Pine Creek Rehabilitation And Nursing
Inspection history, citations, penalties and survey trends for this long-term care facility in Salt Lake City, Utah.
- Location
- 876 West 700 South, Salt Lake City, Utah 84104
- CMS Provider Number
- 46A064
- Inspections on file
- 18
- Latest survey
- October 9, 2025
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Pine Creek Rehabilitation And Nursing during CMS and state inspections, most recent first.
A resident with multiple medical and psychological diagnoses gave a NA $100 after learning of her financial difficulties. The NA accepted the money after the resident insisted, but did not return the funds when the resident later requested them back. The resident reported the issue to staff and became increasingly distressed, while the NA admitted to accepting the money and not knowing it was prohibited. Staff interviews confirmed the resident's upset state, and there was no evidence of specific training addressing this type of incident.
A resident with multiple medical conditions gave $100 to a NA, later requesting its return when needed for personal expenses. The NA did not respond, and the resident reported the issue to staff. The facility verified the misappropriation but failed to report the incident to APS within the required timeframe and did not notify law enforcement, as required by regulations.
Two residents experienced significant health complications after falls due to the facility's failure to provide timely care and monitoring. One resident, with a history of falls and heart disease, was not given neurological assessments after an unwitnessed fall, leading to hospitalization for sinus arrest. Another resident, with a history of brain injury, experienced a fall and subsequent deterioration in condition, resulting in hospitalization for a subdural hematoma. The facility's inaction and delayed response to these acute changes in condition were identified as deficiencies at the Immediate Jeopardy level.
A resident with a complex medical history was not properly secured in a facility vehicle during transport, leading to a fall and serious injuries, including a Thoracic (T)11-T12 fracture. The transportation driver, also the Therapeutic Recreation Specialist, failed to secure the resident with a seatbelt, relying instead on wheelchair straps, which resulted in the resident falling forward and sustaining injuries.
A resident with a history of suicidal ideations did not receive necessary behavioral health services for over two months after a hospitalization for a suicide attempt. Despite a care plan indicating the need for counseling, there was a significant delay in implementing mental health therapy. Interviews revealed staff were unaware of when services began, and no psychosocial assessment was conducted after re-admission. The resident's room contained items that could be used for self-harm, highlighting a lack of environmental safety measures.
The facility failed to ensure a dignified dining experience for residents, as staff were observed standing while assisting with meals, using labels instead of names, and not serving meals simultaneously. A resident with multiple diagnoses struggled during a meal without adequate assistance, and flies were observed landing on them. The DON confirmed that aides should be seated and provide proper assistance.
Two residents experienced incidents that were not reported in a timely manner. A resident with severe cognitive impairment was found with a new bruise, but the facility did not report it to the SSA or APS. Another resident experienced verbal abuse from a CNA, and while the SSA was notified, APS was not. The facility's policies require immediate reporting, but these procedures were not followed, leading to a deficiency in regulatory compliance.
The facility failed to prevent further potential abuse during investigations involving a resident with dementia and bipolar disorder. In two separate incidents, the resident was involved in physical and alleged sexual abuse cases with other residents. Despite implementing 15-minute checks as a corrective measure, the facility did not consistently document these checks, contributing to the deficiency.
The facility failed to document and communicate necessary information during the transfer of four residents to the hospital. This included missing documentation of transfer paperwork and lack of communication of essential details such as the POLST form, care instructions, and comprehensive care plans. Interviews with staff revealed inconsistent practices in ensuring that all required information accompanied residents during transfers.
The facility failed to properly store and label medications, including insulin pens and vaccines, in accordance with professional standards. Insulin pens lacked open dates and resident names, and some medications were expired yet available for use. Staff interviews revealed a lack of adherence to labeling protocols.
The facility failed to obtain necessary lab tests for two residents, leading to deficiencies in care. One resident did not receive INR tests for two months despite physician orders, and another resident's BMP was missed entirely. The DON acknowledged lapses in the lab process, including reliance on a single staff member for accessing lab results and lack of documentation by nurses.
The facility failed to secure resident-identifiable information on two occasions when nurses left computer screens open on medication carts. Additionally, the facility did not maintain complete medical records for a resident with multiple medical conditions, as documentation of a hospital visit following a suicidal incident was initially missing. The DON confirmed the expectation to lock computer screens to protect HIPAA information and later obtained the necessary hospital documentation.
The facility failed to document COVID-19 vaccine education and administration for several residents, as required by its policy. The medical records of four residents with various health conditions lacked evidence of vaccine education, administration, or declination. The DON was unable to locate the necessary documentation, indicating non-compliance with the facility's vaccination policy.
The facility failed to protect residents from abuse, including inappropriate communication by a CNA, verbal abuse by another CNA, and physical abuse between residents. A resident was asked for nude photos by a CNA, another was mocked during a meal service, and a resident was stabbed with a pen by another resident during a manic episode.
The facility failed to notify physicians of significant changes in two residents' conditions. A resident with multiple diagnoses was found with an unexplained bruise, and another resident refused blood tests without proper documentation or physician notification. Interviews revealed inconsistencies in documentation and communication practices.
