Rocky Mountain Care - Logan
Inspection history, citations, penalties and survey trends for this long-term care facility in Logan, Utah.
- Location
- 1480 North 400 East, Logan, Utah 84341
- CMS Provider Number
- 465116
- Inspections on file
- 16
- Latest survey
- February 12, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Rocky Mountain Care - Logan during CMS and state inspections, most recent first.
Three residents did not receive timely assessment and treatment in response to serious changes in condition. One resident on anticoagulation with mobility issues fell in the bathroom, later developed headache, vomiting, lethargy, and unilateral weakness, and was not transferred to the ED for approximately 2.5 hours after these changes, where a large subdural hematoma was found and the resident later died. A second resident with Parkinsonism and mobility impairment fell, immediately complained of left hip pain, and remained in pain despite analgesics while staff awaited imaging; transfer to the hospital for a confirmed femoral neck fracture did not occur until about 10 hours after the fall. A third resident with muscular dystrophy, OSA, and dysphagia had multiple episodes of severely low O2 sats, including readings in the 40s and 50s with cyanosis, without consistent or prompt interventions, follow-up sats, or documentation, and staff described delays in notifying a nurse and initiating oxygen despite obvious hypoxia.
A resident admitted with surgical wounds and MASD, and identified as high risk for pressure sores by Braden Scale, did not receive pressure ulcer prevention and wound care consistent with professional standards. Initial wounds on the posterior left lower extremity related to a brace and coccyx MASD were documented without measurements or detailed descriptions, and an order for barrier cream with each incontinent episode lacked evidence of administration. Over time, the resident developed additional skin breakdown on the sacrum, left inner thigh, left great toe, left posterior calf, and hips, including multiple Stage 4 pressure ulcers, but documentation of wound onset, measurements, descriptions, and preventive interventions was incomplete or absent. A knee immobilizer was ordered twice daily without specific care instructions, and the resident later developed a Stage 4 ulcer on the calf where the immobilizer was applied. Physician notes identified Stage 4 ulcers on the left shin, left hip, right hip, and posterior left lower leg, yet corresponding wound treatments were not consistently reflected on the MAR, and the Administrator could not provide additional documentation of preventive measures beyond the existing record.
The facility failed to ensure that two residents’ discharges and non‑readmissions were justified, coordinated, and accurately documented. One resident with terminal liver cancer and on hospice, whose care plan called for continued LTC, showed clear clinical decline in provider and hospice notes with no mention of discharge, yet was discharged the same day using an outdated discharge summary from a prior stay that listed an incorrect date, an RV destination, and home health instead of hospice, while hospice staff were not informed in advance and social services was not involved. Another resident with TBI, paraplegia, major depression, antisocial personality disorder, and suicidal ideation was discharged after repeated episodes of severe aggression and self‑harm, but the record lacked physician documentation explaining why the facility could not meet the resident’s needs, what interventions were attempted, and why the resident was not readmitted, despite staff interviews describing blue‑sheeting, suicide attempts, and safety concerns. The facility also failed to care plan aggressive behaviors for one resident and did not document coordination with hospice or behavioral interventions before discharge.
The facility failed to provide necessary housekeeping and maintenance services, resulting in cracked and broken drywall, peeling paint, a sticking door handle, and a loose toilet in three residents' rooms. Despite being aware of the issues, the Maintenance Director did not address them in a timely manner, and the Administrator was unaware of the extent of the needed repairs.
The facility failed to ensure medication error rates were below five percent, with a 16% error rate observed. Medications meant to be taken before meals were given post-meal to four residents. RN 3 acknowledged the errors, and the DON confirmed the need to follow doctor's orders for medication administration.
The facility failed to ensure a resident was evaluated for self-administration of medications. Medications were found at the bedside of a resident with severe cognitive impairment and multiple diagnoses, without proper assessment or physician's order. Staff confirmed the resident was not authorized to have medications at their bedside.
The facility inaccurately coded a resident as having received insulin during the seven-day MDS observation period when no insulin was administered. The resident's medical record and Medication Administration Record confirmed the absence of insulin orders or administration, which was acknowledged by the MDS Coordinator.
A resident with severe cognitive impairment and asthma experienced a delay in receiving timely treatment for respiratory symptoms. Despite family concerns and low oxygen levels, the resident was only given nasal spray and Mucinex over the weekend. The physician assistant ordered appropriate interventions on Monday, highlighting a failure in timely care and communication among staff.
A resident with multiple diagnoses, including chronic inflammatory demyelinating polyneuritis and muscle weakness, did not receive recommended restorative nursing services to improve range of motion (ROM). Despite a care plan and physical therapy evaluation recommending PT and participation in a restorative nursing program, the facility failed to provide these services, and the resident was not offered alternative therapies or exercises.
A resident with multiple diagnoses and increased protein needs did not receive the recommended Liquacel supplement twice a day for wound healing. The Liquacel was unavailable for four administrations, and there were issues with ordering and stocking the supplement. Staff interviews revealed inconsistencies in following dietary recommendations and delays in receiving supplies.
A resident was not administered a prescribed protein supplement for wound healing due to it being unavailable. Staff interviews revealed issues in the ordering and stocking process, leading to missed doses and the resident receiving an alternative supplement instead.
The facility failed to act on a pharmacist's recommendation to discontinue atorvastatin during daptomycin therapy for a resident, resulting in the resident receiving both medications concurrently for an extended period. The delay was attributed to the DON being on vacation and the usual process for handling recommendations being disrupted.
