Orem Rehabilitation And Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Orem, Utah.
- Location
- 575 East 1400 South, Orem, Utah 84097
- CMS Provider Number
- 465104
- Inspections on file
- 24
- Latest survey
- May 1, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Orem Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
Two high fall risk residents with significant cognitive and physical impairments experienced multiple falls without the facility implementing new or adequate interventions after each incident. Despite repeated falls and clear documentation of high risk, staff did not update care plans or provide increased supervision, relying instead on repeated education and minor environmental changes. Interviews confirmed that interventions were not sufficiently revised to address the ongoing risk, resulting in a failure to maintain a safe environment and prevent accidents.
Several nurse aides were employed for more than four months without completing the required state-approved training and competency evaluation program. Despite the 120-day limit for certification, these aides continued to work until it was discovered and they were removed from the schedule.
Several residents reported that their meals were often cold, bland, or unappetizing, with food fortification practices involving the addition of cold milk or butter to already plated food. Observations confirmed that food was served at improper temperatures and was not consistently palatable, and the dietary manager was unaware of resident dissatisfaction prior to the survey.
Surveyors identified multiple breaches in food safety standards, including unlabeled and undated food items, improper storage of meat above produce, food and cleaning supplies stored together, and staff personal items in food prep areas. Additionally, a staff member was observed handling food and plates with dirty gloves after touching various surfaces, and water was seen dripping onto the plate warmer.
A resident with chronic pain and intact cognition reported receiving the wrong medication from a nurse when requesting prescribed oxycodone. The resident and his daughter noticed discrepancies, including being given a different colored pill and experiencing symptoms consistent with medication errors. Facility investigation, including video review, confirmed that the nurse diverted the resident's narcotic medication and instead administered other medications, leading to substantiated misappropriation.
A resident with hemiplegia, diabetes, and reduced mobility experienced significant delays in receiving timely specialist appointments for hand contractures and foot drop, despite repeated requests and multiple physician orders. The facility's process required several steps and handoffs before appointments could be scheduled, resulting in the resident having to ask multiple times before an appointment was finally arranged.
A resident receiving oxygen therapy for acute respiratory failure was found to have undated nasal cannulas in use, and there was no physician's order in the medical record for changing oxygen supplies. Staff interviews confirmed that nurses were responsible for changing and dating the cannulas, but the absence of an order led to inconsistent practice and lack of documentation.
Nurse staffing information was not posted daily as required, with outdated postings observed and no updates made on weekends. The receptionist responsible for posting the data was absent on certain days, and no other staff took over the task. The weekend receptionist was not trained to post the information, resulting in missing postings that were later completed retroactively.
A resident with multiple chronic conditions had physician orders for several CBC tests, but the corresponding laboratory results were not found in the clinical record. The facility used two EHR systems, and the lab uploaded results to both; however, Medical Records staff only had access to one system, leading to the omission of required lab reports in the resident's record.
Two residents receiving prophylactic antibiotics for UTI were not consistently monitored under an antibiotic stewardship program. The IP tracked antibiotic use only during the month of initiation and did not maintain ongoing monitoring for long-term use, and the DON did not participate in infection control monitoring.
A resident with a history of trauma was denied the right to exit a room by the ADON, triggering distress. The ADON stood in front of the door during a conversation about the resident's inquiries into staff disciplinary actions, preventing her from leaving. The resident felt trapped, recalling past trauma, and the facility's investigation found the ADON's actions inappropriate, though not malicious.
A facility failed to report an abuse allegation involving a resident and the ADON within the required 2-hour timeframe. The incident, which caused the resident distress, was reported to the SSA 27.5 hours later and to APS eight days later. The resident had multiple health conditions, and the Administrator misunderstood the reporting requirements.
Failure to Implement Effective Fall Prevention Interventions for High-Risk Residents
Penalty
Summary
The facility failed to ensure that the environment was as free from accident hazards as possible and did not provide adequate supervision or implement new interventions to prevent accidents for two high fall risk residents. One resident with multiple diagnoses including dementia, muscle weakness, morbid obesity, and unsteadiness on feet was documented as a high fall risk and experienced several falls within a short period. Despite being a full assist and having a history of falls, no new fall prevention interventions were documented in the medical record after each incident. Staff interviews confirmed that no additional interventions were implemented, and the resident was not on continuous observation, even though the resident had fallen multiple times in a short timeframe and was ultimately sent to the hospital after a change in condition. Another resident with epilepsy, brain deformity, unsteadiness, and muscle weakness was also identified as a high fall risk and experienced multiple falls over several months. After each fall, the interventions implemented were often repeated or limited to education and minor environmental changes, such as providing a non-slip mat or instructing on proper footwear. Despite the resident's cognitive delays, impulsivity, and difficulty following instructions, the interventions did not change significantly after repeated falls, and the care plan was not sufficiently updated to address the ongoing risk. Interviews with nursing staff and consultants revealed that both residents required frequent prompting and supervision due to their cognitive and physical limitations. However, the facility did not implement new or different interventions after repeated falls, and the care plans were not adequately revised to prevent further incidents. The lack of timely and appropriate updates to interventions and care plans contributed to the deficiency in maintaining a safe environment and providing adequate supervision for these high-risk residents.
