Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Mission At Alpine Rehabilitation Center during CMS and state inspections, most recent first.
Multiple residents with severe cognitive impairment were involved in repeated incidents of sexual contact and elopement without proper assessment of their capacity to consent or adequate supervision. Staff and administration failed to document capacity evaluations, relied on superficial signs of consent, and did not conduct thorough abuse investigations, resulting in unaddressed abuse and neglect.
Surveyors found that the facility did not have or implement adequate policies and procedures to prevent abuse, neglect, or theft, particularly regarding sexual abuse and elopement. Multiple residents with severe cognitive impairment were involved in incidents of sexual contact or attempted sexual contact without documented assessments of their capacity to consent or proper investigations. The facility failed to report or thoroughly investigate these incidents, and did not have written protocols defining sexual abuse or procedures for evaluating consent.
Surveyors found that the facility did not promptly report or investigate multiple incidents of alleged abuse, neglect, elopement, and injuries of unknown origin involving residents with severe cognitive impairment. These included unreported sexual contact between cognitively impaired residents, several resident elopements—some resulting in injury, and a resident injury during transport. Staff and administration often failed to recognize or act on the need for immediate reporting to the State Survey Agency, as required by regulations.
Surveyors found that the facility did not thoroughly investigate or report multiple incidents involving abuse, neglect, elopement, and injuries of unknown origin. Several residents with severe cognitive impairment were involved in incidents of sexual contact, elopement, and unexplained injuries, but the facility failed to conduct formal investigations or notify the State Survey Agency as required. Staff and administration acknowledged that these events were not properly handled or documented.
Multiple residents with cognitive impairment eloped from the facility, with some incidents requiring staff to intervene to prevent harm. Two residents experienced falls without subsequent updates to their care plans, and one resident was injured during transport due to improper wheelchair securement. Staff responses and documentation were inconsistent, and not all incidents were reported or investigated as required.
Failure to Protect Residents and Report/Investigate Allegations: The facility failed to ensure residents were free from abuse and neglect, including not assessing capacity to consent to sexual relationships and allowing two residents without capacity to elope. Multiple residents with cognitive impairment eloped, one resident was injured after not being secured in a facility van, two residents fell without interventions, and one resident had injuries of unknown origin. The facility also failed to report allegations of abuse, neglect, mistreatment, injuries of unknown origin, sexual activity between cognitively impaired residents, elopements, and fractures to the SA within 2 hours, and did not thoroughly investigate these allegations.
Failure to Investigate Abuse and Elopement Incidents: The facility did not have effective written policies, data systems, or monitoring for abuse and elopements, and multiple residents were involved in resident-to-resident abuse and repeated elopement events. A resident with TBI and other diagnoses was reportedly sexually assaulted by another resident, while other residents with dementia, psychosis, and behavioral diagnoses were found kissing, undressed, or in sexualized situations with each other. Several residents with dementia and other serious conditions repeatedly climbed or broke through the fence and left the facility grounds, and the DON and Admin acknowledged gaps in elopement policy, investigation, and reporting.
A resident dining service issue was observed where meals and beverages were routinely served on Styrofoam plates, bowls, and cups, including for a legally blind resident. Staff stated this was the usual practice for lunch, with sandwiches cut into pieces and placed in Styrofoam bowls, and other meals such as pizza and quiche also served on disposable ware.
Food items were repeatedly found open to air and some were not dated in the freezer, and a large unlabeled bag of powdered milk was left open in dry storage. Surveyors also observed cracked tiles, chipped paint, and a wall in disrepair in the kitchen and dish room, and dead bugs were found in a freezer. The DM stated staff sometimes forgot to seal food after use, and the RD said she completed monthly kitchen audits for cleanliness and proper labeling and dating.
Missing Signed Hospital Transfer Agreement: The facility did not have a written transfer agreement with a Medicare/Medicaid-approved hospital. The Administrator provided an unsigned, incomplete transfer agreement with no facility or hospital information, and stated the facility only had a verbal arrangement with local hospitals for resident transfers.
The facility did not maintain an effective, data-driven QAPI program and failed to identify and prioritize abuse and elopement concerns. The DON and Admin discussed topics such as dementia care and resident-to-resident altercations, but no formal performance improvement plan was made for abuse or elopements, and the Admin stated he was not sure how effectiveness was measured. Staff education on abuse, falls, and accidents was provided annually, but the facility did not identify the non-compliance in QAPI before survey.
Three residents with complex medical and behavioral needs experienced multiple incidents, including falls, choking, and elopement, without timely updates to their care plans. Despite documentation of these events and staff discussions, care plans were not revised to include new interventions or reflect current needs, and some interventions remained outdated or inappropriate for the residents' conditions.
The facility did not provide staff with required training on abuse, neglect, exploitation, or misappropriation of resident property, nor on proper reporting procedures. Staff interviews and review of in-service records showed that education was inconsistent and did not cover key topics such as definitions of abuse, reporting protocols, or consent. The administrator confirmed that current training did not ensure staff understanding or compliance.
Unnecessary psychotropic use and missing behavior monitoring: A resident with severe cognitive impairment was given risperidone for over affectionate behavior despite staff stating the resident did not initiate inappropriate sexual behavior, while other residents had psychotropic orders with repeated gaps in MAR behavior monitoring and non-pharmacologic documentation. The DON also had no additional documentation to justify extended PRN lorazepam use beyond 14 days for one resident.
Uncertified environmental aides were scheduled to provide resident care even though they had worked beyond the 120-day period for CNA certification. The DON stated these aides were CNAs in training and performed the same duties as CNAs, while the DON IT said the facility left enrollment and testing up to the employee and had not kept up with ensuring certification was completed on time.
Menus and meal service did not meet residents’ nutritional needs. Staff altered the menu structure by removing the continental breakfast, serving a light lunch/snack at noon, and providing a larger dinner, while evening snacks were offered without clear documentation of intake. Observations showed residents receiving inconsistent portions and missing menu items, including lunch sandwiches served without the chips listed on the menu and pureed meals without substitution. The RD approved the modified menus, but the menu system and staff interviews showed the facility could not demonstrate that the meal pattern and snacks were nutritionally adequate for all residents.
Meals and snacks were not consistently provided within the required meal span. A resident with severe cognitive and functional impairment was sometimes not served breakfast until late morning, and staff could not confirm a documented nourishing night snack. Another resident with dementia, diabetes, CKD, and weight loss had multiple meal records showing more than 14 hours between dinner and breakfast, with no documented bedtime snack. Interviews with CNA, LPN, RN, DM, and RD showed confusion about meal timing, snack delivery, and where snack intake was documented.
Failure to Provide Staff Training on QAPI: Mandatory training was not conducted for all staff on the facility’s QAPI program. A facility policy described the QAPI plan, but it did not address sexual abuse, sexual abuse training, or elopement training. Interviews showed multiple staff members, including an NA, LPN, and RNs, did not know what QAPI was, and the DON and Administrator confirmed there was no specific staff training on QAPI; no QAPI-focused in-service was found in the materials reviewed.