Delayed Response to Falls and Hypoxia Resulting in Resident Harm
Penalty
Summary
The deficiency involves the facility’s failure to provide timely assessment and treatment in response to changes in condition after falls and episodes of hypoxia, resulting in harm to residents. One resident with paroxysmal atrial fibrillation, difficulty walking, muscle weakness, and on anticoagulant therapy with an elevated INR experienced an unwitnessed fall in the bathroom. She was found on the floor in soiled clothing, assisted back to the toilet, and then to a chair. Initial neuro checks and vital signs were documented as baseline, and she denied hitting her head with no signs of injury noted. Later neuro documentation showed elevated blood pressure and lethargy, with slow response to verbal stimuli, weakness in hand grasps, and slurred speech, but there was no documented immediate escalation of care at that time. Subsequently, the resident began complaining of a headache and then reported that she had hit her head at the time of the fall. Nursing notes documented nausea, vomiting, not following simple cues, and left-sided weakness in grip strength. Staff interviews indicated that a CNA reported the headache to the nurse, who administered medications including Tylenol and performed neuro checks, noting rising blood pressure but otherwise within normal limits at that time. When the resident vomited and her level of consciousness changed, with inability to open her eyes and no grip in the left hand, the nurse notified the wing nurse, who then initiated notifications and arranged for transfer. The resident was ultimately sent to the emergency department approximately 2.5 hours after the onset of significant change in condition, where a CT scan revealed a very large right subdural hematoma with midline shift and herniation. The facility later provided additional information but did not explain the 2.5-hour delay in sending her to the hospital after the change in condition, and the resident subsequently died. Another resident with Parkinsonism, muscle weakness, difficulty walking, and sepsis sustained an unwitnessed fall and was found lying on the floor next to the bed, complaining of left hip pain. The nurse documented no new bruising or redness at the time, initiated neuro and vital sign checks, administered pain medication, and notified management, the physician, and family. An order was placed for a left hip x-ray, and the resident continued to receive oxycodone for left hip pain, with one dose documented as ineffective. The resident was not discharged to the hospital until later that afternoon, when an x-ray confirmed a left femoral neck fracture, resulting in a delay of approximately 10 hours from the time of the fall and initial complaint of hip pain to hospital transfer. In a later interview, the LPN stated he did not know why the resident was not sent to the emergency room sooner and believed it was probably because he did not have a physician’s order, and that he had attempted to manage the pain at the facility. A third resident with muscular dystrophy, obstructive sleep apnea, and dysphagia experienced repeated episodes of low oxygen saturation without timely or consistent intervention. The resident had orders for cough assist every shift for airway management and BIPAP at night, though the BIPAP order was held for a period without documentation explaining why. Oxygen saturation readings showed multiple episodes of hypoxia, including values in the 80s, 70s, 60s, 50s, and as low as the 40s and 30s, often without documented follow-up saturations or immediate treatment. On one occasion, the resident’s sats were 80% and the provider ordered a chest x-ray and labs, but there was no documentation of treatment for low sats for four hours. On several other dates, low sats were recorded with no follow-up readings documented. Staff interviews revealed that CNAs routinely checked sats early in the morning and that this resident’s sats were often in the 70s and 80s at night. A CNA described a night when the resident was hot and cold, calling frequently, and reported difficulty breathing; the CNA found his sats in the 40s and observed him to be blue in the face and pale. She finished assisting him with a urinal and taking out the garbage before informing the nurse, after which oxygen was started and his sats increased above 90%. Another nurse stated that it was not standard to check sats on night shift, but that if sats were low, oxygen should be provided and saturations rechecked, and that sats below 80% should be reported to the DON, physician, and family. The DON reported receiving a call that this resident’s nurse did not act fast enough when the resident had oxygen issues, and administration initiated an investigation, but the administrator stated she did not review the resident’s prior oxygen levels. These events demonstrate repeated failures to promptly assess and treat significant changes in condition, including post-fall injuries and severe hypoxia, in accordance with professional standards, care plans, and resident needs.
Failure to Prevent and Manage Pressure Ulcers for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer prevention and wound care consistent with professional standards for one resident who was admitted with surgical wounds and Moisture Associated Skin Damage (MASD) and later discharged with a Stage 4 pressure ulcer. On admission, documentation noted breakdown on the proximal posterior left lower extremity related to a brace and MASD on the coccyx, but there were no measurements or detailed descriptions of these wounds. The resident was ordered to have a knee immobilizer applied twice daily, but the order did not specify what care was to be provided with the immobilizer, and nursing documentation only showed it was signed off on the MAR. A Braden Scale assessment identified the resident as high risk for pressure sores, and an order for barrier cream to the buttocks/peri-area with each incontinent episode was in place, but there were no signatures on the Treatment Administration Record to show the treatment was provided. Over the course of the stay, multiple new areas of skin breakdown developed, and documentation was inconsistent, incomplete, or missing. Care plans and nursing notes referenced skin impairment to the sacrum, left inner thigh, left great toe, and left posterior calf, but often lacked wound measurements, descriptions, or clear timelines of onset. A new wound to the left posterior calf was first noted by an aide after a shower, and subsequent notes described the area as black with surrounding pink skin, then later as open with yellow slough, moderate yellow drainage, and foul odor. Weekly skin assessments were delayed, with the first one dated months after admission, and when completed, they sometimes documented skin as pink, dry, warm, and intact at locations where other notes and physician documentation indicated the presence of Stage 4 ulcers. Physician notes later identified a Stage 4 ulcer of the left shin, a Stage 4 ulcer on the left hip, and a Stage 4 pressure ulcer of the right hip, in addition to the posterior left lower leg ulcer, but there were no corresponding wound treatment orders for the right or left hip on the MAR. The resident’s left hip surgical site, previously documented as a surgical wound, was later classified as a Stage 4 pressure ulcer without documentation of interventions to prevent further breakdown. There was also no documentation of when sacral skin breakdown developed. The resident had been admitted with a knee immobilizer and subsequently developed a Stage 4 pressure ulcer on the calf where the immobilizer was applied, and the record lacked documentation of interventions used to prevent skin breakdown. When surveyors requested additional information about preventive measures, the Administrator stated there was no documentation beyond what was in the medical record and was unable to provide further information.
