Four Corners Regional Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Blanding, Utah.
- Location
- 818 North 400 West, Blanding, Utah 84511
- CMS Provider Number
- 465057
- Inspections on file
- 12
- Latest survey
- January 9, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Four Corners Regional Care Center during CMS and state inspections, most recent first.
A LTC facility failed to provide a safe environment and adequate supervision, leading to multiple falls and injuries for residents with cognitive impairments and high fall risks. Despite having care plans with interventions, these were not consistently implemented or updated after falls. Staff interviews revealed communication and documentation issues regarding fall interventions, contributing to repeated falls and injuries.
The facility failed to post daily nurse staffing information, as required, with observations showing outdated and incomplete postings. Interviews revealed confusion over responsibility for posting, with the DON unsure who would post when MR staff were off duty. The Administrator was unaware of the posting requirement.
The facility failed to report allegations of abuse, neglect, and injuries of unknown origin in a timely manner to the SSA and APS. Incidents involving resident-to-resident abuse, sexual abuse, and injuries of unknown origin were not reported within the required time frames. For example, a resident was kissed without consent, another resident fell and fractured a femur, and a third resident had a dislocated shoulder. Delays in reporting were due to a practice of discussing incidents during morning meetings, leading to non-compliance with reporting requirements.
The facility failed to thoroughly investigate and report multiple incidents of abuse, neglect, or mistreatment involving residents. Incidents included a resident-to-resident incident, falls resulting in injuries, and unexplained injuries. The facility did not report these incidents to the SSA or conduct comprehensive investigations, indicating systemic issues in managing such allegations.
The facility failed to provide adequate pharmaceutical services, as narcotic medications like Oxycodone and Hydrocodone were improperly taped back into medication cards after removal. LPNs confirmed this practice, expressing uncertainty about the cleanliness and correctness of the medications. The Administrator and DON acknowledged that this was against protocol, highlighting risks such as contamination and medication diversion.
The facility failed to adhere to professional standards for food service safety, with food items in storage areas left open to air and multiple areas in the kitchen having damaged floor tiles exposing cement. The Dietary Manager acknowledged the issues and stated that staff were expected to label food containers properly, but repairs to the kitchen floor had been requested for years without completion.
The facility failed to maintain an effective infection prevention and control program, as evidenced by uncapped feeding tubes, improper use of PPE, and inadequate sanitation of equipment. A resident's feeding tube was left uncapped, and staff did not wear appropriate PPE while providing care. Additionally, a Hoyer lift was used for multiple residents without being sanitized between uses, and hand hygiene was not consistently performed. These actions contributed to the deficiencies identified during the survey.
A resident with significant weight loss and multiple health conditions did not receive recommended high-calorie supplements due to the facility's failure to implement the RD's dietary recommendations. Despite the resident's inadequate oral intake and refusal of meals, the facility did not order the suggested supplements, leading to continued weight loss. Interviews with staff revealed communication issues and a lack of formalized processes for implementing dietary changes.
A facility failed to act on a pharmacist's recommendation to discontinue hydroxyzine for a resident with multiple diagnoses, including dementia and traumatic brain injury. The pharmacist suggested replacing hydroxyzine with buspirone due to cognitive side effects, and the medical provider agreed. However, the change was delayed because the attending physician was on vacation, leading to a deficiency in medication management.
A resident's medication, Hydroxyzine, was not discontinued as recommended by the pharmacy and medical provider, despite concerns about cognitive side effects and frequent falls. The physician's vacation and limited communication led to a delay in implementing the change to Buspirone, as acknowledged by the DON.
A facility failed to conduct required gradual dose reductions (GDR) for a resident on CarBAMazepine for behavioral disturbance, despite no clinical contraindication. The resident, with multiple diagnoses including dementia and mood disorder, had not received a GDR since 2023. The ADON explained the process for psychotropic medication management but acknowledged the oversight in conducting the necessary GDRs.