Nurse Aides Worked Beyond 120 Days Without Required Certification
Penalty
Summary
The facility failed to ensure that nurse aides who had been employed for more than four months were trained, competent, and had completed a state-approved training and competency evaluation program. Specifically, three nurse aides were found to have worked at the facility for over four months without obtaining certification as nursing assistants. Employee records showed that these nurse aides continued to work beyond the 120-day period allowed for certification. Interviews with the Administrator and the CNA Coordinator confirmed that the aides had exceeded the permitted timeframe for certification and had only recently been removed from the schedule due to this deficiency.
Failure to Provide Palatable and Appropriately Tempered Food
Penalty
Summary
The facility failed to provide food that was palatable, attractive, and at a safe and appetizing temperature for several residents. Multiple residents on specialized and regular diets reported that their food was often cold, bland, or unappetizing. Observations and interviews revealed that food fortification practices involved adding cold milk or drizzling butter onto already prepared and plated food, rather than incorporating these items during the cooking process. The dietary manager (DM) confirmed that fortification was done by adding unmeasured amounts of butter or cold milk directly to the plated food due to space constraints, and that the exact caloric content provided to residents was not tracked. During tray line service, staff were observed squirting cold milk and drizzling butter onto plated meals, resulting in food that was oily, bland, and not at the appropriate temperature. A test tray showed that the pureed chicken was cold and oily, the couscous was bland, and the broccoli was cool to the taste. Residents consistently reported dissatisfaction with the temperature and palatability of their meals, and the DM was unaware of these complaints prior to the survey. These findings were based on direct observation, interviews with residents and staff, and review of food service practices.
Food Storage and Service Safety Deficiencies
Penalty
Summary
Surveyors observed multiple failures in food storage, preparation, and service within the facility's kitchen. Unlabeled and undated food items, including a large container of liquid and carafes of juice, were found in the walk-in refrigerator. An opened box of bacon was stored above open produce, and a can of beets was found on the floor in dry storage. Large bins of rice and cereal were not labeled or dated. Staff personal items, such as cellphones and drink cups without lids, were stored on food preparation tables. Cleaning supplies were stored in the same room as fresh produce. Water was observed dripping from a ceiling vent onto the plate warmer. During meal service, a staff member was seen handling plates and food with dirty gloves after touching other surfaces, including plate covers, meal tickets, the faces of plates, a shelf, and an electrical cord. The Dietary Manager confirmed that these practices were not in accordance with facility policy or professional standards, stating that food should not be stored on the floor, meat should be stored below produce, bins should be labeled and dated, and staff should not have personal items in food preparation areas or touch other surfaces before handling food or plates.
Misappropriation of Resident's Pain Medication by Nursing Staff
Penalty
Summary
A resident with diagnoses including cerebral infarction, respiratory failure, and chronic pain syndrome, and who was cognitively intact, reported concerns about receiving incorrect medications from a specific nurse. The resident stated that on multiple occasions, when requesting his prescribed oxycodone for pain, he was given a different colored pill, which he identified as not being his usual pain medication. The resident's daughter also witnessed the administration of a white pill instead of the expected medication and later raised the issue with facility staff. The resident experienced symptoms such as an upset stomach and noted that his pain medication supply depleted faster than expected, while his heart medication was being administered in excess, as confirmed by his physician. The facility's investigation included interviews, review of medication administration records, and examination of video footage. The footage showed the nurse in question accessing the narcotic drawer, removing medication, and placing it in her pocket rather than administering it to the resident. The nurse was also observed preparing pill packs and explaining the process to the resident's daughter, who expressed confusion about the medication packaging. The nurse denied any wrongdoing but could not account for the discrepancies in medication administration. The facility verified that the resident was not administered his prescribed narcotic as ordered and that the nurse had diverted the medication. The nurse was found to have violated the facility's code of conduct regarding drug diversion. The incident was reported to the appropriate authorities, and the nurse was subsequently terminated. The resident was considered a vulnerable adult with full capacity at the time of the incident, and the misappropriation of his medications was substantiated by both facility and external investigations.