A facility failed to report an allegation of verbal abuse by a CNA towards a resident to Adult Protective Services (APS). The incident involved the CNA mocking the resident while passing breakfast trays. Although the State Survey Agency (SSA) was notified, there was no documentation of APS notification, contrary to the facility's abuse reporting policy.
A facility failed to implement PASRR Level II recommendations for a resident with mental illness, leading to a deficiency. The resident, with a history of major depressive disorder and suicide attempts, did not receive timely counseling services as recommended. Despite experiencing suicidal ideations and being hospitalized, there was no psychosocial assessment conducted, and the initiation of behavioral health services was unclear. Interviews with the DON and an RN highlighted gaps in the facility's response to the resident's mental health needs.
A resident with schizoaffective disorder did not receive their prescribed psychotropic medications due to unavailability from the pharmacy, leading to increased irritability and an aggressive incident. The facility's process for reordering medications was followed, but delays in delivery and lack of availability in the Nexsys system contributed to the deficiency.
Two residents experienced deficiencies in medication management, including inadequate monitoring of blood glucose for a diabetic resident and failure to administer thyroid medication and address pain for another. The facility lacked proper documentation and follow-up on medication effectiveness, highlighting issues in ensuring necessary and effective drug regimens.
A resident with a complex medical history, including schizoaffective disorder and generalized anxiety disorder, was prescribed multiple psychotropic medications without adequate monitoring for adverse side effects or behavioral episodes. The facility failed to document non-pharmacological interventions prior to medication administration, as expected by the DON.
A facility was found to have a medication error rate of 7.41%, exceeding the acceptable 5% threshold. Two residents received incorrect medication dosages due to errors by an RN. One resident was nearly given an incorrect dose of Haloperidol, while another received only half the prescribed dose of Loperamide. The RN admitted to not realizing the errors and lacked knowledge of potential side effects. The DON acknowledged that incident reports were not always completed as required.
A resident's lab results were not communicated to the physician despite being outside clinical reference ranges, and tests were conducted without a physician's order. The DON was responsible for lab orders and follow-ups, but the process lacked proper documentation and verification.
A facility failed to maintain complete laboratory records for a resident, as lab results for lithium level checks were not uploaded into the electronic medical record. The resident, with multiple health conditions including bipolar disorder, had physician orders for lithium monitoring, but the results were missing from the record. The DON confirmed the oversight.
A facility failed to include signed and dated EKG reports in a resident's medical records. The resident, with a complex medical history, was ordered a 12 lead EKG for monitoring, but the reports were not filed. The DON confirmed the report was sent to the provider but not to the facility.
The facility failed to provide food that was palatable, attractive, and at a safe temperature, as evidenced by resident complaints and a test tray evaluation. Two residents reported issues with cold and bland food, and a test tray revealed soggy, bland, and overly salty items. The Corporate Dietitian noted that grievances could be filed for food complaints.
The facility's QAA committee did not include the Medical Director as a participating member, violating regulatory requirements. The committee met quarterly, but the Medical Director's attendance was inconsistent, with the Administrator confirming that the Medical Director did not attend the June 2024 meeting and was unsure about the March 2024 meeting. This deficiency highlights a failure to meet the mandated composition and function of the QAA committee.
A registered nurse in an LTC facility failed to maintain proper infection control practices during medication administration for two residents. The nurse did not perform hand hygiene before preparing medications and was observed dropping medications onto the cart and floor. Despite disposing of dropped medications, the nurse continued without sanitizing hands, contrary to facility expectations.
A resident with multiple diagnoses, including Alzheimer's and diabetes, returned from the hospital with a urinary tract infection and received a Rocephin shot. The facility failed to follow up on culture and sensitivity results from the hospital, leading to inadequate monitoring of antibiotic use. The DON attempted to obtain the necessary records but was unsuccessful, resulting in a deficiency in the facility's infection prevention and control program.
A staff member who was not a CNA, Licensed Nurse, or paid feeding assistant improperly assisted a resident with feeding, contrary to facility policy. The resident, who had multiple health issues including dementia and malnutrition, required varying levels of assistance during meals. The facility lacked paid feeding assistants, and the unqualified staff member intervened when the resident had not received dining assistance.
The facility failed to maintain a clean and homelike environment, as restrooms in resident rooms were found with stains and strong urine odors. Despite the housekeeper's efforts, odors returned shortly after cleaning, attributed to residents urinating outside the toilet bowl. Reduced staffing hours further hindered housekeeping duties, such as washing curtains, which had not been done for over a month. The DON was unaware of the cleaning frequency, indicating a lack of oversight.
Failure to Prevent Misappropriation of Resident Property
Penalty
Summary
A resident with chronic obstructive pulmonary disease, generalized anxiety disorder, and adjustment disorder offered a Nursing Assistant (NA) $100 after learning about the NA's financial struggles. Despite initial refusal, the NA ultimately accepted the money after the resident insisted and placed the funds in the NA's pocket. When the resident later requested the money back to cover personal expenses, the NA did not respond to her messages. The resident reported the issue to two different staff members, expressing increasing distress over not having her funds returned. Multiple staff interviews confirmed the resident's upset state and her repeated attempts to recover the money. The NA admitted to accepting the funds and stated she was unaware that this was not allowed. The incident was reported to facility leadership, but there was no documentation of specific training or guidance provided to staff regarding this type of situation at the time of the incident. The facility's abuse training was conducted twice a year, but there was no evidence of additional or incident-specific training related to this event.