The facility failed to properly label and store insulin vials, resulting in the use of expired medications. An LPN was observed with a medication cart containing Lantus and Tresiba insulin vials that were past their 28-day open dates. The DON confirmed that insulin should not be expired and expressed uncertainty about the inconsistent labeling of the vials.
A resident with multiple diagnoses experienced a five-day delay in urine sample collection for a urinalysis, leading to a delayed UTI diagnosis. The delay was due to the resident's behavior and the staff's reluctance to use alternative collection methods. The DON acknowledged the delay was not routine.
The facility failed to maintain accurate medical records, as two residents' records contained incorrect documentation. A resident's record included a document belonging to another resident, and another resident's record had identifying information and appeal status that should not have been present. The Medical Records staff acknowledged the error and stated that regular audits are conducted to ensure correct documentation.
Inadequate Fall Prevention and Supervision in LTC Facility
Penalty
Summary
The facility failed to ensure a safe environment and adequate supervision for residents, leading to multiple falls and injuries. Resident 41, who had severe cognitive impairment and was at moderate risk for falls, experienced several falls resulting in injuries, including a brain bleed. Despite having a care plan with interventions such as a fall mat and a tilt-in-space wheelchair, these measures were not consistently implemented or updated after each fall. The resident's care plan did not reflect new interventions for falls on specific dates, and there was a lack of IDT meetings for some incidents. Resident 52, diagnosed with Parkinson's Disease and dementia, was also at high risk for falls. The resident experienced multiple falls, some resulting in injuries, but no new fall interventions were implemented in 2023. The resident's care plan was not updated with new interventions after each fall, and there was a lack of consistent monitoring and supervision. The resident's impulsive behavior and poor safety awareness contributed to the falls, but the facility did not adequately address these issues in the care plan. Interviews with facility staff revealed a lack of communication and documentation regarding fall interventions. Staff were not always aware of the specific interventions in place for residents, and there was inconsistency in updating care plans and communicating changes to the staff. The facility's failure to implement and document appropriate fall interventions and supervision contributed to the residents' repeated falls and injuries.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to comply with the requirement to post daily nurse staffing information, which includes the facility name, current date, total number, and actual hours worked by Registered Nurses, Licensed Practical Nurses, Certified Nursing Assistants, and the resident census. Observations on multiple occasions revealed that the nurse staffing information was outdated and incomplete, lacking the actual hours worked by the nursing staff. Specifically, on January 6th and January 8th, the posted information was dated January 5th and did not include the necessary details. Interviews with facility staff highlighted a lack of clarity and responsibility regarding the posting of nurse staffing information. The Director of Nursing indicated that Medical Records was responsible for posting the information, but was unsure who would do so when Medical Records staff were off duty. The Medical Records staff confirmed their responsibility but noted that their schedule and duties sometimes prevented them from posting the information. The facility Administrator was unaware of the requirement to post nurse staffing information, indicating a gap in knowledge and communication within the facility's management.
Failure to Timely Report Abuse and Injuries
Penalty
Summary
The facility failed to report allegations of abuse, neglect, and injuries of unknown origin in a timely manner to the State Survey Agency (SSA) and Adult Protective Services (APS). For six residents, incidents involving resident-to-resident abuse, sexual abuse, and injuries of unknown origin were not reported within the required time frames. Specifically, incidents involving residents 13 and 36, where a male resident kissed a female resident without consent, were not reported immediately as required. The incident was observed by a Certified Nursing Assistant (CNA) and reported to the Assistant Director of Nursing (ADON), but the facility administration did not report it to the SSA or APS promptly. Another incident involved resident 53, who fell after an altercation with another resident, resulting in a fractured femur. The facility staff became aware of the incident on the day it occurred, but the Administrator was not informed until the following day, and the SSA was notified even later. APS was not notified at all. This delay in reporting was attributed to a practice of discussing incidents during morning meetings, which led to a failure to meet the required reporting timelines. Additionally, resident 49 experienced a dislocated shoulder, and the incident was not reported to the SSA until two days later. The Administrator was not informed until the day after the incident. Similarly, resident 17 had a fall resulting in a laceration, but there was no record of the incident being reported to the SSA. The facility's policy required immediate reporting of such incidents, but the practice of waiting until the next day to inform the Administrator led to significant delays in reporting to the appropriate authorities.
