Sandy Health And Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Sandy, Utah.
- Location
- 50 East 9000 South, Sandy, Utah 84070
- CMS Provider Number
- 465111
- Inspections on file
- 26
- Latest survey
- April 16, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Sandy Health And Rehab during CMS and state inspections, most recent first.
Multiple residents and staff reported persistent foul odors and visible cleanliness issues in a shower room, including strong urine and sewage smells, soiled linens, and stained furniture. Observations confirmed broken tiles, mold, and a non-functioning toilet in other shower rooms. Staff interviews revealed inconsistent reporting and unclear responsibilities for maintenance and housekeeping, resulting in ongoing disrepair and an environment that was not safe, clean, or homelike.
Multiple residents reported that food was often cold, bland, unappetizing, and nutritionally inadequate, with observations confirming improper food temperatures and unattractive presentation. Resident council minutes and grievance forms documented ongoing dissatisfaction with food quality, and interviews with dietary staff and administration revealed a lack of awareness and oversight regarding these issues.
Dietary staff failed to follow sanitary food handling practices by touching multiple unclean surfaces and then handling plates and food with the same gloves, as well as chopping food on a cutting board that was not cleaned between uses. Both the cook and dietary manager acknowledged these lapses, confirming that food was prepared and served in a manner not consistent with professional standards.
Several residents with chronic medical conditions were not properly offered or administered influenza and COVID-19 vaccines, despite signed consents indicating acceptance. Documentation was missing for both the offer and administration of vaccines, as confirmed by facility leadership.
Two residents were unable to access their personal funds on weekends because only the Business Office Manager, who worked weekdays, could distribute money. Staff confirmed that no one was available to provide funds outside of business hours, and delays in obtaining cash from the corporate office further limited access.
A resident with multiple diagnoses returned from the hospital with sutures on the bridge of the nose and instructions for removal in 7 days. Facility staff failed to remove the sutures within the specified timeframe, and the resident was observed with the sutures still in place and tugging at them. Staff interviews revealed confusion about the correct removal period, and the DON confirmed the removal was overdue.
A resident with multiple chronic conditions did not have required serum phenytoin and phenobarbital lab results documented in the electronic medical record, despite pharmacy recommendations and physician approval for these labs. Staff interviews revealed that while diagnostic results were supposed to be scanned and uploaded promptly, the necessary laboratory reports were missing from the resident's chart.
A resident receiving antibiotics for pneumonia did not have a signed and dated chest x-ray report filed in their clinical record, despite staff confirming that such a report should have been present to support the diagnosis and treatment.
A resident with multiple documented food allergies, including peas, was served a meal containing peas despite clear indications on her meal ticket and care plan. The resident reported receiving foods she was allergic to on a recurring basis, and observation confirmed the presence of an allergen on her tray. The deficiency persisted even after previous complaints and staff education.
Several shower and bathing areas lacked working call lights or had missing cords, preventing residents from summoning staff assistance. Multiple residents and CNAs confirmed the call lights were non-functional or inaccessible, and maintenance staff noted cords should be floor-length but were absent. The administrator acknowledged the system's age and frequent failures, with staff compensating by checking on residents more often or remaining present during showers.
Two residents with cognitive impairments and a history of wandering eloped from a facility due to inadequate supervision and safety measures. One resident sustained severe burns after leaving without staff knowledge, while another was found outside the facility twice despite having a wander guard. The facility's safety systems were insufficient to prevent these incidents.
Two residents in an LTC facility did not receive appropriate wound care and documentation. One resident with a toe injury experienced a delay in treatment and lack of monitoring, while another resident with burns had no documented wound measurements. The facility failed to adhere to professional standards and care plans, leading to deficiencies in care.
The facility failed to maintain a sanitary environment in resident shower rooms, as black spots were observed on the baseboard near the shower entrance. Staff interviews revealed inconsistencies in cleaning responsibilities, with CNAs and housekeeping having different understandings of their roles. The Administrator identified the spots as potential mold or moisture, indicating a need for a deep clean.
A resident on hospice services with multiple diagnoses, including a brain bleed, was found on the floor with a laceration above the right eye. The facility failed to thoroughly investigate the incident, lacking interviews with key staff and detailed documentation of the resident's condition and preventive measures. Inconsistencies in records and inadequate assessment of the resident's fall risk contributed to the deficiency.
Two residents did not receive prescribed antibiotics due to transcription errors and failure to order from the pharmacy. One resident with a toe injury and another with severe burns were affected. The DON acknowledged the oversight and lack of a 24-hour chart check.
