Thatcher Brook Rehabilitation & Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Clearfield, Utah.
- Location
- 1795 South Chelemes Way, Clearfield, Utah 84015
- CMS Provider Number
- 465169
- Inspections on file
- 16
- Latest survey
- July 23, 2025
- Citations (last 12 mo.)
- 23
Citation history
Health deficiencies cited at Thatcher Brook Rehabilitation & Care Center during CMS and state inspections, most recent first.
Surveyors found that drugs and biologicals were not consistently labeled with open or expiration dates, including insulin vials and pens for two residents with diabetes. Medications such as sucralfate and daptomycin were improperly stored in a medication room sink, and a medication cart was observed left unlocked and unattended. Staff interviews confirmed these practices did not align with facility policy or professional standards.
Several residents reported dissatisfaction with meal quality, including unappetizing taste, tough meat, lack of seasoning, and cold or improperly prepared food. Observations of a test tray confirmed issues with food temperature and appearance. Dietary staff relied on informal feedback, and alternative menu options were not consistently offered or accessible.
Surveyors found that food items in the kitchen were not consistently stored, labeled, or sealed according to professional standards, with multiple items left open to air in freezers and refrigerators, and some lacking required dates. The stove and oven surfaces were also observed to be unclean, with crumbs, debris, grease, and powder present. Staff interviews confirmed that procedures for dating and sealing food were in place but not consistently followed.
Staff failed to consistently follow Enhanced Barrier Precautions and infection control protocols, including not donning required PPE, not performing hand hygiene during dressing changes, and improper cleaning techniques for central line care. PPE signage was inconsistently marked, and staff demonstrated confusion about EBP requirements, resulting in care for residents with wounds, central lines, and indwelling devices being provided without appropriate infection prevention measures.
A resident with limited mobility and dexterity, requiring assistance with eating, was observed being fed by a CNA who stood at the bedside rather than sitting, contrary to facility expectations. The DON confirmed that staff should be seated while feeding residents to maintain dignity and respect.
A resident with complex medical needs was emergently transferred to the hospital after a seizure, but the facility did not provide written notice of transfer or discharge, nor written information about the bed-hold policy, to the resident or their representative as required. Verbal notification was given, but no written documentation was included with the transfer or provided afterward.
Two residents with documented preferences for group and individual activities were only offered bingo three times a week, with no other scheduled activities provided. Interviews and review of the activities calendar confirmed the lack of variety, and both the Activities Director and Administrator acknowledged that other available materials and options were not actively promoted or scheduled.
A resident with severe cognitive impairment and a history of falls did not have new interventions added to their care plan after experiencing multiple falls. Despite repeated incidents and the resident's ongoing fall risk, staff relied on verbal communication and did not formally update the care plan with new measures following each event.
A resident with end stage renal disease, sepsis, and heart failure did not receive immediate monitoring or documentation of vital signs and dialysis fistula assessment upon return from dialysis. Staff relied on information from the dialysis center and performed assessments at other times, but did not follow facility expectations for immediate post-dialysis evaluation and documentation.
A resident with a prescribed soft-bite and pre-cut food diet did not receive appropriate menu substitutions for garlic bread and salad, as required by her dietary restrictions. Despite the menu indicating alternatives should be provided, the resident was served a meal without suitable substitutes, leading to dissatisfaction and a failure to meet her nutritional needs.
A resident with multiple chronic conditions and a documented dislike of pork and pork products was repeatedly served sausage, despite her preferences being clearly noted on her dietary records and meal tickets. Staff interviews and record reviews confirmed that the resident's dislikes were known, but pork products were still provided.
A resident with a history of recurrent UTIs was prescribed Macrobid daily as a prophylactic antibiotic without documented evidence of current infection or symptoms, and the order lacked a stop date. The facility's antibiotic stewardship policy required clear documentation of treatment duration and monitoring, but these protocols were not followed, resulting in a deficiency related to antibiotic use monitoring.
A resident with multiple chronic conditions received the initial PCV-13 pneumococcal vaccine, but the facility failed to document administration, offer, or declination of the second recommended pneumococcal vaccine dose. The resident's vaccination status was marked as 'unable to determine,' and there was no evidence that the required follow-up was completed according to facility policy.