Failure to Timely Report Misappropriation of Resident Property
Penalty
Summary
The facility failed to ensure that an allegation of misappropriation of resident property was reported immediately, as required, to Adult Protective Services (APS) and local law enforcement. A resident with multiple diagnoses, including chronic obstructive pulmonary disease and anxiety disorders, reported giving $100 to a nursing assistant (NA) after learning of the NA's financial struggles. The resident later requested the money be returned, but the NA did not respond, prompting the resident to report the issue to two staff members. The NA admitted to accepting the money after repeated offers from the resident and stated she was unaware it was not allowed. The facility verified the allegation and terminated the NA's employment. Despite the verification of misappropriation, the facility did not report the incident to APS until 17 days after the allegation was made, and there was no report made to local law enforcement. Interviews with the Resident Advocate and Administrator revealed that the incident was communicated internally, but proper external reporting protocols were not followed. Staff training on abuse recognition and reporting was provided biannually, but there was no documentation of training specific to this incident.
Failure to Provide Timely Care After Falls
Penalty
Summary
The facility failed to provide appropriate treatment and care for two residents following falls, leading to significant health complications. Resident 9, who had a history of repeated falls and various medical conditions including epidural hemorrhage and heart disease, experienced a fall in the bathroom. Despite the fall being unwitnessed, no neurological assessments were conducted, and the physician was notified five hours later. The resident later exhibited symptoms of hypotension and bradycardia, leading to hospitalization for sinus arrest. The lack of timely intervention and monitoring after the fall contributed to the resident's acute change in condition. Resident 87, with a history of traumatic brain injury and use of anticoagulants, fell from a wheelchair and sustained a scalp laceration. Although neuro checks were initiated, the resident's condition deteriorated with symptoms of hypertension, tachycardia, and respiratory distress. Despite attempts to contact medical providers, there was a delay in emergency intervention. The resident was eventually sent to the hospital with a subdural hematoma and brain compression, requiring emergent intubation. The delay in recognizing and responding to the resident's declining condition after the fall was a critical factor in the deficiency. Both cases highlight the facility's failure to adhere to professional standards of practice and the comprehensive person-centered care plan. The lack of prompt identification, monitoring, and intervention for acute changes in condition following falls resulted in severe health outcomes for the residents. The deficiencies were identified at the Immediate Jeopardy level, indicating a serious threat to the health and safety of the residents involved.
Resident Unsecured During Transport Results in Injury
Penalty
Summary
The facility failed to ensure adequate supervision and safety measures for a resident during transportation, resulting in a serious accident. A resident, who was cognitively intact and required extensive assistance for mobility, was not properly secured in a facility vehicle during transport. The resident fell out of her wheelchair, sustaining a Thoracic (T)11-T12 fracture and a contusion of the abdominal wall. The incident occurred because the seatbelt was not secured, and the resident was unrestrained in the back of the van. The transportation driver, who was also the Therapeutic Recreation Specialist (TRS), did not secure the resident with a seatbelt, relying instead on the straps that secured the wheelchair to the floor of the van. The TRS admitted that he did not see the lap belt at the time of the accident and attempted to use an old shoulder strap that did not function properly. The TRS had been under the impression that the wheelchair straps were sufficient for securing the resident, which led to the resident falling forward and hitting the driver's seat before falling to the floor. The resident involved had a complex medical history, including a stable burst fracture of the Thoracic (T)11-T12 vertebra, type II diabetes mellitus, chronic obstructive pulmonary disease, and other conditions. At the time of the incident, the resident was returning from a hospital appointment and was not properly restrained, leading to the fall and subsequent injuries. The facility's failure to ensure the resident's safety during transport was a significant oversight, resulting in harm to the resident.
Failure to Provide Timely Behavioral Health Services
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to a resident with a history of suicidal ideations, leading to a deficiency in ensuring the resident's highest practicable physical, mental, and psychosocial well-being. The resident, who had a complex medical history including major depressive disorder and a previous suicide attempt, was hospitalized for suicidal ideations but did not receive behavioral health services for over two months following the hospitalization. This gap in care occurred despite the resident's comprehensive assessment and care plan indicating the need for such services. The resident's medical records showed multiple diagnoses, including major depressive disorder, and a history of suicidal ideations. Physician orders included medications for depression, but there was a significant delay in implementing mental health therapy after the resident's hospitalization for a suicide attempt. The resident's care plan and PASRR Level II evaluation recommended counseling services to help cope with psychiatric symptoms, yet these services were not provided in a timely manner. Interviews with facility staff revealed a lack of awareness and follow-through regarding the resident's behavioral health needs. The Director of Nursing and other staff members were unable to confirm when behavioral health services began, and there was no psychosocial assessment conducted after the resident's re-admission. Additionally, the resident's room contained items that could be used for self-harm, indicating a lack of environmental safety measures. These oversights contributed to the facility's failure to meet the resident's behavioral health care needs, as outlined in their care plan.
