George E. Wahlen Ogden Veterans Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Ogden, Utah.
- Location
- 1102 North 1200 West, Ogden, Utah 84404
- CMS Provider Number
- 465172
- Inspections on file
- 17
- Latest survey
- February 28, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at George E. Wahlen Ogden Veterans Home during CMS and state inspections, most recent first.
A resident with severe cognitive impairment was subjected to abuse by her husband, who was also a resident. The husband attempted to force medication into another resident's mouth and forcibly removed his wife's clothing. The facility failed to implement interventions to prevent further abuse, and staff did not adequately document or report the incidents, contributing to the deficiency.
A facility failed to report an alleged abuse incident where a resident's husband attempted to force medication into her mouth, resulting in immediate jeopardy. The incident was not documented or communicated to the Administrator, who oversees abuse allegations. The residents involved had significant medical and cognitive conditions, and the facility acknowledged a breakdown in internal reporting processes.
Two residents requiring supplemental oxygen were found using nearly empty portable oxygen tanks, despite their medical conditions necessitating consistent oxygen supply. Facility staff, including the ADON, CNA, LPN, and DON, acknowledged procedures for checking and replacing tanks, but these were not consistently followed, resulting in the deficiency.
Two residents in a LTC facility did not receive care according to professional standards and their care plans. One resident was given medications despite being unable to self-administer and showing signs of overdose, leading to hospitalization. Another resident experienced low oxygen levels without proper monitoring. Staff interviews revealed inadequate documentation and understanding of protocols for changes in condition.
A resident with severe dementia and Parkinson's disease fell from a high bed, hitting his head on a feeding tube pump, due to inadequate supervision and failure to follow the care plan. The call light was not promptly answered, and the bed was not in the lowest position as required. The resident sustained injuries and was later diagnosed with a brain bleed at the hospital. Staff failed to notify the physician of the fall and the resident's declining condition in a timely manner.
The facility failed to provide adequate pain management for two residents. One resident with severe cognitive impairment experienced a fall and a delayed x-ray revealed a lumbar fracture. Despite complaints and non-verbal pain indicators, pain management interventions were not effectively implemented. Another resident under hospice care reported severe pain that was not effectively managed by prescribed medications, with documented instances of ineffective pain relief. Staff interviews revealed inconsistencies in pain assessment and management practices.
The facility did not post daily nurse staffing information as required. Observations showed outdated postings, with one date being illegible. The CNAC stated the night supervisor was responsible for updates, which varied daily based on staff schedules.
A facility exceeded the acceptable medication error rate with two errors out of 35 opportunities, resulting in a 5.71% error rate. A resident received Levothyroxine after breakfast instead of on an empty stomach, and Digoxin was administered without obtaining an apical pulse. Staff interviews revealed non-compliance with medication protocols, and the resident's care plan lacked documentation of medication preferences.
Two residents in a facility experienced significant medication errors. One resident received incorrect dosages of Methadone and Xanax, leading to increased pain and discomfort. Another resident had a blood thinner held for over a month due to a communication lapse, despite a 7-day hold order following a fall. Staff interviews revealed issues with medication administration protocols and communication.
A medication cart was left unlocked and unattended by an RN, and a Basaglar kwikpen labeled for a resident was found past its expiration date. The LPN acknowledged the oversight, and the Unit Manager confirmed that expired medications should be checked by nurses, with random audits by leadership.
The facility did not employ a full-time Registered Dietitian (RD) or a certified Dietary Manager (DM) to serve as the director of nutrition services. The DM was in the process of obtaining certification but had not completed it due to a medical concern. Another employee had completed the certification but was not working in that role. The RD conducted monthly audits and provided recommendations, but the facility lacked the required full-time qualified staff.
The facility failed to store food items in the walk-in freezer and refrigerator according to professional standards, with several items left open to air. The Dietary Manager acknowledged the issue, stating that items should be sealed and dated to prevent freezer burn or contamination. Daily checks were conducted by morning managers, and the Registered Dietitian performed monthly audits.