Failure to Maintain Clean and Safe Shower Rooms
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment in its shower rooms, as evidenced by multiple resident and staff interviews and direct observations. Several residents reported refusing to use the 100-hall shower room due to persistent unpleasant odors described as similar to soiled diapers, sewage, or urine. Staff corroborated these complaints, noting that the odor was strong and that some residents would not use the shower room because of it. Observations confirmed the presence of a strong urine and sewage-like odor, soiled linens in unlabeled garbage cans, a fabric chair with brown and white stains, and shower chairs with brown substances on the seat area. Large garbage cans, one without a liner and half full of briefs and trash, contributed to the odor, and the trash was not being emptied regularly according to staff interviews. In addition to odor issues, the physical condition of the shower rooms was found to be in disrepair. The south 300 hallway shower room had missing and broken tiles at the base of a divider wall, and the Maintenance Director acknowledged that the open gap between tiles could allow humidity to penetrate the wall, potentially causing further damage. Mold was observed around a sprinkler head and in a corner with a large water spot, and the toilet in the 200-hall shower room was out of order due to a broken main pipe and was covered with a plastic sheet. These maintenance issues were confirmed by the Maintenance Director, who stated that repairs were needed but had not been requested until a recent resident complaint. Communication and reporting of these issues were inconsistent. While some CNAs reported entering complaints into the maintenance system, others were unsure if the system was being utilized. The Assistant Director of Nursing was unaware of any complaints regarding the odor, and there was confusion among staff about responsibilities for emptying trash and reporting maintenance needs. Housekeeping staff stated that shower rooms were cleaned daily with disinfectant, odor control, and floor cleaner, but persistent odors and cleanliness issues remained. The Administrator was aware of the ongoing odor problem and noted that a plumber had previously worked on the issue, but the problem persisted intermittently.
Failure to Provide Palatable, Attractive, and Safe-Temperature Food
Penalty
Summary
The facility failed to provide food that was palatable, attractive, and served at a safe and appetizing temperature for a significant number of residents. Multiple residents reported that the food was often cold, bland, unappetizing, and sometimes unidentifiable. Several residents described the food as processed, lacking in variety, and not meeting their nutritional needs, with some specifically noting insufficient protein and small portion sizes. Observations confirmed that salads were not kept at the required temperature, with temperatures recorded well above the safe threshold prior to serving. Additionally, test trays revealed that hot foods were bland and cold foods, such as milk and salad, were served at improper temperatures. Resident council minutes and grievance forms documented ongoing complaints about food quality, including issues with food temperature, lack of adherence to meal tickets, and dissatisfaction with the taste and nutritional content of meals. Residents also reported receiving food items they disliked or were not supposed to have, and some noted that requests for snacks or alternative items were not accommodated. These complaints were consistent over several months, indicating a pattern of unresolved issues related to food service. Interviews with dietary staff and facility administration revealed a lack of awareness regarding the extent of the food quality and temperature issues. The Dietary Manager acknowledged that salads should have been kept refrigerated until use and recognized that improper handling led to elevated temperatures. The Administrator was unaware of the temperature problems and only generally aware of resident dissatisfaction with the food. These findings demonstrate that the facility did not ensure food was consistently palatable, attractive, and served at safe temperatures, as required.
Unsanitary Food Handling and Surface Cleaning Deficiencies
Penalty
Summary
During a lunch service tray line, multiple instances of unsanitary food handling practices were observed among dietary staff. One dietary aide donned gloves and then touched various surfaces, including a thermometer, sink, and refrigerator handle, before touching the face of plates with the same gloved hand. A cook was also seen wearing gloves while touching oven doors, sink handles, and a spatula handle, then touching the face of plates prior to plating food for residents. Additionally, the cook slid plates across a white cutting board and used the same board to chop carrots without cleaning it before or after use. The chopped carrots were then plated and served to residents. Another staff member repositioned food on plates with gloved hands after touching multiple surfaces, including plates, covers, fridge door, cart, and sink handles, without performing hand hygiene or changing gloves before handling the food. Interviews with the cook and the dietary manager confirmed that staff should not touch the face of plates or food with dirty gloves and that gloves should be changed between tasks. Both acknowledged that the white cutting board, used for chopping food for mechanically soft diets, was not cleaned prior to use, despite being used to move plates along the tray line. The dietary manager admitted that this practice was inappropriate as the surface was dirty at the time food was prepared on it.
Failure to Offer and Administer Required Vaccinations
Penalty
Summary
The facility failed to ensure that residents were properly offered and administered influenza, pneumococcal, and COVID-19 vaccines as required. Specifically, two residents had signed consent forms indicating their acceptance of the 2024/2025 COVID-19 booster, but there was no documentation that the booster was administered to them. Additionally, one resident did not have any documentation showing that they were offered the influenza or COVID-19 booster vaccines for the 2024/2025 season. These findings were based on interviews and record reviews conducted by surveyors. The residents involved had various medical conditions, including epilepsy, chronic systolic heart failure, and Alzheimer's disease. The facility's process included obtaining vaccination consents during admission and pre-ordering vaccines, but the records reviewed did not show that the required vaccines were offered or administered as indicated by the residents' consents. The Regional Nurse Consultant confirmed the lack of documentation and administration for the affected residents.
Residents Denied Timely Access to Personal Funds
Penalty
Summary
The facility failed to provide two residents with ready and reasonable access to their personal funds, despite having been authorized to manage these funds. One resident reported being unable to access her money on weekends because no staff member with access to the funds was available outside of weekday business hours. She was told she would have to wait until Monday to obtain her money. Another resident had previously filed a grievance stating that there was no one available to distribute money on weekends, and the business office confirmed that funds were only accessible during the week. Interviews with facility staff, including the Business Office Manager and the Administrator, confirmed that residents could not access their funds on weekends. The Business Office Manager stated he was solely responsible for distributing funds and only worked Monday through Friday. The Administrator acknowledged gaps in the process, including times when no staff were available to distribute funds and instances when there was no cash available due to delays in obtaining money from the corporate office. These actions and inactions resulted in residents not having reasonable access to their personal funds as required.