Inadequate Investigation and Reporting of Incidents
Penalty
Summary
The facility failed to thoroughly investigate and report allegations of abuse, neglect, or mistreatment for several residents. For instance, a resident reported a resident-to-resident incident involving unwanted physical contact in the dining room, which was observed by staff but not reported to the State Survey Agency (SSA) or investigated thoroughly. The Assistant Director of Nursing (ADON) and the Director of Nursing (DON) were aware of the incident, but no formal investigation was conducted, and the incident was not reported to the SSA. Another resident experienced a fall resulting in a hip fracture, but the facility's investigation was inconclusive, and the root cause of the injury was not determined. The facility did not provide additional investigative documentation when requested. Similarly, a resident with a dislocated shoulder did not have a thorough investigation conducted, and the facility was unable to determine the cause of the injury. The facility's response to these incidents was inadequate, as they failed to notify other agencies or conduct comprehensive investigations. Additionally, several residents experienced falls or injuries of unknown origin, and the facility did not conduct thorough investigations or report these incidents to the SSA. In some cases, the facility did not provide requested documentation or follow-up investigation reports. The lack of thorough investigations and reporting indicates a systemic issue within the facility in addressing and managing allegations of abuse, neglect, or mistreatment.
Improper Handling of Narcotic Medications
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to meet the needs of each resident, as evidenced by improper handling of narcotic medications. During an observation of the medication carts, it was found that narcotic medications such as Oxycodone and Hydrocodone were improperly taped back into their medication cards after being removed. This practice was confirmed by interviews with LPNs who stated that medications were sometimes taped back if accidentally pushed through the backing or if not administered. The LPNs expressed uncertainty about the cleanliness and correctness of the medications once taped back, indicating a lack of proper procedures for handling such situations. The facility's Administrator and Director of Nursing (DON) acknowledged that the practice of taping medications back into the cards was against protocol. The Administrator stated that narcotics should be wasted in the sharps container, and the DON emphasized the need for two witnesses when wasting narcotics. The DON also noted the risks associated with taping medications back, such as potential contamination, incorrect medication being taped back, and the possibility of medication diversion. Despite these acknowledgments, the practice of taping medications back into the cards was observed, indicating a deficiency in the facility's pharmaceutical services.
Food Storage and Kitchen Maintenance Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. During an initial walk-through of the kitchen, it was observed that several food items in the walk-in refrigerator, freezer, and dry storage room were open to the air, including containers without labels or dates and boxes of dough and bacon bits. Additionally, the kitchen had multiple areas with damaged floor tiles, exposing the cement underneath, which were noted in the dish machine area, near the three sink area, by the walk-in refrigerator, and in the food preparation area. The Dietary Manager (DM) acknowledged that food deliveries were initially placed in storage areas and that staff were expected to label containers with delivery, open, and use-by dates. The DM admitted that improperly stored food could lead to decreased food quality and stated that she would dispose of any improperly stored items. Despite conducting monthly in-services to educate dietary staff, the DM reported that kitchen staff had been requesting floor repairs for years, and although the previous Administrator had planned to replace the floor, it was never completed. The DM also mentioned that the consultant Registered Dietitian conducted quarterly kitchen audits, including sanitation reviews, and communicated findings to her for correction.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several deficiencies observed during the survey. For Resident 348, the feeding tube was repeatedly observed to be uncapped when not in use, despite the Assistant Director of Nursing (ADON) acknowledging that it should be capped. Additionally, the Licensed Practical Nurse (LPN) and Certified Nursing Assistant Coordinator (CNAC) did not wear appropriate Personal Protective Equipment (PPE) while providing care to Resident 348, who was on Enhanced Barrier Precautions (EBP). The ADON later discovered that tube feedings required EBP, leading to the placement of an EBP sign on the resident's door. The use of the Hoyer lift was another area of concern. Certified Nursing Assistant (CNA) 4 was observed using the Hoyer lift to transfer multiple residents without sanitizing it between uses. This included residents on EBP, where additional precautions were necessary. Furthermore, CNA 4 did not perform hand hygiene between resident care, which was expected by the facility's Director of Nursing (DON) and Administrator. Interviews with staff revealed a lack of clarity regarding the responsibility for cleaning the Hoyer lifts and the frequency of hand hygiene practices. In another instance, CNA 4 entered Resident 23's room, who was on EBP, without donning the required PPE. Despite signage indicating the need for gloves and a gown for high-contact activities, CNA 4 did not adhere to these precautions. This oversight was consistent across multiple observations, with no hand hygiene performed after resident care. The facility's failure to enforce proper infection control measures and PPE usage contributed to the deficiencies identified during the survey.