A resident who was unable to perform activities of daily living did not receive the necessary care and assistance from staff, resulting in unmet care needs.
Two residents with cognitive impairment and complex medical histories experienced significant weight loss due to the facility's failure to provide necessary mealtime cueing, adaptive equipment, and consistent monitoring. Staff did not always follow care plan interventions, and there were gaps in documentation and understanding of snack and supplement intake, resulting in inadequate support for maintaining nutritional status.
The facility did not provide necessary behavioral health care and services to a resident, resulting in unmet behavioral health needs.
Failure to notify the physician when PRN meds were ineffective. A resident with Parkinson’s disease had PRN carbidopa-levodopa, Inbrija, and Vistaril documented as ineffective, and another resident with dementia and other diagnoses had Tums documented as ineffective for heartburn/indigestion. In both cases, there was no documentation that the provider was notified.
A resident with Parkinson’s disease, dementia, repeated falls, depressive episodes, and dorsalgia stated he wanted more activities and to get out more, including missing a trip to the aquarium and wanting to go to a local store. Review of the MDS showed the resident was not assessed for daily preferences related to activities, and the MDS coordinator stated the MDS was not completed and section F should have been completed.
A resident with TBI, cerebral infarction, aphasia, anxiety, depression, and intellectual disability was identified on PASRR Level II as needing SRS outside the scope of the facility. The resident displayed behaviors including profanity, sitting on the floor, and digging in dirt, while the MDS showed significant cognitive impairment and behavioral symptoms. Interviews revealed the resident was never referred for SRS, and the RA and DON described delays and uncertainty about whether those services had ever been provided.
Failure to follow BP hold parameters for an antihypertensive medication: A resident with dementia, DM2, HTN, and other diagnoses had a physician order for losartan 25 mg with instructions to hold if SBP was below 130. The MAR showed the medication was administered multiple times when SBP was below the ordered threshold. RN and DON interviews confirmed that hold parameters were expected to be followed as ordered.
A resident with dementia, Korsakoff syndrome, and dependence for eating was repeatedly given late meals and was at times not served breakfast or lunch while staff were unsure who was responsible for feeding him. Another resident with dementia and multiple medical conditions received a lunch of fruit salad alone, which the RD said was not a well-balanced meal, despite care plans calling for set-up assistance, cueing, and diet as ordered. Staff interviews showed confusion about meal delivery and feeding responsibilities, and a nursing note documented the resident needed cueing and assistance with his breakfast tray.
Incomplete and inaccurate resident records were identified when staff reported repeated resident-to-resident abuse, including a sexual assault allegation involving two residents, but no documentation or investigation could be found in the medical records. Surveyors also found conflicting meal documentation for a resident with dementia and other serious diagnoses, and a mismatch between a resident’s EMR banner showing DNR/comfort measures and the POLST indicating CPR with limited interventions.
Uncovered food was observed being transported and served during hallway meal service, with CNAs moving a cart room to room and offering pizza and sandwiches to residents while the food remained exposed. Staff were also observed not sanitizing hands between residents, one CNA delivered a plate of pizza down the hallway without covering it, and another CNA touched food in a bowl before serving it to a resident without observed hand hygiene.
A resident with multiple comorbidities and a surgical wound infection had a wound culture that grew Pseudomonas aeruginosa, but the organism was not susceptible to Bactrim DS. Despite the culture and sensitivity results, the orthopedic surgeon ordered Bactrim DS and the medication was administered. The ADON stated she told the surgeon the organism identified but did not report the resistance, and the IP and DON stated the IP was responsible for reviewing cultures, tracking antibiotic use, and ensuring the correct antibiotic was ordered.
Failure to document and provide flu and pneumococcal immunizations for two residents. One resident had no record of being offered, given, or refusing the current pneumococcal vaccine despite prior PPSV23 documentation, and another resident signed consent for influenza and pneumococcal vaccines but there was no record the vaccines were administered. The IP stated the vaccines were overseen by the ADON and DON and that one resident's immunization process had fallen through the cracks.
Failure to Protect Cognitively Impaired Residents from Abuse, Neglect, and Unassessed Sexual Contact
Penalty
Summary
The facility failed to protect multiple residents from abuse and neglect, specifically failing to ensure that residents with severe cognitive impairment were free from sexual abuse and neglect. Several residents with diagnoses such as dementia, Alzheimer's disease, traumatic brain injury, and other cognitive disorders were involved in repeated incidents of sexual contact without documented assessments of their capacity to consent. In multiple cases, residents with severe cognitive impairment were found engaging in sexual acts or intimate behaviors with other residents, and staff determined these interactions to be consensual based on superficial observations, such as the absence of resistance or distress, rather than formal capacity assessments. There was no evidence in the medical records that any of the involved residents had been evaluated for their ability to consent to sexual activity, despite clear documentation of severe cognitive deficits and fluctuating mental status. The report details several specific incidents, including residents being found undressed together, engaging in sexual acts, or being discovered in each other's rooms. In one case, a resident with a BIMS score of 3 and a MOCA score of 7, both indicating severe cognitive impairment, was repeatedly found in intimate situations with other residents, some of whom also had severe cognitive impairment. Staff and administration often relied on the residents' apparent comfort or lack of protest to determine consent, even when family members and staff acknowledged the residents' confusion and inability to understand their circumstances. In another case, a resident with a traumatic brain injury and aphasia was found in a sexual situation with another cognitively impaired resident, and the facility failed to conduct or document an abuse investigation or implement effective safety measures to prevent recurrence. Additionally, the facility failed to prevent neglect in the form of elopement, as two residents were able to leave the facility and return without staff knowledge. The lack of supervision and failure to update or implement appropriate care plan interventions for residents at risk of elopement further contributed to the finding of neglect. The surveyors identified these failures as Immediate Jeopardy, citing the facility's lack of adherence to Centers for Medicare and Medicaid Services recommended practices to prevent abuse and neglect, and the absence of thorough investigations and documentation regarding incidents of sexual contact and elopement among cognitively impaired residents.
