but could not explain why these were not labeled. In a subsequent interview, the DON confirmed the pens had been unlabeled and stated they should have been labeled in accordance with professional standards.
The facility failed to sustain effective QAPI processes related to pharmacist medication regimen reviews, resulting in repeated noncompliance with F756. Surveyors found that medical records for four residents lacked documentation showing that a pharmacist had reviewed medications, identified potential irregularities, or made recommendations to attending physicians, an issue previously cited. The DON reported she did not have time to maintain this documentation, and the Administrator acknowledged there was no formal performance improvement project in place, though some plans were noted in QAPI minutes, and no supporting documents were produced to demonstrate ongoing compliance.
Staff failed to follow infection control practices during medication administration and did not maintain organized infection surveillance documentation. An LPN was observed handling an oral medication with bare hands before administering it to a resident, contrary to the DON’s stated expectation that pills be dispensed directly into medication cups without hand contact and that any contaminated dose be discarded. Additionally, the DON, who also served as the Infection Preventionist, reported that several residents had influenza during a past holiday season but had no list of affected residents or rooms, and the requested infection control surveillance logs and a formal tracking system were not available.
The facility lacked an antibiotic stewardship program, with no protocols to ensure appropriate indication, dose, and duration of antibiotic prescriptions and no system to monitor antibiotic use or resistance patterns. When surveyors requested Infection Control Surveillance Logs, including antibiotic tracking information, the logs were not available. In an interview, the DON, who also functioned as the Infection Preventionist, acknowledged that she did not track resident antibiotic utilization, clinical indications, or treatment durations.
A resident with multiple chronic conditions, including DM, HTN, anxiety, major depressive disorder, and PTSD, reported that a CNA on night shift failed to hold open a smoking-area door, leading the resident to grab the door and sustain a finger cut that bled. The resident completed a grievance with the RA, who documented that the CNA swung the door open and walked away and that no abuse or neglect allegation was initially identified. However, the grievance lacked documentation of investigative steps, a summary of findings, a conclusion on whether the grievance was confirmed, and any decision date or required signatures, and leadership later reported they had not been informed of the incident, demonstrating the grievance was not promptly resolved or fully tracked through conclusion.
Failure to Inform Residents of Risks, Benefits, and Alternatives Before Starting Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents, or their representatives, were informed of and allowed to participate in decisions regarding psychotropic medication treatment, including being informed in advance of the risks, benefits, and treatment alternatives. For four sampled residents, medical record review showed new orders for multiple psychotropic medications without any documentation that the resident or representative had been informed of these elements prior to initiation. Resident 8, with diagnoses including hemiplegia and hemiparesis following cerebral infarction, psychotic disorder with delusions, dementia, and major depressive disorder, was started on haloperidol lactate, donepezil, buspirone, quetiapine, and sertraline on various dates, with no documentation of informed discussion or consent. Resident 4, with unspecified dementia and anxiety disorder, was started on zaleplon, quetiapine, and buspirone, again with no record that risks, benefits, or alternatives were discussed in advance. Resident 54, diagnosed with early-onset Alzheimer’s disease and dementia in other diseases classified elsewhere, was started on sertraline and quetiapine, and Resident 6, diagnosed with Parkinson’s disease without dyskinesia, was started on buspirone, quetiapine (Seroquel), and sertraline, with no documentation that either resident or their representative had been informed of the risks and benefits or treatment options before these psychotropic medications were initiated. During an interview, the DON stated that the facility notifies families when medications are started or doses are changed but does not discuss risks and benefits, provide alternative options, or obtain signed consent. This practice contributed to the lack of documented evidence that residents or their representatives were fully informed and able to participate in treatment decisions regarding psychotropic medications.