Delay in Specialist Referrals for Contractures and Foot Drop
Penalty
Summary
A deficiency was identified when a resident with hemiplegia, hemiparesis, type 2 diabetes mellitus, reduced mobility, and major depressive disorder was not provided timely appointments with referred specialists for hand contractures and foot drop. The resident, who had intact cognition as indicated by a BIMS score of 15, repeatedly requested to see an orthopedic hand surgeon and a podiatrist for worsening contractures and drop foot. Despite multiple encounter notes and physician orders documenting the need for these referrals, there were significant delays in scheduling the appointments. The process for scheduling specialist appointments involved several steps: the in-house physician would order the referral, the floor nurse would enter and print the order for the physician's signature, and the signed order would then be routed to the Director of Transportation (DT) for scheduling. Interviews with staff revealed that the DT could only schedule appointments after receiving the signed order, and that delays could occur due to the need for provider acceptance, insurance verification, and document transmission. The DT, nurses, and DON described a workflow that required multiple handoffs and physical movement of paperwork, which contributed to the delay. Documentation showed that the resident's requests and the need for specialist evaluation were repeatedly noted from early February through late March, with orders for referrals being placed and re-affirmed multiple times. However, the actual appointment for the orthopedic hand surgeon was not scheduled until late April, with the appointment set for early May. The resident reported having to ask multiple times before the appointment was finally arranged, indicating that the facility did not reasonably accommodate her needs and preferences in a timely manner.
Failure to Ensure Proper Orders and Documentation for Oxygen Supply Changes
Penalty
Summary
A deficiency was identified when a resident with acute respiratory failure with hypoxia, epilepsy, and subarachnoid hemorrhage was observed using oxygen therapy without proper documentation or adherence to professional standards for respiratory care. The resident was seen with undated nasal cannulas attached to both an oxygen concentrator and a portable oxygen tank. Multiple staff interviews confirmed that nurses were responsible for changing and dating the nasal cannulas, and that such changes were expected to occur weekly. However, there was no physician's order in the medical record for changing the oxygen supplies, and the cannulas in use were not dated as required. Further review and staff interviews revealed that the process for changing and documenting oxygen supplies was not being followed due to the absence of a physician's order in the resident's medical record. The lack of an order resulted in the failure to consistently change and date the nasal cannulas as per facility protocol and professional standards. This lapse was confirmed by nursing staff and the regional nurse consultant, who acknowledged that the required order was missing and that the changes had not been occurring as expected.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post daily nurse staffing information as required, with observations showing that the posted information was outdated and not updated on weekends. During an initial tour, the nurse staffing posting was found to be several days old. Interviews revealed that the receptionist, who was responsible for posting the staffing data, was absent on certain days and no one else assumed the responsibility in her absence. Additionally, the daily nurse staffing information was not posted on weekends because the weekend receptionist was not trained to do so. For days when the information was not posted, the receptionist later completed the records retroactively and stored them in a binder.
Failure to File Laboratory Reports in Resident Record
Penalty
Summary
A deficiency was identified when it was found that laboratory reports for a resident were not filed in the resident's clinical record as required. The resident, who had multiple diagnoses including type 2 diabetes, congestive heart failure, essential hypertension, schizoaffective disorder, Bell's palsy, anxiety disorder, and depression, had physician orders for Complete Blood Count (CBC) tests on several occasions. However, no laboratory results for the CBCs ordered on three specific dates could be located in the resident's electronic medical record. During interviews, it was revealed that the facility used two electronic health record (EHR) applications, and the laboratory uploaded results to both. The Medical Records staff only had access to one of these applications and could only file results that were uploaded to the system they could access. The missing laboratory results were uploaded to the EHR application that Medical Records did not have access to, resulting in the reports not being filed in the resident's clinical record.
Failure to Monitor Long-Term Antibiotic Use
Penalty
Summary
The facility failed to maintain an effective antibiotic stewardship program that included protocols and a system to monitor all antibiotic use for residents. Specifically, two residents with orders for prophylactic antibiotics were not adequately monitored. One resident had a physician's order for Keflex 500 mg at bedtime for UTI prophylaxis, and another had a physician's order for Cephalexin 250 mg daily for chronic UTI prophylaxis related to long-term antibiotic use. Record reviews confirmed that these residents were on long-term antibiotic therapy. Interviews with facility staff revealed gaps in the monitoring process. The Infection Preventionist (IP) stated that antibiotic reviews were not consistently performed for residents on long-term prophylactic antibiotics, and tracking was only done for the month the antibiotic was initiated, without ongoing monitoring in subsequent months. The IP also confirmed there was no system in place to track residents on long-term antibiotic use. The Director of Nursing (DON) indicated that she did not participate in infection control monitoring, leaving all antibiotic stewardship responsibilities to the IP.
