Monument Healthcare South Salt Lake
Inspection history, citations, penalties and survey trends for this long-term care facility in Salt Lake City, Utah.
- Location
- 2472 South 300 East, Salt Lake City, Utah 84115
- CMS Provider Number
- 465146
- Inspections on file
- 20
- Latest survey
- June 19, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Monument Healthcare South Salt Lake during CMS and state inspections, most recent first.
Surveyors found that the facility failed to prevent accident hazards and provide adequate supervision, including allowing excessively hot water in resident rooms, unsupervised smoking by residents who required supervision, and incidents of residents with cognitive impairment eloping from the facility undetected. Staff interviews revealed confusion about supervision policies, and additional hazards such as a non-working front doorbell and unsafe storage in resident areas were observed.
A resident with a mental disorder, psychosocial adjustment difficulty, or a history of trauma and/or PTSD did not receive the necessary treatment and services to address their mental health and psychosocial needs.
The facility did not consistently calibrate glucometers according to manufacturer instructions, with calibration logs showing irregular entries and some logs missing. Interviews with nursing staff revealed confusion about calibration procedures and documentation, and not all staff were authorized or trained to perform blood sugar checks. This resulted in laboratory services not meeting resident needs.
Residents were served beverages in Styrofoam cups and prepackaged juice containers during meal service, with some food items also provided in disposable containers. Staff used these items due to a shortage of regular cups, as explained by the Dietary Manager. These actions did not support the maintenance or enhancement of residents' dignity and quality of life.
Three residents experienced incidents involving elopement and alleged abuse that were not reported to the State Survey Agency or Adult Protective Services within the required timeframe. In one case, a resident with dementia eloped and was returned by a CNA, but APS was not notified. Another resident with cognitive impairment left with a friend and did not return, with no evidence of required notifications. A third resident alleged inappropriate touching by a CNA, but the allegation was not promptly reported or investigated.
Surveyors found that expired eye drops and insulin, as well as multiple opened eye drop bottles without open dates, were present in medication carts and administered to residents. Staff, including RNs and LPNs, acknowledged that medications should be labeled with open dates and discarded after 28 days, but this was not consistently done, resulting in expired or improperly labeled drugs being used.
Surveyors identified multiple deficiencies in food storage, preparation, and sanitation, including soiled kitchen surfaces and equipment, improper sanitizer solution levels, open spices, and a broken steamer. A Registered Dietitian was also observed in the food prep area without a hairnet, and cleaning routines were found inadequate to maintain professional standards.
The facility did not ensure effective policies were in place to correct identified deficiencies, resulting in unsafe hot water temperatures in resident rooms, unsupervised smoking by residents who required supervision, and incidents of resident elopement. Despite previous QAPI plans, the facility failed to maintain updated supervision lists, assess residents for smoking safety, or consistently implement interventions for elopement risks. Repeat deficiencies from a prior survey were also cited again.
The facility did not ensure that two residents or their representatives were informed and able to participate in care decisions, including starting an antidepressant and placing a wanderguard device, as both interventions were initiated before obtaining proper consent.
Two residents were discharged or left the facility without receiving written notification of discharge and the reasons for transfer in a language and manner they understood, and the Office of the State LTC Ombudsman was not notified as required. Staff interviews revealed inconsistent practices regarding notification and documentation for residents discharged to hospitals or who left against medical advice.
A resident with a documented history of depression and ongoing treatment with escitalopram did not have this diagnosis reflected in their medical record or MDS assessment. Multiple staff members were unaware of the depression diagnosis, and the DON confirmed it was not updated in the chart, leading to an inaccurate assessment.
A resident lost the ability to perform ADLs without a documented medical reason. The facility did not ensure that the decline in the resident's functional abilities was clinically unavoidable, as required by regulations.
A resident did not receive care and treatment in accordance with physician orders and their stated preferences and goals, as observed and documented by surveyors.
Two residents were not provided with the therapeutic diets ordered for their medical conditions. One resident with diabetes received high-carbohydrate meals instead of a carbohydrate-controlled diet, while another with end stage renal disease was served high-potassium foods despite a renal diet order. Dietary staff and the RD were unaware of the residents' specific needs and preferences, and the meal planning system did not consistently ensure compliance with diet orders.