Failure to Perform Regular GDR and Limit PRN Antipsychotic Orders
Penalty
Summary
Surveyors found that the facility did not ensure appropriate management of psychotropic medications for three sampled residents. For two residents with dementia and related psychiatric diagnoses, the medical records from late April 2026 showed only one documented psychotropic medication review and gradual dose reduction (GDR) attempt, completed in January 2026. There was no documentation of any GDR attempts or psychotropic reviews prior to January 2026, despite the DON stating that such reviews and GDRs should be completed quarterly. The records for these residents did not contain additional GDR attempts beyond the January 2026 review. For a third resident with hemiplegia following cerebral infarction, psychotic disorder with delusions, dementia, and major depressive disorder, a physician’s order dated February 8, 2026, prescribed PRN intramuscular haloperidol lactate every 12 hours for delusions, hallucinations, paranoia, and agitation, without an end date. Review of the MARs for February through April 2026 showed that this PRN antipsychotic was administered on two occasions, and no end date was documented on the MAR. In an interview, the DON acknowledged that the PRN haloperidol order extended beyond 14 days and that the physician had not documented a reason for continuing the order beyond that period.
Failure to Report Alleged Abuse and Serious Injuries to State Survey Agency
Penalty
Summary
The deficiency involves the facility’s failure to ensure that all alleged violations of abuse, including injuries of unknown source and incidents involving major injuries, were reported immediately to the State Survey Agency and other officials as required by state law. For four sampled residents, the Administrator acknowledged that incidents were reported only to the state’s patient safety website and not to the State Survey Agency’s incident reporting website. This omission meant that the State Survey Agency did not receive timely notice of serious events, including an allegation of sexual abuse and multiple incidents resulting in significant fractures and surgery. For one resident with severely impaired cognition and diagnoses including hemiplegia and hemiparesis, nursing notes documented that the resident was found on the floor after attempting to get out of bed, was sent to the ER, and returned with immobilizing braces on both legs due to bilateral femur fractures. The resident’s bones were not strong enough for surgery, and he was placed on comfort care. Despite the seriousness of the injuries and the requirement to treat such events as potential abuse or neglect until ruled out, the Administrator stated that this incident was reported only to the state’s patient safety website and not to the State Survey Agency’s incident reporting system. Another resident with Parkinson’s disease and severely impaired cognition was found on the floor after a wheelchair alarm sounded, initially with no visible injury and able to bear weight. A few days later, staff documented complaints of left leg pain, tenderness, and wincing with movement, leading to an order for x‑rays and transfer for imaging. X‑ray results revealed a femur fracture, and surgery was not pursued. The Administrator reported this incident to the state’s patient safety website but not to the State Survey Agency’s incident reporting website. A third resident with severe cognitive impairment experienced a fall with complaints of pain in the left knee, left elbow, and fingers, and later underwent ORIF surgery for fractures of the right fourth and fifth metacarpals; this incident also was not reported to the State Survey Agency’s incident reporting system, according to the Administrator. For another resident with dementia, adjustment disorder with anxiety, hearing and visual loss, and age‑related debility, a document in the facility’s abuse binder described a possible molestation allegation originating from a phone call by the resident’s nephew. The nephew reported that his mother, the resident’s sister and then‑POA, was emotionally unstable and had stated she felt the resident had reported being molested. The Administrator documented that the nephew did not believe the allegation was credible, that the sister had dementia and emotional issues, and that the Administrator considered the report “not a viable allegation.” The Administrator noted that he interviewed the resident, who denied being touched, and that the sister could not provide more details beyond stating that a man had groped the resident’s breast. The Administrator concluded the allegation was not credible and did not report it to any agencies or law enforcement. The incident was not documented in the resident’s medical record, and the Administrator confirmed in interview that he did not report this sexual abuse allegation to the State Survey Agency’s incident reporting website. Across these four residents, the common deficiency was the facility’s failure to treat serious injuries and a sexual abuse allegation as reportable events to the State Survey Agency, as required. Instead, the Administrator limited reporting to the state’s patient safety website or chose not to report at all when he personally judged an allegation as not credible. This pattern of inaction regarding mandated reporting requirements formed the basis of the cited deficiency.
