Rocky Mountain Care - Willow Springs
Inspection history, citations, penalties and survey trends for this long-term care facility in Tooele, Utah.
- Location
- 85 East 2000 North, Tooele, Utah 84074
- CMS Provider Number
- 465089
- Inspections on file
- 23
- Latest survey
- March 31, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Rocky Mountain Care - Willow Springs during CMS and state inspections, most recent first.
The facility failed to timely report alleged abuse to SSA and APS after staff twice observed a resident with dementia and acute systolic CHF receiving zealous, open-mouthed kisses on the mouth from her brother. On two separate occasions, a CNA and an LPN witnessed or were informed of these unusual kissing interactions, which they later described as awkward and not typical of a sibling relationship. Despite this, the nursing staff did not immediately report the incidents as potential abuse to the Administrator, and the allegation was not brought forward until a staff meeting days later, resulting in the required notifications to external authorities not being made within the mandated 2-hour timeframe.
A resident with muscle weakness, gait abnormalities, atrial fibrillation, and on a blood thinner sustained an unwitnessed bathroom fall, reported hitting her head, and developed rapidly worsening right facial swelling and a swollen‑shut eye that prevented pupillary assessment. Initial vitals and neuro checks were performed, oxygen was applied, and x‑rays were ordered, but despite the significant change in condition and the resident’s anticoagulation status, the provider was not notified of the worsening condition at the time it occurred and the resident was not sent to the hospital until the next day when an NP assessed her and ordered transfer. In the ED, the physician documented that no evaluation for the injuries had occurred the prior evening and CT imaging showed traumatic subdural and subarachnoid hemorrhages and a large facial hematoma, demonstrating that the facility failed to provide timely, standard‑of‑care treatment and hospital transfer after the fall and subsequent change in condition.
A resident with cognitive impairment, neurological conditions, and substance-related diagnoses was assessed as being at risk for elopement and documented as having poor safety awareness, poor judgment, and wandering behavior requiring frequent redirection. Nursing staff observed the resident wandering in the hall and behind the nurse’s station and communicated during shift report that a WanderGuard was recommended, but no device was applied because staff did not know where to obtain one. The resident later left the building through the front door, was not immediately detected as missing, and was ultimately found by a medication technician about a mile away walking on a sidewalk near a restaurant, demonstrating a failure to provide adequate supervision and timely elopement interventions.
A resident with complex medical needs, assessed as requiring extensive two-person assistance for bed mobility, fell from bed and sustained serious injuries during a one-person assist for incontinence care. Staff were unclear about the required level of assistance, and the resident's care plan and KARDEX did not consistently reflect her needs, leading to inadequate supervision and a preventable accident.
A resident with COPD, emphysema, and a-fib was allowed to self-administer multiple inhalers without a documented assessment by the facility's interdisciplinary team, as required by policy. Nursing staff and the DON were unaware that the resident had several inhalers at bedside and had not reassessed her ability to safely self-administer medications after her initial admission.
A resident was admitted to hospice care and experienced changes in medication, but the facility did not complete a Significant Change MDS assessment within the required 14-day period. MDS Coordinators confirmed that this assessment should have been performed following the initiation of hospice services.
A resident with multiple chronic conditions was found with a cup of 13 pills left unattended at her bedside, and the nurse who administered the medications did not supervise or verify their consumption. The resident's care plan required medications to be administered as prescribed and monitored for side effects, but staff interviews confirmed that the standard practice of observing medication intake was not followed. The DON acknowledged that medication should not be left at the bedside and that the timing of administration was important, especially for medications with specific schedules.
A resident with multiple chronic conditions had a physician's order for a vaginal culture due to vaginal discharge, but the resulting laboratory report was not filed in the electronic medical record. Staff confirmed that the lab results from an outside facility were not requested or uploaded as required.
A resident with chronic pain and multiple diagnoses received narcotic pain medication that was documented in the narcotic record book but not signed out as administered on the MAR. Staff interviews confirmed the medication was given, but the required documentation on the MAR was missing, resulting in incomplete and inaccurate medical records.
A facility failed to prevent significant medication errors for several residents, including one who received another's medications, leading to hospitalization. Other residents received incorrect dosages or medications not aligned with physician orders, including one with a known allergy. The errors were acknowledged by the DON and documented in medical records.