A resident with complex psychiatric and medical conditions did not receive scheduled Invega IM injections on multiple occasions because the medication was not available at the facility, with missed doses attributed to delivery delays and insurance coverage issues. Documentation confirmed the missed administrations, and in one instance, no reason was documented for the omission.
Two residents did not receive timely outside professional services as required. One resident, needing dental care for decay causing injury, had no documented appointment or refusal for outside dental treatment. Another resident with uncontrolled diabetes had multiple referrals for endocrinology, but there were delays and unclear follow-through in scheduling the specialist appointment. Staff interviews revealed confusion and lack of documentation regarding responsibility and process for arranging these services.
Two residents' medical records were found to be incomplete and not systematically organized. One resident's record lacked an updated PASRR reflecting a new depression diagnosis, despite documentation of depression and related treatment in progress notes. Another resident's record did not contain any documentation of a reported elopement event, contrary to facility policy requiring such incidents to be recorded.
Staff did not consistently use Enhanced Barrier Precautions, such as wearing gowns, when providing care to a resident with chronic wounds and a feeding tube. The resident's tube feed was also left uncapped when disconnected, contrary to facility protocols. Interviews indicated staff were unclear about EBP requirements, and observations confirmed lapses in infection control practices.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
Multiple Failures in Accident Prevention, Supervision, and Elopement Safeguards
Penalty
Summary
Surveyors identified multiple deficiencies related to accident hazards and inadequate supervision throughout the facility. Hot water temperatures in resident rooms were found to be excessively high, ranging from 121.7 to 145.5 degrees Fahrenheit, well above the safe range of 105-115 degrees as stated by the Maintenance Director. Residents with varying degrees of cognitive impairment and physical limitations were exposed to these hazardous water temperatures, with some residents reporting the water was hot enough to make noodles. The facility's water temperature logs over the previous six months did not reflect these high temperatures, instead showing much lower readings, and discrepancies were noted between the surveyors' thermometers and the facility's infrared thermometer during testing. In addition to the water temperature issue, the facility failed to provide adequate supervision for residents who required it while smoking. Several residents who were assessed as needing supervision were observed smoking unsupervised in various locations, including outside the facility and near the sidewalk. Some residents kept their own smoking materials despite care plans and evaluations indicating that these should be stored by staff and only used under supervision. There were inconsistencies in the facility's smoking policy implementation, with staff interviews revealing confusion about which residents required supervision and how smoking materials were managed. One resident was not properly evaluated for smoking, and the list of supervised smokers was outdated. The facility also failed to prevent elopement for residents assessed as being at risk. Two residents with significant cognitive impairment and histories of wandering were able to leave the facility without staff knowledge. In one case, a resident was found walking two blocks away and returned by a CNA, while another resident was found by police after leaving the facility and becoming combative. The facility's elopement prevention measures, such as wander guards, were not effective in preventing these incidents, and staff were unsure how a resident was able to exit the building while wearing a wander guard. Additional hazards were noted, such as a non-functioning front doorbell that left residents locked outside and unable to alert staff, and the storage of metal bed frames and boxes in a dayroom occupied by residents.
Failure to Provide Appropriate Mental Health and Psychosocial Services
Penalty
Summary
A resident who displayed or was diagnosed with a mental disorder, psychosocial adjustment difficulty, or had a history of trauma and/or post-traumatic stress disorder did not receive the appropriate treatment and services as required. The facility failed to ensure that the necessary care and interventions were provided to address the resident's mental health and psychosocial needs, as observed and documented by surveyors.