Deficiencies in Medication Storage, Labeling, and Security
Penalty
Summary
Surveyors identified multiple deficiencies related to the storage and labeling of drugs and biologicals for four residents. For one resident with type 2 diabetes mellitus and end stage renal disease, an opened insulin vial was found without an open or expiration date. The responsible RN confirmed the vial was opened and subsequently labeled it during the observation. Another resident with diabetes had an insulin pen in the medication cart that was also missing an open or expiration date, and the LPN interviewed was unsure of the exact duration insulin remained viable after opening. This resident had already been discharged at the time of the observation. Additional deficiencies were observed with medications not being properly stored. A bubble pack of sucralfate for a resident with gastro-esophageal reflux and cyclical vomiting was found in the medication room sink with one tablet remaining. Similarly, compounded daptomycin vials for a resident with sepsis and pneumonia were also found in the medication room sink. The DON stated that medications should not be stored in the sink and explained that these were intended to be returned to the pharmacy, which collects unused medications twice daily. Surveyors also observed a medication cart left unlocked and unattended in a hallway. The DON and LPN confirmed that the cart should be locked when not attended, and the RN responsible for the cart stated she had left her keys with the LPN during her break but was unsure if the cart had been left unlocked. The DON reiterated that medication carts should always be locked when unattended and that no medications or resident information should be left exposed.
Failure to Provide Palatable, Attractive, and Properly Tempered Meals
Penalty
Summary
The facility failed to provide food and drink that was palatable, attractive, and at a safe and appetizing temperature for 8 of 26 sampled residents. Multiple residents reported dissatisfaction with the quality, taste, and temperature of the meals served. Specific complaints included food being unappetizing, tough meat, lack of seasoning, cold vegetables, and not receiving menu-listed items or appropriate condiments. Some residents stated they were not offered alternatives and, in some cases, resorted to ordering food from outside sources due to dissatisfaction with facility meals. Observations of meal service and a test tray revealed further issues. The test tray included pork roast that was dry, tough, and served at 124.9°F, wild rice pilaf that was lukewarm and unsavory, overcooked and bland asparagus at 117.3°F, a flattened and unappetizing apple crisp dessert at 53.1°F, and a dinner roll at 70.3°F. These findings confirmed that food was not consistently served at appetizing temperatures or in an appealing manner. Additionally, the test tray and resident interviews indicated that food preparation methods did not conserve flavor or appearance. Interviews with dietary staff revealed that while the Registered Dietitian (RD) and Dietary Manager (DM) were involved in resident assessments and occasional tray audits, feedback mechanisms were informal and not consistently documented. The alternative menu was not readily accessible to all residents, as it was separate from the main menu and only provided upon request. These actions and inactions contributed to the deficiency in providing meals that met regulatory standards for palatability, appearance, and temperature.
Improper Food Storage and Kitchen Cleanliness
Penalty
Summary
Surveyors observed multiple instances where food items in the facility's kitchen were not stored, prepared, or maintained according to professional food service safety standards. During walk-throughs, several food items in both the walk-in and reach-in freezers, such as diced carrots, peas, French toast, cookie dough, sausage links, and dinner rolls, were found open to the air. Additionally, the stove and the top of the oven were noted to have crumbs, debris, grease, and a white powder, indicating a lack of cleanliness. In the walk-in refrigerator, containers of chicken breasts and pork roast were covered with plastic wrap but were not dated, and a large bucket of pickles did not have an open date. Interviews with kitchen staff and the Dietary Manager revealed that food items were supposed to be dated when received and when opened, and that cleaning duties were assigned to all kitchen staff. The Dietary Manager confirmed that food in the refrigerator should be dated even if it was to be used the same day, and that food in the freezer should be sealed to prevent freezer burn. Despite these stated procedures, the observed deficiencies indicated that these practices were not consistently followed, resulting in improper food storage and cleanliness issues.
Failure to Implement and Adhere to Enhanced Barrier Precautions and Infection Control Protocols
Penalty
Summary
Surveyors identified that the facility failed to maintain an effective infection prevention and control program for three out of twenty-six sampled residents. Staff were observed not donning required Personal Protective Equipment (PPE) for residents on Enhanced Barrier Precautions (EBP), not performing hand hygiene during dressing changes, and engaging in cross-contamination during a central line dressing change. Specifically, signage for PPE requirements was inconsistently marked, and staff demonstrated confusion regarding when and what type of PPE was necessary for care activities involving residents with indwelling devices or wounds. For one resident with a central line for IV antibiotic administration due to infective endocarditis, staff did not wear a gown during medication administration or dressing changes, despite EBP policy requiring both gown and gloves for such high-contact care. Additionally, hand hygiene was not performed prior to donning sterile gloves, and improper technique was used when cleaning the central line insertion site, with the nurse going back over the insertion site after cleaning outward. The PPE signage outside the resident’s room was not properly marked until after the dressing change, and staff interviews revealed a lack of understanding about EBP requirements. Other residents with wounds, feeding tubes, or indwelling urinary catheters also had EBP signage posted, but staff were observed providing care and assistance, including transfers and therapy, without donning the required PPE. Interviews with staff indicated inconsistent knowledge and application of EBP protocols, and in some cases, there were no physician orders for EBP found in the records. The facility’s policy required gown and gloves for high-contact care activities for residents with wounds or indwelling devices, but these procedures were not consistently followed.