Failure to Investigate Major Injuries and Alleged Abuse
Penalty
Summary
The deficiency involves the facility’s failure to initiate and document investigations into multiple major injuries and an allegation of sexual abuse, as required for all alleged violations involving abuse and injuries of unknown source. For one resident with hemiplegia, hemiparesis, and severely impaired cognition (BIMS score of 6), nursing notes documented that his roommate activated the call bell after the resident fell while attempting to get out of bed by himself. He was found on the floor between his bed and the window, reported knee pain with a popping sensation, and was sent to the ER. On return from the hospital, he was noted to have bilateral femur fractures, immobilizing braces on both legs, and was placed on comfort care due to bones not being strong enough for surgery. The Administrator acknowledged awareness of the bilateral femur fractures, stated he did not believe neglect or abuse caused the injury, and confirmed he did not investigate the cause of this major injury. Another resident with Parkinson’s disease and a BIMS score of 0 (rarely/never understood) was documented in an incident note as sitting in a wheelchair in the dining room when his alarm sounded; he was found supine on the floor, denied hitting his head or injury, and was assisted back into the chair with no signs of injury noted. Several days later, nursing notes recorded that CNAs reported the resident complaining of left leg pain when getting him out of bed. On assessment, he had tenderness and wincing with movement of the left leg but was able to bear weight. The MD was notified, an x-ray was ordered, and the resident was transported for imaging, which revealed a femur fracture for which surgery was not pursued. The Administrator stated he was aware of the femur fracture, did not feel neglect or abuse caused the major injury, and did not investigate the cause of the injury. A third resident with COPD, scoliosis, and severely impaired cognition (BIMS score of 7) had an incident note documenting that her bed alarm sounded and staff found her in a kneeling position leaning into her recliner after she attempted to get up from bed to go to the bathroom, stating her walker “didn't go where she was going.” She complained of left knee, left elbow, and right pinky pain, with no visible injury except an abrasion on the right ring finger. A later nursing note documented that she underwent ORIF of fractures of the right fourth and fifth metacarpals at a hospital and returned from surgery the same day. The Administrator reported being aware of the fractures, described the resident as very independent and wanting to wander the facility, stated he did not feel neglect or abuse caused the major injury, and confirmed he did not investigate the cause of the injury. Across these three residents, the facility did not initiate or document investigations into the causes of the major injuries or the related allegation of sexual abuse, nor did it determine causation or responsible parties as required.
Failure to Complete Monthly Pharmacist Reviews and Timely Act on Medication Recommendations
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a licensed pharmacist conducted and documented monthly drug regimen reviews for multiple residents and to ensure that identified medication irregularities were acted upon by the attending physician. For four sampled residents, the medical records lacked monthly pharmacist medication regimen review notes for at least two consecutive months. Specifically, residents with diagnoses including Parkinson’s disease, unspecified dementia, Alzheimer’s disease with early onset, and dementia related to other diseases had no documented pharmacist review notes for March and April 2026. The DON confirmed that the pharmacist had not completed pharmacy reviews for those months and that the notes, which should have been uploaded into each resident’s electronic medical record, were absent. In addition, the facility failed to act promptly on a pharmacist’s recommendation for a resident receiving psychotropic medications. One resident with hemiplegia following cerebral infarction, psychotic disorder with delusions, dementia, and major depressive disorder had a pharmacist recommendation in November 2025 to add a low-dose daytime Seroquel due to behavioral issues and afternoon anxiety. Nursing documentation showed that the pharmacist discussed the resident’s response to Seroquel versus Abilify and suggested a low-dose daytime Seroquel, but this recommendation was not communicated to the physician at that time. The LPN later stated she did not speak to the physician about the pharmacist’s recommendation because the resident had not needed PRN Haldol around that time. The physician did not write the order for daytime Seroquel until early February 2026, after a nurse raised concerns about the resident’s behaviors and reminded the physician of the prior pharmacist recommendation. The DON acknowledged that the pharmacist’s November 2025 recommendation was not completed until February 2026 and stated she did not have time to stay on top of such issues.
Unlabeled Insulin Pens Found in Medication Refrigerator
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled in accordance with accepted professional principles when two open insulin pens belonging to resident 56 were found without the resident’s name on them. During an observation of the south medication refrigerator on 4/29/26 at 10:50 AM, surveyors noted a plastic bin labeled only with resident 56’s first name, containing two loose, open insulin pens that had no resident identification labels affixed directly to the pens. In a concurrent interview, RN 1 confirmed that the two insulin pens belonged to resident 56 and stated that staff always put residents’ names on insulin pens, but was unsure why these pens had not been labeled. Later that day at 2:17 PM, the DON stated in an interview that the two insulin pens in question had been unlabeled and acknowledged that the insulin pens should have been labeled with the resident’s information.