Failure to Ensure Dignified Dining Experience for Residents
Penalty
Summary
The facility failed to treat residents with respect and dignity during meal times, as observed in several instances. Staff were seen standing while assisting residents with eating, which is contrary to the facility's protocol of sitting next to residents to promote dignity. Additionally, staff used labels instead of residents' names when addressing them, which further undermines the residents' dignity. During meal service, residents were not served meals simultaneously, and some residents did not receive the necessary assistance, as evidenced by Resident 11 receiving his meal significantly later than others. Resident 18, who has multiple diagnoses including dementia and major depressive disorder, was observed struggling during a meal service. Despite requiring supervision and setup help for dining, Resident 18 was seen attempting to eat with an empty fork, and the assisting staff did not fully assist in feeding. Furthermore, flies were observed landing on Resident 18 during the meal, indicating a lack of attention to the resident's environment. The Director of Nursing confirmed that aides should be seated with residents and provide appropriate assistance during meals, which was not adhered to in these instances.
Failure to Report Abuse and Injuries in a Timely Manner
Penalty
Summary
The facility failed to report alleged violations involving abuse or injuries of unknown source within the required timeframe for two residents. Resident 18, who has severe cognitive impairment, was found with a new bruise on the upper thigh, but the incident was not reported to the State Survey Agency (SSA) or Adult Protective Services (APS). The facility's Director of Nursing (DON) acknowledged that the bruise's location could be suspicious and should have been reported, but the nurse's documentation lacked sufficient detail to determine the bruise's exact location or characteristics. Resident 22 experienced verbal abuse from a Certified Nurse Assistant (CNA), who was observed yelling in a mocking tone. Although the incident was reported to the SSA, there was no documentation that APS was notified. The facility's Administrator stated that he would ensure resident safety and gather information before reporting to the necessary authorities, but the report to APS was not completed as required. The facility's policies on abuse and reporting require immediate action and notification to appropriate authorities, but these procedures were not followed in these cases. The policies were last revised in 2024, indicating that the facility should have been aware of the requirements. The failure to report these incidents in a timely manner represents a deficiency in the facility's adherence to regulatory requirements for reporting suspected abuse or injuries of unknown origin.
Failure to Prevent Further Potential Abuse During Investigation
Penalty
Summary
The facility failed to prevent further potential abuse while investigations were in progress for three residents. Resident 86, who had a history of multiple medical conditions including dementia and bipolar disorder, was involved in two separate incidents. In the first incident, Resident 86 and Resident 14, who also had a complex medical history including dementia and substance abuse, were found on the floor after an argument over a radio. Both residents sustained minor injuries, but the facility did not document the completion of 15-minute safety checks that were supposed to be implemented as a corrective measure. In a second incident, Resident 86 was involved in an alleged sexual abuse case with Resident 85, who had Alzheimer's disease and significant cognitive deficits. An LPN witnessed Resident 86 engaging in inappropriate behavior with Resident 85. Although the residents were separated, the facility again failed to consistently document the 15-minute checks that were intended to monitor Resident 86's behavior following the incident. Interviews with the Director of Nursing (DON) and the Administrator (ADM) revealed that the facility struggled to maintain the 15-minute checks due to staffing challenges and the demographic of the residents. The DON acknowledged that the checks were not a typical intervention and were difficult to maintain, while the ADM noted that the checks were essentially a 1:1 staffing situation and were not effectively implemented. The lack of consistent documentation and monitoring contributed to the facility's failure to prevent further potential abuse during the investigation period.
Deficiency in Resident Transfer Documentation and Communication
Penalty
Summary
The facility failed to ensure proper documentation and communication during the transfer or discharge of residents to the hospital, affecting four out of 28 sampled residents. The deficiency was identified through interviews and record reviews, revealing that the necessary information was not documented in the residents' medical records nor communicated to the receiving providers. This information should have included the contact details of the practitioner responsible for the resident's care, resident representative information, advanced directives, special instructions or precautions for ongoing care, comprehensive care plan goals, and other necessary information to ensure a safe and effective transition of care. Resident 9 was transferred to the hospital due to hypotension, lethargy, and bradycardia, but there was no documentation of the transfer paperwork or what information was sent to the receiving provider. Interviews with the nursing staff and the Director of Nursing (DON) revealed that while some information, such as the medication list and face sheet, was given to the paramedics, the Physician Order for Life Sustaining Treatment (POLST) form was not included. The DON confirmed that the POLST form should accompany the resident to the hospital, but it was not documented in the progress notes. Similarly, Resident 14 was transferred to the hospital after attempting self-harm, yet there was no documentation of the transfer paperwork or information sent to the receiving provider. Resident 8 experienced multiple hospital transfers due to various medical conditions, including low oxygen saturation and falls, but again, there was no documentation of the transfer paperwork or information sent to the hospital. Resident 19 was also transferred to the hospital without proper documentation or communication of necessary information. Interviews with the nursing staff and the DON highlighted the lack of consistent documentation practices, such as using the e-interact system, to ensure that all necessary information was communicated during resident transfers.