Failure to Implement Dietary Recommendations for Resident with Significant Weight Loss
Penalty
Summary
The facility failed to ensure that a resident maintained acceptable nutritional status, as recommendations from the Registered Dietitian (RD) were not implemented. The resident, who had a history of significant weight loss, was not provided with the recommended high-calorie supplements such as Mighty Shake or Ensure, despite the RD's suggestions. The resident's medical record indicated a significant weight loss over several months, and the RD had noted the resident's inadequate oral intake and refusal of meals. The resident, identified as having moderate cognitive impairment and multiple health conditions including type 2 diabetes, major depressive disorder, and legal blindness, was at nutritional risk. The care plan included interventions such as encouraging the resident not to hoard food and setting up the plate in a clock pattern to assist with eating. However, the facility did not order the recommended supplements, and the resident continued to experience significant weight loss. Interviews with facility staff, including the Assistant Director of Nursing (ADON) and the RD, revealed a lack of communication and follow-through on dietary recommendations. The ADON acknowledged that the skin and weight meetings were not formalized, and there was confusion about the implementation of RD recommendations. The RD reported limited access to the electronic medical record system, which hindered the ability to input orders directly, relying instead on staff to implement dietary changes. The Director of Nursing (DON) was also unsure of how recommendations were being implemented, indicating a breakdown in the process of addressing the resident's nutritional needs.
Delayed Implementation of Pharmacist's Medication Recommendation
Penalty
Summary
The facility failed to ensure that a pharmacist's recommendation to discontinue hydroxyzine for a resident was acted upon in a timely manner. The resident, who had multiple diagnoses including hemiplegia, traumatic brain injury, and dementia, was prescribed hydroxyzine for anxiety. The pharmacist recommended discontinuing hydroxyzine due to its cognitive side effects and suggested replacing it with buspirone, a medication with fewer cognitive side effects. This recommendation was communicated to the medical provider, who agreed to the change. However, the change was not implemented promptly. The delay in implementing the medication change was attributed to the attending physician being on vacation, which limited communication. The Director of Nursing (DON) stated that the corporate pharmacist reviewed each resident's medications monthly and typically communicated recommendations to the doctor. However, in this case, the recommendation to discontinue hydroxyzine was not executed as expected, resulting in a deficiency in the facility's medication management process.
Failure to Discontinue Unnecessary Medication
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs, as required by regulations. Specifically, for one resident, the medication Hydroxyzine was not discontinued as recommended by both the pharmacy and the medical provider. The resident, who had multiple diagnoses including hemiplegia, traumatic brain injury, and dementia, was prescribed Hydroxyzine for anxiety. Despite recommendations to discontinue Hydroxyzine and replace it with Buspirone due to concerns about cognitive side effects and the resident's frequent falls, the medication continued to be administered. The deficiency occurred because the physician was on vacation, leading to limited communication and a delay in implementing the recommended changes. The Director of Nursing (DON) acknowledged that the facility's process involved the corporate pharmacist reviewing medications monthly and communicating with the doctor, but the change was not executed in a timely manner. The resident continued to receive Hydroxyzine even after the medical provider had agreed to the change, highlighting a breakdown in communication and protocol adherence within the facility.