Resident Denied Right to Exit Room by ADON
Penalty
Summary
The deficiency involved a resident who was denied the right to exit a room by facility staff, specifically the Assistant Director of Nursing (ADON). The resident, who was cognitively intact with a BIMS score of 15, had a history of trauma and was triggered by the ADON's actions. The incident occurred when the ADON brought the resident into his office to address a concern about the resident asking staff about a disciplinary action involving another staff member. During the conversation, the resident attempted to leave, but the ADON stood in front of the door, preventing her from exiting, which caused the resident distress and triggered memories of past trauma. The facility's investigation revealed that the ADON's actions were inappropriate, although not malicious. The ADON admitted to standing in front of the door to stop the resident from leaving, which was confirmed by RN 1, who was present during the conversation. The ADON's demeanor and communication style were perceived as stern and could have been interpreted as intimidating by the resident. The resident reported feeling trapped and compared the situation to past experiences with her ex-husband, which exacerbated her distress. The facility's policy on abuse and involuntary seclusion was reviewed, which defines involuntary seclusion as the separation of a resident from others or confinement against their will. The ADON acknowledged that he should have allowed the resident to leave when she expressed a desire to do so. The incident highlighted a failure to respect the resident's right to freedom from involuntary seclusion, as the ADON's actions effectively confined the resident to the office against her will.
Delayed Reporting of Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident and the Assistant Director of Nursing (ADON) within the required timeframe. The incident occurred when the ADON brought a resident into his office to discuss a concern raised by a Certified Nurse Assistant (CNA) regarding inappropriate inquiries made by the resident. During the conversation, the resident attempted to leave the office, but the ADON stood in front of the door, insisting on continuing the discussion, which caused the resident distress. This incident was reported to the State Survey Agency (SSA) 27.5 hours after the allegation was made, exceeding the regulatory requirement of reporting within 2 hours if the event involved abuse. The resident involved had multiple diagnoses, including Parkinson's disease, congestive heart failure, and type II diabetes mellitus, among others, and was discharged from the facility on a later date. The facility also failed to notify Adult Protective Services (APS) of the incident until eight days after the allegation was made. The Administrator believed the report to the SSA was timely, misunderstanding the requirement, thinking he had 24 hours to report since the allegation did not result in serious bodily injury.
Latest citations in Utah
Surveyors found that the facility did not ensure residents or their representatives were informed of and able to participate in decisions about psychotropic medications. Several residents with conditions such as dementia, early-onset Alzheimer’s disease, major depressive disorder, psychotic disorder, and Parkinson’s disease were started on drugs including haloperidol, donepezil, buspirone, quetiapine, zaleplon, and sertraline without documentation that risks, benefits, or alternative treatments were discussed in advance. The DON reported that staff notify families when medications are started or changed but do not review risks and benefits, offer alternative options, or obtain signed consent, resulting in no evidence of informed decision-making for these psychotropic treatments.
Surveyors determined that the facility failed to consistently manage psychotropic medications for three residents. Two residents with dementia and psychiatric conditions had only one documented psychotropic medication review and gradual dose reduction (GDR) attempt, completed in January, with no evidence of quarterly reviews or additional GDR efforts. Another resident with hemiplegia, psychotic disorder, dementia, and major depressive disorder had a PRN IM haloperidol order written without an end date, which remained active and was administered on multiple occasions beyond 14 days, and the DON confirmed there was no physician documentation justifying the extended PRN antipsychotic order.
The facility failed to ensure that alleged abuse and serious injuries were reported to the State Survey Agency as required, instead either reporting only to a state patient safety system or not reporting at all. One resident with severe cognitive impairment sustained bilateral femur fractures after a fall, another cognitively impaired resident with Parkinson’s disease was later found to have a femur fracture after being discovered on the floor, and a third cognitively impaired resident required ORIF surgery for fractures following a fall; none of these incidents were reported through the State Survey Agency’s incident reporting website, per the ADM. In addition, an allegation that a resident with dementia and sensory impairments may have been molested was documented in the abuse binder but not in the medical record, and the ADM did not report the allegation to agencies or law enforcement after deeming it not credible, despite interviewing the resident and family. These actions and omissions resulted in multiple unreported events that met criteria for immediate reporting of alleged abuse and injuries of unknown source.