Failure to Implement Abuse Prevention and Consent Assessment Policies
Penalty
Summary
Surveyors identified that the facility failed to implement and follow written policies and procedures to prevent abuse, neglect, and theft, specifically regarding sexual abuse, capacity to consent to sexual activity, and elopement. The facility did not have written definitions or protocols for evaluating a resident's capacity to consent to sexual relationships, nor did it have adequate procedures for investigating and reporting allegations of abuse. Multiple incidents involving residents with severe cognitive impairment engaging in sexual contact or being found in compromising situations were documented without evidence of proper assessment of their ability to consent or thorough investigation of the events. Several residents with diagnoses such as dementia, traumatic brain injury, and other cognitive disorders were involved in incidents of sexual contact or attempted sexual contact. For example, one resident with a BIMS score indicating severe cognitive impairment was found in multiple situations involving physical intimacy with other residents, none of whom had documented assessments of their capacity to consent. Another resident with a history of neurocognitive disorder and severe cognitive impairment was found in other residents' rooms and beds, sometimes with residents who were partially undressed or engaged in physical contact. In one case, a resident was found with her underwear down and another resident attempting to initiate sexual contact, but there was no documentation of an abuse investigation or capacity assessment. The facility's records showed repeated failures to document or conduct assessments for capacity to consent to sexual activity, despite clear evidence of cognitive impairment and repeated incidents. Incident reports and progress notes often described the events as consensual or inconclusive without supporting documentation or proper evaluation. In some cases, incidents were not reported to the State Survey Agency or law enforcement as required, and there was no evidence of timely or thorough investigation into allegations of abuse or neglect. These failures were cited at the Immediate Jeopardy level due to the facility's lack of effective policies and procedures to prevent and address abuse, neglect, and elopement.
Failure to Timely Report Abuse, Neglect, Elopement, and Injuries
Penalty
Summary
Surveyors identified that the facility failed to immediately report, within the required two-hour timeframe, multiple alleged violations involving abuse, neglect, exploitation, mistreatment, injuries of unknown origin, and elopement to the State Survey Agency. In several cases, incidents involving sexual contact between cognitively impaired residents were not reported or investigated, despite both residents having severe cognitive impairment as indicated by low BIMS and SLUMS scores. Staff and administration assumed the interactions were consensual, even though the residents' cognitive status called their ability to consent into question. Additionally, an incident involving a resident being found undressed with another resident, and another case where a resident was found in another's bed, were not reported or investigated as potential abuse or sexual assault. The facility also failed to report multiple incidents of resident elopement. Several residents with severe cognitive impairment and a history of wandering or elopement were able to leave the facility grounds unsupervised, sometimes by climbing or breaking through fences. In some cases, residents were found by staff or police outside the facility, and in one instance, a resident sustained a skin tear during an elopement. These incidents were not reported to the State Survey Agency as required, and in some cases, the administration was unaware of the reporting requirements for elopement events. Additional deficiencies included failure to report injuries of unknown origin and incidents during transportation. One resident with severe cognitive impairment was observed with a large bruise to the eye, and the cause could not be determined, but the incident was not reported for investigation. Another resident fell out of a wheelchair during transport due to improper securing, resulting in a head abrasion, and this incident was reported late. In all these cases, the facility did not follow required protocols for timely reporting and investigation of potential abuse, neglect, or injury, as confirmed by staff and administrative interviews and record reviews.
Failure to Investigate and Report Abuse, Neglect, Elopement, and Injuries
Penalty
Summary
Surveyors identified that the facility failed to thoroughly investigate and report multiple allegations of abuse, neglect, and mistreatment involving several residents. Incidents included sexual contact between residents with severe cognitive impairment, elopements, injuries of unknown origin, and fractures. In several cases, residents with diagnoses such as dementia, psychotic disorders, and traumatic brain injuries were involved in situations where their ability to consent was questionable, yet no formal investigations were conducted. For example, one resident with a BIMS score indicating severe cognitive impairment was found in close proximity or engaging in physical contact with other residents on multiple occasions, but the facility did not document any investigation into these incidents. In another case, a resident was found with another resident in a compromising situation, and although staff separated them, no investigation was initiated, and the event was not reported to the State Survey Agency. The facility also failed to investigate and report multiple elopement incidents. Residents with significant cognitive impairment and a documented history of wandering or elopement risk were able to leave the facility premises on several occasions. In some instances, residents were found outside the facility or even on public streets, and staff had to intervene to bring them back. Despite these events, there was no evidence of a formal investigation or reporting to the State Survey Agency. Staff interviews confirmed that these incidents were not investigated or reported as required, and the administrator acknowledged that these events should have been handled differently. Additionally, the facility did not investigate injuries of unknown origin. For example, a resident with severe cognitive impairment was observed with a large bruise to her right eye, and although the incident was noted in the medical record, there was no documentation of an investigation to determine the cause. The DON stated that such injuries should be investigated and reported if the cause is unknown, but no investigation was provided. The administrator also confirmed that investigations were primarily informal and that some incidents were not reported due to a lack of clarity on reporting requirements.
Failure to Prevent Elopement, Falls, and Transport Injuries Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure that residents received adequate supervision to prevent accidents, resulting in multiple incidents involving elopement, falls, and injuries. Three residents with cognitive impairment eloped from the facility, with two of these incidents reaching the level of immediate jeopardy. In one case, a resident with severe cognitive impairment and a history of elopement repeatedly escaped the facility by breaking through or climbing over fences, sometimes requiring staff intervention to prevent the resident from entering traffic. Documentation showed that staff were aware of the resident's behaviors, but interventions were limited to verbal redirection and monitoring, and not all incidents were reported or investigated as required. Another resident with vascular dementia and agitation also eloped on multiple occasions by climbing over fences, resulting in a skin tear during one incident. Despite these events, there was no evidence that the resident's elopements were investigated or reported to the state survey agency. Additionally, this resident experienced several falls, including incidents where the resident hit his head or was found on the floor, but the care plan was not updated to reflect new interventions after these falls. Staff interviews confirmed that interventions were not consistently added to the care plan following such incidents. A separate incident involved a resident who was not properly secured in a facility van during transport, resulting in the resident tipping backward in his wheelchair and sustaining a head abrasion. The staff member responsible for transport admitted to not securing the wheelchair correctly and stated that initial training was verbal and lacked demonstration. Documentation of training was incomplete, and the facility could not provide evidence that the staff member had been properly trained prior to the incident. Other residents were also found in unsafe positions, such as lying on the floor or between the bed and wall, without staff present or timely intervention.
Failure to Protect Residents and Report and Investigate Allegations
Penalty
Summary
The facility was not administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Multiple residents were identified as being in Immediate Jeopardy and/or having experienced harm, including residents 7, 11, 12, 25, 27, 33, 31, 36, 42, 47, and 49. The report states that for 7 of 32 sampled residents, the facility did not ensure residents had the right to be free from abuse and neglect because residents were not assessed for the capacity to consent to a sexual relationship. It also states that two residents without capacity were able to elope from the facility. The facility also failed to ensure the environment was as free of accident hazards as possible and that residents received adequate supervision and assistance devices to prevent accidents. Three residents with cognitive impairment eloped from the facility, a resident was not secured in a facility van and suffered an injury, two residents experienced falls with no interventions put into place, and one resident had injuries of unknown origin. In addition, for 9 of 32 sampled residents, alleged abuse, neglect, exploitation, mistreatment, injuries of unknown origin, sexual relations between cognitively impaired residents, multiple elopements, and fractures were not reported immediately, but not later than 2 hours after the allegation was made, to the State Survey Agency. The facility also did not thoroughly investigate allegations of sexual abuse, elopements, injuries of unknown origin, and fractures, and it did not establish and implement written policies and procedures for feedback, data collection systems, monitoring, and adverse event monitoring.