Failure to Sustain QAPI Actions and Documentation for Pharmacist Medication Reviews
Penalty
Summary
The deficiency involves the facility’s failure, as part of its performance improvement activities, to take actions aimed at performance improvement, measure the success of those actions, and track performance to ensure that improvements were realized and sustained, specifically related to F756. Record review and interviews showed that the facility did not maintain documentation in the medical records to demonstrate that a pharmacist reviewed residents’ medications, identified potential irregularities, or provided recommendations to the attending physician for four sampled residents, despite this same issue having been cited in the previous health survey in 2024. During an interview, the DON stated she did not have time to maintain this required documentation. In a separate interview, the Administrator stated he did not have a performance improvement project, though he had QAPI minutes that captured some improvement plans, and he believed the facility had achieved compliance with F756, which had been cited previously, but no documents demonstrating compliance were provided when requested by surveyors.
Failure in Medication Handling and Infection Surveillance Documentation
Penalty
Summary
The facility failed to ensure a safe and sanitary environment during medication administration and infection surveillance. During an observation of medication pass for resident 23, an LPN was seen popping an oral pill directly from a blister pack into her bare hand and then placing it into a medication cup, after which the medication was administered to the resident. In a subsequent interview, the DON stated that staff were expected to pop pills directly into medication cups and never touch medications with bare hands, and that any medication contacting a staff member’s bare hand was to be discarded and replaced, indicating that the observed practice did not follow facility expectations. The facility also failed to maintain infection control surveillance documentation and an organized tracking system for infections. When Infection Control Surveillance Logs were requested, the DON reported that several residents had contracted influenza during the 2025 holiday season, attributed to an increased number of visitors, and that symptomatic residents were kept in their rooms. However, the DON stated she did not have a list of affected residents or rooms, and the requested surveillance logs were unavailable for review. In a later interview, the DON, who also served as the facility’s Infection Preventionist, confirmed that the facility lacked an infection control surveillance manual or organized system for tracking infections.
Failure to Implement and Monitor an Antibiotic Stewardship Program
Penalty
Summary
The facility failed to develop and implement an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use. There was no established facility-wide system to ensure appropriate indication, dose, and duration for antibiotic prescriptions, and no process for monitoring antibiotic usage or resistance data. On 4/29/26 at 8:20 AM, when surveyors requested the facility’s Infection Control Surveillance Logs, including any prescribed antibiotic tracking information, these logs were unavailable. On 4/30/26 at 12:28 PM, during an interview, the DON, who also served as the facility’s designated Infection Preventionist, stated that she did not track resident antibiotic utilization, including the specific clinical indications for the medications or the prescribed durations of treatment. No specific residents, their medical histories, or clinical conditions at the time of the deficiency were described in the report.
Failure to Promptly Resolve and Document Resident Grievance Regarding Door Injury
Penalty
Summary
The deficiency involves the facility’s failure to promptly resolve and properly document a resident grievance in accordance with its grievance policy. A resident with type II DM, HTN, anxiety disorder, major depressive disorder, and PTSD reported that a CNA on night shift did not hold open the smoking door for her and another resident, and that when she went to grab the door, it slammed on or closed against her finger, causing a cut to bleed. The resident stated she reported this to the Resident Advocate (RA) and completed a grievance form, and that nursing staff applied Neosporin and a bandage to the finger. The resident did not know the CNA’s name but identified that the CNA worked nights and stated that no one should be treating residents that way. The grievance form dated 4/10/26 documented the concern that the CNA on night shift did not hold the smoking door open and instead swung the door open and walked away, and that upon initial interview no allegation of abuse or neglect was identified. However, the grievance form contained no documentation of investigative steps taken, no summary of findings or conclusion, and no indication whether the grievance was confirmed or not. The form also lacked a written decision date, resident signature, grievance officer signature, and Administrator signature. The RA reported that the resident told her the door incident caused a small cut to reopen and that the CNA seemed in a hurry, but did not state that the CNA acted intentionally or purposefully toward her. The Administrator and DON later stated they had not been informed of the incident, and the Regional Nurse Consultant noted that nothing was filled out on the back of the grievance form, indicating it remained incomplete despite having been initiated several days earlier.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