Failure to Properly Justify, Plan, and Document Resident Discharges and Non‑Readmissions
Penalty
Summary
The deficiency involves the facility’s failure to ensure that transfers and discharges were only carried out under permissible conditions, were properly planned and coordinated, and were supported by complete and accurate documentation. For one resident with liver cell carcinoma, heart failure, and a terminal prognosis who had been admitted for comfort management and hospice, the care plan and social services documentation identified a discharge plan of continued LTC with skilled nursing and hospice. Subsequent provider and hospice notes documented clinical decline, including dizziness, severe abdominal pain, weakness, nausea, vomiting, jaundice, and markedly reduced oral intake, without any indication of an upcoming discharge. Despite this, the resident was discharged on the same day a hospice nurse documented further decline, and the first mention of discharge in the record appeared in a hospice chaplain note stating the resident was being asked to leave and did not know where he was going. The facility’s discharge documentation for this resident was incomplete and inaccurate. A Transition of Care/Discharge Summary was printed on the day of discharge using an incorrect discharge date from a prior year and listing the discharge destination as the resident’s RV with home health services, with a goal that he would continue to get stronger with home health. The document omitted any reference to hospice services. All signatures were dated later that afternoon, after the hospice chaplain note, and a nursing progress note recorded that discharge teaching was done and the resident left in a private vehicle with a three‑day supply of medications. Hospice records later showed the resident was actually on LOA and staying at his ex‑wife’s home, and the Social Services Director stated she did not complete the discharge summary, was not involved in the discharge process, and that this lack of involvement was not normal. The Regional Social Work Director determined that staff had reused a prior discharge summary from a previous discharge to the RV, and the hospice director confirmed there was no prior hospice documentation of a planned facility discharge. For a second resident with diffuse TBI, spastic hemiplegia, major depressive disorder, paraplegia, antisocial personality disorder, and suicidal ideations, the facility discharged the resident following episodes of severe aggression and self‑harm behaviors without required physician documentation supporting the discharge and non‑readmission. A nursing progress note described escalating verbal aggression, vulgar language, physical aggression toward staff, attempts to tip the wheelchair, and throwing objects at staff. A discharge summary later characterized the resident as having physical and verbal aggression that staff were unable to manage and a history of suicidal ideation, but there was no physician documentation explaining why the facility was unable to care for the resident, what interventions had been attempted, or why the resident was not readmitted after hospital transfer. Interviews with the Restorative Therapy Aide, ADON, SSD, and Administrator described multiple aggressive incidents, blue‑sheeting to the hospital, suicide attempts, and the facility’s decision not to readmit the resident due to safety concerns, but these details were not supported by corresponding physician documentation in the medical record. Additionally, for the first resident, there was no care plan addressing aggressive behaviors despite multiple progress notes documenting such behaviors, and no documentation of hospice being contacted about behavioral concerns, medication adjustments, or room changes prior to discharge.
Failure to Maintain Sanitary and Comfortable Environment
Penalty
Summary
The facility did not provide the necessary housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable environment for its residents. Specifically, three residents experienced issues with their rooms, including cracked and broken drywall, peeling paint, a door handle that sticks, and a loose toilet. Resident 37 reported having to tape a large hole in the wall, a wobbly toilet, and a door handle that was difficult to use. Despite informing the Maintenance Director, no repairs were made. Resident 24's room had chipped and peeling paint and drywall near the bathroom door. Resident 18's room had peeling paint and drywall near the sink and bathroom, a main door missing pieces of Formica, and chipped cabinets, which were reportedly caused by his roommate's behavior. The Maintenance Director acknowledged being aware of the issues in the residents' rooms but had not addressed them in a timely manner. He mentioned that he was still figuring out what products were required for the repairs and was unsure of the timeframe for completing them. The Administrator was unaware of the multiple repairs needed in Resident 37's room and stated that there was no specific timeframe for maintenance items to be completed unless they were emergent issues. The Administrator also mentioned that repairs related to fixing or painting walls could take up to a week, but nothing should take over a month to be addressed and fixed by maintenance.
Medication Administration Errors
Penalty
Summary
The facility did not ensure that medication error rates were not five percent or greater. During observations of 25 medication opportunities, four medication errors were identified, resulting in a 16% medication error rate. Specifically, for four out of 28 sampled residents, medications that were supposed to be taken at least 30 minutes before meals were given to the residents after they had consumed a meal. The residents involved were identified as 23, 33, 51, and 69. The errors included pantoprazole, gabapentin, metoclopramide, and omeprazole being administered post-meal instead of pre-meal as per the doctor's orders. RN 3 was observed administering these medications incorrectly and acknowledged the errors during interviews. RN 3 stated that resident 23 preferred taking medications after breakfast, and resident 51 was often hard to locate in the mornings, leading to the medication being given after meals. The Director of Nursing (DON) confirmed that there was no documentation of residents' medication preferences in the medical records and emphasized that all nurses need to follow the doctor's orders for medication administration. The DON stated that medications ordered to be given before meals must be administered before meals, and if this is not feasible, the doctor's orders need to be updated accordingly.
Failure to Evaluate Resident for Self-Administration of Medications
Penalty
Summary
The facility did not ensure that the interdisciplinary team had evaluated and determined that a resident's right to self-administer medications was clinically appropriate. Specifically, medications were found at the bedside of a resident who had not been assessed for self-administration. The resident, identified as having severe cognitive impairment and multiple diagnoses including polyneuropathy, dementia, and major depressive disorder, had Tums at their bedside, which they took as needed without proper evaluation or physician's order. Interviews with staff, including an LPN, RN, and the DON, revealed that the facility's policy required a self-administration assessment and a physician's order for residents to keep medications at their bedside. The staff confirmed that resident 43 had not been assessed for self-administration and was not authorized to have medications at their bedside. The DON emphasized that the purpose of the assessment was to ensure the resident's safety in self-administering medications, and resident 43 was not among those permitted to do so.
Inaccurate Resident Assessment for Insulin Administration
Penalty
Summary
The facility did not ensure that the resident assessment accurately reflected the resident's status. Specifically, for one resident, the facility coded the resident as having received insulin during the seven-day Minimum Data Set (MDS) observation period when the resident had not received any insulin. The resident was admitted with diagnoses including infection and inflammatory reaction due to internal left knee prosthesis, type 2 diabetes mellitus with hyperglycemia, and type 2 diabetes mellitus without complications. A review of the resident's medical record and Medication Administration Record showed no orders or documentation of insulin administration since admission. The MDS Coordinator confirmed that the MDS assessment had been miscoded.