Improper Storage and Labeling of Medications
Penalty
Summary
The facility failed to ensure the safe and secure storage of drugs and biologicals in accordance with accepted professional principles. During an inspection of the medication refrigerator, it was observed that a multi-dose vial of Tuberculin was open and lacked an open date. Additionally, a Prevnar 13 vaccine was found to be expired and still available for use. Several insulin pens, including Tresiba, Lantus, and aspart insulin flex pens, were either missing open dates or resident names, and one Lantus insulin pen was noted to be expired. Interviews with staff revealed a lack of adherence to proper labeling protocols. RN 1 acknowledged that insulin pens should be discarded if the name or date is unreadable, yet some pens lacked this information. The Director of Nursing confirmed that all medications should be labeled with the resident's name and that insulin should be marked with an open date and stored properly. The DON also stated that insulin is viable for 30 days once opened, and only medications should be stored in the refrigerator.
Failure to Obtain Required Lab Tests for Residents
Penalty
Summary
The facility failed to provide necessary laboratory services for two residents, leading to deficiencies in care. Resident 31, who had multiple complex medical conditions including chronic embolism and thrombosis, had physician orders for INR labs to be drawn every four weeks. However, the facility did not obtain INR results for May and June 2024, despite the importance of monitoring INR levels for residents on warfarin treatment. The Director of Nursing (DON) acknowledged that the phlebotomist contracted by the facility likely did not obtain the labs for those months, which was confirmed by pharmacy consultant reviews noting the absence of routine monitoring. Similarly, Resident 9, who had a range of serious health issues including type 2 diabetes and hypertensive heart disease, had a physician order for a Basic Metabolic Panel (BMP) on August 13, 2024. The BMP was not obtained, and the DON confirmed that the order was missed. The facility's process involved placing lab orders in a computer system and notifying the DON through a portal when results were ready. However, the lack of a carbon copy for facility records and the reliance on a single staff member to access the portal contributed to the oversight. The DON also noted that nurses were expected to document lab completion in progress notes, which did not occur in this instance.
Confidentiality and Record-Keeping Deficiencies
Penalty
Summary
The facility failed to maintain the confidentiality and completeness of medical records for one resident. On two separate occasions, registered nurses left a computer screen open on a medication cart, displaying resident-identifiable information, while unattended and in the presence of other residents. This action was contrary to the facility's policy, as confirmed by interviews with the nurses and the Director of Nursing (DON), who stated that the expectation was to lock the computer screen to protect Health Insurance Portability and Accountability Act (HIPAA) protected information. Additionally, the facility did not maintain complete medical records for a resident who had a history of multiple medical conditions, including cerebral infarction and major depressive disorder. The resident was taken to the hospital following a suicidal incident, but there was no documentation of the hospital visit in the electronic medical records. The DON later discovered that the hospital had no record of the resident's admission, although the ambulance service confirmed the transport. Eventually, the facility obtained the hospital history and physical documentation, revealing a lapse in the systematic organization and accessibility of the resident's medical records.
Failure to Document COVID-19 Vaccine Education and Administration
Penalty
Summary
The facility failed to ensure that residents or their representatives were given the opportunity to accept or refuse a COVID-19 vaccine, and that their medical records included documentation of education regarding the vaccine's benefits and risks, as well as records of vaccine administration or declination. Specifically, for four out of five sampled residents, there was no evidence in their medical records that they were provided education about the COVID-19 vaccine, received the vaccine, or declined it. The residents involved had various medical conditions, including chronic obstructive pulmonary disease, dementia, hypertension, and Alzheimer's disease. The facility's policy required that residents be given the opportunity to accept or refuse the vaccine, be educated about its benefits and risks, and sign a consent form before vaccination. Additionally, the policy mandated that documentation of vaccine administration or declination be included in the resident's record. However, the Director of Nursing was unable to locate the documentation for the residents' COVID-19 immunization records, indicating a failure to adhere to the facility's vaccination policy.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from various forms of abuse, including sexual, verbal, and physical abuse. In one incident, a Certified Nurse Assistant (CNA) engaged in inappropriate communication with a resident, asking for nude photos and expressing a desire for a romantic relationship, which made the resident uncomfortable. The resident, who was cognitively intact, reported the incident to the facility staff, leading to the CNA's termination. However, the facility's initial response did not prevent the CNA from continuing to contact the resident, causing further distress. In another incident, a resident with a history of neurocognitive disorder and impulse control issues was verbally abused by a CNA who mocked her in a loud and aggressive manner. This behavior was witnessed by other staff members, and the resident, who had a BIMS score of 0, was unable to fully articulate her feelings about the incident. The verbal abuse occurred during a meal service when the resident was seeking food, a behavior consistent with her medical history. Additionally, the facility failed to prevent physical abuse between residents. A resident with a history of psychiatric disorders and aggressive behavior stabbed another resident with a pen during a manic episode. The facility's investigation confirmed the physical abuse, but there was a lack of immediate intervention to prevent such incidents, as evidenced by the absence of a skin assessment for the victim immediately following the altercation.
Failure to Notify Physician of Resident Condition Changes
Penalty
Summary
The facility failed to immediately consult with the resident's physician and notify them of significant changes in the resident's condition for two residents. Resident 18, who had multiple diagnoses including asthma, dementia, and chronic pain, was found with a bruise of unknown origin on their upper thigh. Despite the discovery, there was no documentation of an assessment of the bruise, and the physician was not notified. The care plan for Resident 18 did not include interventions related to monitoring, reporting, or treating altered skin conditions. Interviews with the RN and DON revealed inconsistencies in documentation and notification practices. Resident 14, with a complex medical history including cerebral infarction and chronic obstructive pulmonary disease, had physician orders for blood tests that were not completed due to the resident's refusal. However, there was no documentation of the refusal or notification to the physician. The DON confirmed that the refusal should have been documented in a progress note and communicated to the physician, but this was not done, indicating a lapse in the facility's communication and documentation processes.