Failure to Investigate Abuse and Elopement Incidents
Penalty
Summary
The facility failed to establish and implement written policies and procedures for feedback, data collection systems, monitoring, and adverse event monitoring, including for abuse and elopements. Survey findings identified multiple residents involved in incidents of resident-to-resident abuse and repeated elopements, and the facility did not develop or implement policies to address the underlying causes of the problems or identify how corrective actions were taken and monitored. The report states that several residents were identified as being in Immediate Jeopardy related to abuse and elopements. Resident 11, who had diagnoses including traumatic brain injury, cerebral infarction, aphasia, anxiety disorder, unspecified intellectual disabilities, and depression, was reportedly sexually assaulted by resident 49. An APS investigator reported that on 3/14/25 a CNA found resident 49 with his pants down on top of resident 11 and attempting to initiate sexual contact. The facility’s abuse investigation documentation contained no investigation into this incident. The Administrator later confirmed that resident 49 had been found on top of resident 11 in bed pulling his pants down and trying to undress her, and also had previously tried to pull resident 11 into his room, rubbed her shoulder, and tried to hold her hand. The Administrator confirmed there was no investigation into these incidents. Resident 33, who had Parkinson’s disease with dyskinesia, dementia, psychotic disorder with delusions due to non-psychological conditions, and anxiety disorder, was involved in multiple resident-to-resident sexual or intimate encounters with residents 27 and 31. Progress notes documented resident 33 kissing resident 27 while lying on top of her, being found in another resident’s room with a female resident, holding hands and kissing resident 31, and being found undressed with resident 31 in a sexualized position. The DON IT stated that residents 31 and 33 had expressed a desire to engage in sexual activity, and that family was notified after one incident. Resident 27, who had neurocognitive disorder, anxiety disorder, personality disorder, vascular dementia, and psychosis, was also documented as being found in resident 33’s bed with resident 33 on top of her and being kissed by resident 33. Another incident report documented resident 49 with his pants down and leaning close to resident 27’s head, with no investigation date or time clearly documented. Resident 42, diagnosed with vascular dementia with agitation, anxiety disorder, psychotic disorder with delusions, and depressive disorder, repeatedly eloped or attempted to elope by climbing or breaking through the fence and leaving the facility grounds. Progress notes documented the resident jumping the fence, being found outside, kicking the front door, stepping on wood beside the fence to climb over it, and later kicking the fence out and eloping. Resident 36, who had traumatic subdural hemorrhage with loss of consciousness, pain, generalized anxiety disorder, major depressive disorder, bipolar disorder, and a personal history of suicidal behaviors, also repeatedly escaped through or over the fence and left the facility. Notes documented the resident walking home after breaking through the fence, being found outside after knocking down the fence, escaping through the fence and walking down the street, and later taking fence panels apart, stepping off a retaining wall, and walking into the road before staff redirected him. The DON stated the facility did not have a policy and procedure for elopements, and the Administrator stated that investigations were primarily done by talking with nurses and looking into events, that some incidents were not reported to the state, and that the incidents involving residents 42 and 36 should have been investigated and reported.
Lunch Service Served on Disposable Ware
Penalty
Summary
The facility did not care for residents in a manner and in an environment that promotes maintenance or enhancement of quality of life and recognizes each resident's individuality. During lunch service, residents were observed being served on small Styrofoam plates, in Styrofoam bowls, and with beverages in Styrofoam cups. On 8/12/25, residents in the dining room were served lunch on Styrofoam plates and cups, and resident 41 was served lunch in a Styrofoam bowl. Resident 18, who was legally blind, was served lunch in a Styrofoam bowl with juice in a Styrofoam cup. Observations and interviews showed this was routine practice. CNA 1 stated the sandwiches served that day were cut into pieces and placed in Styrofoam bowls using tongs, and that the food was not usually measured. NA 6 stated the lunch was half of a ham sandwich that could be served as bite sized or pureed, that residents received milk or juice, and that lunch was usually always served in Styrofoam plates, bowls, and cups. Additional observations on other dates showed pizza, quiche, cottage cheese, and muffins being served on Styrofoam or plastic items, with beverages in Styrofoam or plastic cups. Resident 18 was also observed sitting with a blanket over her head and lap, asking for half of a sandwich and later asking for a clothing protector, but no staff were nearby to hear her request.
Food Storage and Kitchen Sanitation Deficiencies
Penalty
Summary
Food was not stored, prepared, distributed, and served in accordance with professional standards for food service safety. During an initial walkthrough of the kitchen, surveyors found a box of frozen green beans and a box of cubed carrots open to air in the walk-in freezer, along with a bag of breaded chicken and a bag of frozen fried rice that were not dated. In the dry storage room, a large plastic bag of white powder was open to air and not labeled; a dietary staff member identified it as powdered milk. Surveyors also observed several cracked tiles outside the walk-in freezer and walk-in refrigerator, cracked tiles in the dish room, and the wall under the dish machine in disrepair, with chipped paint on the wall next to the steam table. On a later walkthrough, surveyors again observed food items left open to air in the freezer, including a box of chicken gyros, a box of dinner rolls, and a box of California vegetable blend. The same areas of the kitchen and dish room still had cracked tiles, chipped paint next to the steam table, and the wall under the dish machine remained in disrepair. In addition, dead bugs were observed in the freezer in the dining room. The dietary manager stated staff sometimes forgot to seal food items in the freezer after obtaining what they needed and acknowledged the cracked tiles and planned kitchen update, while the registered dietitian stated she completed monthly kitchen audits that included cleanliness and proper food labeling and dating.
Missing Signed Hospital Transfer Agreement
Penalty
Summary
The facility did not have a written transfer agreement with one or more hospitals approved for participation under the Medicare and Medicaid programs. During record review, a hospital transfer agreement provided by the Administrator on 8/7/24 was observed to be void of any facility information, hospital information, or signatures. In an interview on 8/7/25, the Administrator stated the facility only had a verbal agreement with local hospitals that residents could be sent there if the facility sent a face sheet, medication list, and allergy list. In a follow-up interview on 8/20/25, the Administrator stated the facility did not have a signed transfer agreement with the local hospitals.