Failure to Protect Resident from Abuse by Spouse
Penalty
Summary
The facility failed to protect a resident from abuse, resulting in an immediate jeopardy situation. A resident's husband was involved in two incidents where he exhibited aggressive behavior towards his wife and another resident. In one incident, he attempted to force medication into another resident's mouth, and in another, he shoved his wife and forcibly removed her clothing to change her. These actions were not prevented by the facility, and no interventions were in place to protect the resident from further abuse. The resident involved in the incidents had severe cognitive impairment due to Alzheimer's disease and dementia, making her vulnerable to abuse. Despite her condition, the facility did not implement adequate measures to ensure her safety. The resident's husband, who was cognitively intact, had been her primary caregiver and was experiencing caregiver burnout, which contributed to his aggressive behavior. The facility staff were aware of the husband's frustration and the resident's resistance to care but failed to intervene appropriately. Interviews with staff revealed that the incidents were not properly documented or reported to management in a timely manner. The facility's administrator and director of nursing were not informed of a previous incident involving the husband, which could have influenced their response to the recent events. The lack of documentation and communication among staff members contributed to the facility's failure to protect the resident from abuse and address the husband's caregiver burnout effectively.
Failure to Report Alleged Abuse Incident
Penalty
Summary
The facility failed to report an alleged abuse incident involving a resident's husband to the State Survey Agency, resulting in a deficiency. The incident occurred when the husband attempted to force medication into the resident's mouth using a spoon. This event was not reported immediately as required, and the facility did not document the incident in the resident's medical record. The failure to report and document the incident led to the identification of immediate jeopardy. The deficiency involved two residents, one of whom was diagnosed with Alzheimer's disease, dementia, muscle weakness, and cognitive communication deficit, with a BIMS score indicating severe cognitive impairment. The other resident, who attempted to force the medication, was diagnosed with PTSD and recurrent severe major depressive disorder, with a BIMS score indicating cognitive intactness. The incident was not communicated to the facility's Administrator, who oversees abuse allegations, until much later, highlighting a breakdown in the facility's internal reporting processes. The Administrator was unaware of the incident until informed by the Social Service Director, indicating a lapse in communication and reporting within the facility. The Administrator stated that if she had been informed earlier, she would have sought guidance from the corporate office. The facility acknowledged that staff had not consistently notified management about incidents, which contributed to the deficiency and the subsequent immediate jeopardy finding.
Failure to Provide Adequate Respiratory Care
Penalty
Summary
The facility failed to provide adequate respiratory care for two residents who required supplemental oxygen. Resident 7, who had a history of acute respiratory failure with hypoxia, chronic obstructive pulmonary disease, and chronic systolic congestive heart failure, was observed using a portable oxygen tank with the indicator in the red refill area, indicating it was nearly empty. This observation was made despite a care plan that documented the resident's need for supplemental oxygen to maintain oxygen saturation. Additionally, the facility's grievance records revealed multiple complaints about low or empty oxygen tanks being used by residents. Similarly, Resident 8, diagnosed with acute respiratory failure with hypoxia and chronic respiratory failure with hypercapnia, was found using a portable oxygen tank with the indicator on zero in the red area. The resident expressed a need for oxygen due to shortness of breath. Interviews with facility staff, including the ADON, CNA, LPN, and DON, revealed that while there were procedures in place for checking and replacing oxygen tanks, these were not consistently followed. Staff acknowledged the need to change tanks when indicators were in the red, but observations showed this was not done in a timely manner, leading to the deficiency.
Failure to Monitor and Document Resident Conditions
Penalty
Summary
The facility failed to ensure that two residents received treatment and care in accordance with professional standards of practice, their comprehensive person-centered care plans, and their choices. One resident, who was cognitively intact and had multiple diagnoses including respiratory failure and congestive heart failure, was administered medications by a nurse despite being unable to put them in his mouth and showing signs of confusion, difficulty staying awake, and low oxygen saturation. The resident was later discharged to the hospital with an overdose, and there was no documented monitoring of his change in condition. Another resident, who was also cognitively intact and had diagnoses including paroxysmal atrial fibrillation and chronic obstructive pulmonary disease, experienced low oxygen levels in the evening. Despite being provided increased oxygen, there was no documented monitoring throughout the night to ensure the oxygen saturation remained above 90 percent. The resident's medical record lacked documentation of follow-up actions or monitoring after the initial intervention. Interviews with staff revealed a lack of understanding and adherence to protocols for monitoring changes in residents' conditions. The staff failed to document vital signs and changes in condition, and there was confusion about the appropriate actions to take when residents exhibited signs of overdose or respiratory distress. The facility did not have a policy regarding resident overdose, contributing to the deficiencies observed.