Failure to Report Verbal Abuse Allegation to APS
Penalty
Summary
The facility failed to implement its written policies and procedures to ensure the reporting of all alleged violations to the appropriate authorities. Specifically, an allegation of verbal abuse by a Certified Nurse Assistant (CNA) towards a resident, identified as Resident 22, was not reported to Adult Protective Services (APS). The incident involved the CNA yelling 'Goodbye' in an aggravating and mocking tone to the resident while passing breakfast trays. Although the facility notified the State Survey Agency (SSA) using form 358, there was no documentation indicating that APS was informed of the incident. Resident 22, who was admitted to the facility with multiple diagnoses including frontotemporal neurocognitive disorder, mood disorder, and anxiety disorder, was the subject of the verbal abuse allegation. During an interview, the Administrator (ADM) described the process followed upon receiving an abuse allegation, which included ensuring resident safety, gathering information, interviewing witnesses, and reporting the incident to the SSA, APS, and the ombudsman within two hours. However, the facility's investigation documentation lacked evidence of APS notification, indicating a failure to adhere to the facility's abuse reporting policy.
Failure to Implement PASRR Recommendations for Mental Health Services
Penalty
Summary
The facility failed to implement the recommendations from the Pre-Admission Screening and Resident Review (PASRR) Level II evaluation for a resident with a history of mental illness. The resident, who had multiple diagnoses including major depressive disorder and a history of suicide attempts, was admitted and readmitted to the facility. Despite the PASRR Level II evaluation recommending counseling services to help the resident cope with psychiatric symptoms, these services were not initiated in a timely manner. The resident experienced suicidal ideations and was hospitalized after an incident involving self-harm behavior, yet there was no psychosocial assessment conducted post-incident, and it was unclear when behavioral health services began. Interviews with the Director of Nursing (DON) and a Registered Nurse (RN) revealed gaps in the facility's response to the resident's mental health needs. The DON acknowledged that the resident did not receive a psychosocial assessment after expressing suicidal ideations and that the resident was not evaluated by a Social Service Worker (SSW) following the incident. The RN confirmed that the resident did not have therapy services prior to the hospitalization for suicidal ideations and was uncertain about the details of any therapy received afterward. This lack of adherence to the PASRR recommendations and inadequate follow-up on the resident's mental health needs contributed to the deficiency identified by the surveyors.
Medication Unavailability Leads to Resident Aggression
Penalty
Summary
The facility failed to provide routine and emergency drugs and biologicals to a resident, identified as Resident 9, due to unavailability from the pharmacy. Resident 9, who was admitted with multiple diagnoses including schizoaffective disorder, bipolar type, and generalized anxiety disorder, did not receive their prescribed psychotropic medications for several days. Specifically, Lurasidone, Haloperidol, and Escitalopram were not administered on multiple occasions as they were not available from the pharmacy. The medical records and progress notes for Resident 9 indicated that the medications were on order but not available from the pharmacy on several dates. The resident's Medication Administration Record (MAR) documented that these medications were not administered due to unavailability. This lack of medication led to an incident where Resident 9 exhibited aggressive behavior, reportedly stabbing another resident with a pen due to increased irritability and manic symptoms from being off their medication. Interviews with the facility's RN and DON revealed that the process for reordering medications involved pulling a sticker from the blister pack and placing it on a reorder sheet. However, there were delays in medication delivery from the pharmacy, and the facility's Nexsys system did not have the medication available. The DON acknowledged the issue and contacted the pharmacy, but the explanation provided was insufficient, as there was no dose change ordered at the time the medication was unavailable.
Medication Management Deficiencies in Resident Care
Penalty
Summary
The facility failed to ensure that the drug regimens for two residents were free from unnecessary drugs, as evidenced by inadequate monitoring and administration of medications. Resident 32, who had multiple diagnoses including type 2 diabetes mellitus, was prescribed insulin and required regular blood glucose monitoring. However, there were several instances where blood glucose levels were not recorded, and the facility did not provide documentation of any orders to cease finger sticks, despite the resident's expressed discomfort with the procedure. Interviews with nursing staff revealed a lack of clarity regarding the necessity of blood glucose monitoring and the documentation of such orders. Resident 9, with a complex medical history including hypothyroidism and chronic pain, did not receive their prescribed thyroid medication on one occasion, and there was no documentation to confirm its administration. Additionally, the resident's pain management was inadequate, as the prescribed oxycodone was documented as ineffective, yet there was no follow-up or documentation of alternative pain management strategies. Interviews with nursing staff indicated that there should have been communication with the provider and documentation of any additional interventions, but this was not evident in the resident's records. The deficiencies highlight a failure in the facility's medication management processes, particularly in monitoring and documenting the administration and effectiveness of medications. The lack of adequate monitoring and documentation for these residents' drug regimens suggests systemic issues in ensuring that residents receive necessary and effective medication management, as required by their medical conditions and physician orders.