QAPI Program Failed to Address Abuse and Elopement Issues
Penalty
Summary
The facility did not develop, implement, and maintain an effective, comprehensive, data-driven QAPI program. Based on interview and record review, the facility did not identify and prioritize problems related to resident abuse and elopements, and corrective actions were not identified, monitored, or evaluated for effectiveness. The facility was cited at an Immediate Jeopardy level for non-compliance with F600, F607, F609, F610, and F689, with resident identifiers 7, 11, 12, 27, 31, 33, 36, 42, 47, and 49 involved in the findings. During interview, the Administrator stated that the QAPI team met monthly and included department heads and the Medical Director, and that topics reviewed included drywall repairs, concrete hazards in the courtyard, and dementia care. He stated that a performance improvement plan was completed for dementia training after the need for it had been identified about one year earlier, and that monthly dementia in-services were being done. He also stated that monitoring was conducted by the ADON, but he was not sure how effectiveness was measured. The Administrator stated that staff were educated annually on abuse, fall hazards, and accidents, but the facility did not identify the non-compliance related to abuse and elopements in QAPI before survey, and although resident-to-resident altercations and elopements were discussed, no formal performance improvement plan was made for those areas.
Failure to Update and Implement Comprehensive Care Plans After Changes in Resident Condition
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for three residents, as required by regulation. For each resident, the care plans did not include measurable objectives and timeframes to address their medical, nursing, mental, and psychosocial needs as identified in their comprehensive assessments. Specifically, care plans were not updated following significant changes in condition or incidents, resulting in care plans that did not reflect the current needs or required services for the residents. One resident with vascular dementia, agitation, and a history of falls experienced multiple falls over several months. Despite documentation of these incidents in progress notes and incident reports, the resident's care plan was not updated after each fall to reflect new interventions or changes in care. Interviews with staff confirmed that interventions discussed in meetings and huddles were not consistently incorporated into the written care plan in a timely manner. Another resident with severe cognitive impairment, alcohol dependence, and a history of falls and choking incidents had multiple documented falls and a choking event. The care plan included outdated interventions, such as providing a bowl of nuts, which was not appropriate for the resident's current dietary needs. The care plan was not updated with new interventions after each incident, and staff interviews revealed a lack of awareness of the resident's current care needs. A third resident with severe cognitive impairment and exit-seeking behaviors had multiple documented elopements and attempts to leave the facility. Despite these incidents, the care plan was not updated with new approaches after each event, and staff interviews indicated uncertainty about who was responsible for updating care plans.
Failure to Provide Required Staff Training on Abuse, Neglect, and Reporting Procedures
Penalty
Summary
The facility failed to provide staff training that met minimum requirements for educating staff on abuse, neglect, exploitation, and misappropriation of resident property, as well as procedures for reporting such incidents and preventing abuse and neglect. Interviews with staff, including a nursing assistant and a registered nurse, revealed that while some education was provided, it was generally limited to addressing issues that needed correction and did not consistently cover the required topics. Staff were unclear about the content and purpose of Quality Assurance and Performance Improvement (QAPI) meetings, and there was no evidence that education on consent or comprehensive abuse prevention was included in the training. Review of in-service training records from January through July showed that none of the agendas included specific abuse training. While there were trainings on dementia, assault, de-escalation, and communication, these did not define abuse, explain its types, outline reporting procedures, or clarify who could give consent. The administrator acknowledged that the abuse training needed updating and that current education did not ensure staff understanding or practice of the required concepts.
Unnecessary psychotropic use and missing behavior monitoring
Penalty
Summary
The facility did not ensure that residents were free from unnecessary psychotropic medications or medications used as restraints for discipline or convenience, and it did not consistently monitor residents receiving psychotropic drugs. The report identified 4 of 32 sampled residents with concerns involving psychotropic medication use, lack of behavior monitoring, lack of documentation of non-pharmacological interventions, and lack of follow-up when medications were ineffective or when PRN use extended beyond the allowed timeframe. Resident 27 had diagnoses including neurocognitive disorder, anxiety disorder, personality disorder, vascular dementia, and psychosis, and had a BIMS score of 0 indicating severe cognitive impairment. The resident was ordered cimetidine for hypersexuality, clonazepam for anxiety, Depakote for hypersexuality, and risperidone for behaviors related to frontotemporal neurocognitive disorder and unspecified psychosis. Facility monitoring records for antidepressant and anti-anxiety treatment showed no behaviors documented and no non-pharmacological interventions provided for multiple days in May and June, with additional missing documentation. Progress notes showed no hypersexual behavior documented in February, March, or April, yet a provider note on 5/16/25 stated the resident had over affectionate behavior and risperidone 0.5 mg twice daily was added. Staff interviews stated the resident was calm, wandered, smiled, giggled, and would rub backs or give hugs, but did not initiate sexual behavior or seek out residents, and several staff stated the resident did not exhibit inappropriate behaviors with other residents. Resident 24 had diagnoses including vascular dementia, bipolar disorder, borderline personality disorder, PTSD, suicidal ideation, hypertension, and type 2 diabetes mellitus. The resident was ordered citalopram, prazosin, quetiapine, and Depakote for psychiatric conditions. The July MAR showed missing documentation for monitoring of antidepressant, antipsychotic, and mood stabilizer behaviors and non-pharmacologic interventions on multiple doses. Resident 41 had diagnoses including Parkinson’s disease, dementia, anxiety disorder, mild cognitive impairment, Lewy body neurocognitive disorder, and psychotic disorder with hallucinations. The resident was ordered clonazepam, lorazepam PRN for anxiety, Nuplazid, and quetiapine. The August MAR lacked documentation for anti-anxiety, antipsychotic, and hypnotic monitoring on multiple days, and the DON stated there was no additional information or documentation to justify extending PRN Ativan beyond 14 days. Resident 40 had diagnoses including dementia, diabetes, hypertension, psychotic disorder with delusions and hallucinations, anxiety disorder, insomnia, schizophrenia, and major depressive disorder. The resident was ordered Celexa, scheduled lorazepam, PRN lorazepam, and quetiapine. The July MAR lacked documentation for multiple behavior monitoring entries and showed missed documentation for scheduled lorazepam doses and PRN administration, while the DON stated there was no additional information or documentation for the rationale for extended lorazepam use.
Uncertified nurse aides provided resident care beyond the 120-day training period
Penalty
Summary
The facility used individuals working as nurse aides for more than 4 months who were not certified and were still providing resident care. A review of the facility’s list of Nursing Assistants, Certified Nursing Assistants, and Environmental Aides showed seven environmental aides with hire dates ranging from 12/6/24 to 1/30/24, including two hired in 2023 and early 2024. The facility staff schedules for the weeks of 8/3/25 through 8/16/25 showed that NA 1 through NA 7 were all scheduled and assigned sections of the facility to provide care for residents during those weeks. During interview, NA 6 stated she had worked at the facility for a while but was not certified because her CNA license had expired. The DON stated the environmental aides were CNAs in training, performed the same duties as CNAs, and should be certified and tested within 120 days of hire. The DON also stated she knew NA 2, NA 4, and NA 7 had taken the class and only needed to take the test. The DON IT stated the facility did not have a specific training program and left it up to the employee to get signed up, and that it was her responsibility to follow through and ensure the NAs completed training and testing. The DON IT reviewed the list of environmental aides and stated each had gone over 120 days and should have completed certification, but she had not kept up on making sure they were certified within the required time frame.