The facility failed to investigate multiple major injuries and an allegation of sexual abuse involving three residents with severe cognitive impairment and significant medical conditions. One resident, dependent for transfers, was found on the floor after attempting to get out of bed and was later found to have bilateral femur fractures. Another resident with Parkinson’s disease was found on the floor after a wheelchair alarm sounded and was later diagnosed with a femur fracture following complaints of leg pain. A third resident, described as very independent, triggered a bed alarm and was found kneeling by a recliner, later requiring ORIF for fractures of the right 4th and 5th metacarpals. In each case, the ADM acknowledged awareness of the fractures, stated there was no belief of neglect or abuse, and confirmed that no investigation into the cause of the injuries or the alleged abuse was initiated or documented.
Surveyors found that the facility failed to ensure monthly pharmacist drug regimen reviews were completed and documented for several residents with conditions such as Parkinson’s disease, dementia, and Alzheimer’s disease, with no pharmacist notes present for at least two consecutive months. Additionally, a pharmacist’s recommendation to add a low-dose daytime antipsychotic for a resident with dementia, psychotic disorder, and behavioral symptoms was not communicated to the physician or implemented for several months, despite documented behavioral concerns. An LPN reported not relaying the pharmacist’s recommendation because PRN Haldol had not been needed at that time, and the DON confirmed that the pharmacist reviews for the missing months were not done and that she did not have time to monitor follow-through on such recommendations.
Surveyors identified a failure to properly label medications when two open insulin pens were found in a medication refrigerator bin marked only with a resident’s first name, with no labels directly on the pens. During an observation, an RN confirmed the pens belonged to a resident and acknowledged that pens are supposed to be labeled with the resident’s name but could not explain why these were not labeled. In a subsequent interview, the DON confirmed the pens had been unlabeled and stated they should have been labeled in accordance with professional standards.
The facility failed to sustain effective QAPI processes related to pharmacist medication regimen reviews, resulting in repeated noncompliance with F756. Surveyors found that medical records for four residents lacked documentation showing that a pharmacist had reviewed medications, identified potential irregularities, or made recommendations to attending physicians, an issue previously cited. The DON reported she did not have time to maintain this documentation, and the Administrator acknowledged there was no formal performance improvement project in place, though some plans were noted in QAPI minutes, and no supporting documents were produced to demonstrate ongoing compliance.
Staff failed to follow infection control practices during medication administration and did not maintain organized infection surveillance documentation. An LPN was observed handling an oral medication with bare hands before administering it to a resident, contrary to the DON’s stated expectation that pills be dispensed directly into medication cups without hand contact and that any contaminated dose be discarded. Additionally, the DON, who also served as the Infection Preventionist, reported that several residents had influenza during a past holiday season but had no list of affected residents or rooms, and the requested infection control surveillance logs and a formal tracking system were not available.
The facility lacked an antibiotic stewardship program, with no protocols to ensure appropriate indication, dose, and duration of antibiotic prescriptions and no system to monitor antibiotic use or resistance patterns. When surveyors requested Infection Control Surveillance Logs, including antibiotic tracking information, the logs were not available. In an interview, the DON, who also functioned as the Infection Preventionist, acknowledged that she did not track resident antibiotic utilization, clinical indications, or treatment durations.
A resident with multiple chronic conditions, including DM, HTN, anxiety, major depressive disorder, and PTSD, reported that a CNA on night shift failed to hold open a smoking-area door, leading the resident to grab the door and sustain a finger cut that bled. The resident completed a grievance with the RA, who documented that the CNA swung the door open and walked away and that no abuse or neglect allegation was initially identified. However, the grievance lacked documentation of investigative steps, a summary of findings, a conclusion on whether the grievance was confirmed, and any decision date or required signatures, and leadership later reported they had not been informed of the incident, demonstrating the grievance was not promptly resolved or fully tracked through conclusion.
Failure to Inform Residents of Risks, Benefits, and Alternatives Before Starting Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents, or their representatives, were informed of and allowed to participate in decisions regarding psychotropic medication treatment, including being informed in advance of the risks, benefits, and treatment alternatives. For four sampled residents, medical record review showed new orders for multiple psychotropic medications without any documentation that the resident or representative had been informed of these elements prior to initiation. Resident 8, with diagnoses including hemiplegia and hemiparesis following cerebral infarction, psychotic disorder with delusions, dementia, and major depressive disorder, was started on haloperidol lactate, donepezil, buspirone, quetiapine, and sertraline on various dates, with no documentation of informed discussion or consent. Resident 4, with unspecified dementia and anxiety disorder, was started on zaleplon, quetiapine, and buspirone, again with no record that risks, benefits, or alternatives were discussed in advance. Resident 54, diagnosed with early-onset Alzheimer’s disease and dementia in other diseases classified elsewhere, was started on sertraline and quetiapine, and Resident 6, diagnosed with Parkinson’s disease without dyskinesia, was started on buspirone, quetiapine (Seroquel), and sertraline, with no documentation that either resident or their representative had been informed of the risks and benefits or treatment options before these psychotropic medications were initiated. During an interview, the DON stated that the facility notifies families when medications are started or doses are changed but does not discuss risks and benefits, provide alternative options, or obtain signed consent. This practice contributed to the lack of documented evidence that residents or their representatives were fully informed and able to participate in treatment decisions regarding psychotropic medications.