Failure to Consistently Calibrate Glucometers per Manufacturer Guidelines
Penalty
Summary
The facility failed to provide or obtain laboratory services to meet the needs of its residents, specifically regarding the calibration and quality control of glucometers. Review of calibration logs for various hallways revealed inconsistent and infrequent calibration dates, with some logs missing or not readily available on medication carts. Interviews with nursing staff, including LPNs, RNs, and CMAs, indicated a lack of consistent understanding and adherence to the manufacturer's instructions for glucometer calibration. Some staff believed calibration was performed weekly by the night shift, while others were unsure of the frequency or location of calibration logs. The Director of Nursing confirmed that not all staff were authorized to perform blood sugar checks, as some had not been properly trained or passed off. Further interviews with the Regional Nurse Consultant and review of the glucometer manual confirmed that calibration and control solution testing should be performed weekly and under specific circumstances, such as when using a new bottle of test strips or if the accuracy of the meter was in question. However, the facility was not consistently following these requirements, as evidenced by the irregular calibration dates and staff uncertainty. This failure to adhere to manufacturer guidelines for glucometer calibration resulted in the facility not meeting the laboratory service needs of its residents.
Use of Disposable Cups and Containers During Meal Service
Penalty
Summary
Surveyors observed that residents dining in the facility's dining room were served beverages in Styrofoam cups and prepackaged juice cups, rather than in standard dining ware. During multiple meal services, staff distributed milk and water in Styrofoam cups, while juices were provided in small cartons or foil-covered cups. Coffee and tea were served in coffee cups, and some food items, such as strawberries, were served in disposable containers. One resident was observed with multiple beverage containers, including cartons and Styrofoam cups, at their dining table. The Dietary Manager explained that the use of Styrofoam cups was due to a shortage of regular cups, as several had gone missing and replacements had not yet arrived. The facility had some regular cups available, but not enough for all residents. These practices did not promote an environment that maintained or enhanced residents' quality of life or recognized their individuality, as required by regulations regarding dignity and respect in resident care.
Failure to Timely Report Alleged Abuse, Neglect, and Elopement
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, or elopement were reported immediately, but no later than two hours after the allegation was made, to the State Survey Agency (SSA) and Adult Protective Services (APS) for three residents. In the first case, a resident with a history of traumatic brain injury and dementia eloped from the facility and was found by a community member. The CNA who located the resident notified the Director of Nursing (DON) of the elopement, but there was no documentation that APS was notified as required. In the second case, a resident with paranoid schizophrenia, major depressive disorder, and moderate cognitive impairment left the facility with a friend and did not return as expected. The facility made attempts to contact the resident but did not notify law enforcement, APS, or the Ombudsman about the resident's absence. The resident eventually returned to collect belongings and stated he would not be returning, but there was no evidence that the required notifications were made regarding his prolonged absence or potential elopement. In the third case, a resident with Parkinson's disease, schizoaffective disorder, dementia, and other chronic conditions alleged that a CNA had inserted her fingers into the resident's private parts during care. The resident reported the incident to the CNA Coordinator, who did not recall the name of the CNA involved and did not initiate an investigation or report the allegation to the DON or administrator in a timely manner. The CNA Coordinator stated she discussed the situation with the DON, but there was no documentation that the incident was reported to the SSA or APS within the required timeframe. The administrator later acknowledged that the incident was not recognized as an abuse allegation until much later, resulting in a failure to report as required.
Expired and Unlabeled Medications Found in Use
Penalty
Summary
Surveyors identified that the facility failed to ensure drugs and biologicals were labeled and stored according to professional standards for four residents. Specifically, expired medications were found in use, including Ketotifen Fumarate eye drops administered to a resident after the labeled open date had passed, and an insulin pen that was past its expiration date. Additionally, several eye drop bottles, both prescription and over-the-counter, were found without open dates, making it impossible to determine if they were still safe for use. Staff interviews confirmed that medications such as eye drops and insulin are expected to be discarded after a set period post-opening, but this protocol was not consistently followed. The observations included a nurse administering expired eye drops, multiple medication carts containing opened eye drops and insulin pens without proper labeling, and staff acknowledging the lack of required open dates or the presence of expired medications. Medication administration records confirmed that these medications were actively being given to residents. The Director of Nursing and other staff stated that all opened eye drops and insulin should be discarded after 28 days, but this was not adhered to, resulting in the use and storage of expired or improperly labeled medications.