Delay in Treatment for Respiratory Illness
Penalty
Summary
The facility failed to ensure that a resident with a respiratory illness received timely treatment and care in accordance with professional standards of practice and the resident's comprehensive person-centered care plan. Resident 43, who had severe cognitive impairment and multiple diagnoses including asthma, experienced a delay in receiving appropriate medical intervention for their respiratory symptoms. Despite the resident's family member notifying the Director of Nursing (DON) about the resident's condition over the weekend, the resident was only given nasal spray and Mucinex until the physician assistant saw them on Monday and ordered a chest x-ray, breathing treatment, and oxygen therapy. The medical record review revealed that the resident's oxygen saturation was documented to be 89% on one occasion and 80% on another, yet no immediate interventions were put in place to address these low oxygen levels. Interviews with the nursing staff indicated that although the resident had been complaining of respiratory symptoms and had received some as-needed medications, there was a lack of timely and appropriate response to the resident's deteriorating condition. The DON acknowledged that the nurses should have followed standing orders for oxygen and notified the physician and DON about the resident's low oxygen saturation. The deficiency was further highlighted by the fact that the resident's condition was not adequately monitored or addressed over the weekend, leading to a delay in receiving necessary medical treatment. The DON and nursing staff provided inconsistent accounts of the events and actions taken, indicating a breakdown in communication and adherence to protocols. The resident's family member expressed concern that the resident's condition should have been treated sooner, underscoring the facility's failure to provide timely and appropriate care.
Failure to Provide Recommended Restorative Nursing Services for Resident with Limited ROM
Penalty
Summary
The facility did not ensure that a resident with limited range of motion (ROM) received appropriate treatment and services to increase ROM and prevent further decline. Specifically, for one resident with chronic inflammatory demyelinating polyneuritis, diabetes mellitus, difficulty walking, hypertension, chronic pain syndrome, and muscle weakness, the facility failed to provide restorative nursing services recommended by physical therapy. The resident expressed a desire for physical or occupational therapy due to perceived loss of mobility and ROM, but was informed that his insurance would not cover these services and was not offered alternative therapies or exercises by the facility. The resident's care plan included encouraging PT/OT services and assisting with ADL tasks. An orthopedic note and a physical therapy evaluation recommended PT for the resident's right knee and participation in the restorative nursing program for upper and lower extremity ROM. However, the Director of Rehab was unaware of the therapy needs, and the Minimum Data Set Coordinator could not locate a referral for the restorative nursing program. The Director of Nursing acknowledged the resident's ongoing ROM issues but was unsure if there had been a decline since admission. The Administrator was also unaware of the resident's desire for therapy services and believed the resident was already receiving restorative nursing assistance.
Failure to Provide Adequate Nutritional Supplements
Penalty
Summary
The facility failed to ensure that a resident maintained acceptable parameters of nutritional status. Specifically, a resident with a recommendation for Liquacel twice a day for wound healing and increased protein needs had the Liquacel order implemented daily, and the Liquacel was unavailable for four administrations. The resident had multiple diagnoses, including infection and inflammatory reaction due to internal left knee prosthesis, type 2 diabetes mellitus, and peripheral vascular disease. The care plan included offering supplements and double portions, providing diet and snacks as prescribed, and weight monitoring, among other interventions. The resident's medical record indicated that the resident was at moderate risk for malnutrition due to poor medical history, poor mobility, and inadequate oral intake. Despite the dietary recommendation for Liquacel 30 mL twice a day, the order was implemented as once a day. The resident expressed concerns about not getting enough protein and the dietary recommendations were not consistently followed. The April and May Medication Administration Records showed that the Liquacel was not administered on four occasions due to unavailability. Interviews with staff revealed that there were issues with ordering and stocking the Liquacel. The Registered Nurse stated that the Liquacel was ordered with over-the-counter medications and that Central Supply was responsible for ordering it. The Transportation Director, who had just started working in Central Supply, confirmed that the Liquacel was ordered weekly and that there were sometimes delays in receiving items. The Registered Dietician and Dietary Director confirmed that the Liquacel was recommended for wound healing and that the order should have been twice a day. The Director of Nursing stated that dietary recommendations were discussed in meetings and that the Unit Manager was responsible for inputting the orders.
Failure to Provide Prescribed Supplement
Penalty
Summary
The facility failed to provide routine and emergency drugs and biologicals to a resident, specifically a protein supplement necessary for wound healing. Resident 18, who had multiple diagnoses including infection due to a knee prosthesis, diabetes, and muscle weakness, was not administered Liquacel as ordered by the physician. The resident's medical record indicated that the supplement was recommended by the dietitian and agreed upon by the resident, but it was not available on several occasions, leading to missed doses on 4/25/24, 5/5/24, 5/6/24, and 5/7/24. Interviews with staff revealed a breakdown in the ordering and stocking process for the supplement. The Registered Nurse (RN) responsible for medication refills stated that the Liquacel was ordered through Central Supply and should have been available in the medication room. However, the Transportation Director, who had recently taken over central supply duties, indicated that she had not yet ordered Liquacel and was unaware of its shortage until it was too late. The process for ordering over-the-counter medications involved a weekly review and order, which led to delays in obtaining the necessary supplement. Further interviews with the Registered Dietician (RD) and the Director of Nursing (DON) confirmed that the dietary recommendations were communicated during Nutrition At Risk (NAR) meetings and should have been followed up with appropriate orders. Despite these procedures, the supplement was not available when needed, and the resident was given an alternative (Metamucil) when the Liquacel was out of stock. This deficiency highlights a failure in the facility's system to ensure timely availability of prescribed supplements for resident care.
Failure to Act on Pharmacist's Medication Recommendation
Penalty
Summary
The facility did not ensure that the pharmacist's recommendation to discontinue atorvastatin during daptomycin therapy was acted upon in a timely manner. Specifically, for one resident, the recommendation to discontinue atorvastatin to avoid potential myopathy and rhabdomyolysis was accepted by the Physician Assistant on 3/15/24 but was not implemented until 4/2/24. During this period, the resident continued to receive atorvastatin daily while also being administered daptomycin, contrary to the pharmacist's recommendation. The delay in implementing the recommendation was attributed to the Director of Nursing (DON) being on vacation and the process of handling the pharmacist's recommendations being disrupted. The DON stated that the pharmacist's reports were usually reviewed and acted upon within 24 to 48 hours, but due to her absence, the recommendations were not updated and noted in a timely manner. This lapse resulted in the resident receiving potentially harmful medication concurrently for an extended period.