A resident with multiple health conditions fell and sustained injuries after being left unattended during a brief change. The facility's investigation into the incident was incomplete, lacking interviews with key staff and the resident. The CNA reported the resident attempted to retrieve a stuffed dog from the floor, leading to the fall. The investigation concluded without verifying neglect, highlighting a failure to conduct a thorough investigation.
A resident with a history of falls and requiring a Hoyer lift for transfers was manually lifted by two staff members due to a Hoyer lift battery failure, resulting in an assisted fall and shoulder pain. The resident was sent to the emergency department, where no acute fracture was found, but a likely rotator cuff injury was noted. The incident revealed a failure to ensure equipment functionality and adherence to the care plan.
Failure to Timely Report Alleged Sexual Abuse to SSA and APS
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse and neglect were reported immediately, but no later than two hours after the allegation was made, to the State Survey Agency (SSA) and Adult Protective Services (APS). Resident 3, who was admitted with unspecified dementia and acute systolic congestive heart failure, was involved in two separate incidents in which her brother was observed kissing her on the mouth in a manner staff described as zealous, enthusiastic, sloppy, and not typical of a brother-sister interaction. On 12/28/25, CNA 1 observed a well-dressed man enter Resident 3's room, hug her, and give her a zealous kiss on the mouth. CNA 1 assumed the man was the resident's husband and reported this to LPN 1, who knew the visitor was the resident's brother. LPN 1 looked into the room and did not see anything out of the ordinary, and neither CNA 1 nor LPN 1 reported this incident as a potential allegation of abuse to the Administrator at that time. On 1/4/26, LPN 1 and CNA 1 entered Resident 3's room to address the resident's pain and request for catheter removal and to assist with a brief and linen change. Resident 3 had two visitors present, including her brother. When asked to step out for privacy, the female visitor left, but the brother hesitated and then gave Resident 3 a sloppy, open-mouthed kiss on the mouth lasting about three seconds, again in the presence of staff. The brother stated that Resident 3 was his older sister and that she had taken care of him since they were very small. LPN 1 did not report either the 12/28/25 or 1/4/26 kissing incidents to the Administrator. The Administrator later stated that the alleged abuse was first mentioned during a meeting on 1/6/26, at which time staff described the kiss as a weird, awkward kiss and not a typical brother-sister kiss, and acknowledged that nursing staff had not reported the suspicious activity in a timely manner, resulting in failure to notify SSA and APS within two hours of the allegation.
Delayed Hospital Transfer After Fall With Head Trauma and Anticoagulation
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident who experienced a fall with head trauma and was on anticoagulation received timely treatment and care in accordance with professional standards of practice. The resident had diagnoses including generalized muscle weakness, gait and mobility abnormalities, and unspecified atrial fibrillation, and was on a blood thinner. On the evening of the fall, nursing documentation showed that the resident was found on the bathroom floor after her roommate called out. The resident reported hitting her head, had facial pain rated 5/10, and initial vital signs showed an O2 saturation of 88–90% with other vitals within normal limits. A neurological assessment was initiated, oxygen was applied, and the on‑call provider was notified, who ordered x‑rays of the resident’s head and left hand. As the evening progressed, the resident’s condition changed. The nurse documented that the resident’s right eye became increasingly swollen to the point that by 9:15 PM it was swollen shut and pupillary reactivity could no longer be assessed, while the left eye remained equal and reactive to light. The neurological exam form recorded that the provider was notified of the fall at 8:00 PM, but did not indicate that the provider was notified when the right eye became swollen shut at 9:15 PM. The DON later stated that this change in the resident’s condition occurred at 9:15 PM and that the medical provider was not notified of this change until the provider came to the facility the following day. The DON also stated that if a resident on a blood thinner experienced a fall with head strike, she expected staff to send the resident to the hospital, and that she was not sure why this resident was not immediately sent. The resident remained in the facility overnight while x‑rays were obtained around 1:00–1:30 AM, with results reportedly available sometime between early morning hours and mid‑morning. The next morning, the NP assessed the resident due to the fall and documented significant right facial swelling, focal tenderness over the zygoma, difficulty visualizing the right eye, and concern for occult injury and possible orbital blowout fracture in the context of anticoagulation. The NP ordered transfer to the emergency department for CT imaging of the head and face. In the emergency department, the physician documented that no evaluation for the resident’s injuries had occurred the previous evening and that the facility had reported the resident seemed slightly altered the prior night and had worsening swelling by the time EMS was called. CT imaging revealed traumatic small subdural and subarachnoid hemorrhages without mass effect and a large facial hematoma. Interviews with nursing staff showed that the RN on duty was very concerned about the resident’s rapidly increasing facial swelling and difficulty administering medications due to lip swelling, but was waiting for a physician order to send the resident to the hospital and was unaware at the time that she could initiate a hospital transfer without such an order. These actions and inactions resulted in a delay in sending the resident to the hospital after a significant change in condition following a fall with head trauma while on a blood thinner. The facility’s Change of Condition/SBAR Evaluation Policy outlined expectations for describing changes in condition, documenting vital signs, identifying changes from baseline (including neurological status changes), and notifying the provider and responsible party, as well as documenting immediate actions and outcomes such as transfer to the hospital. Despite this policy, the neurological exam form did not reflect timely provider notification when the resident’s right eye became swollen shut, and the resident was not transferred until the following day after the NP’s in‑person assessment. The DON confirmed that the change in condition at 9:15 PM was not communicated to the provider until the next day. The surveyors determined that, for this resident, the facility did not ensure timely hospital transfer and did not provide treatment and care in accordance with professional standards of practice after a fall with head injury and subsequent change in condition.