Menus and meal service did not meet residents’ nutritional needs
Penalty
Summary
The facility did not have menus that met the nutritional needs of residents in accordance with established nutritional guidelines, and the menus were altered from their original form to remove the continental breakfast, add a snack during the lunch time, and provide a larger dinner meal. Although the menus were reviewed by the facility’s dietitian, the menus did not demonstrate nutritional adequacy for the resident population. The report identified residents 5, 18, and 25 in connection with the meal service observations. On 8/4/25, breakfast was observed and residents were served 2 pieces of French toast, hot cereal, cold cereal if desired, 1 sausage link, orange juice, and milk. On 8/5/25, lunch was observed and residents were served 1 slice of cheese pizza with lemonade or water. The posted weekly menu showed lunch items that varied by day, including deli Swiss sandwich, BBQ pulled pork on a bun, Hawaiian grilled cheese, fruit cocktail, and chicken patty sandwich. The posted breakfast menus included items such as French toast, Mediterranean quiche, cheese omelet, muffins, breakfast biscuit and gravy, and waffles, along with hot cereal, cold cereal, juice, and milk. The posted dinner menus included larger meals such as chicken rice bake, BBQ pork ribs, hamburger steak with gravy, sweet and sour chicken, lemon garlic fish, and burgundy beef and noodles. During observations on 8/12/25, lunch was served as a sandwich meal, but residents were not consistently offered the chips listed on the menu. Resident 18 received cut-up sandwich pieces and water, with no measured portion and no chips offered. Another resident received pureed sandwich in a bowl with no substitution for the chips that were supposed to be offered. Resident 25 and his wife were each given 1/2 sandwich and a drink while leaving the building, and chips were not offered; the CNA told resident 25 to enjoy his snack. Staff interviews showed the lunch meal was referred to as a snack, but the DM stated it was really the lunch meal. The DM and RD stated the facility served brunch from 8:30 until 11:00, a lunch/snack during the noon hour, and a larger dinner at 4:00, with evening snacks available around 7:00 PM. The DM also stated she did not know where snack intake was documented, and CNA 1 stated there was no place in the medical record to document whether residents ate during the continental breakfast or evening snack. The RD acknowledged that some residents had cognitive impairment and might not be able to verbalize their needs.
Meal Timing and Snack Documentation Deficiency
Penalty
Summary
Meals and snacks were not consistently served within the required time span between a substantial evening meal and breakfast the following day. The report states that for 2 of 32 sampled residents, the facility went over 14 hours between dinner and breakfast, and there was no documented nourishing bedtime snack to extend the meal span. Staff interviews showed uncertainty about meal timing, snack documentation, and whether residents who missed scheduled snacks were receiving alternative nourishment. One resident with alcohol dependence with Korsakoff syndrome, dementia, psychotic disorder, altered mental status, and seizures required full assistance with eating and could not reliably verbalize hunger. He was observed in bed in the morning on more than one occasion before breakfast was provided, and staff stated he sometimes did not receive breakfast until later because he could not be awakened or because a meal ticket did not print. The posted schedule showed breakfast beginning at 8:30 AM, dinner at 4:00 PM, and a 7:00 PM night cap, but staff and dietary interviews indicated the resident could go from dinner to breakfast with approximately 17 hours between meals if dinner was served as scheduled and breakfast was not provided until around 10:00 AM. The record review also showed no documentation of a night snack being provided. A second resident with diagnoses including right humerus fracture, diabetes, Alzheimer’s disease, CKD stage 3, and prior cerebrovascular disease had documented weight loss over several weeks. Meal task documentation showed multiple spans of more than 14 hours between dinner and breakfast, including approximately 16 to 18 hours on several occasions, and there was no documentation of a night snack being provided. The resident’s weight decreased from 155.4 pounds to 141.4 pounds over the reviewed period, while the care plan noted low intake, restorative shakes, appetite support, and ongoing monitoring. Staff interviews indicated snack documentation was unclear, the DM did not know where snack intake was recorded, and the breakfast schedule and evening snack process were not being tracked in a way that confirmed residents received nourishment within the required meal span.
Failure to Provide Staff Training on QAPI
Penalty
Summary
Mandatory training was not conducted for all staff on the facility’s QAPI program. A facility policy titled, 2025 QAPI Plan, revised in July 2025, stated that the QAPI program was intended to support safety and high quality with clinical interventions and service delivery, while emphasizing autonomy, choice, and quality of daily life through data collection tools and monitoring systems for proactive analysis, system failure analysis, and corrective action. The policy did not address sexual abuse, sexual abuse training, or elopement training as part of the QAPI program. Interviews with multiple staff members showed they did not know what QAPI was or what was covered in QAPI meetings. NA 6 stated education was usually done during in-services or daily huddles and was focused on things that needed to be fixed, but was unsure what the QAPI meetings were about. LPN 4 stated she did not know what QAPI was. RN 6 and RN 2 both stated they received education at work but were unsure what QAPI was. The DON stated there was no specific staff training on what was covered in the QAPI meetings, and the Administrator stated there had not been any staff training on QAPI. The in-services provided to surveyors were reviewed, and no in-service focused on QAPI was noted.
Failure to Assist Residents with Activities of Daily Living
Penalty
Summary
A deficiency was identified when care and assistance were not provided to perform activities of daily living (ADLs) for residents who were unable to do so themselves. The report notes that residents requiring help with ADLs did not receive the necessary support from staff, resulting in unmet care needs. This failure was observed and documented by surveyors during their review of facility practices.
Failure to Maintain Nutritional Status and Provide Adequate Mealtime Assistance
Penalty
Summary
Two residents experienced significant weight loss due to the facility's failure to maintain acceptable nutritional parameters and provide necessary assistance during meals. One resident, with severe cognitive impairment and multiple comorbidities including Parkinson's disease and dementia, lost 14.4 pounds over six months without new interventions being implemented. Despite care plan interventions such as monitoring for malnutrition and providing adaptive equipment, the resident was not observed using specialized dinnerware and continued to lose weight even while documented as consuming 76-100% of meals on most days. Staff interviews revealed inconsistent understanding of the resident's needs, and the resident was not always cued to eat as required. Another resident, with diagnoses including Alzheimer's disease, diabetes, and recent fractures, also experienced ongoing weight loss. Observations showed the resident frequently left the dining room without eating, required cueing to eat, and sometimes attempted to eat with inappropriate utensils. Although the care plan indicated the need for setup assistance and cueing, staff did not consistently provide this support, and meal intake documentation showed frequent low consumption or refusal of meals. Supplement and snack intake were also low, and there was confusion among staff regarding documentation and provision of snacks. Interviews with dietary and nursing staff highlighted gaps in communication and documentation regarding residents' nutritional intake, especially for snacks and supplemental feedings. The registered dietician acknowledged concerns about weight loss and was unsure where snack intakes were documented. The dietary manager and CNAs were unclear about procedures for residents who missed snacks or required additional assistance, contributing to the facility's failure to ensure adequate food and fluid intake to maintain residents' health.