Latest citations in Utah
A resident with Parkinson’s Disease was being transferred from bed to a chair using a mechanical (Hoyer) lift operated by two CNAs when a sling strap snapped, causing the resident to fall and strike the back of the head. The resident sustained an abrasion, a 1 cm scalp laceration with bleeding, and severe back pain rated 9/10, and was sent to the hospital for evaluation. Manufacturer instructions required staff to inspect slings and straps for wear before each use, but there was no evidence the specific sling used in this transfer had been inspected for integrity, and the Administrator acknowledged that the strap breakage led to the resident’s fall and injury.
The facility failed to timely report alleged abuse to SSA and APS after staff twice observed a resident with dementia and acute systolic CHF receiving zealous, open-mouthed kisses on the mouth from her brother. On two separate occasions, a CNA and an LPN witnessed or were informed of these unusual kissing interactions, which they later described as awkward and not typical of a sibling relationship. Despite this, the nursing staff did not immediately report the incidents as potential abuse to the Administrator, and the allegation was not brought forward until a staff meeting days later, resulting in the required notifications to external authorities not being made within the mandated 2-hour timeframe.
A resident with muscle weakness, gait abnormalities, atrial fibrillation, and on a blood thinner sustained an unwitnessed bathroom fall, reported hitting her head, and developed rapidly worsening right facial swelling and a swollen‑shut eye that prevented pupillary assessment. Initial vitals and neuro checks were performed, oxygen was applied, and x‑rays were ordered, but despite the significant change in condition and the resident’s anticoagulation status, the provider was not notified of the worsening condition at the time it occurred and the resident was not sent to the hospital until the next day when an NP assessed her and ordered transfer. In the ED, the physician documented that no evaluation for the injuries had occurred the prior evening and CT imaging showed traumatic subdural and subarachnoid hemorrhages and a large facial hematoma, demonstrating that the facility failed to provide timely, standard‑of‑care treatment and hospital transfer after the fall and subsequent change in condition.
A resident with cognitive impairment, neurological conditions, and substance-related diagnoses was assessed as being at risk for elopement and documented as having poor safety awareness, poor judgment, and wandering behavior requiring frequent redirection. Nursing staff observed the resident wandering in the hall and behind the nurse’s station and communicated during shift report that a WanderGuard was recommended, but no device was applied because staff did not know where to obtain one. The resident later left the building through the front door, was not immediately detected as missing, and was ultimately found by a medication technician about a mile away walking on a sidewalk near a restaurant, demonstrating a failure to provide adequate supervision and timely elopement interventions.
A nurse failed to follow professional standards for medication administration by not properly identifying a resident before giving medications, resulting in the administration of Lorazepam and Carvedilol that were intended for another resident. The error was discovered and documented, with monitoring showing the resident remained stable and without distress, and the hospice nurse, NP, and family were notified. Leadership, including the DON and administrators, acknowledged that the failure to correctly verify the resident’s identity led to the wrong medications being administered.
A resident with multiple comorbidities and an above-knee amputation requested that staff heat prepackaged ramen soup in a microwave at the nutrition station; staff followed package directions and returned the hot soup, which the resident, who used a motorized wheelchair and insisted on carrying items independently, then spilled while turning, causing a third-degree burn to the palmar side of the left wrist. Staff interviews showed that, before this incident, CNAs and an LPN heated food based on package instructions and judged safety by touch without thermometers, and the DON confirmed that no thermometers were available and that staff relied on touch to determine if food was safe to serve.
The facility failed to provide sufficient nursing staff with appropriate skills to respond promptly to call lights and assist residents with toileting, resulting in multiple residents experiencing incontinence and being left unattended on the toilet. Several residents with significant mobility and medical issues reported waiting long periods, including up to 30–45 minutes or more, for call lights to be answered, particularly during evenings, nights, shift changes, and weekends. Surveyors directly observed call lights sounding for 8–13 minutes before staff responded. Staff reported that CNA hours had been cut after a change in ownership, many staff had quit, and they were unable to complete all care tasks due to understaffing. Grievances and resident council notes over several months documented repeated complaints about slow call light response times, residents being left on the toilet for extended periods, and delays in getting to meals, while leadership acknowledged staffing was based on census rather than acuity despite the written facility assessment describing an acuity-based approach.
Multiple residents and a family member reported that meals were bland, unappetizing, sometimes raw or over-roasted, difficult to chew, and often cold by the time they reached residents’ rooms, with no consistent offer of alternatives when food was disliked. Resident council minutes and grievances documented concerns about cold meals, limited variety, lack of fruit, and meals perceived as too high in carbohydrates. A test tray showed hot items, including chicken tenders and tater tots, were served at low temperatures, with mushy, cold textures and dry, tough meat, and there was no plate warmer used while CNAs, rather than dietary staff, passed trays on the halls after a change in kitchen operations.
A resident with a right humerus fracture, chronic right arm pain, dementia (BIMS 9), and impaired use of one upper extremity required setup/clean-up assistance with eating, including cut food and opened containers, as reflected in the MDS and care plan. Despite this, surveyors observed multiple meals where the resident’s food was not consistently cut into bite-sized pieces and containers (such as lidded bowls, syrup packets, and juice boxes) were left unopened, leading family members to cut food on at least one occasion. The diet order and meal card lacked instructions for cut-up food or setup assistance, and interviews with CNAs, the DM, the MDS coordinator, and an RN confirmed that the resident needed this help but that it was not incorporated into formal orders or consistently implemented.
Two residents on modified diets for dementia and chewing/swallowing concerns were given snacks that did not match their ordered textures. One resident on a pureed diet, ordered after staff observed food being held in the mouth and poor chewing, was repeatedly provided ham sandwiches, potato chips, and an ice cream cone. Another resident on a minced & moist Level 5 diet with cut‑up foods was served a peanut cluster and later offered a crunchy “bird’s nest” snack with chow mein noodles and candy. Staff interviews revealed that activities staff supplied their own snacks without verifying diet orders, that the ST had not been consulted for a swallow evaluation in at least one case, and that nursing and dietary staff expected physician diet orders to be followed.