Failure to Perform Regular GDR and Limit PRN Antipsychotic Orders
Penalty
Summary
Surveyors found that the facility did not ensure appropriate management of psychotropic medications for three sampled residents. For two residents with dementia and related psychiatric diagnoses, the medical records from late April 2026 showed only one documented psychotropic medication review and gradual dose reduction (GDR) attempt, completed in January 2026. There was no documentation of any GDR attempts or psychotropic reviews prior to January 2026, despite the DON stating that such reviews and GDRs should be completed quarterly. The records for these residents did not contain additional GDR attempts beyond the January 2026 review. For a third resident with hemiplegia following cerebral infarction, psychotic disorder with delusions, dementia, and major depressive disorder, a physician’s order dated February 8, 2026, prescribed PRN intramuscular haloperidol lactate every 12 hours for delusions, hallucinations, paranoia, and agitation, without an end date. Review of the MARs for February through April 2026 showed that this PRN antipsychotic was administered on two occasions, and no end date was documented on the MAR. In an interview, the DON acknowledged that the PRN haloperidol order extended beyond 14 days and that the physician had not documented a reason for continuing the order beyond that period.
Failure to Report Alleged Abuse and Serious Injuries to State Survey Agency
Penalty
Summary
The deficiency involves the facility’s failure to ensure that all alleged violations of abuse, including injuries of unknown source and incidents involving major injuries, were reported immediately to the State Survey Agency and other officials as required by state law. For four sampled residents, the Administrator acknowledged that incidents were reported only to the state’s patient safety website and not to the State Survey Agency’s incident reporting website. This omission meant that the State Survey Agency did not receive timely notice of serious events, including an allegation of sexual abuse and multiple incidents resulting in significant fractures and surgery. For one resident with severely impaired cognition and diagnoses including hemiplegia and hemiparesis, nursing notes documented that the resident was found on the floor after attempting to get out of bed, was sent to the ER, and returned with immobilizing braces on both legs due to bilateral femur fractures. The resident’s bones were not strong enough for surgery, and he was placed on comfort care. Despite the seriousness of the injuries and the requirement to treat such events as potential abuse or neglect until ruled out, the Administrator stated that this incident was reported only to the state’s patient safety website and not to the State Survey Agency’s incident reporting system. Another resident with Parkinson’s disease and severely impaired cognition was found on the floor after a wheelchair alarm sounded, initially with no visible injury and able to bear weight. A few days later, staff documented complaints of left leg pain, tenderness, and wincing with movement, leading to an order for x‑rays and transfer for imaging. X‑ray results revealed a femur fracture, and surgery was not pursued. The Administrator reported this incident to the state’s patient safety website but not to the State Survey Agency’s incident reporting website. A third resident with severe cognitive impairment experienced a fall with complaints of pain in the left knee, left elbow, and fingers, and later underwent ORIF surgery for fractures of the right fourth and fifth metacarpals; this incident also was not reported to the State Survey Agency’s incident reporting system, according to the Administrator. For another resident with dementia, adjustment disorder with anxiety, hearing and visual loss, and age‑related debility, a document in the facility’s abuse binder described a possible molestation allegation originating from a phone call by the resident’s nephew. The nephew reported that his mother, the resident’s sister and then‑POA, was emotionally unstable and had stated she felt the resident had reported being molested. The Administrator documented that the nephew did not believe the allegation was credible, that the sister had dementia and emotional issues, and that the Administrator considered the report “not a viable allegation.” The Administrator noted that he interviewed the resident, who denied being touched, and that the sister could not provide more details beyond stating that a man had groped the resident’s breast. The Administrator concluded the allegation was not credible and did not report it to any agencies or law enforcement. The incident was not documented in the resident’s medical record, and the Administrator confirmed in interview that he did not report this sexual abuse allegation to the State Survey Agency’s incident reporting website. Across these four residents, the common deficiency was the facility’s failure to treat serious injuries and a sexual abuse allegation as reportable events to the State Survey Agency, as required. Instead, the Administrator limited reporting to the state’s patient safety website or chose not to report at all when he personally judged an allegation as not credible. This pattern of inaction regarding mandated reporting requirements formed the basis of the cited deficiency.