Failure to Provide Necessary Behavioral Health Services
Penalty
Summary
The facility failed to ensure that each resident received necessary behavioral health care and services. This deficiency was identified based on observations and records indicating that the required behavioral health interventions and supports were not provided to residents who needed them. As a result, residents did not receive the behavioral health care and services necessary to address their individual needs, as required by regulations.
Failure to Notify Physician When PRN Medications Were Ineffective
Penalty
Summary
The facility failed to notify the resident’s physician when PRN medications were documented as ineffective for two residents. Resident 41 was admitted with Parkinson’s disease, dementia, anxiety disorder, mild cognitive impairment, and neurocognitive disorder with Lewy bodies. The resident reported tremors when medication was not given on time and stated he had to request PRN medication every 3 to 6 hours. His orders included carbidopa-levodopa for breakthrough Parkinson’s symptoms, Inbrija for Parkinson’s symptoms, and Vistaril for itching. The August MAR documented carbidopa-levodopa as ineffective on 8/5/25, Inbrija as ineffective on 8/6/25, and Vistaril as ineffective on 8/5/25, but there was no documentation that the physician was notified of these ineffective treatments. Resident 24 was admitted with vascular dementia, bipolar disorder, borderline personality disorder, morbid obesity, hypertension, and type 2 diabetes mellitus. The physician ordered Tums 500 mg, 2 tablets every 2 hours PRN for heartburn and indigestion, not to exceed 15 tablets per day. The July MAR documented Tums as ineffective on 7/24/25, and there was no documentation that any additional doses were given or that the physician was notified of the ineffective medication treatment. The DON stated that when a medication is documented as ineffective, the nurse should follow up with the resident and notify the provider, but no documentation was found showing that this occurred for either resident.
Incomplete MDS Activity Assessment
Penalty
Summary
An assessment did not accurately reflect Resident 41’s status because the Minimum Data Set (MDS) was not completed for activities. Resident 41 was admitted with diagnoses including Parkinson’s disease with dyskinesia, repeated falls, dementia, depressive episodes, and dorsalgia. During an interview, the resident stated he wanted more activities, wanted to get out more, missed a trip to the aquarium, and wanted to go to a local store. Review of the MDS showed the resident was not assessed for daily preferences related to activities. The MDS coordinator stated the MDS was not completed and did not know why those items were not answered, and stated section F should have been completed.
PASRR Specialized Services Not Arranged for Resident With ID and TBI
Penalty
Summary
The facility did not ensure that a resident admitted with a mental disorder and intellectual disability, and identified on PASRR Level II as requiring specialized rehabilitative services, received care and services appropriate to meet her needs. The resident was admitted with diagnoses including traumatic brain injury, cerebral infarction, aphasia, anxiety disorder, unspecified intellectual disabilities, and depression. Her admission MDS documented that she was rarely or never understood, had short- and long-term memory deficits, was unable to recall the current season or recognize staff, and had moderately impaired cognition for daily decision making. The resident’s care plan identified behaviors including aggression, agitation, hypersexuality/affection, yelling profanities, sitting on the floor, digging in dirt, and getting dirt on her clothing. Observations showed the resident walking in the hallway and responding with profanity, sitting on the dining room floor after spilling crackers and eating them off the floor, and later sitting on the back patio digging in the dirt. The DON assisted the resident off the floor and discarded the crackers during one of the observations. The PASRR Level II assessment documented that the resident required specialized services outside the scope of the nursing facility for her intellectual disability and traumatic brain injury, including services to improve survival skills, ADL completion, communication, interpersonal functioning, academics, and dietary needs. It also recommended ongoing physical, occupational, speech, and restorative therapies and follow-up regarding DSPD services. Interviews with the RA and Administrator showed the resident was not referred for specialized services, the RA could not recall why, and the facility had been working on obtaining a contract for SRS only recently. The Administrator stated the last SRS provider visit was January 30 and that he was not sure the resident had ever received SRS services.
Failure to Follow Blood Pressure Hold Parameters for Antihypertensive Medication
Penalty
Summary
The facility did not ensure that Resident 40’s drug regimen was free from unnecessary drugs because physician-ordered blood pressure hold parameters were not followed. Resident 40 was admitted and re-admitted with diagnoses including dementia, type II diabetes mellitus, hypertension, psychotic disorder with delusions and hallucinations, anxiety disorder, insomnia, and major depressive disorder. On 6/24/25, the physician ordered Losartan Potassium 25 mg by mouth in the morning for hypertension with instructions to hold the medication if systolic blood pressure was less than 130. Review of Resident 40’s July 2025 MAR showed that Losartan 25 mg was administered on multiple occasions when the systolic blood pressure was below the ordered hold parameter. The medication was given with blood pressures of 126/50, 114/50, 127/56, 114/69, 127/50, 127/50, 125/50, 105/74, 101/62, and 121/38. During interviews, RN 2 stated that medication hold parameters would be found in the administration details and that holds or related provider notifications should be documented there or in a progress note. The DON stated that hold parameters would be located in the medication instructions and that nurses were expected to follow the physician’s orders with parameters to hold.
Failure to Provide Timely, Well-Balanced Meals
Penalty
Summary
The facility failed to provide each resident with a nourishing, palatable, well-balanced diet that met daily nutritional and special dietary needs for 2 of 32 sampled residents. One resident, who had diagnoses including alcohol dependence with Korsakoff syndrome, alcohol-induced persisting amnesic disorder, mild dementia with agitation, major depressive disorder, psychotic disorder with delusions, altered mental status, and seizures, was dependent on staff for eating and had a puree diet order. Staff observations showed the resident was not provided breakfast until late on multiple occasions, and on one occasion lunch was not served while he remained in bed sleeping. Staff interviews indicated confusion about who was responsible for feeding him, and meal task documentation showed delayed meal times. The care conference noted staff had learned his shouting was usually due to hunger or dehydration and that food or drink would comfort him. The second resident had diagnoses including cerebral infarction, Alzheimer's disease, major depressive disorder, anxiety, chronic kidney disease, vitamin B12 deficiency, dysphagia, prediabetes, and hallucinations. Care plans indicated the resident needed supervision or set-up assistance for eating, cueing and reorientation as needed, and that diet should be provided as ordered. A nursing progress note documented the resident’s breakfast tray was upside down and he was eating with his fingers until the RN assisted with cueing and repositioning the drinks and silverware. During the survey, CNA 1 stated the resident could eat on his own but needed set-up assistance. For lunch, the dietary manager and registered dietician stated the resident was supposed to receive an egg roll with fruit salad, and that fruit salad alone was not a well-balanced meal. The dietary manager stated the CNA should have notified the kitchen if the egg roll was unavailable, and the RD stated she was not aware of any residents not being served a meal because staff was not delivering them. The DON stated the resident could become confused about time and situation, might need cueing for breakfast, and would not be able to recognize that he had not received the egg roll or know to ask for one.