Delay in Suture Removal Following Hospital Discharge
Penalty
Summary
A resident with a history of Alzheimer's disease, generalized anxiety disorder, lack of coordination, and major depressive disorder was admitted to the facility following a fall that resulted in a fractured nose and knee. Upon return from the hospital, the resident had sutures placed on the bridge of her nose and a brace on her left leg, with hospital discharge instructions specifying that the sutures should be removed in 7 days. Observations made more than two weeks after the incident revealed that the sutures were still present, with scabs forming over them, and the resident was seen tugging at the sutures. Interviews with facility staff indicated a lack of clarity regarding the appropriate timeframe for suture removal. One LPN believed the sutures should remain for 14-21 days, while the Director of Nursing confirmed that the sutures should have been removed on the date specified in the hospital discharge instructions. The delay in suture removal demonstrated that the resident did not receive care in accordance with professional standards of practice, the comprehensive care plan, or the resident's preferences and goals.
Failure to Maintain Complete Laboratory Records in Resident Chart
Penalty
Summary
A deficiency was identified when the facility failed to maintain complete, dated laboratory records in a resident's clinical record. Specifically, for one resident with multiple complex diagnoses, including benign neoplasm of the brain, chronic respiratory failure with hypoxia, heart failure, chronic obstructive pulmonary disease, and epilepsy, laboratory results for serum phenytoin and phenobarbital were not found in the electronic medical record. The pharmacy had recommended these labs due to the resident's medication regimen, and the attending physician had agreed to the orders. However, a review of the resident's chart revealed that no such lab results were present for the past six months, and there were no routine orders in place for these labs to be drawn. Interviews with facility staff revealed that diagnostic results were sent to medical records to be scanned and uploaded into the electronic medical record. The DON stated that this process typically took about a week, while the medical records staff indicated that she aimed to upload records the same day she received them and then destroyed the originals. Despite these procedures, the required laboratory reports for the resident were not located in the electronic medical record, resulting in incomplete documentation.
Missing Signed and Dated Chest X-ray Report in Resident Record
Penalty
Summary
A deficiency was identified when the facility failed to file a signed and dated chest x-ray report in the clinical record of a resident who was being treated for pneumonia. The resident, who had a history of chronic respiratory failure with hypoxia, transient cerebral ischemic attack, and chronic obstructive pulmonary disease, was admitted with these diagnoses and subsequently received two different antibiotics for infectious pneumonitis and pneumonia. Documentation in the medical record included orders for Amoxicillin-Potassium Clavulanate and Doxycycline, as well as nursing notes referencing the treatment for pneumonia. Despite the clinical indications and treatment for pneumonia, a review of the resident's medical record revealed that the chest x-ray report, which would have confirmed the diagnosis, was not present in the file. Interviews with nursing staff and the regional nurse consultant confirmed that a chest x-ray would have been ordered to support the diagnosis, but the report was not located in the record at the time of review. The absence of a signed and dated radiological report in the resident's clinical record constituted the deficiency.
Failure to Accommodate Documented Food Allergies
Penalty
Summary
A deficiency occurred when a resident with documented allergies, including peas, was served fried rice containing peas. The resident reported that she is allergic to peas due to an enzyme deficiency that causes her stomach upset, and stated that she is served foods she is allergic to at least once a week. Observation confirmed the presence of peas on her lunch tray, and the meal ticket clearly listed peas as an allergy and as a strong dislike. The resident's medical record and care plan both documented her allergies, including peas, and her history of multiple medical conditions such as IBS, GERD, obesity, and eating disorders. Despite these documented allergies and clear instructions on the meal ticket, the resident continued to receive foods containing her allergens. A previous grievance report indicated that the resident had complained about being served her allergens, and staff had been educated on the issue. However, the deficiency persisted, as evidenced by the recent incident where the resident was again served peas. The Dietary Manager acknowledged that allergies are highlighted on meal tickets and that multiple staff are supposed to check trays, but was unable to explain how the error occurred.
Non-Functioning Call Light System in Shower and Bathing Areas
Penalty
Summary
The facility failed to ensure that a functioning call system was available in each resident's bathroom and bathing area, as required. Observations revealed that in the 200 and north 300-hall shower rooms, at least one call light was not operational, and there were no cords attached to the call lights in the 100, 200, and north 300-hall shower rooms. Multiple residents and staff confirmed that the call lights either did not work or were missing cords, making it impossible for residents to call for assistance if needed. In one instance, a resident reported concern about being unable to summon help if she became stuck in the shower. Another resident stated that the call light in the 200-hall shower room had not worked since repairs were made, and staff had to remain present during his showers due to the non-functioning system. Further observations showed that in some shower rooms, the call light switches were present but lacked cords, and in at least one case, activating the call light did not result in any visible signal in the hallway. Staff interviews confirmed awareness of the issue, with maintenance staff noting that cords should be long enough to reach residents on the floor, and CNAs describing the need to check on residents frequently due to the lack of a working call system. The facility administrator acknowledged that the call light system was old and prone to frequent bulb outages, and that audits of the system had only recently begun.
