Holladay Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Salt Lake City, Utah.
- Location
- 4782 South Holladay Boulevard, Salt Lake City, Utah 84117
- CMS Provider Number
- 465109
- Inspections on file
- 20
- Latest survey
- March 26, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Holladay Healthcare Center during CMS and state inspections, most recent first.
The facility did not ensure that the dish machine consistently met required sanitation standards, as observed through multiple cycles with wash and rinse temperatures below 120°F and inconsistent sanitizer levels. Staff continued to use and store dishes as clean despite these deficiencies, and documentation did not clearly specify compliance with professional food safety standards.
Four residents with complex medical conditions did not have their quarterly MDS assessments completed within the required three-month interval. The MDS coordinator confirmed that assessments were submitted late due to falling behind and prioritizing current over overdue assessments.
Several residents reported that meals were consistently cold, bland, and did not match their menu selections or dietary preferences. Direct observation confirmed that food was served at improper temperatures and lacked seasoning. Resident council minutes documented ongoing complaints about food quality, temperature, and presentation, indicating a persistent failure to provide palatable and appetizing meals.
Staff were observed assisting multiple residents with eating and delivering meal trays without performing hand hygiene between resident interactions or between handling trays. This failure to follow infection control protocols was confirmed by interviews with nursing leadership, who stated that hand hygiene was expected between each resident and tray delivery.
A resident with multiple chronic conditions did not receive a comprehensive MDS assessment within the required 12-month period. The MDS coordinator confirmed the delay, stating that overdue assessments were sometimes deprioritized in favor of current ones.
A resident with multiple chronic conditions was provided oxygen therapy without an active physician's order, and staff did not follow standardized procedures for changing oxygen tubing and humidifier. Staff relied on the resident or equipment settings to determine oxygen needs, and there was no documentation of scheduled equipment changes. The facility also failed to address the resident's request for a smaller portable oxygen tank.
A resident with complex cardiac and renal conditions was administered metoprolol on multiple occasions despite physician orders to hold the medication for systolic blood pressure below 100. Nursing staff did not adhere to the specified parameters, resulting in the administration of the drug when it was not indicated.
An opened Lantus insulin pen, labeled with an open date beyond the recommended 28-day period, was found in the medication cart and available for use for a resident with multiple health conditions. Nursing staff confirmed that insulin should be discarded after 28 days, but the expired medication was not removed as required.
A resident with impaired mobility and a physician's order for podus boots to prevent pressure ulcers did not consistently have the boots applied as required. Despite documentation indicating the intervention was in place, direct observations showed the boot was not on the resident's foot during several checks, and the resident expressed concern about the lack of action. Staff reported that orders were communicated via shift reports and electronic alerts, but the intervention was not reliably implemented.
A resident with severe dementia and behavioral issues was exposed to accident hazards when tools and an unsecured toilet were left in her accessible bathroom during repairs, despite her known wandering and impulsive behavior. Staff confirmed the presence of these hazards and acknowledged the resident could access the area. Additionally, a staff member was observed carrying unsecured oxygen tanks through the hallway, contrary to safety protocols.
A nurse aide was employed full-time for about eight months without completing the required state-approved training and competency evaluation program. The aide was hired and worked beyond the four-month limit without certification, and facility leadership could not provide a clear explanation for this lapse, citing possible confusion over a staffing waiver.
Failure to Maintain Proper Dish Machine Sanitation Standards
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, specifically related to dish machine sanitation. Observations and record reviews revealed that the dish machine was not consistently reaching the required temperatures for proper sanitation. On multiple occasions, the wash and rinse cycles of the dish machine were documented at temperatures below the minimum standard of 120 degrees Fahrenheit. Additionally, the sanitizer solution was found to be at 0 parts per million (PPM) during one observation, despite logs indicating 200 PPM. Staff were observed placing dishes, utensils, and kitchenware away as clean after cycles that did not meet the required temperature or sanitizer levels. Interviews with dietary staff and the dietary manager confirmed awareness of the required temperature and sanitizer standards, but also revealed that the dish machine was used even when these standards were not met. The dish machine logs for several months showed inconsistent documentation, with no clear specification of which temperature was being recorded. The dietary manager acknowledged that water temperatures were lower when the laundry was in use and confirmed that the dish machine was not always operating at the required sanitation levels.