Failure to Implement Elopement Precautions and Supervision for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and implement elopement precautions for a cognitively impaired resident who was identified as being at risk for elopement. The resident was admitted with multiple neurological and substance-related diagnoses, including cerebral infarction, ataxia, Wernicke’s encephalopathy, alcohol and opioid dependence, and traumatic subdural hemorrhage. On admission, the resident’s elopement risk screening showed a score of 12, indicating elopement risk, and nursing documentation described poor safety awareness, poor judgment, and a need for continuous cues with self-care and ADLs. The resident was also noted to require 1:1 supervision during meals due to quick eating behavior. In the hours leading up to the elopement, nursing staff observed the resident wandering in the hallway and behind the nurse’s station and reported that he required constant redirection. The night shift RN informed the day shift LPN during report that the resident had been wandering since early morning and that a WanderGuard was recommended. Despite this, no WanderGuard was applied before the resident left the building. The LPN later stated that she did not know where to obtain a WanderGuard, and the DON confirmed that both the RN and LPN had not placed a WanderGuard because they did not know its location. On the day of the incident, the resident went to the kitchen and requested water, and kitchen staff noticed a fall risk bracelet on his wrist. After this interaction, staff discovered that the resident was no longer in the building. Facility investigation determined that the resident exited through the front door at approximately 9:37 AM and was later found off premises, about one mile away, walking on a sidewalk near a restaurant. A medication technician, who had previously seen the resident wandering in only a gown and had informed the nurse, located the resident and returned him to the facility. These events demonstrate that, despite known elopement risk and observed wandering behavior, the facility did not implement timely elopement precautions or ensure adequate supervision to prevent the resident from eloping.
Failure to Ensure Adequate Supervision and Assistance During Bed Mobility
Penalty
Summary
A deficiency occurred when a resident, who had significant medical conditions including chronic respiratory failure, COPD, high BMI, and diabetes, sustained a fall from bed during incontinence care. The resident was identified in the most recent Minimum Data Set (MDS) assessment as requiring extensive assistance from two or more persons for bed mobility. However, at the time of the incident, only one Certified Nursing Assistant (CNA) was providing care, and the resident was rolled to her side for a brief change, resulting in her falling from the bed. The care plan and documentation regarding the required level of assistance for the resident were inconsistent and unclear. Interviews with staff revealed confusion about whether the resident required a one-person or two-person assist for bed mobility and brief changes. Some CNAs reported that the resident was often changed by one person, sometimes by two, and that the resident herself sometimes requested only one CNA. The MDS Coordinator confirmed that the resident's last quarterly assessment indicated a need for two-person assistance, but this was not consistently reflected in the care plan or communicated to all staff. The Director of Nursing (DON) acknowledged that prior to the fall, the resident's assistance status was not listed in the KARDEX or care plan, and staff relied on informal sources such as the "CNA Bible" or verbal communication to determine assistance needs. At the time of the fall, the resident's bed was in an elevated position, which was her preference, and she was on an air pressure mattress (APM) that was in alternating mode. The CNA providing care stated she had performed one-person brief changes for this resident multiple times without issue until the incident. The lack of clear, updated documentation and communication regarding the resident's assistance needs, combined with the use of only one staff member for a resident assessed as needing two-person assistance, directly led to the fall and resulting injuries, which included multiple fractures and a head laceration.