Inadequate Supervision and Safety Measures Lead to Resident Elopements
Penalty
Summary
The facility failed to ensure a safe environment for residents, leading to two significant incidents involving elopement and inadequate supervision. Resident 26, who had a history of wandering and was identified as a high elopement risk, managed to leave the facility without staff knowledge. Despite having a wander guard, the resident was able to remove it and elope, resulting in severe burns after falling on hot pavement. The resident's medical history included cognitive impairments and a history of wandering, which were not adequately addressed by the facility's safety measures. In another incident, Resident 10, who was admitted with conditions such as Wernicke's encephalopathy and alcohol abuse, also eloped from the facility. The resident was found outside the facility on two occasions, despite having a wander guard. The facility's records indicated that the resident was confused and exhibited wandering behaviors, yet the safety measures in place were insufficient to prevent the elopements. The facility's doors did not have a comprehensive wander guard system, and the alarms were either not functioning or not responded to by staff. Both incidents highlight the facility's failure to maintain a secure environment and provide adequate supervision for residents at risk of elopement. The lack of effective monitoring and the inability to ensure that safety devices were properly used and maintained contributed to these deficiencies. The facility's response to these incidents, including the submission of investigations to the State Survey Agency, confirmed the occurrences but did not prevent the initial failures in resident safety.
Deficiencies in Wound Care and Documentation
Penalty
Summary
The facility failed to provide appropriate treatment and care according to professional standards and the residents' care plans for two residents. Resident 15, who was admitted with multiple diagnoses including congestive heart failure and difficulty walking, suffered a laceration and dislocation of the right fifth toe after an incident involving a wheelchair. Despite hospital discharge instructions to buddy tape the toes and monitor the wound, the facility did not document the completion of dressing changes or monitoring for infection. Additionally, there was a four-day delay in implementing the ordered Medihoney treatment for the wound, and the resident's toe was noted to be discolored and detached. Resident 26, who had a history of hemiplegia, epilepsy, and burns, did not have documented measurements for their burn wounds on the back and buttocks. The resident sustained second and third-degree burns after an incident involving methamphetamine use and prolonged exposure to hot pavement. Although the facility had a wound nurse and NP to assess wounds weekly, the NP was unable to obtain accurate measurements due to the nature of the burns. The lack of documented measurements hindered the ability to track wound healing and make necessary adjustments to the care plan. The Director of Nursing acknowledged the importance of wound measurements for assessing healing and adjusting care but confirmed that measurements were not consistently documented for Resident 26. This oversight in documentation and treatment implementation for both residents indicates a failure to adhere to professional standards and the residents' comprehensive care plans, resulting in deficiencies in the care provided.
Inadequate Cleaning Practices in Resident Shower Rooms
Penalty
Summary
The facility failed to maintain a sanitary, orderly, and comfortable environment in the resident shower rooms, as evidenced by the presence of black spots on the lower corner baseboard near the shower entrance. Observations made on the 200-hall resident shower room revealed these black spots, which were identified by the Administrator as potentially being mold or moisture spots requiring a deep clean. This deficiency was noted during an observation conducted on August 13, 2024. Interviews with facility staff revealed inconsistencies in the cleaning responsibilities and practices for the shower rooms. Housekeeping staff indicated that certified nursing assistants (CNAs) were responsible for cleaning the resident shower rooms, while housekeeping only cleaned resident rooms and common areas. A CNA stated that housekeeping cleaned the showers once a week, and CNAs were responsible for cleaning up after resident showers, including sanitizing shower chairs. The Assistant Director of Nursing confirmed that housekeeping disinfected shower floors and toilets, but the presence of black spots suggested inadequate cleaning practices.
Failure to Investigate Allegation of Neglect
Penalty
Summary
The facility failed to thoroughly investigate an allegation of neglect involving a resident who was admitted on hospice services with multiple diagnoses, including traumatic subdural hemorrhage and chronic obstructive pulmonary disease. The incident occurred when the resident was found on the floor with a laceration above the right eye. The staff did not conduct a comprehensive investigation to determine the circumstances leading to the fall, such as the resident's condition prior to the fall, the position of the bed, or whether routine checks were being performed. The report highlights that the resident was a high fall risk due to increased weakness and disorientation, as noted in hospice documentation. Despite this, there was no evidence that the facility had adequately assessed or documented the resident's risk factors or preventive measures in place at the time of the incident. The facility's records did not include interviews with the CNA who discovered the resident or detailed information about the resident's condition before the fall. Additionally, there were inconsistencies in the documentation regarding the resident's primary diagnosis and the use of the term "terminal agitation" after the fall. The nurse involved in the incident later stated that they would not have used the term "terminal agitation" and believed that routine checks were being conducted, although they were unsure of the specifics. This lack of thorough investigation and documentation contributed to the deficiency identified by the surveyors.