Failure to Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary psychotropic drugs. Specifically, the resident's psychotropic medications were not adequately monitored for behavioral episodes, non-pharmacological interventions, and adverse side effects. The resident, who had a complex medical history including schizoaffective disorder, generalized anxiety disorder, and a history of suicidal behavior, was prescribed multiple psychotropic medications, including Escitalopram, Lurasidone, Clonazepam, and Haloperidol. However, there was no documentation indicating that the facility monitored the resident for adverse side effects or episodes of anxiety, nor was there evidence of non-pharmacological interventions being attempted prior to medication administration. During an interview, the Director of Nursing (DON) acknowledged that licensed nurses should monitor for adverse side effects, medication effectiveness, and behavioral episodes. Despite this expectation, the report found no evidence of such monitoring in the resident's records. The lack of documentation and monitoring suggests a failure in the facility's processes to ensure the safe and appropriate use of psychotropic medications for this resident.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility was found to have a medication error rate of 7.41%, exceeding the acceptable threshold of 5%. This was observed during a survey on 9/24/24, involving two residents. For Resident 12, a registered nurse (RN 1) was observed to have spilled a medication cup and subsequently replaced the medications incorrectly, resulting in an incorrect dosage of Haloperidol being prepared. The nurse was about to administer the wrong dosage when stopped by a surveyor. The nurse admitted to not realizing the error and expressed a lack of knowledge regarding the potential side effects or overdose symptoms of Haloperidol. According to the physician's orders, Resident 12 was supposed to receive two tablets of Haloperidol 1 mg, but three tablets were prepared. For Resident 31, RN 1 administered only one tablet of Loperamide 2 mg instead of the prescribed two tablets. The nurse claimed to always double-check medications before administration, but this was not reflected in the observed actions. The Director of Nursing (DON) later explained the protocol for handling medication errors, which includes contacting the provider and completing an incident report, although it was noted that this was not always done. The errors were classified as wrong dose errors, and the facility's failure to adhere to proper medication administration protocols led to these deficiencies.
Failure to Notify Physician of Abnormal Lab Results and Conduct Tests Without Orders
Penalty
Summary
The facility failed to promptly notify the ordering physician of laboratory results that were outside of clinical reference ranges for one resident. Specifically, the resident's Basic Metabolic Panel (BMP) and lipid panel results showed abnormal values, but there was no documentation indicating that the physician was informed of these results. Additionally, the laboratory tests were conducted without a physician's order, which is a breach of protocol. The resident involved had a complex medical history, including conditions such as cerebral infarction, hemiplegia, cognitive communication deficit, and several other chronic conditions. The Director of Nursing (DON) was responsible for placing lab orders and following up with providers. However, the process lacked proper documentation and verification, as evidenced by the absence of a physician's order for the labs conducted on January 30, 2024. The DON stated that the lab results were automatically uploaded to a portal and faxed to the facility, but there was no evidence that the results were reviewed or signed by a provider. This oversight in communication and documentation led to the deficiency identified by the surveyors.
Failure to Maintain Complete Laboratory Records
Penalty
Summary
The facility failed to maintain complete and dated laboratory records in the clinical record of a resident, identified as Resident 31. This deficiency was identified during a review of the resident's medical records, which revealed that laboratory reports for lithium level checks were not filed or uploaded in the resident's electronic medical record. Specifically, there were two instances where physician orders for lithium level monitoring were placed, but the corresponding lab results were not documented in the electronic medical record. The facility was able to provide copies of the lab results upon request, indicating that the lithium levels were within normal limits. Resident 31 was admitted with multiple diagnoses, including bipolar disorder, chronic obstructive pulmonary disease, asthma, and other significant health conditions. The deficiency was confirmed during an interview with the Director of Nursing, who acknowledged that the lithium lab results should have been uploaded into the resident's medical record. The absence of these records in the electronic medical record constitutes a failure to comply with the requirement to keep complete and dated laboratory records in the resident's clinical record.
Missing EKG Reports in Resident's Medical Records
Penalty
Summary
The facility failed to maintain complete medical records for one resident, identified as Resident 14, by not including signed and dated reports of diagnostic services. Resident 14, who had a complex medical history including cerebral infarction, hemiplegia, cognitive communication deficit, and other conditions, was ordered a 12 lead EKG for monitoring over two days. However, the EKG reports were not found in the resident's medical records. During an interview, the Director of Nursing (DON) acknowledged that the EKG report was obtained but was sent to the provider instead of being filed in the facility's records.
Deficiency in Food Quality and Temperature
Penalty
Summary
The facility failed to ensure that food and drink provided to residents were palatable, attractive, and served at a safe and appetizing temperature. This deficiency was identified through observations, interviews, and record reviews involving two residents. Resident 17 complained during a lunchtime meal observation that the food was too cold and would be better if served warm. Additionally, a resident council note from earlier in the month documented a complaint about undercooked and tough pork, while another note from July mentioned burnt eggs being served frequently at breakfast. Further investigation included a test lunch tray on September 25, which revealed several issues with the meal's quality. The collard greens were soggy and bland, the potatoes had a chunky texture, and the cornbread was overly salty and not sweet. The soup was also overly salty, and the apple pie mousse dessert tasted like plain sour yogurt. Resident 30 expressed dissatisfaction with the food, describing it as bland. The Corporate Dietitian mentioned that residents could fill out grievance forms for food complaints, and the dietary manager would follow up individually with those who filed grievances.