Failure to Investigate Major Injuries and Alleged Abuse
Penalty
Summary
The deficiency involves the facility’s failure to initiate and document investigations into multiple major injuries and an allegation of sexual abuse, as required for all alleged violations involving abuse and injuries of unknown source. For one resident with hemiplegia, hemiparesis, and severely impaired cognition (BIMS score of 6), nursing notes documented that his roommate activated the call bell after the resident fell while attempting to get out of bed by himself. He was found on the floor between his bed and the window, reported knee pain with a popping sensation, and was sent to the ER. On return from the hospital, he was noted to have bilateral femur fractures, immobilizing braces on both legs, and was placed on comfort care due to bones not being strong enough for surgery. The Administrator acknowledged awareness of the bilateral femur fractures, stated he did not believe neglect or abuse caused the injury, and confirmed he did not investigate the cause of this major injury. Another resident with Parkinson’s disease and a BIMS score of 0 (rarely/never understood) was documented in an incident note as sitting in a wheelchair in the dining room when his alarm sounded; he was found supine on the floor, denied hitting his head or injury, and was assisted back into the chair with no signs of injury noted. Several days later, nursing notes recorded that CNAs reported the resident complaining of left leg pain when getting him out of bed. On assessment, he had tenderness and wincing with movement of the left leg but was able to bear weight. The MD was notified, an x-ray was ordered, and the resident was transported for imaging, which revealed a femur fracture for which surgery was not pursued. The Administrator stated he was aware of the femur fracture, did not feel neglect or abuse caused the major injury, and did not investigate the cause of the injury. A third resident with COPD, scoliosis, and severely impaired cognition (BIMS score of 7) had an incident note documenting that her bed alarm sounded and staff found her in a kneeling position leaning into her recliner after she attempted to get up from bed to go to the bathroom, stating her walker “didn't go where she was going.” She complained of left knee, left elbow, and right pinky pain, with no visible injury except an abrasion on the right ring finger. A later nursing note documented that she underwent ORIF of fractures of the right fourth and fifth metacarpals at a hospital and returned from surgery the same day. The Administrator reported being aware of the fractures, described the resident as very independent and wanting to wander the facility, stated he did not feel neglect or abuse caused the major injury, and confirmed he did not investigate the cause of the injury. Across these three residents, the facility did not initiate or document investigations into the causes of the major injuries or the related allegation of sexual abuse, nor did it determine causation or responsible parties as required.
Failure to Complete Monthly Pharmacist Reviews and Timely Act on Medication Recommendations
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a licensed pharmacist conducted and documented monthly drug regimen reviews for multiple residents and to ensure that identified medication irregularities were acted upon by the attending physician. For four sampled residents, the medical records lacked monthly pharmacist medication regimen review notes for at least two consecutive months. Specifically, residents with diagnoses including Parkinson’s disease, unspecified dementia, Alzheimer’s disease with early onset, and dementia related to other diseases had no documented pharmacist review notes for March and April 2026. The DON confirmed that the pharmacist had not completed pharmacy reviews for those months and that the notes, which should have been uploaded into each resident’s electronic medical record, were absent. In addition, the facility failed to act promptly on a pharmacist’s recommendation for a resident receiving psychotropic medications. One resident with hemiplegia following cerebral infarction, psychotic disorder with delusions, dementia, and major depressive disorder had a pharmacist recommendation in November 2025 to add a low-dose daytime Seroquel due to behavioral issues and afternoon anxiety. Nursing documentation showed that the pharmacist discussed the resident’s response to Seroquel versus Abilify and suggested a low-dose daytime Seroquel, but this recommendation was not communicated to the physician at that time. The LPN later stated she did not speak to the physician about the pharmacist’s recommendation because the resident had not needed PRN Haldol around that time. The physician did not write the order for daytime Seroquel until early February 2026, after a nurse raised concerns about the resident’s behaviors and reminded the physician of the prior pharmacist recommendation. The DON acknowledged that the pharmacist’s November 2025 recommendation was not completed until February 2026 and stated she did not have time to stay on top of such issues.