Failure to Administer Prescribed Antibiotics
Penalty
Summary
The facility failed to ensure that two residents were free from significant medication errors. Resident 15, who was admitted with multiple diagnoses including congestive heart failure and difficulty swallowing, suffered a laceration and dislocation of the right fifth toe after an incident involving his wheelchair. The emergency department prescribed Cephalexin to prevent infection, but the medication was neither transcribed onto the medication administration records (MARs) nor ordered from the pharmacy, resulting in the resident not receiving the prescribed antibiotics. Resident 26, who was readmitted with severe burns and other complex medical conditions, also did not receive prescribed antibiotics. An order for Keflex was issued to treat the burns, but it was not transcribed into the electronic medical record. Despite an interdisciplinary review identifying this oversight, the antibiotics were not administered in a timely manner. The Director of Nursing acknowledged the failure to implement the order and the lack of a 24-hour chart check to ensure new orders were followed.
Latest citations in Utah
Surveyors found that the facility did not ensure residents or their representatives were informed of and able to participate in decisions about psychotropic medications. Several residents with conditions such as dementia, early-onset Alzheimer’s disease, major depressive disorder, psychotic disorder, and Parkinson’s disease were started on drugs including haloperidol, donepezil, buspirone, quetiapine, zaleplon, and sertraline without documentation that risks, benefits, or alternative treatments were discussed in advance. The DON reported that staff notify families when medications are started or changed but do not review risks and benefits, offer alternative options, or obtain signed consent, resulting in no evidence of informed decision-making for these psychotropic treatments.
Surveyors determined that the facility failed to consistently manage psychotropic medications for three residents. Two residents with dementia and psychiatric conditions had only one documented psychotropic medication review and gradual dose reduction (GDR) attempt, completed in January, with no evidence of quarterly reviews or additional GDR efforts. Another resident with hemiplegia, psychotic disorder, dementia, and major depressive disorder had a PRN IM haloperidol order written without an end date, which remained active and was administered on multiple occasions beyond 14 days, and the DON confirmed there was no physician documentation justifying the extended PRN antipsychotic order.
The facility failed to ensure that alleged abuse and serious injuries were reported to the State Survey Agency as required, instead either reporting only to a state patient safety system or not reporting at all. One resident with severe cognitive impairment sustained bilateral femur fractures after a fall, another cognitively impaired resident with Parkinson’s disease was later found to have a femur fracture after being discovered on the floor, and a third cognitively impaired resident required ORIF surgery for fractures following a fall; none of these incidents were reported through the State Survey Agency’s incident reporting website, per the ADM. In addition, an allegation that a resident with dementia and sensory impairments may have been molested was documented in the abuse binder but not in the medical record, and the ADM did not report the allegation to agencies or law enforcement after deeming it not credible, despite interviewing the resident and family. These actions and omissions resulted in multiple unreported events that met criteria for immediate reporting of alleged abuse and injuries of unknown source.
The facility failed to investigate multiple major injuries and an allegation of sexual abuse involving three residents with severe cognitive impairment and significant medical conditions. One resident, dependent for transfers, was found on the floor after attempting to get out of bed and was later found to have bilateral femur fractures. Another resident with Parkinson’s disease was found on the floor after a wheelchair alarm sounded and was later diagnosed with a femur fracture following complaints of leg pain. A third resident, described as very independent, triggered a bed alarm and was found kneeling by a recliner, later requiring ORIF for fractures of the right 4th and 5th metacarpals. In each case, the ADM acknowledged awareness of the fractures, stated there was no belief of neglect or abuse, and confirmed that no investigation into the cause of the injuries or the alleged abuse was initiated or documented.
Surveyors found that the facility failed to ensure monthly pharmacist drug regimen reviews were completed and documented for several residents with conditions such as Parkinson’s disease, dementia, and Alzheimer’s disease, with no pharmacist notes present for at least two consecutive months. Additionally, a pharmacist’s recommendation to add a low-dose daytime antipsychotic for a resident with dementia, psychotic disorder, and behavioral symptoms was not communicated to the physician or implemented for several months, despite documented behavioral concerns. An LPN reported not relaying the pharmacist’s recommendation because PRN Haldol had not been needed at that time, and the DON confirmed that the pharmacist reviews for the missing months were not done and that she did not have time to monitor follow-through on such recommendations.
Surveyors identified a failure to properly label medications when two open insulin pens were found in a medication refrigerator bin marked only with a resident’s first name, with no labels directly on the pens. During an observation, an RN confirmed the pens belonged to a resident and acknowledged that pens are supposed to be labeled with the resident’s name but could not explain why these were not labeled. In a subsequent interview, the DON confirmed the pens had been unlabeled and stated they should have been labeled in accordance with professional standards.
The facility failed to sustain effective QAPI processes related to pharmacist medication regimen reviews, resulting in repeated noncompliance with F756. Surveyors found that medical records for four residents lacked documentation showing that a pharmacist had reviewed medications, identified potential irregularities, or made recommendations to attending physicians, an issue previously cited. The DON reported she did not have time to maintain this documentation, and the Administrator acknowledged there was no formal performance improvement project in place, though some plans were noted in QAPI minutes, and no supporting documents were produced to demonstrate ongoing compliance.
Staff failed to follow infection control practices during medication administration and did not maintain organized infection surveillance documentation. An LPN was observed handling an oral medication with bare hands before administering it to a resident, contrary to the DON’s stated expectation that pills be dispensed directly into medication cups without hand contact and that any contaminated dose be discarded. Additionally, the DON, who also served as the Infection Preventionist, reported that several residents had influenza during a past holiday season but had no list of affected residents or rooms, and the requested infection control surveillance logs and a formal tracking system were not available.