Failure to Assess Resident for Safe Self-Administration of Medications
Penalty
Summary
A deficiency occurred when a resident with a history of atrial fibrillation, COPD, and emphysema was allowed to self-administer multiple inhalers without a documented assessment to determine if self-administration was clinically appropriate. The resident was observed to have four inhalers at her bedside, including Arnuity, Spiriva, Albuterol, and Fluticasone, which she obtained from her purse. The resident reported self-administering these medications and keeping the Albuterol inhaler at bedside for emergencies. She also expressed concerns about side effects from one of the inhalers and had refused doses of Arnuity on several occasions. Review of the resident's medical record revealed no documentation of a self-administration of medications assessment, despite the facility's policy requiring an interdisciplinary team evaluation to determine if self-administration was safe and appropriate. Interviews with nursing staff and the DON confirmed that no such assessment had been conducted after admission, even though the resident was provided inhalers at bedside and was self-administering them. The DON stated that the resident was asked about self-administration upon admission and declined, but no further assessments were performed when the situation changed. The facility's policy outlined specific criteria for evaluating a resident's ability to self-administer medications, including physical and cognitive abilities, understanding of medication instructions, and safe storage. However, these procedures were not followed in this case, as the resident was not reassessed for self-administration capability when she began keeping and using inhalers at her bedside. Staff interviews indicated a lack of awareness and oversight regarding the resident's possession and use of multiple inhalers.
Failure to Complete Significant Change MDS Assessment After Hospice Admission
Penalty
Summary
A deficiency occurred when the facility failed to comprehensively assess a resident within 14 days after a significant change in condition, specifically following the initiation of hospice services. The resident, who had a diagnosis including cervical disc degeneration, was admitted to hospice care as documented by a physician's order and completed hospice admission paperwork. Despite the initiation of hospice and changes to the resident's medications, there was no Significant Change Minimum Data Set (MDS) assessment completed within the required timeframe. Interviews with MDS Coordinators confirmed that a significant change MDS assessment should have been completed when hospice was started, but this was not done for the resident in question.
Unattended Medication Administration and Lack of Supervision
Penalty
Summary
A deficiency was identified when a resident with multiple complex medical conditions, including heart failure, end stage renal disease, and hypertension, was found with a cup containing 13 pills left unattended at her bedside. The medications were intended for her morning dose, but the licensed nurse who administered them did not remain to supervise their consumption or verify that they were taken in a timely manner. The resident confirmed that the pills were her morning medications, and the state licensor was unable to determine the exact number of pills as they were not removed from the cup for counting. Review of the resident's Medication Administration Record showed that several medications, including blood pressure medications, anticoagulants, supplements, and pain medication, were documented as administered that morning by a registered nurse. The resident's care plan included interventions to administer medications as prescribed and monitor for side effects, particularly due to her risk for complications from anticoagulant and psychotropic medication use. Interviews with nursing staff and the Director of Nursing confirmed that the facility's standard practice was for the licensed nurse to observe residents taking their medications, especially for this resident who was known to doze off and forget to take her pills. It was also noted that some medications, such as Tylenol and Lanthanum Carbonate, were scheduled at specific times and could pose risks if not administered as directed. The Director of Nursing acknowledged that medication should not be left at the bedside unattended and that the nurse should have stayed to observe the resident taking the medication. The DON also stated that the timing of medication administration was important, particularly for medications with flex time ranges, and that leaving medication at the bedside made it difficult to determine when the resident actually took them. The facility did not provide specific education to nurses on this expectation, but it was considered a standard taught in nursing school. Reference materials cited in the report emphasized the importance of adhering to the rights of medication administration and timely delivery of scheduled medications.
Failure to File Laboratory Results in Resident Record
Penalty
Summary
The facility failed to maintain complete, dated laboratory records in the clinical record for one resident. Specifically, a resident with multiple diagnoses, including bilateral primary osteoarthritis of the knee, type 1 diabetes mellitus with diabetic polyneuropathy, anxiety disorder, and mood disorder, was admitted and later readmitted to the facility. On a specified date, a physician's assistant ordered a vaginal culture for yeast, trichomonas vaginalis, and sexually transmitted diseases due to a diagnosis of vaginal discharge. Although the order was completed, the laboratory results were not found in the resident's electronic medical record during a review. Interviews with facility staff confirmed that the lab results, which were from an outside facility, had not been requested or uploaded to the resident's record.