QAA Committee Lacks Required Medical Director Participation
Penalty
Summary
The facility failed to ensure that the Quality Assessment and Assurance (QAA) committee met the required composition and frequency as mandated by regulations. Specifically, the QAA committee did not include the Medical Director as a participating member, which is a requirement. The committee was composed of the Administrator, Director of Nursing (DON), Therapeutic Recreation Specialist (TRS), Resident Advocate (RA), Maintenance Director, Business Office Manager, and Dietary Manager. However, there was no evidence that the Medical Director participated in the quarterly Quality Assurance and Performance Improvement (QAPI) meetings, as required by the facility's 2024 QAPI Plan. During an interview, the Administrator confirmed that the QAA committee met quarterly and as needed, but the Medical Director's attendance was inconsistent. The Administrator stated that the Medical Director was invited to the meetings but often did not attend due to scheduling conflicts, and instead, the Medical Director was typically followed up with meeting notes. The Administrator was unsure if the Medical Director attended the March 2024 meeting and confirmed that he did not attend the June 2024 meeting. This lack of participation by the Medical Director in the QAPI meetings is a deficiency in meeting the regulatory requirements for the QAA committee's composition and function.
Inadequate Infection Control During Medication Administration
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of a registered nurse (RN) during medication administration. On the morning of September 24, 2024, RN 1 was observed preparing medications for two residents without performing proper hand hygiene. Specifically, RN 1 did not sanitize her hands before removing medications from their packs. During the medication pass for Resident 12, RN 1 dropped medications onto the medication cart and the floor, then proceeded to scoop up a medication that was partially on the cart and place it back into the medication cup before administering it to the resident. Additionally, RN 1 was observed dropping medication onto the cart and floor while preparing medications for Resident 25. She picked up the medication from the floor and disposed of it in the sharps container but continued with the medication preparation without performing hand hygiene. During an interview, RN 1 acknowledged that she sometimes gets distracted and may touch residents or other objects before returning to medication preparation. The Director of Nursing confirmed that the facility's expectation was for staff to perform hand hygiene before any resident care tasks, including medication preparation.
Failure to Monitor Antibiotic Use for Resident with UTI
Penalty
Summary
The facility failed to establish an effective infection prevention and control program, specifically lacking an antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use. This deficiency was identified in the case of a resident who was receiving an antibiotic for a urinary tract infection. The facility did not follow up with the hospital to obtain the culture and sensitivity results necessary to guide appropriate antibiotic use. The Director of Nursing (DON) acknowledged that the hospital discharge instructions indicated a culture and sensitivity test was to be performed, but the results were not verified or obtained by the facility. Resident 19, who was involved in this deficiency, was admitted and readmitted to the facility with multiple diagnoses, including Alzheimer's Disease, dementia, type 2 diabetes mellitus, and other conditions. Upon returning from the hospital, the resident was noted to have a urinary tract infection and was given a Rocephin shot. However, the facility did not ensure the continuation of appropriate antibiotic treatment due to the lack of follow-up on the culture and sensitivity results. Despite attempts by the DON to contact the hospital for these records, the necessary information was not obtained, leading to a gap in the resident's care management.
Unqualified Staff Member Assisted Resident with Feeding
Penalty
Summary
The facility failed to ensure that a staff member assisting with feeding was properly trained as a paid feeding assistant, as required by state regulations. Specifically, a staff member who was not a Certified Nursing Assistant (CNA), Licensed Nurse, or a paid feeding assistant provided feeding assistance to a resident. This occurred despite the facility's policy that only CNAs, Nurses, Speech Therapists, or paid feeding assistants should assist residents with feeding. The resident involved had multiple diagnoses, including aphasia following cerebrovascular disease, moderate protein-calorie malnutrition, and dementia with agitation. The resident's records indicated varying levels of assistance needed during meals, ranging from independent eating to total dependence on staff. On the day of the incident, the resident had not received any dining assistance with breakfast until the unqualified staff member intervened. Interviews with staff revealed that the facility had no paid feeding assistants and that the staff member who assisted was not qualified to do so.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for its residents, as evidenced by the condition of the restrooms. Observations revealed that restrooms in resident rooms had stains around the base of the toilets and strong odors of urine. Despite the housekeeper's efforts to clean the restrooms with disinfectant, the odors returned shortly after cleaning. The housekeeper attributed the persistent odor to residents urinating outside the toilet bowl and noted that her ability to complete all housekeeping duties was hindered by reduced staffing hours. The Director of Nursing (DON) was unaware of the frequency of room cleaning, indicating a lack of oversight in maintaining cleanliness standards. The housekeeper reported that the reduction in hours for the part-time housekeeper further limited her ability to perform tasks such as washing and cleaning curtains, which had not been done for over a month. This deficiency in maintaining a clean and homelike environment was observed after the housekeeper had completed her cleaning duties for the day, highlighting the inadequacy of the current housekeeping schedule and staffing levels.
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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