Incomplete and Inaccurate Resident Medical Records
Penalty
Summary
The facility did not maintain complete, accurately documented, readily accessible, and systematically organized medical records for 4 of 32 sampled residents. Surveyors found that multiple incidents of resident-to-resident abuse were reported by staff, but no documentation of the incidents could be located in the affected residents’ medical records, and the facility had no evidence that the allegations were investigated. Resident 11 had diagnoses including traumatic brain injury, cerebral infarction, aphasia, anxiety disorder, unspecified intellectual disabilities, and depression, and Resident 49 had diagnoses including traumatic brain injury, anoxic brain damage, chronic viral hepatitis, delusional disorders, psychotic disorder, major depressive disorder, opioid abuse, anxiety disorder, unspecified mood disorder, and antisocial personality disorder. An APS investigator reported that Resident 11 was sexually assaulted by Resident 49 after a CNA found Resident 49 with his pants down on top of Resident 11 and attempting to initiate sexual contact. A CNA interview described repeated incidents in which Resident 49 sought out Resident 11, sat near her during meals, held her hand, rubbed her shoulder, and was found on top of her in bed with clothing displaced. The CNA stated this was a consistent cycle of events and recalled about five instances of Resident 49 attempting to get Resident 11 into his room or onto his bed and trying to undress himself or her. Despite these reports, no documentation of the incident could be found in either resident’s medical record, and the Administrator confirmed there was no investigation into the incidents. The record review also identified inaccurate documentation for Resident 12 and Resident 5. Resident 12, who had diagnoses including alcohol dependence with Korsakoff syndrome, alcohol-induced persisting amnesic disorder, mild dementia with agitation, major depressive disorder, psychotic disorder with delusions, altered mental status, and seizures, had conflicting meal documentation: staff observations and interviews indicated breakfast had not been provided as documented, and a CNA stated the Meal Task times were not accurate because documentation was completed at the end of the shift. Resident 5’s chart also contained a mismatch between the electronic medical record banner, which listed DNR with comfort measures, and a POLST form indicating CPR with limited interventions; the DON IT and DON confirmed the banner and POLST did not match.
Uncovered Food and Poor Hand Hygiene During Meal Service
Penalty
Summary
An infection prevention and control program was not established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. During lunch service in the hallways, Certified Nursing Assistants served food from a cart while moving room to room, and the food was observed uncovered as it was transported between resident rooms. On one observation, a large pizza was sitting uncovered on top of the cart while CNAs offered slices to residents in their rooms, and the CNAs did not sanitize their hands between serving each resident. Additional observations showed similar meal service practices. CNAs and a Nursing Assistant served half of an Italian sandwich from a metal sheet using tongs and placed the food on Styrofoam plates for residents. In another observation, a CNA delivered a slice of pizza to a resident's room from the dining room without covering the plate while walking down the hallway. A CNA was also observed touching the food inside a Styrofoam bowl before giving it to a resident, and hand hygiene was not observed before serving that resident. The Dietary Manager stated she was unaware that food was being rolled through the hallways uncovered and said the proper method was to keep food covered until it reached the resident's room.
Antibiotic stewardship program failed to monitor susceptibility of prescribed antibiotic
Penalty
Summary
The facility did not ensure its antibiotic stewardship program included effective antibiotic use monitoring when a resident was prescribed an antibiotic that the identified organism was not susceptible to treat. Resident 25 had multiple diagnoses including Alzheimer's disease, diabetes mellitus type 2, chronic kidney disease, hypertension, and recent orthopedic injuries and surgery involving the left hip, left femur, and right humerus. The resident developed redness, warmth, mild pain, and a sore at the right upper extremity incision site, and a wound culture was obtained after the physician was notified. The wound culture grew Pseudomonas aeruginosa, and the culture and sensitivity report documented that the organism was not susceptible to TMP/SMX (Bactrim DS) and that it was not a recommended antimicrobial. Despite this, the orthopedic surgeon ordered Bactrim DS 800-160 mg twice daily for 14 days for the wound infection, and the medication was administered for 27 doses. The nursing documentation showed that the surgeon was informed of the culture results, but the record did not show that the susceptibility results were communicated to the surgeon or that the antibiotic choice was reviewed for susceptibility before administration. During interviews, the ADON stated she informed the surgeon of the organism identified but did not tell him it was resistant to Bactrim, and she was not aware of the resistance. The IP stated she reviewed cultures and antibiotics as part of tracking and trending and that it was her responsibility to ensure the correct antibiotic was ordered, while the DON stated the IP was responsible for the antibiotic stewardship program and for reviewing lab results to determine susceptibility. Facility policy required culture and sensitivity results and the clinical situation to be communicated to the prescriber and stated that infections treated with antibiotics would be reviewed by the IP, including situations where the organism was not susceptible to the chosen antibiotic.
Failure to Document and Provide Flu and Pneumococcal Immunizations
Penalty
Summary
The facility did not ensure that influenza and pneumococcal immunizations were offered and documented for two sampled residents, and did not document education regarding the benefits and potential side effects of the immunizations. One resident, admitted with diagnoses including dementia, mood disorder, anxiety disorder, insomnia, and unilateral inguinal hernia, had documentation showing a pneumococcal 23 vaccination in 2005, but there was no documentation that the resident was offered, administered, or declined the PCV20 or PCV21 immunization since admission to the facility. Another resident, admitted with diagnoses including dementia, schizophrenia, insomnia, and depression, signed a consent form on 3/28/25 authorizing influenza and pneumococcal vaccines, but no documentation was found showing that either vaccine was administered. The Infection Preventionist stated that the resident had refused the vaccines at a previous facility, that the family wanted the facility to try again, and that the resident consented in March, but the vaccines had not been given. The IP also stated that the ADON and DON were responsible for resident immunizations and that the resident's immunization administration had fallen through the cracks. The facility policy required residents to be assessed for pneumococcal vaccination status and offered the vaccine within the specified timeframes, and required influenza vaccine offers during flu season or within five working days of admission, with documentation of administration or refusal.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 105 citations issued within 25 miles in the last 12 months — including the 3 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Pleasant Grove
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Stonehenge Of American Fork | 2.7 mi | ★★★★★ | 0 | 0 |
| Monument Healthcare American Fork | 3.2 mi | ★★★★★ | 7 | 0 |
| Cascades At Orchard Park | 4.1 mi | ★★★★★ | 0 | 0 |
| Stonehenge Of Orem | 4.4 mi | ★★★★★ | 1 | 0 |
| Orem Rehabilitation And Nursing Center | 6.7 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.