Failure to Inspect Mechanical Lift Sling Results in Resident Fall and Injury
Penalty
Summary
The deficiency involved the facility’s failure to ensure a resident’s environment was free from accident hazards and that equipment used for transfers was in safe, functional condition. A resident with Parkinson’s Disease was being transferred from bed to a chair using a mechanical (Hoyer) lift operated by two CNAs. One CNA reported that when she arrived to assist, the resident was already positioned in the sling, and as the lift was raised, a sling strap snapped, causing the resident to fall and strike the back of the head. Review of the manufacturer’s instructions for the lift and slings showed that staff were required to inspect slings and lifting straps for signs of wear, fraying, or weakness prior to every use. Record review showed that the resident sustained an abrasion to the back of the head, a 1 cm scalp laceration, and reported pain in the shoulders and neck following the fall, and was transferred to the hospital for evaluation. Subsequent NP documentation confirmed the 1 cm scalp laceration was bleeding and that the resident rated back pain as 9/10 on a numeric pain scale. Although maintenance records reflected a general audit of equipment had been conducted several weeks before the incident, there was no evidence that the specific sling used for this transfer had been inspected for integrity prior to use. During interview, the Administrator acknowledged that the equipment failure and strap breakage resulted in the resident’s fall and injury.
Failure to Timely Report Alleged Sexual Abuse to SSA and APS
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse and neglect were reported immediately, but no later than two hours after the allegation was made, to the State Survey Agency (SSA) and Adult Protective Services (APS). Resident 3, who was admitted with unspecified dementia and acute systolic congestive heart failure, was involved in two separate incidents in which her brother was observed kissing her on the mouth in a manner staff described as zealous, enthusiastic, sloppy, and not typical of a brother-sister interaction. On 12/28/25, CNA 1 observed a well-dressed man enter Resident 3's room, hug her, and give her a zealous kiss on the mouth. CNA 1 assumed the man was the resident's husband and reported this to LPN 1, who knew the visitor was the resident's brother. LPN 1 looked into the room and did not see anything out of the ordinary, and neither CNA 1 nor LPN 1 reported this incident as a potential allegation of abuse to the Administrator at that time. On 1/4/26, LPN 1 and CNA 1 entered Resident 3's room to address the resident's pain and request for catheter removal and to assist with a brief and linen change. Resident 3 had two visitors present, including her brother. When asked to step out for privacy, the female visitor left, but the brother hesitated and then gave Resident 3 a sloppy, open-mouthed kiss on the mouth lasting about three seconds, again in the presence of staff. The brother stated that Resident 3 was his older sister and that she had taken care of him since they were very small. LPN 1 did not report either the 12/28/25 or 1/4/26 kissing incidents to the Administrator. The Administrator later stated that the alleged abuse was first mentioned during a meeting on 1/6/26, at which time staff described the kiss as a weird, awkward kiss and not a typical brother-sister kiss, and acknowledged that nursing staff had not reported the suspicious activity in a timely manner, resulting in failure to notify SSA and APS within two hours of the allegation.
Delayed Hospital Transfer After Fall With Head Trauma and Anticoagulation
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident who experienced a fall with head trauma and was on anticoagulation received timely treatment and care in accordance with professional standards of practice. The resident had diagnoses including generalized muscle weakness, gait and mobility abnormalities, and unspecified atrial fibrillation, and was on a blood thinner. On the evening of the fall, nursing documentation showed that the resident was found on the bathroom floor after her roommate called out. The resident reported hitting her head, had facial pain rated 5/10, and initial vital signs showed an O2 saturation of 88–90% with other vitals within normal limits. A neurological assessment was initiated, oxygen was applied, and the on‑call provider was notified, who ordered x‑rays of the resident’s head and left hand. As the evening progressed, the resident’s condition changed. The nurse documented that the resident’s right eye became increasingly swollen to the point that by 9:15 PM it was swollen shut and pupillary reactivity could no longer be assessed, while the left eye remained equal and reactive to light. The neurological exam form recorded that the provider was notified of the fall at 8:00 PM, but did not indicate that the provider was notified when the right eye became swollen shut at 9:15 PM. The DON later stated that this change in the resident’s condition occurred at 9:15 PM and that the medical provider was not notified of this change until the provider came to the facility the following day. The DON also stated that if a resident on a blood thinner experienced a fall with head strike, she expected staff to send the resident to the hospital, and that she was not sure why this resident was not immediately sent. The resident remained in the facility overnight while x‑rays were obtained around 1:00–1:30 AM, with results reportedly available sometime between early morning hours and mid‑morning. The next morning, the NP assessed the resident due to the fall and documented significant right facial swelling, focal tenderness over the zygoma, difficulty visualizing the right eye, and concern for occult injury and possible orbital blowout fracture in the context of anticoagulation. The NP ordered transfer to the emergency department for CT imaging of the head and face. In the emergency department, the physician documented that no evaluation for the resident’s injuries had occurred the previous evening and that the facility had reported the resident seemed slightly altered the prior night and had worsening swelling by the time EMS was called. CT imaging revealed traumatic small subdural and subarachnoid hemorrhages without mass effect and a large facial hematoma. Interviews with nursing staff showed that the RN on duty was very concerned about the resident’s rapidly increasing facial swelling and difficulty administering medications due to lip swelling, but was waiting for a physician order to send the resident to the hospital and was unaware at the time that she could initiate a hospital transfer without such an order. These actions and inactions resulted in a delay in sending the resident to the hospital after a significant change in condition following a fall with head trauma while on a blood thinner. The facility’s Change of Condition/SBAR Evaluation Policy outlined expectations for describing changes in condition, documenting vital signs, identifying changes from baseline (including neurological status changes), and notifying the provider and responsible party, as well as documenting immediate actions and outcomes such as transfer to the hospital. Despite this policy, the neurological exam form did not reflect timely provider notification when the resident’s right eye became swollen shut, and the resident was not transferred until the following day after the NP’s in‑person assessment. The DON confirmed that the change in condition at 9:15 PM was not communicated to the provider until the next day. The surveyors determined that, for this resident, the facility did not ensure timely hospital transfer and did not provide treatment and care in accordance with professional standards of practice after a fall with head injury and subsequent change in condition.