Failure to Accurately Document Narcotic Administration on MAR
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident who was prescribed narcotic pain medication. Specifically, the resident, who had diagnoses including cervical disc degeneration, bilateral primary osteoarthritis of the knee, and chronic pain syndrome, was observed to be in pain and requested pain relief. The resident had a physician's order for Morphine Sulfate Solution to be administered as needed for pain. Upon review, it was found that although the Narcotic Record Book documented administration of Morphine on multiple occasions, these administrations were not signed out as given on the Medication Administration Record (MAR). Interviews with staff confirmed that the resident received pain medications, and the narcotic record indicated doses were given. However, both the LPN and the Unit Manager acknowledged that the administration of Morphine was not documented on the MAR as required. The failure to sign out the medication on the MAR resulted in incomplete and inaccurate medical records for the resident.
Medication Errors Affect Multiple Residents
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, affecting 7 out of 14 sampled residents. One resident received another resident's medications, including Xanax, Eliquis, Norco, Lyrica, and Zoloft, which led to a hospital admission for sinus bradycardia and required continuous heart monitoring. The Director of Nursing acknowledged the error, which was documented in an incident report. Another resident did not receive medications according to physician orders, receiving incorrect dosages of Oxycodone and Pantoprazole. The resident was given 10 mg of Oxycodone instead of the prescribed 5 mg and 40 mg of Pantoprazole instead of 20 mg. The errors were acknowledged by the facility's Director of Nursing, and the discrepancies were noted in the resident's medical records and progress notes. Additional errors included a resident receiving a medication to which they had a known allergic reaction, and two residents receiving incorrect medications. One resident was given short-acting insulin instead of long-acting insulin, and another received a different patient's medications, including insulin, which they did not take. These errors were documented in progress notes and incident reports, and the Director of Nursing acknowledged the failures in medication administration.
Incomplete Investigation of Resident Fall
Penalty
Summary
The facility failed to thoroughly investigate an allegation of neglect involving a resident who fell and sustained injuries. The resident, who had a history of polyneuropathy, chronic respiratory failure, dementia, restless leg syndrome, and type 2 diabetes mellitus, was found on the floor with a large bump on the forehead, blood on the nose, and numbness in the right arm and hand. The incident occurred when a CNA left the resident unattended during a brief change to retrieve a new sheet, and upon returning, found the resident on the floor. The investigation into the incident was incomplete, as it lacked interviews with key staff members and the resident involved. The facility's final investigation form did not include interviews with the nurse or unit manager, and there was no documentation regarding the duration the CNA was absent or the positioning of the resident's bed. The CNA reported that the resident had a tendency to act independently and had rolled out of bed to retrieve a stuffed dog from the floor. The Social Service Workers involved in the investigation acknowledged that they relied on existing progress notes instead of conducting thorough interviews with all relevant parties. The investigation concluded that the allegation of neglect was not verified, despite the lack of comprehensive evidence collection. This deficiency highlights the facility's failure to conduct a complete and thorough investigation into the alleged neglect, as required by regulatory standards.
Inadequate Supervision and Equipment Failure During Resident Transfer
Penalty
Summary
The facility failed to ensure adequate supervision and use of assistance devices for a resident, leading to an incident where the resident was manually lifted by two staff members instead of using a Hoyer lift. This resulted in an assisted fall to the ground. The resident, who had a history of repeated falls and required a Hoyer lift for transfers, experienced a pop in her right shoulder during the manual transfer, causing her pain. The resident, identified as cognitively intact, had a care plan that included interventions to prevent falls, such as staff education on safe transfer techniques and keeping the room free of clutter. However, during the incident, the Hoyer lift ran out of batteries, prompting the staff to attempt a manual transfer. The resident reported shoulder pain and was sent to the emergency department, where X-rays showed no acute fracture but a likely rotator cuff injury. Interviews with the staff involved revealed that the Hoyer lift was not properly charged, leading to its failure during the transfer. The staff attempted to manually lift the resident, unaware of her shoulder issues, which resulted in the resident experiencing pain. The facility's investigation documented that the resident did not sustain any major injury, but the incident highlighted a lapse in following the care plan and ensuring the availability of functional equipment for safe transfers.
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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