Unlabeled Insulin Pens Found in Medication Refrigerator
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled in accordance with accepted professional principles when two open insulin pens belonging to resident 56 were found without the resident’s name on them. During an observation of the south medication refrigerator on 4/29/26 at 10:50 AM, surveyors noted a plastic bin labeled only with resident 56’s first name, containing two loose, open insulin pens that had no resident identification labels affixed directly to the pens. In a concurrent interview, RN 1 confirmed that the two insulin pens belonged to resident 56 and stated that staff always put residents’ names on insulin pens, but was unsure why these pens had not been labeled. Later that day at 2:17 PM, the DON stated in an interview that the two insulin pens in question had been unlabeled and acknowledged that the insulin pens should have been labeled with the resident’s information.
Failure to Sustain QAPI Actions and Documentation for Pharmacist Medication Reviews
Penalty
Summary
The deficiency involves the facility’s failure, as part of its performance improvement activities, to take actions aimed at performance improvement, measure the success of those actions, and track performance to ensure that improvements were realized and sustained, specifically related to F756. Record review and interviews showed that the facility did not maintain documentation in the medical records to demonstrate that a pharmacist reviewed residents’ medications, identified potential irregularities, or provided recommendations to the attending physician for four sampled residents, despite this same issue having been cited in the previous health survey in 2024. During an interview, the DON stated she did not have time to maintain this required documentation. In a separate interview, the Administrator stated he did not have a performance improvement project, though he had QAPI minutes that captured some improvement plans, and he believed the facility had achieved compliance with F756, which had been cited previously, but no documents demonstrating compliance were provided when requested by surveyors.
Failure in Medication Handling and Infection Surveillance Documentation
Penalty
Summary
The facility failed to ensure a safe and sanitary environment during medication administration and infection surveillance. During an observation of medication pass for resident 23, an LPN was seen popping an oral pill directly from a blister pack into her bare hand and then placing it into a medication cup, after which the medication was administered to the resident. In a subsequent interview, the DON stated that staff were expected to pop pills directly into medication cups and never touch medications with bare hands, and that any medication contacting a staff member’s bare hand was to be discarded and replaced, indicating that the observed practice did not follow facility expectations. The facility also failed to maintain infection control surveillance documentation and an organized tracking system for infections. When Infection Control Surveillance Logs were requested, the DON reported that several residents had contracted influenza during the 2025 holiday season, attributed to an increased number of visitors, and that symptomatic residents were kept in their rooms. However, the DON stated she did not have a list of affected residents or rooms, and the requested surveillance logs were unavailable for review. In a later interview, the DON, who also served as the facility’s Infection Preventionist, confirmed that the facility lacked an infection control surveillance manual or organized system for tracking infections.
Failure to Implement and Monitor an Antibiotic Stewardship Program
Penalty
Summary
The facility failed to develop and implement an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use. There was no established facility-wide system to ensure appropriate indication, dose, and duration for antibiotic prescriptions, and no process for monitoring antibiotic usage or resistance data. On 4/29/26 at 8:20 AM, when surveyors requested the facility’s Infection Control Surveillance Logs, including any prescribed antibiotic tracking information, these logs were unavailable. On 4/30/26 at 12:28 PM, during an interview, the DON, who also served as the facility’s designated Infection Preventionist, stated that she did not track resident antibiotic utilization, including the specific clinical indications for the medications or the prescribed durations of treatment. No specific residents, their medical histories, or clinical conditions at the time of the deficiency were described in the report.
Failure to Promptly Resolve and Document Resident Grievance Regarding Door Injury
Penalty
Summary
The deficiency involves the facility’s failure to promptly resolve and properly document a resident grievance in accordance with its grievance policy. A resident with type II DM, HTN, anxiety disorder, major depressive disorder, and PTSD reported that a CNA on night shift did not hold open the smoking door for her and another resident, and that when she went to grab the door, it slammed on or closed against her finger, causing a cut to bleed. The resident stated she reported this to the Resident Advocate (RA) and completed a grievance form, and that nursing staff applied Neosporin and a bandage to the finger. The resident did not know the CNA’s name but identified that the CNA worked nights and stated that no one should be treating residents that way. The grievance form dated 4/10/26 documented the concern that the CNA on night shift did not hold the smoking door open and instead swung the door open and walked away, and that upon initial interview no allegation of abuse or neglect was identified. However, the grievance form contained no documentation of investigative steps taken, no summary of findings or conclusion, and no indication whether the grievance was confirmed or not. The form also lacked a written decision date, resident signature, grievance officer signature, and Administrator signature. The RA reported that the resident told her the door incident caused a small cut to reopen and that the CNA seemed in a hurry, but did not state that the CNA acted intentionally or purposefully toward her. The Administrator and DON later stated they had not been informed of the incident, and the Regional Nurse Consultant noted that nothing was filled out on the back of the grievance form, indicating it remained incomplete despite having been initiated several days earlier.
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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.
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