Deficient Food Storage, Preparation, and Sanitation Practices Identified
Penalty
Summary
Surveyors observed multiple deficiencies in food storage, preparation, and sanitation practices within the facility's kitchen. During initial and follow-up tours, areas behind and under kitchen equipment such as the steamer, storage shelves, and carts were found to be soiled with substances including white splatter, debris, grease, and a black substance. The table supporting the steamer was rusty and also had visible splatter. The floor under preparation sinks and storage areas was similarly soiled, and tape was found on the ceiling above a preparation sink. Large bins containing powdered milk, sugar, flour, and oatmeal were soiled around the tops, and spices were left open to air. Plastic drawers containing serving utensils were also found to be soiled. Sanitizer solution used in the kitchen did not meet professional standards, as test strips failed to register the required parts per million (PPM) for quaternary ammonium sanitizer, with the color on the strip not matching the required range. The Dietary Manager confirmed the sanitizer was recently changed but was unable to verify the correct concentration. Additionally, a Registered Dietitian was observed in the food preparation area without a hairnet. The facility's steamer, used for cooking vegetables, pork ribs, and mashed potatoes, had been broken for about a year, requiring staff to boil foods instead, which was reported to be less effective. Cleaning routines for various kitchen areas and equipment were described by the Dietary Manager, but observations indicated that these routines were not sufficient to maintain required sanitation standards.
Failure to Correct Hazards and Supervision Deficiencies Through QAPI
Penalty
Summary
The facility failed to establish and implement effective policies to correct identified deficiencies, as evidenced by repeated areas of non-compliance and failure to detect or address immediate jeopardy situations through the QAPI process. Specifically, for 12 out of 61 sampled residents, the environment was not maintained free of accident hazards, and residents did not consistently receive adequate supervision or assistive devices to prevent accidents. Hot water temperatures in resident rooms were observed to range from 121.7 to 145.5 degrees Fahrenheit, significantly exceeding safe limits. However, facility water temperature logs for the same period recorded much lower temperatures, indicating a lack of accurate monitoring or reporting. Additionally, residents assessed as requiring supervision while smoking were observed smoking unsupervised, and some residents were not evaluated for smoking safety at all. There were also incidents of residents with a history of wandering eloping from the facility without staff awareness. Despite previous QAPI plans addressing supervised smoking and elopement risks, the facility did not maintain updated lists of residents requiring supervision, failed to assess residents for smoking safety, and did not ensure interventions for elopement risks were consistently in place. Repeat deficiencies from a prior survey were cited again, including those related to accident hazards, resident rights, medication management, and infection control. The Administrator confirmed that QAPI meetings were held monthly and that action plans had been created for some issues, but hot water concerns had not been identified or addressed through the QAPI process.
Failure to Inform and Obtain Consent for Medication and Wanderguard Placement
Penalty
Summary
The facility failed to ensure that two residents or their representatives were fully informed and able to participate in decisions regarding their care and treatment. For one resident with severe vascular dementia and significant cognitive impairment, the facility initiated an antidepressant medication (Escitalopram) without notifying or obtaining consent from the resident's representative prior to starting the medication. Record review and interviews confirmed that no documentation of consent or notification was found before the medication was administered. In another case, a resident who had recently eloped from the facility was fitted with a wanderguard device upon return. Documentation showed that the wanderguard was placed before obtaining informed consent from the resident or her guardian. The consent form and related progress note were completed two days after the device was applied, and staff interviews confirmed that consent should have been obtained prior to placement. These actions demonstrate a failure to inform and involve residents or their representatives in advance of significant care interventions.