The facility lacked an antibiotic stewardship program, with no protocols to ensure appropriate indication, dose, and duration of antibiotic prescriptions and no system to monitor antibiotic use or resistance patterns. When surveyors requested Infection Control Surveillance Logs, including antibiotic tracking information, the logs were not available. In an interview, the DON, who also functioned as the Infection Preventionist, acknowledged that she did not track resident antibiotic utilization, clinical indications, or treatment durations.
A resident with multiple chronic conditions, including DM, HTN, anxiety, major depressive disorder, and PTSD, reported that a CNA on night shift failed to hold open a smoking-area door, leading the resident to grab the door and sustain a finger cut that bled. The resident completed a grievance with the RA, who documented that the CNA swung the door open and walked away and that no abuse or neglect allegation was initially identified. However, the grievance lacked documentation of investigative steps, a summary of findings, a conclusion on whether the grievance was confirmed, and any decision date or required signatures, and leadership later reported they had not been informed of the incident, demonstrating the grievance was not promptly resolved or fully tracked through conclusion.
Failure to Inform Residents of Risks, Benefits, and Alternatives Before Starting Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents, or their representatives, were informed of and allowed to participate in decisions regarding psychotropic medication treatment, including being informed in advance of the risks, benefits, and treatment alternatives. For four sampled residents, medical record review showed new orders for multiple psychotropic medications without any documentation that the resident or representative had been informed of these elements prior to initiation. Resident 8, with diagnoses including hemiplegia and hemiparesis following cerebral infarction, psychotic disorder with delusions, dementia, and major depressive disorder, was started on haloperidol lactate, donepezil, buspirone, quetiapine, and sertraline on various dates, with no documentation of informed discussion or consent. Resident 4, with unspecified dementia and anxiety disorder, was started on zaleplon, quetiapine, and buspirone, again with no record that risks, benefits, or alternatives were discussed in advance. Resident 54, diagnosed with early-onset Alzheimer’s disease and dementia in other diseases classified elsewhere, was started on sertraline and quetiapine, and Resident 6, diagnosed with Parkinson’s disease without dyskinesia, was started on buspirone, quetiapine (Seroquel), and sertraline, with no documentation that either resident or their representative had been informed of the risks and benefits or treatment options before these psychotropic medications were initiated. During an interview, the DON stated that the facility notifies families when medications are started or doses are changed but does not discuss risks and benefits, provide alternative options, or obtain signed consent. This practice contributed to the lack of documented evidence that residents or their representatives were fully informed and able to participate in treatment decisions regarding psychotropic medications.
Failure to Perform Regular GDR and Limit PRN Antipsychotic Orders
Penalty
Summary
Surveyors found that the facility did not ensure appropriate management of psychotropic medications for three sampled residents. For two residents with dementia and related psychiatric diagnoses, the medical records from late April 2026 showed only one documented psychotropic medication review and gradual dose reduction (GDR) attempt, completed in January 2026. There was no documentation of any GDR attempts or psychotropic reviews prior to January 2026, despite the DON stating that such reviews and GDRs should be completed quarterly. The records for these residents did not contain additional GDR attempts beyond the January 2026 review. For a third resident with hemiplegia following cerebral infarction, psychotic disorder with delusions, dementia, and major depressive disorder, a physician’s order dated February 8, 2026, prescribed PRN intramuscular haloperidol lactate every 12 hours for delusions, hallucinations, paranoia, and agitation, without an end date. Review of the MARs for February through April 2026 showed that this PRN antipsychotic was administered on two occasions, and no end date was documented on the MAR. In an interview, the DON acknowledged that the PRN haloperidol order extended beyond 14 days and that the physician had not documented a reason for continuing the order beyond that period.