Failure to Complete Quarterly MDS Assessments Within Required Timeframe
Penalty
Summary
The facility failed to ensure that each resident’s assessment was updated at least once every three months, as required. Specifically, four residents with various diagnoses, including multiple sclerosis, major depressive disorder, hypertension, type 2 diabetes mellitus, fibromyalgia, spinal stenosis, Alzheimer's disease, heart failure, nontraumatic subdural hemorrhage, and vascular dementia, had quarterly Minimum Data Set (MDS) assessments completed more than three months apart. The assessment reference dates (ARD) and completion dates for these residents showed that the required quarterly reviews were not performed within the mandated timeframe. During an interview, the MDS coordinator acknowledged that the MDS assessments for these residents were completed late. The coordinator explained that when she fell behind on her workload, she prioritized current assessments over those that were already overdue, resulting in the late completion of the required quarterly MDS assessments for the affected residents.
Failure to Provide Palatable and Properly Tempered Food
Penalty
Summary
The facility failed to provide food that was palatable, attractive, and served at a safe and appetizing temperature for 8 out of 37 sampled residents. Multiple residents reported that their meals were consistently cold, bland, and did not match their menu selections or dietary preferences. Specific complaints included being served unwanted carbohydrates, cold eggs, and food that was not seasoned or appealing. Some residents stated they avoided eating due to the poor quality and temperature of the food, and one resident relied on family to bring meals. Resident council meeting minutes over several months documented ongoing concerns about food temperature, presentation, and the facility not honoring residents' menu choices or dietary dislikes. Direct observation of a test tray revealed that food items such as rice and peas were served at temperatures below recommended hot holding standards and were bland and unseasoned. The meat was tough and also lacked flavor, while the dessert was palatable. The Dietary Manager acknowledged a recent change in tray plating and service but was not aware of significant complaints about cold food. The Administrator confirmed that food complaints had been recurring and noted changes in food service organization and equipment, but issues with food temperature and accuracy of meal orders persisted as evidenced by resident feedback and council minutes.
Failure to Perform Hand Hygiene During Meal Service
Penalty
Summary
The facility failed to implement an effective infection prevention and control program, as evidenced by multiple instances where staff did not perform hand hygiene between resident interactions during meal service. Certified Nursing Assistants (CNAs) were observed assisting several residents with eating, including putting on clothing protectors, touching utensils, feeding, and wiping mouths, without using hand sanitizer or washing hands between each resident. Additionally, CNAs and other staff members were seen delivering and setting up meal trays for different residents in various rooms without performing hand hygiene between handling trays, touching room surfaces, and interacting with residents. Interviews with the Assistant Director of Nursing and the Director of Nursing confirmed that staff were expected to sanitize their hands between feeding residents and passing meal trays, but this was not observed in practice. The deficiency was identified through direct observation of staff actions during lunch service and was corroborated by staff interviews, indicating a lack of adherence to established infection control protocols designed to prevent the transmission of communicable diseases and infections among residents.
Late Completion of Annual MDS Assessment
Penalty
Summary
The facility failed to complete a comprehensive assessment for a resident at least every 12 months as required. Specifically, one resident, who was admitted with diagnoses including biomechanical lesions of the thoracic region, heart failure, and chronic kidney disease, did not have their annual Minimum Data Set (MDS) assessment completed within the required timeframe. The assessment reference date was set, but the MDS was not completed until over 13 months after the previous annual assessment. During an interview, the MDS coordinator acknowledged the delay, explaining that when behind on assessments, priority was given to current MDSs due, resulting in some assessments being completed late.
Failure to Provide Physician-Ordered Respiratory Care
Penalty
Summary
A deficiency occurred when a resident with a history of osteomyelitis, type 2 diabetes, foot ulcer, and chronic obstructive pulmonary disease was observed using an oxygen concentrator without an active physician's order for oxygen therapy. The resident's care plan indicated oxygen should be administered as ordered by a physician, but the only order found in the medical record was discontinued prior to the current stay. Staff interviews confirmed that there were no current orders for oxygen use or for changing the tubing and humidifier, and the tubing and humidifier on the resident's equipment were not dated. Multiple staff members, including nursing assistants and registered nurses, reported relying on the resident or the oxygen concentrator settings to determine oxygen needs, rather than following a physician's order. Staff also described inconsistent practices regarding the changing of tubing and humidifier water, with changes occurring when equipment appeared dirty or as needed, rather than according to a set schedule or order. The facility did not provide smaller portable oxygen tanks requested by the resident, and management was unaware of the request. The lack of physician orders and standardized procedures for respiratory care led to the deficiency.