Failure to Implement Elopement Precautions and Supervision for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and implement elopement precautions for a cognitively impaired resident who was identified as being at risk for elopement. The resident was admitted with multiple neurological and substance-related diagnoses, including cerebral infarction, ataxia, Wernicke’s encephalopathy, alcohol and opioid dependence, and traumatic subdural hemorrhage. On admission, the resident’s elopement risk screening showed a score of 12, indicating elopement risk, and nursing documentation described poor safety awareness, poor judgment, and a need for continuous cues with self-care and ADLs. The resident was also noted to require 1:1 supervision during meals due to quick eating behavior. In the hours leading up to the elopement, nursing staff observed the resident wandering in the hallway and behind the nurse’s station and reported that he required constant redirection. The night shift RN informed the day shift LPN during report that the resident had been wandering since early morning and that a WanderGuard was recommended. Despite this, no WanderGuard was applied before the resident left the building. The LPN later stated that she did not know where to obtain a WanderGuard, and the DON confirmed that both the RN and LPN had not placed a WanderGuard because they did not know its location. On the day of the incident, the resident went to the kitchen and requested water, and kitchen staff noticed a fall risk bracelet on his wrist. After this interaction, staff discovered that the resident was no longer in the building. Facility investigation determined that the resident exited through the front door at approximately 9:37 AM and was later found off premises, about one mile away, walking on a sidewalk near a restaurant. A medication technician, who had previously seen the resident wandering in only a gown and had informed the nurse, located the resident and returned him to the facility. These events demonstrate that, despite known elopement risk and observed wandering behavior, the facility did not implement timely elopement precautions or ensure adequate supervision to prevent the resident from eloping.
Medication Administration Error Due to Failure to Verify Resident Identity
Penalty
Summary
The deficiency involves a failure to provide necessary care and services in accordance with professional standards of practice during medication administration. For one resident reviewed for medication administration, a nurse did not follow the Five Rights of medication administration, specifically failing to properly identify the resident before giving medications. As a result, the nurse administered 0.25 mL of Lorazepam, an anti-anxiety medication, and 25 mg of Carvedilol, a beta-blocker used for blood pressure, that were intended for a different resident to Resident #1. Following the administration error, Resident #1’s vital signs were monitored throughout the night, and documentation indicated the resident remained stable, alert, and without signs of distress during the shift. The hospice nurse, nurse practitioner, and family were notified of the error. During interviews, the Administrator and DON acknowledged the medication error, and the DON confirmed that the nurse’s failure to correctly identify the resident prior to administering the medications was the cause of the wrong medications being given.
Burn Injury from Hot Soup Due to Inadequate Supervision and Temperature Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and accident prevention for a resident who sustained a burn injury from hot food. One resident with end stage renal disease, type 2 diabetes mellitus, pericardial effusion, chronic obstructive pulmonary disease, and an above-knee amputation of the left leg requested that staff heat a prepackaged ramen soup. Facility staff heated the soup in a microwave located in the nutrition station behind the nurse’s station according to the package directions and then returned the hot soup to the resident. After receiving the heated soup, the resident, who used a motorized wheelchair and was described as very independent, turned in his power wheelchair, causing the ramen to spill and the hot liquid to burn the palmar side of his left wrist. A progress note documented that the resident received a burn to his left wrist after spilling the hot soup, that the wound was assessed, wound care was provided, and new orders were placed following consultation with a wound provider. The resident reportedly tolerated treatment well and denied pain or other concerns at that time. Subsequent documentation by a wound provider classified the burn on the resident’s left wrist as a third-degree burn. Staff interviews revealed that, prior to this incident, staff heated residents’ food according to package directions and determined whether it was safe to return based on touch, without using thermometers to verify temperature. A CNA reported that the resident often asked CNAs to heat food and insisted on carrying it himself, and that staff declined to heat his food when he refused to allow them to carry it due to safety concerns. An LPN and the DON both confirmed that thermometers were not available for use before the burn occurred and that staff relied on touch to judge food temperature.
Insufficient Nursing Staff and Delayed Call Light Response Leading to Incontinence and Unattended Toileting
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff with appropriate competencies and skills to meet residents’ needs, particularly in timely response to call lights and assistance with toileting, which resulted in incontinent episodes and residents being left unattended. Multiple residents reported long call light wait times, especially during evening and night shifts and on weekends, when there were as few as three CNAs for the entire building. Residents with significant physical limitations, including recent hip fractures, hemiplegia, and other serious conditions, described being unable to get to the bathroom without staff assistance and experiencing incontinence because staff did not respond promptly to their call lights. One resident with a periprosthetic hip fracture, hemiplegia, an artificial hip joint, major depressive disorder, and anxiety reported that from 6:00 PM to 6:00 AM there were only three CNAs for three hallways, resulting in long waits for call light responses. This resident stated she had incontinent bladder episodes when she first arrived because she could not hold her urine while waiting for help, including one instance where she waited 35 minutes for a response. Another resident with a left femur fracture, chronic pain, lupus, and epilepsy reported waiting an hour for her call light to be answered, leading to urinating in her brief because staff did not arrive in time to take her to the bathroom. A third resident with metabolic encephalopathy, acute respiratory failure with hypoxia, pneumonia, UTI, and end-stage renal disease on dialysis stated she had been left on the toilet and had to get herself off and back to bed due to lack of staff. CNA documentation showed multiple incontinent episodes for these residents despite staff describing them as continent of bowel and bladder. Additional residents and a family member reported frequent long call light wait times, including waits of 30–45 minutes, particularly during shift changes and on weekends. The Resident Council President reported that since a change in ownership, residents complained that call lights took 30–40 minutes to be answered and that there were not enough CNAs on the night shift to handle residents’ needs during evening and bedtime hours. Direct observations by surveyors documented call lights sounding for 8 to 13 minutes before being answered on multiple occasions. Staff interviews confirmed that CNA hours had been cut after the ownership change, that many staff had quit, and that staff were asked to work a lot of overtime and were sometimes unable to complete showers due to understaffing. One staff member reported a resident had an incontinent episode after waiting about 45 minutes for a call light response. Grievance records and resident council notes showed a repeated pattern of complaints over several months about slow call light response times, residents being left on the toilet for extended periods, and delays in getting to meals due to insufficient staff. Grievances included reports of residents waiting over an hour to be taken to breakfast, feeling ignored when requests were not fulfilled, and being left on the toilet for almost three hours, causing discomfort. Resident council notes repeatedly documented concerns about call lights taking a long time to be answered, not enough CNAs in the dining room at mealtimes, and residents being left on the toilet or not getting to breakfast on time. Although the facility’s written facility assessment and staffing plan referenced using acuity and tools such as the MDS and RAI to determine staffing, the DON stated that in practice staffing coverage was based on census rather than acuity and acknowledged there had been many issues with call lights since staffing was cut after the change in ownership.