Failure to Conduct Gradual Dose Reduction for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident who was using psychotropic drugs received gradual dose reductions (GDR) as required. Specifically, for one resident, who was taking an anticonvulsant medication, CarBAMazepine, for behavioral disturbance, a GDR had not been attempted since 2023, despite the absence of a documented clinical contraindication. The resident was admitted with multiple diagnoses, including senile degeneration of the brain, dementia, essential hypertension, atrial fibrillation, and mood disorder. During an interview, the Assistant Director of Nursing (ADON) explained the process for managing psychotropic medications, which involved discussions with the pharmacy and obtaining physician approval for recommendations. However, the ADON acknowledged that the required GDRs were not conducted for the resident in question. The facility's process included the pharmacist notifying when medications were due for a GDR, but this was not followed in this instance, leading to the deficiency.
Expired Insulin Vials Found in Medication Cart
Penalty
Summary
The facility failed to label and store drugs and biologicals in accordance with accepted professional principles, leading to the use of expired insulin vials. During an observation of the Team 2 medication cart, it was found that a vial of Lantus insulin was opened and available for use, labeled with an open date that was 8 days past the 28-day open date. Similarly, a vial of Tresiba insulin was also found to be open and available for use, labeled with an open date that was 6 days past the 28-day open date. These findings were confirmed during an immediate interview with an LPN, who stated that the insulin was being used for residents and that the nurses were supposed to write the date on the insulin when it was taken out of the fridge. The Director of Nursing (DON) was interviewed and stated that the facility's expectation was for nurses to administer the correct medications to the correct residents and that insulin should not be expired. The DON mentioned that insulin was considered good for 30 days after being opened and that nurses were supposed to date the insulin when they retrieved a new one from the fridge. However, the DON was unsure why the insulin vials had two different dates written on them, indicating a lack of proper labeling and storage practices within the facility.
Delayed Urine Sample Collection for Resident
Penalty
Summary
The facility failed to provide timely laboratory services for a resident, identified as Resident 17, who had a urinalysis (UA) ordered. The urine sample was not collected until five days after the order was given. Resident 17 was admitted with multiple diagnoses, including hemiplegia, traumatic brain injury, and dementia, among others. The physician's order for a UA with reflex to culture was placed on September 25, 2024, but the sample was not collected until September 30, 2024. The delay in collecting the urine sample resulted in a delay in diagnosing a urinary tract infection (UTI) and initiating treatment. Interviews with facility staff revealed that the delay was due to the resident's behavior of urinating in the sink, which made it difficult to collect the sample. The Director of Nursing (DON) explained that after moving the resident to another room, they were able to collect the urine sample using a hat placed in the sink. The DON acknowledged that it was not routine to wait five days to collect a urine sample and attributed the delay to the resident being difficult and the staff's reluctance to use other measures to collect the urine.
Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to maintain accurate medical records for its residents, as evidenced by the incorrect documentation found in the medical records of two residents. Resident 246, who was admitted with conditions including paraplegia, chronic obstructive pulmonary disease, and anxiety disorder, had a document labeled KEPRO_5.23.23.pdf belonging to another resident, Resident 247, in their medical record. This error was discovered during a review of Resident 246's medical record. Similarly, Resident 247, who was admitted with diagnoses such as polyneuropathy and dementia, had their medical record reviewed, revealing patient-identifying information and appeal status that should not have been present. The Medical Records staff acknowledged the error, stating that regular audits are conducted to ensure correct documentation, and any incorrect documents found are removed and placed in the correct resident's record. The Administrator confirmed that it is against policy to include another resident's name or information in a different resident's chart, in compliance with the Health Insurance Portability and Accountability Act.
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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