Failure to Notify Ombudsman and Provide Written Discharge Notices
Penalty
Summary
The facility failed to provide required written notification of discharge and the reasons for transfer in a language and manner understandable to the resident, and did not send a copy of the discharge notice to the Office of the State Long-Term Care Ombudsman for two residents. For one resident with diagnoses including type 1 diabetes mellitus and end-stage renal disease, multiple hospital transfers were documented in the medical record. However, the Admissions Marketing Director (AMD) stated that the Ombudsman was only notified monthly of residents discharged against medical advice (AMA) or to the community, and not when residents were transferred to a hospital. The Regional Nurse Consultant (RNC) confirmed that the Ombudsman should be notified of all discharges, including hospital transfers, but this was not done for this resident. Another resident with a history of paranoid schizophrenia, major depressive disorder, and other medical conditions left the facility with a friend and did not return. The resident later came back to collect belongings and stated he would not return. The Administrator acknowledged that no AMA form or discharge instructions were provided because the resident was in a rush, and the Ombudsman was not notified of the resident's departure. The AMD considered the situation as leaving AMA, but did not follow the required notification procedures. Interviews with facility staff, including the Administrator, AMD, RNC, and Director of Nursing (DON), revealed inconsistent practices regarding notification of the Ombudsman and provision of discharge documentation. Staff described procedures for contacting residents or families and involving law enforcement if a resident did not return from a leave of absence, but did not consistently notify the Ombudsman or provide written discharge notices as required.
Failure to Accurately Document Depression Diagnosis in Resident Assessment
Penalty
Summary
A deficiency was identified when the facility failed to ensure that a resident's assessment accurately reflected their current medical status. The resident in question had a documented history of severe vascular dementia, hypertension, attention and concentration deficit following cerebral infarction, depression, and cognitive communication deficit. Multiple psychiatric and nursing notes, as well as physician orders, indicated that the resident was being treated for depression with escitalopram (Lexapro), and the diagnosis of depression was referenced in several clinical documents. Despite this, the resident's medical diagnoses list and the Quarterly Minimum Data Set (MDS) did not include depression as a diagnosis. Interviews with facility staff revealed a lack of awareness and documentation regarding the resident's depression diagnosis. Registered nurses and the social service worker were either unsure or unaware of the depression diagnosis, and the face sheet did not reflect it. The Director of Nursing confirmed that the resident had been diagnosed with depression, but this information was not updated in the medical chart or the MDS, resulting in an inaccurate assessment of the resident's condition.
Failure to Prevent Unnecessary Decline in ADL Abilities
Penalty
Summary
Residents experienced a loss in their ability to perform activities of daily living (ADLs) without a documented medical reason. The facility failed to ensure that residents maintained their highest practicable level of functioning in ADLs, as required, unless a decline was clinically unavoidable due to a medical condition. This deficiency was identified through surveyor observation and review of resident records, which did not provide evidence of a medical justification for the decline in ADL performance.
Failure to Follow Treatment Orders and Resident Preferences
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, as well as the resident's preferences and goals. This deficiency was identified through surveyor observation and review of records, which showed that care provided did not align with the documented orders or the expressed wishes and care goals of the resident involved.
Failure to Provide Ordered Therapeutic Diets to Residents
Penalty
Summary
Two residents were not provided with the therapeutic diets ordered for their medical conditions. One resident with type 1 diabetes, who was on a carbohydrate-controlled diet, consistently received high-carbohydrate meals and was not offered low-carbohydrate options as requested by the resident and family. The resident experienced high blood glucose readings, and the family expressed concern that insulin was administered without regard to the carbohydrate content of meals. Observations confirmed that the resident was served meals inconsistent with the prescribed diet, such as being given bread pudding instead of fruit, and the dietary manager was unable to specify the carbohydrate content of meals provided. Another resident, with end stage renal disease, diabetes, and gastroparesis, reported not receiving a renal diet as ordered by the physician. The resident stated that meals included high-potassium foods such as beans and bananas, which are not appropriate for a renal diet. The resident had communicated these concerns to dietary staff without resolution. Review of dietary records and interviews with the dietary manager and registered dietitian revealed a lack of awareness and oversight regarding the specific dietary needs and preferences of these residents, and the computer system used for meal planning did not consistently ensure compliance with therapeutic diet orders.