Failure to Follow Medication Parameters for Antihypertensive Administration
Penalty
Summary
A deficiency was identified when a resident with multiple diagnoses, including acute idiopathic pericarditis, supraventricular tachycardia, single subsegmental thrombotic pulmonary embolism, chronic kidney disease, and thyrotoxicosis, received metoprolol tartrate outside of the physician-ordered parameters. The medication order specified that metoprolol should be held if the resident's systolic blood pressure (SBP) was less than 100 or if the pulse was less than 50. Despite these parameters, nursing staff administered metoprolol on several occasions when the resident's SBP was documented below 100. Specifically, the medication was given on at least six documented dates when the resident's SBP ranged from 92 to 98, all below the ordered threshold. Interviews with the Assistant Director of Nursing and the Clinical Resource Nurse confirmed that staff were expected to follow medication order parameters, but these expectations were not met in this case, resulting in the administration of an unnecessary drug as defined by regulatory standards.
Expired Insulin Pen Not Discarded After 28 Days
Penalty
Summary
A deficiency was identified when an opened Lantus insulin pen, labeled with an open date exceeding the recommended 28-day usage period, was found in the medication cart for one resident. The insulin pen had been opened for 34 days, which is 6 days past the professional standard for safe use. The insulin was available for use despite being past the acceptable timeframe for administration. Interviews with nursing staff confirmed that insulin should be labeled with the date it is opened and discarded after 28 days. Both LPNs and the Assistant Director of Nursing acknowledged that the insulin should have been disposed of once it reached the 28-day mark, but it remained in the medication cart and was not discarded as required. The resident involved had a medical history including acute diastolic congestive heart failure, paroxysmal atrial fibrillation, and type 2 diabetes mellitus.
Failure to Consistently Apply Physician-Ordered Podus Boots for Pressure Ulcer Prevention
Penalty
Summary
A deficiency was identified when a resident with multiple diagnoses, including dementia, weakness, and impaired mobility, did not consistently receive a physician-ordered intervention to prevent pressure ulcers. The resident had a history of skin breakdown risk and was ordered to have podus boots applied every shift as a preventative measure for a developing area of redness on the left lateral ankle. Despite this order, observations on multiple occasions revealed that the podus boot was not applied to the resident's left foot while the resident was in bed, and the boot was found in the corner of the room instead. Documentation in the Treatment Administration Record indicated the boot was in place, but direct observation contradicted this record. Interviews with the resident, who was cognitively intact, confirmed awareness of the need for the boot and concern that the intervention was not being implemented. Staff interviews revealed that communication about the podus boot order was provided during shift reports and through alerts in the electronic medical record, and that nurses were expected to verify the application of the boots. However, the failure to ensure the podus boot was consistently applied as ordered resulted in the resident not receiving the necessary treatment and services to prevent pressure ulcer development.
Failure to Prevent Accident Hazards and Provide Adequate Supervision
Penalty
Summary
The facility failed to ensure an environment free from accident hazards and did not provide adequate supervision to prevent accidents for a resident with severe cognitive impairment. A resident with dementia, behavioral disturbances, and a BIMS score indicating severe cognitive impairment was found to have tools left in her bathroom while the toilet was unsecured and out of use for several days. Multiple staff interviews confirmed that the bathroom contained tools, an open hole in the floor, and the toilet lying on the ground, while the resident, known for wandering and impulsive behavior, remained in the room. The bathroom was not able to be locked, and the resident was physically able to access the area with these hazards present. Staff and family interviews indicated that the resident's bathroom was blocked off with caution tape, but the resident continued to stay in the room and was taken to the shower room for toileting needs. The maintenance director acknowledged possibly leaving tools in the bathroom and confirmed that the resident could have accessed the area while repairs were ongoing. Staff also reported that the resident was eventually placed on one-to-one supervision due to her confusion and wandering, but at the time of the incident, she was able to enter the hazardous bathroom environment. Additionally, a staff member was observed carrying unsecured oxygen tanks through the hallway, rather than using a dolly as required. Interviews with clinical staff confirmed that oxygen tanks should not be carried by hand due to the risk of dropping them. These actions demonstrate a failure to maintain a safe environment and provide adequate supervision to prevent accidents for residents, particularly those with cognitive impairments.
Nurse Aide Employed Beyond Four Months Without Certification
Penalty
Summary
A nurse aide was employed on a full-time basis for approximately eight months without completing a state-approved training and competency evaluation program, as required for individuals working in such roles for more than four months. Review of the employee record showed the nurse aide was hired on February 9, 2024, but did not receive nurse aide certification until October 8, 2024, indicating a period of employment beyond four months without proper certification. During an interview, the Regional Nurse Consultant was unable to explain why the nurse aide remained employed without certification and suggested there may have been confusion regarding a staffing waiver.
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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