Failure to Report Alleged Abuse and Serious Injuries to State Survey Agency
Penalty
Summary
The deficiency involves the facility’s failure to ensure that all alleged violations of abuse, including injuries of unknown source and incidents involving major injuries, were reported immediately to the State Survey Agency and other officials as required by state law. For four sampled residents, the Administrator acknowledged that incidents were reported only to the state’s patient safety website and not to the State Survey Agency’s incident reporting website. This omission meant that the State Survey Agency did not receive timely notice of serious events, including an allegation of sexual abuse and multiple incidents resulting in significant fractures and surgery. For one resident with severely impaired cognition and diagnoses including hemiplegia and hemiparesis, nursing notes documented that the resident was found on the floor after attempting to get out of bed, was sent to the ER, and returned with immobilizing braces on both legs due to bilateral femur fractures. The resident’s bones were not strong enough for surgery, and he was placed on comfort care. Despite the seriousness of the injuries and the requirement to treat such events as potential abuse or neglect until ruled out, the Administrator stated that this incident was reported only to the state’s patient safety website and not to the State Survey Agency’s incident reporting system. Another resident with Parkinson’s disease and severely impaired cognition was found on the floor after a wheelchair alarm sounded, initially with no visible injury and able to bear weight. A few days later, staff documented complaints of left leg pain, tenderness, and wincing with movement, leading to an order for x‑rays and transfer for imaging. X‑ray results revealed a femur fracture, and surgery was not pursued. The Administrator reported this incident to the state’s patient safety website but not to the State Survey Agency’s incident reporting website. A third resident with severe cognitive impairment experienced a fall with complaints of pain in the left knee, left elbow, and fingers, and later underwent ORIF surgery for fractures of the right fourth and fifth metacarpals; this incident also was not reported to the State Survey Agency’s incident reporting system, according to the Administrator. For another resident with dementia, adjustment disorder with anxiety, hearing and visual loss, and age‑related debility, a document in the facility’s abuse binder described a possible molestation allegation originating from a phone call by the resident’s nephew. The nephew reported that his mother, the resident’s sister and then‑POA, was emotionally unstable and had stated she felt the resident had reported being molested. The Administrator documented that the nephew did not believe the allegation was credible, that the sister had dementia and emotional issues, and that the Administrator considered the report “not a viable allegation.” The Administrator noted that he interviewed the resident, who denied being touched, and that the sister could not provide more details beyond stating that a man had groped the resident’s breast. The Administrator concluded the allegation was not credible and did not report it to any agencies or law enforcement. The incident was not documented in the resident’s medical record, and the Administrator confirmed in interview that he did not report this sexual abuse allegation to the State Survey Agency’s incident reporting website. Across these four residents, the common deficiency was the facility’s failure to treat serious injuries and a sexual abuse allegation as reportable events to the State Survey Agency, as required. Instead, the Administrator limited reporting to the state’s patient safety website or chose not to report at all when he personally judged an allegation as not credible. This pattern of inaction regarding mandated reporting requirements formed the basis of the cited deficiency.
Failure to Investigate Major Injuries and Alleged Abuse
Penalty
Summary
The deficiency involves the facility’s failure to initiate and document investigations into multiple major injuries and an allegation of sexual abuse, as required for all alleged violations involving abuse and injuries of unknown source. For one resident with hemiplegia, hemiparesis, and severely impaired cognition (BIMS score of 6), nursing notes documented that his roommate activated the call bell after the resident fell while attempting to get out of bed by himself. He was found on the floor between his bed and the window, reported knee pain with a popping sensation, and was sent to the ER. On return from the hospital, he was noted to have bilateral femur fractures, immobilizing braces on both legs, and was placed on comfort care due to bones not being strong enough for surgery. The Administrator acknowledged awareness of the bilateral femur fractures, stated he did not believe neglect or abuse caused the injury, and confirmed he did not investigate the cause of this major injury. Another resident with Parkinson’s disease and a BIMS score of 0 (rarely/never understood) was documented in an incident note as sitting in a wheelchair in the dining room when his alarm sounded; he was found supine on the floor, denied hitting his head or injury, and was assisted back into the chair with no signs of injury noted. Several days later, nursing notes recorded that CNAs reported the resident complaining of left leg pain when getting him out of bed. On assessment, he had tenderness and wincing with movement of the left leg but was able to bear weight. The MD was notified, an x-ray was ordered, and the resident was transported for imaging, which revealed a femur fracture for which surgery was not pursued. The Administrator stated he was aware of the femur fracture, did not feel neglect or abuse caused the major injury, and did not investigate the cause of the injury. A third resident with COPD, scoliosis, and severely impaired cognition (BIMS score of 7) had an incident note documenting that her bed alarm sounded and staff found her in a kneeling position leaning into her recliner after she attempted to get up from bed to go to the bathroom, stating her walker “didn't go where she was going.” She complained of left knee, left elbow, and right pinky pain, with no visible injury except an abrasion on the right ring finger. A later nursing note documented that she underwent ORIF of fractures of the right fourth and fifth metacarpals at a hospital and returned from surgery the same day. The Administrator reported being aware of the fractures, described the resident as very independent and wanting to wander the facility, stated he did not feel neglect or abuse caused the major injury, and confirmed he did not investigate the cause of the injury. Across these three residents, the facility did not initiate or document investigations into the causes of the major injuries or the related allegation of sexual abuse, nor did it determine causation or responsible parties as required.
Failure to Complete Monthly Pharmacist Reviews and Timely Act on Medication Recommendations
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a licensed pharmacist conducted and documented monthly drug regimen reviews for multiple residents and to ensure that identified medication irregularities were acted upon by the attending physician. For four sampled residents, the medical records lacked monthly pharmacist medication regimen review notes for at least two consecutive months. Specifically, residents with diagnoses including Parkinson’s disease, unspecified dementia, Alzheimer’s disease with early onset, and dementia related to other diseases had no documented pharmacist review notes for March and April 2026. The DON confirmed that the pharmacist had not completed pharmacy reviews for those months and that the notes, which should have been uploaded into each resident’s electronic medical record, were absent. In addition, the facility failed to act promptly on a pharmacist’s recommendation for a resident receiving psychotropic medications. One resident with hemiplegia following cerebral infarction, psychotic disorder with delusions, dementia, and major depressive disorder had a pharmacist recommendation in November 2025 to add a low-dose daytime Seroquel due to behavioral issues and afternoon anxiety. Nursing documentation showed that the pharmacist discussed the resident’s response to Seroquel versus Abilify and suggested a low-dose daytime Seroquel, but this recommendation was not communicated to the physician at that time. The LPN later stated she did not speak to the physician about the pharmacist’s recommendation because the resident had not needed PRN Haldol around that time. The physician did not write the order for daytime Seroquel until early February 2026, after a nurse raised concerns about the resident’s behaviors and reminded the physician of the prior pharmacist recommendation. The DON acknowledged that the pharmacist’s November 2025 recommendation was not completed until February 2026 and stated she did not have time to stay on top of such issues.