Failure to Provide Scheduled Invega Injections Due to Medication Unavailability
Penalty
Summary
A deficiency occurred when a resident with multiple psychiatric and medical diagnoses, including severe dementia with agitation, paranoid schizophrenia, and schizoaffective disorder, did not receive scheduled doses of Invega intramuscular injections as ordered. On several occasions, the medication was not available at the facility when it was due to be administered. Specifically, on one occasion, the injection was not given because it had not arrived at the facility, and on another, the medication was unavailable due to issues with insurance coverage. Documentation in the Medication Administration Record (MAR) and nurse notes confirmed these missed doses, with one instance lacking a documented reason for non-administration. The resident's medication orders for Invega were adjusted multiple times, including changes in dosage and administration schedule, in an effort to accommodate insurance requirements. Despite these adjustments, there were repeated failures to provide the medication as scheduled, resulting in missed doses. The facility's process for ordering and ensuring the timely availability of the medication was insufficient, as evidenced by the need to call the pharmacy to reorder the medication and the subsequent delay in administration.
Failure to Arrange Timely Outside Professional Services
Penalty
Summary
The facility failed to arrange for timely outside professional services for two residents who required them. One resident, with multiple diagnoses including Parkinson's disease, schizoaffective disorder, and dementia, was identified as needing dental care after an in-room dental exam revealed decay causing injury to her lip and a need for fillings. Despite a care plan intervention to coordinate dental care and transportation, there was no documentation that an outside dental appointment was scheduled or that the resident refused or canceled such appointments. Interviews with nursing staff and the former unit manager revealed confusion about who was responsible for scheduling and documenting these appointments, and a lack of clarity regarding insurance coverage and the current process for arranging outside services. Another resident, with diagnoses including hemiplegia, chronic respiratory failure, morbid obesity, major depressive disorder, type 1 diabetes, and epilepsy, was referred multiple times to an endocrinologist due to poorly controlled diabetes, as evidenced by elevated Hemoglobin A1c levels. Although the need for an endocrinology referral was documented in several provider notes and discussed in an interdisciplinary team meeting, there was a significant delay in arranging the appointment. The resident's family specifically requested a preferred endocrinologist, and while a referral was eventually made and an assessment conducted, staff interviews indicated uncertainty about when or if previous referrals were acted upon, and the responsible unit manager was unavailable for clarification. In both cases, the facility did not ensure that required outside professional services were arranged in a timely manner, as evidenced by the lack of documentation and follow-through on referrals and appointments. The deficiencies were identified through interviews with residents, staff, and review of medical records, which showed gaps in the process for coordinating and documenting outside care.
Incomplete and Disorganized Medical Records for Two Residents
Penalty
Summary
The facility failed to maintain complete, accurate, and systematically organized medical records for two residents. For one resident with severe vascular dementia, hypertension, and depression, the medical record did not contain an updated Pre-admission Screening/Resident Review (PASRR) reflecting a new diagnosis of depression, despite multiple psychiatric and nursing notes indicating the presence of depression and the initiation of antidepressant therapy. Interviews with staff confirmed that the PASRR was not updated in the medical chart when the new diagnosis was made, and the updated PASRR was not initially available in the resident's record. For another resident with a history of atherosclerotic heart disease, hypertension, diabetes, bipolar disorder, and muscle weakness, there was no documentation in the medical record regarding an elopement event that had been reported by the facility. The Regional Nurse Consultant confirmed that any change of condition, such as an elopement, should be documented in the progress notes, but no such documentation was found in the resident's file.
Failure to Implement Enhanced Barrier Precautions and Maintain Tube Feed Sanitation
Penalty
Summary
Staff failed to implement Enhanced Barrier Precautions (EBP) for a resident with chronic wounds and a feeding tube. Multiple observations showed that staff, including registered nurses and certified nursing assistants, did not wear gowns while providing direct care such as changing bed linens and briefs, or when reconnecting the resident's tube feed. The resident reported that staff wore gloves but not gowns during care. Staff interviews revealed inconsistent knowledge about the requirement to use gowns as part of EBP for residents with tube feeds and chronic wounds. Additionally, the resident's tube feed was observed to be disconnected and left uncapped, exposing the end of the tube to air. Both nursing staff and the regional nurse consultant confirmed that the tube should be capped when not in use to prevent contamination. The facility had a system in place to identify residents requiring EBP and provided gowns and masks outside the resident's room, but these precautions were not consistently followed by staff during care activities.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the actions, inactions, or events leading to the deficiency, nor information about the residents involved or their medical conditions at the time, are provided in the report.
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.