Staff Stood While Feeding Dependent Resident
Penalty
Summary
A deficiency was identified when a certified nursing assistant (CNA) was observed standing while feeding a resident who was lying in bed with the head of the bed elevated and the bed in its highest position. The resident, who had a history of cellulitis, sepsis, and hypertension, required assistance with eating due to difficulty with dexterity and was dependent on a Hoyer lift for mobility. During interviews, staff confirmed that the resident struggled to feed herself and that CNAs were expected to sit while feeding residents, as stated by the Director of Nursing (DON). However, the observed practice did not align with this expectation, resulting in a failure to treat the resident with respect and dignity and to provide care in a manner that promoted the resident's quality of life and recognized her individuality.
Failure to Provide Written Transfer/Discharge and Bed-Hold Policy Notification
Penalty
Summary
A deficiency was identified when a resident with multiple medical conditions, including a left tibia and fibula fracture, respiratory failure with hypoxia, neuralgia, type 2 diabetes, anxiety disorder, epilepsy, and morbid obesity, was emergently transferred to the hospital after experiencing a seizure and becoming unresponsive. Although internal discharge paperwork was completed, there was no discharge documentation found in the resident's medical record. The facility's policy requires that notice of transfer or discharge, including the reason for transfer and bed-hold policy details, be provided to the resident and their representative in writing as soon as practicable, especially in emergency situations. Interviews with the DON and Administrator revealed that while some paperwork, such as a face sheet, resident orders, and a POLST form, was sent with the resident, no written notice of transfer or discharge or bed-hold policy was provided to the resident or their representative. The DON stated that the bed-hold policy was communicated verbally but not in writing, and the Administrator confirmed that a bed-hold agreement was not sent with residents transferred to the hospital. This failure to provide required written notifications and documentation at the time of transfer or discharge constituted the deficiency.
Failure to Provide Comprehensive Activity Program for Residents
Penalty
Summary
The facility failed to provide an ongoing program of activities to meet the interests and support the physical, mental, and psychosocial well-being of its residents, as required. For two out of 26 sampled residents, it was observed and confirmed through interviews that the only scheduled activity was bingo, which occurred three times a week, with no other group or individual activities offered. The activities calendar reflected this lack of variety, listing only bingo on select days and leaving other days, including weekends, blank. Residents expressed dissatisfaction, stating there were no other activities available and some days had no activities at all. Review of the residents' medical records showed that both had expressed preferences for group activities and participation in their favorite pastimes, as documented in their Minimum Data Set (MDS) assessments and care plans. Despite these documented preferences, the only interventions listed were to acquaint residents with the facility and its routines. The Activities Director (AD) confirmed that activity packets with puzzles and word games were distributed, and that some materials like books and board games were available, but these were not actively promoted or scheduled as part of a structured program. The AD also stated she had no helpers and had not received training. The Administrator acknowledged the lack of variety in activities and that residents were not informed about available options beyond bingo and activity packets.
Failure to Update Fall Interventions After Multiple Resident Falls
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment, generalized weakness, and a history of falls did not have new interventions implemented after experiencing multiple falls. The resident, who was at risk for falls due to lack of coordination and recent hospitalization, experienced at least three documented falls within a short period. Despite these incidents, the care plan was not updated with new interventions following the falls on 7/3/25 and 7/12/25. The existing care plan included general fall prevention measures such as therapy, use of gait belts, frequent safety checks, and encouragement to use the call light, but did not address the specific circumstances or patterns of the recent falls. Interviews with nursing staff and administration revealed inconsistent practices regarding the updating of care plans and communication of interventions. The DON and ADON indicated that interventions were not always updated after each fall, and that staff were often informed of required interventions verbally rather than through formal documentation. The care plan was reviewed only every 30 days, and there was no evidence of new interventions being added after the most recent falls, despite the resident's ongoing risk and repeated incidents.
Failure to Provide Immediate Post-Dialysis Assessment and Documentation
Penalty
Summary
A deficiency was identified in the care of a resident with end stage renal disease, sepsis, and heart failure who required dialysis services. Upon review of the resident's medical record and interviews with the resident, nursing staff, and the Director of Nursing (DON), it was found that the facility did not provide immediate monitoring and documentation of the resident's vital signs or assessment of the dialysis fistula upon the resident's return from the dialysis treatment center. The resident reported that after returning from dialysis, a Certified Nursing Assistant (CNA) assisted him to his room, but no vital signs were taken and a nurse did not assess his dialysis fistula at that time. Further interviews revealed that the LPN relied on the Dialysis Progress Note from the dialysis center, which included vital signs, weights, and new orders, and stated that vital signs were taken in the morning before dialysis and again in the evening, with fistula assessments completed every morning. However, there was no documentation in the resident's medical record of immediate post-dialysis vital signs or fistula assessment. The DON confirmed that facility policy expected nurses to assess the resident and the dialysis fistula immediately upon return from dialysis and to document these findings, but this was not done in this case.