Failure to Prevent Fall and Ensure Timely Medical Response
Penalty
Summary
The facility failed to ensure a safe environment for Resident 119, who was at risk for falls due to multiple medical conditions, including severe dementia and Parkinson's disease. The resident was dependent on staff for mobility and had a care plan in place to mitigate fall risks, which included keeping the bed in the lowest position and conducting hourly safety checks. However, the resident rolled out of a high bed and sustained injuries after hitting his head on a feeding tube pump. This incident occurred despite the presence of a call light system, which was not promptly responded to by staff. The incident report and subsequent interviews revealed that the bed was not in the lowest position as required by the care plan, and the call light was activated for over four minutes before staff responded. The resident's fall resulted in a laceration to the scalp and eyebrow, as well as a skin tear on the knee. The resident's family member noticed a change in the resident's condition and transported him to the hospital, where a brain bleed was diagnosed. The facility's documentation indicated that the nurse on duty failed to notify the physician of the fall and the resident's declining condition in a timely manner. Interviews with facility staff, including a registered nurse and a unit manager, highlighted lapses in communication and monitoring following the fall. The RN supervisor was not informed of the fall or the resident's decreasing blood pressure, which should have prompted immediate medical intervention. The facility's fall prevention program, which includes regular assessments and interventions, was not effectively implemented in this case, leading to the resident's injury and subsequent hospitalization.
Inadequate Pain Management for Two Residents
Penalty
Summary
The facility failed to provide adequate pain management for two residents, leading to deficiencies in care. Resident 78, who had severe cognitive impairment and a history of falls, sustained a fall in the facility's bathroom. Despite complaints of pain from the resident and observations of non-verbal pain indicators, an x-ray was not obtained until 15 days later, revealing a fracture in the lumbar spine. The care plan for Resident 78 included interventions for pain management, but these were not effectively implemented, as evidenced by the delayed response to the resident's pain and the use of an inappropriate pain assessment scale. Resident 77, who was under hospice care with a terminal prognosis, reported severe pain that was not effectively managed by the prescribed pain medications. Despite receiving scheduled and as-needed doses of Morphine, the resident continued to experience high levels of pain, with documented instances where the medication was ineffective. The facility's failure to promptly administer additional doses or alternative pain management strategies contributed to the resident's ongoing discomfort. Interviews with staff revealed inconsistencies in pain assessment and management practices. Staff members acknowledged the challenges in assessing pain for residents with cognitive impairments and noted the use of a numerical pain scale that was not suitable for Resident 78. Additionally, there were delays in obtaining necessary diagnostic tests and adjustments to pain management plans, which further exacerbated the residents' pain and discomfort.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to comply with the requirement to post daily nurse staffing information. Observations on two separate occasions revealed that the postings were not updated daily as required. On one occasion, the postings were dated from two weeks prior, and on another occasion, they were from three days prior. The postings were located in the facility entry area, but the dates were not current, and one date was difficult to read. An interview with the Certified Nursing Aide Coordinator indicated that the night supervisor was responsible for updating the postings, and the information varied daily based on the staff schedule. This indicates a lapse in maintaining up-to-date and legible nurse staffing information accessible to residents and visitors.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5 percent, as evidenced by two medication errors out of 35 opportunities, resulting in a 5.71 percent error rate. The errors involved a resident who was administered thyroid medication, Levothyroxine, not on an empty stomach as required, and Digoxin without obtaining an apical pulse beforehand. The resident had just finished breakfast when the medications were administered, contrary to the physician's order for Levothyroxine to be given at 6:00 AM on an empty stomach. The Licensed Practical Nurse (LPN) administering the medication did not obtain an apical pulse for Digoxin, despite acknowledging that it is a standard nursing practice to do so. Interviews with nursing staff revealed a lack of adherence to medication administration protocols. The LPN stated that the heart rate was checked using a machine, but no apical pulse was obtained, and the supervising Registered Nurse (RN) confirmed that Levothyroxine should be administered 30 minutes to 1 hour before food or other medications. The Unit Manager also confirmed that the resident's care plan did not document preferences for medication administration, which contributed to the errors. The Nursing 2022 Drug Handbook specifies that an apical-radial pulse should be taken for 1 minute before administering Digoxin, highlighting the deviation from standard practice in this case.