Unlabeled Insulin Pens Found in Medication Refrigerator
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled in accordance with accepted professional principles when two open insulin pens belonging to resident 56 were found without the resident’s name on them. During an observation of the south medication refrigerator on 4/29/26 at 10:50 AM, surveyors noted a plastic bin labeled only with resident 56’s first name, containing two loose, open insulin pens that had no resident identification labels affixed directly to the pens. In a concurrent interview, RN 1 confirmed that the two insulin pens belonged to resident 56 and stated that staff always put residents’ names on insulin pens, but was unsure why these pens had not been labeled. Later that day at 2:17 PM, the DON stated in an interview that the two insulin pens in question had been unlabeled and acknowledged that the insulin pens should have been labeled with the resident’s information.
Failure to Sustain QAPI Actions and Documentation for Pharmacist Medication Reviews
Penalty
Summary
The deficiency involves the facility’s failure, as part of its performance improvement activities, to take actions aimed at performance improvement, measure the success of those actions, and track performance to ensure that improvements were realized and sustained, specifically related to F756. Record review and interviews showed that the facility did not maintain documentation in the medical records to demonstrate that a pharmacist reviewed residents’ medications, identified potential irregularities, or provided recommendations to the attending physician for four sampled residents, despite this same issue having been cited in the previous health survey in 2024. During an interview, the DON stated she did not have time to maintain this required documentation. In a separate interview, the Administrator stated he did not have a performance improvement project, though he had QAPI minutes that captured some improvement plans, and he believed the facility had achieved compliance with F756, which had been cited previously, but no documents demonstrating compliance were provided when requested by surveyors.
Failure in Medication Handling and Infection Surveillance Documentation
Penalty
Summary
The facility failed to ensure a safe and sanitary environment during medication administration and infection surveillance. During an observation of medication pass for resident 23, an LPN was seen popping an oral pill directly from a blister pack into her bare hand and then placing it into a medication cup, after which the medication was administered to the resident. In a subsequent interview, the DON stated that staff were expected to pop pills directly into medication cups and never touch medications with bare hands, and that any medication contacting a staff member’s bare hand was to be discarded and replaced, indicating that the observed practice did not follow facility expectations. The facility also failed to maintain infection control surveillance documentation and an organized tracking system for infections. When Infection Control Surveillance Logs were requested, the DON reported that several residents had contracted influenza during the 2025 holiday season, attributed to an increased number of visitors, and that symptomatic residents were kept in their rooms. However, the DON stated she did not have a list of affected residents or rooms, and the requested surveillance logs were unavailable for review. In a later interview, the DON, who also served as the facility’s Infection Preventionist, confirmed that the facility lacked an infection control surveillance manual or organized system for tracking infections.
Failure to Implement and Monitor an Antibiotic Stewardship Program
Penalty
Summary
The facility failed to develop and implement an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use. There was no established facility-wide system to ensure appropriate indication, dose, and duration for antibiotic prescriptions, and no process for monitoring antibiotic usage or resistance data. On 4/29/26 at 8:20 AM, when surveyors requested the facility’s Infection Control Surveillance Logs, including any prescribed antibiotic tracking information, these logs were unavailable. On 4/30/26 at 12:28 PM, during an interview, the DON, who also served as the facility’s designated Infection Preventionist, stated that she did not track resident antibiotic utilization, including the specific clinical indications for the medications or the prescribed durations of treatment. No specific residents, their medical histories, or clinical conditions at the time of the deficiency were described in the report.
Failure to Promptly Resolve and Document Resident Grievance Regarding Door Injury
Penalty
Summary
The deficiency involves the facility’s failure to promptly resolve and properly document a resident grievance in accordance with its grievance policy. A resident with type II DM, HTN, anxiety disorder, major depressive disorder, and PTSD reported that a CNA on night shift did not hold open the smoking door for her and another resident, and that when she went to grab the door, it slammed on or closed against her finger, causing a cut to bleed. The resident stated she reported this to the Resident Advocate (RA) and completed a grievance form, and that nursing staff applied Neosporin and a bandage to the finger. The resident did not know the CNA’s name but identified that the CNA worked nights and stated that no one should be treating residents that way. The grievance form dated 4/10/26 documented the concern that the CNA on night shift did not hold the smoking door open and instead swung the door open and walked away, and that upon initial interview no allegation of abuse or neglect was identified. However, the grievance form contained no documentation of investigative steps taken, no summary of findings or conclusion, and no indication whether the grievance was confirmed or not. The form also lacked a written decision date, resident signature, grievance officer signature, and Administrator signature. The RA reported that the resident told her the door incident caused a small cut to reopen and that the CNA seemed in a hurry, but did not state that the CNA acted intentionally or purposefully toward her. The Administrator and DON later stated they had not been informed of the incident, and the Regional Nurse Consultant noted that nothing was filled out on the back of the grievance form, indicating it remained incomplete despite having been initiated several days earlier.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