Failure to Provide Appropriate Menu Substitutions for Special Diet
Penalty
Summary
A deficiency was identified when a resident with special dietary needs did not receive appropriate menu substitutions in accordance with her prescribed diet. The resident, who had recently discontinued tube feedings and was transitioning back to oral intake, was observed at lunch receiving spaghetti with small pieces of meat and green peas, along with a pudding-type dessert. The menu for that meal listed spaghetti, garlic bread, and a green salad, but the resident did not receive suitable substitutes for the garlic bread or salad, despite her dietary restrictions. The resident expressed disappointment with her meal, noting the lack of appropriate alternatives. Review of the resident's medical record showed she required a soft-bite and pre-cut food diet, as approved by the Registered Dietitian (RD), and had specific restrictions to avoid certain foods due to severe inflammation and gastric irritants. The daily menu spreadsheet indicated that substitutions should have been provided, such as soft steamed vegetables or mashed vegetables for salad, and pureed bread for garlic bread. The Dietary Manager confirmed that changes to diet orders were communicated by the RD and entered into the dietary system, but acknowledged that appropriate substitutions were not made for this resident's meal.
Failure to Accommodate Resident's Documented Food Preferences
Penalty
Summary
A deficiency was identified when a resident with multiple medical diagnoses, including infective endocarditis, atrial fibrillation, chronic kidney disease, cystitis, type 2 diabetes mellitus, bacteremia, hypolipidemia, and hypokalemia, received food items that did not accommodate her documented dietary preferences and dislikes. The resident had a clearly documented dislike of pork and pork products, including ham and sausage, as noted on her Nutrition Screening Intake Form and her meal ticket. Despite these documented preferences, the resident reported receiving pork products, specifically sausage, on multiple occasions, including during a breakfast observation where a sausage patty was present on her tray. Interviews with the resident, a CNA, and a staff member responsible for dietary preferences confirmed that the resident's dislikes were known and documented, and that pork products should not have been served. The staff member acknowledged that the resident's meal ticket listed pork, ham, and sausage as dislikes and that eggs were typically provided as an alternative. The presence of sausage on the resident's tray was verified by both the CNA and the kitchen, indicating a failure to follow the resident's documented dietary preferences.
Failure to Monitor and Document Antibiotic Use per Stewardship Protocols
Penalty
Summary
A deficiency was identified when a resident with a history of recurrent urinary tract infections (UTIs), neoplasm of the right kidney, and hypertension was prescribed Macrobid (nitrofurantoin) 100 mg daily as a prophylactic antibiotic for chronic UTIs. The physician's order for the antibiotic was open-ended, lacking a stop date, and was continued without documented evidence of current infection or symptoms. Medical records and progress notes indicated that the resident did not exhibit signs or symptoms of a UTI during the period the antibiotic was administered, and a urine dip was negative. There was also no documentation that a urinalysis was performed as ordered. The facility's antibiotic stewardship policy required that antibiotic orders include a duration of treatment, specifying start and stop dates or the number of days of therapy. The policy also emphasized monitoring antibiotic use and providing education on the risks associated with antibiotics. Despite this, the resident received ongoing prophylactic antibiotic treatment without adherence to these protocols, and the facility did not ensure that its antibiotic stewardship program included effective monitoring or protocols for antibiotic use as required.
Failure to Document and Offer Second Pneumococcal Vaccine Dose
Penalty
Summary
A deficiency was identified when the facility failed to offer or document the administration or declination of the second dose of the pneumococcal immunization series for one resident. The resident, who had a medical history including a right fibula fracture, congestive heart failure, chronic kidney disease, type 2 diabetes mellitus, a prosthetic heart valve, cardiomyopathy, and hypertension, had received the PCV-13 pneumococcal vaccine. However, there was no documentation in the medical record indicating that the resident was administered, offered, or declined the subsequent recommended pneumococcal vaccine. The facility's process involved the ADON checking the Statewide Immunization Information System for new admissions and completing a vaccine form. In this case, the resident's vaccination consent form was marked as "unable to determine" for the pneumococcal vaccine, and the DON confirmed that there was no evidence of the second vaccine being offered or declined. The facility's policy required assessment and offering of the pneumococcal vaccine series upon admission, with documentation of administration or refusal, but this was not followed for the resident in question.
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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