Failure to Provide Palatable, Attractive Meals at Appropriate Temperatures
Penalty
Summary
The deficiency involves the facility’s failure to consistently provide food and drink that were palatable, attractive, and served at safe and appetizing temperatures for multiple residents. Several residents reported that the food was bland, horrible, disgusting, or generally “not good,” and one resident stated that if she did not like what was served, staff did not offer an alternative and that she repeatedly received dark meat she did not like. A family member reported that a resident with a poor appetite received chicken that was dry and needed more moisture. Resident council minutes documented concerns that hamburgers were sometimes too raw, vegetables were roasted to the point of tasting burned, pork chops were difficult to cut or chew, and that food delivered to rooms was cold by the time it arrived when CNAs passed trays. Surveyors’ direct observation of a test tray showed that hot items were not maintained at appetizing temperatures and were of poor quality. After the last tray was plated and placed in the cart, CNAs—not dietary staff—were responsible for passing trays to residents, and there was no plate warmer between the plate and the plastic base. When the test tray was checked, the chicken tender and tater tots were below typical hot-holding temperatures, with the tater tots described as mushy and cold and the chicken tender as dry, tough to chew, and salty. The cold item, a carrot coin salad, was measured at a chilled temperature. Grievances documented that meals were served too cold and that residents were dissatisfied with the variety, fruit options, and perceived high carbohydrate content of the meals. The Dietary Manager acknowledged that dietary staff no longer delivered trays to residents after a change in ownership and attributed cold food to CNAs not passing trays quickly enough, while the Administrator acknowledged there had been complaints about food quality.
Failure to Provide Required Meal Setup and Cut Food Assistance for Resident With Upper Extremity Impairment
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate treatment and services to maintain or improve a resident’s ability to perform ADLs related to dining and eating, specifically cutting food into bite-sized pieces and opening containers as assessed and care planned. A resident with a right humerus fracture, chronic right arm pain, dementia with moderate cognitive impairment (BIMS 9), polyneuropathy, osteoarthritis, chronic pain syndrome, and a right artificial shoulder joint reported being unable to cut her own food and demonstrated that she had to guide her right arm with her left hand. Surveyors observed on multiple occasions that her meals were not consistently prepared or set up to match her assessed need for setup/clean-up assistance with eating. At one meal, her family reported they had to cut up her food and that this was not the first time. At another meal, her breakfast tray included whole sausage links, a lidded bowl, an unopened syrup packet, and a closed juice box with the straw still wrapped, despite her limited use of one arm. The resident’s MDS indicated impairment in one upper extremity and a need for setup or clean-up assistance with eating, and her care plan documented a focus on ADL self-care performance deficit related to dementia and impaired balance, with an intervention that she required setup or clean-up assistance to eat. However, her physician’s diet order specified only a regular diet with regular texture and consistency, with no instruction for cut-up food or meal setup assistance. The Dietary Manager confirmed there were no directions on the resident’s meal card to cut up her food and stated that food was sometimes cut into strips, including pork cutlets, based on the type of food. The MDS Coordinator and an RN both stated that the resident needed her food cut up and lids removed for meal setup and that it would be too difficult for her to manage with one arm, but acknowledged these needs were not reflected in physician orders. Staff also noted that the resident likely could not cut her own food due to right arm pain and limited function and that she would not usually ask for help even when needed, yet the kitchen and nursing staff did not consistently ensure her food was cut into bite-sized pieces or that containers were opened for her.
Failure to Provide Ordered Diet Textures During Nursing and Activities Snacks
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents received food in the texture ordered to meet their individual needs. One resident with dementia and Alzheimer’s disease had a physician’s order for a pureed diet after nursing, the DON, and the nurse practitioner observed that she was not eating well on a regular diet, was cheeking food, holding it in her mouth, and not chewing. Despite this pureed diet order, multiple nursing progress notes documented that she was given ham sandwiches and potato chips on several nights, and an activities note documented that she ate an ice cream cone. Staff interviews confirmed that she was on a pureed diet because she would let food sit in her mouth and that chips and sandwiches are not part of a pureed diet. The speech therapist stated he had not been asked to evaluate her swallowing, that he normally would want to screen residents whose diets were downgraded, and that non‑pureed foods for someone who holds food in their mouth would be a choking concern. Another resident with dementia and a severe cognitive impairment, as evidenced by a BIMS score of 3, had a physician’s order for a regular diet with minced and moist (Level 5) texture and cut‑up foods due to loose teeth. Nonetheless, an activities progress note documented that she ate a peanut cluster during a cooking social, and the Activities Director later reported that she was also given a “bird’s nest” snack made of crunchy chow mein noodles with candy on top, which she did not eat. Nursing staff stated that this resident did not have the mental capacity to chew, required extensive cueing, and that they would be concerned about choking if she were served non‑minced and moist foods. The Dietary Manager reported that the Activities Department provided its own snacks and did not ensure residents received the correct diet textures, and the DON stated that staff were expected to follow physician orders for diet textures despite limited availability of the speech therapist.
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