Medication Errors and Delayed Treatment in Residents
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, affecting two residents. Resident 50 was administered pain medication and anti-anxiety medications not according to physician's orders. Specifically, there were multiple instances where Resident 50 received incorrect dosages of Methadone, a pain medication. On one occasion, the resident was given 10 mg of Methadone instead of the prescribed 30 mg, and on another, the resident received Xanax instead of Methadone. These errors were identified through narcotic records and incident reports, and the resident experienced increased pain and discomfort as a result. In another case, Resident 119 had a blood thinner, Plavix, held for longer than the prescribed 7 days following a fall with a head injury. The order to hold the medication was communicated by the resident's son, based on advice from a cardiologist, but the facility failed to follow up appropriately to restart the medication. As a result, Resident 119 did not receive the blood thinner from April 24 until May 30, which could have posed significant health risks given the resident's medical history, including atherosclerotic heart disease. Interviews with facility staff revealed lapses in communication and medication administration protocols. LPNs and RNs involved in the care of Resident 50 admitted to errors in medication dispensing and administration, often due to oversight or unfamiliarity with the resident's medication regimen. Similarly, the delay in restarting Resident 119's blood thinner was attributed to a lack of proactive communication with the physician and reliance on family members for medical decisions. These deficiencies highlight significant gaps in the facility's medication management processes.
Medication Storage and Labeling Deficiency
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored and labeled according to accepted professional principles. During an observation, a medication cart was found unlocked and unattended in the 200 hallway by RN 6, who admitted to leaving it in that state. This lapse in protocol could potentially lead to unauthorized access to medications, posing a risk to resident safety. Additionally, a Basaglar kwikpen labeled for resident 60 was found on the medication cart with an open date of 6/29/24, indicating it was past its 28-day usability period. LPN 3 acknowledged that the medication should have been discarded. The Unit Manager confirmed that the process for checking expired medications was the responsibility of the nurses, with random audits conducted by the leadership team. However, the expired medication was not identified and removed in a timely manner, highlighting a gap in the facility's medication management practices.
Deficiency in Nutrition Services Staffing
Penalty
Summary
The facility was found to have a deficiency in employing a clinically qualified full-time dietitian or another clinically qualified nutrition professional to serve as the director of nutrition services. The Dietary Manager (DM) was in the process of obtaining her certification but had not yet completed it due to a medical concern, despite having two years of experience in the role. Another full-time kitchen employee had completed the certification for DM but was not working in that capacity. The Registered Dietitian (RD) conducted monthly kitchen audits and provided recommendations based on her findings, but the facility did not have a full-time RD or a certified DM in place as required.
Food Storage Deficiencies in Kitchen
Penalty
Summary
The facility was found to have deficiencies in the storage, preparation, distribution, and serving of food in accordance with professional standards for food service safety. During an initial kitchen tour, it was observed that several food items in the walk-in freezer, including peanut butter cookie dough, egg patties, corn on the cob, breaded chicken, and corn dogs, were left open to air. A follow-up kitchen tour revealed similar issues, with additional items such as parmesan cheese in the refrigerator and sausage links, frozen cut corn, frozen peas, chicken fried beef patties, and corn dogs in the freezer also being open to air. An interview with the Dietary Manager (DM) revealed that the facility's protocol involved returning partially used food items to the freezer, either wrapped and dated or thrown away if there was very little left. The DM stated that items in the refrigerator and freezer were checked daily by morning managers, and cooks were expected to ensure proper storage. The Registered Dietitian (RD) visited the facility weekly and conducted monthly kitchen audits, sharing any concerns with the DM, administrator, Infection Control coordinator, and corporate dietitian. The DM acknowledged that items left open to air could result in freezer burn or contamination, emphasizing the need for all items to be sealed and dated.
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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