Maple Ridge Rehabilitation And Nursing
Inspection history, citations, penalties and survey trends for this long-term care facility in Salt Lake City, Utah.
- Location
- 455 South 900 East, Salt Lake City, Utah 84102
- CMS Provider Number
- 46A058
- Inspections on file
- 18
- Latest survey
- June 2, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Maple Ridge Rehabilitation And Nursing during CMS and state inspections, most recent first.
The facility did not employ a full-time clinically qualified dietitian or a certified dietary manager to direct nutrition services. The current DM had not completed required training or certifications and confirmed that the RD was not full-time. The ADM was aware of these deficiencies when the DM was moved into the position after the previous DM resigned.
The facility did not ensure that laboratory results for several residents were filed in their medical records as required. For four residents with complex medical conditions and multiple lab orders, the actual lab reports were missing from their clinical files, despite documentation that labs were ordered and sometimes reviewed. This deficiency was confirmed through record review and staff interviews, revealing a breakdown in the process for uploading lab results.
A resident with multiple complex medical conditions was documented as full code without a completed POLST or Advance Directive in the medical record. Required documentation and processes for determining and recording advance directive preferences were not followed, leaving the resident's code status and treatment wishes unclear.
A resident reported a missing wallet containing identification and Medicaid card and requested assistance from the Resident Advocate, who did not follow up or document the grievance investigation as required by facility policy. No evidence of prompt resolution or investigation was found in the grievance records.
A resident with a history of behavioral issues and multiple medical conditions was prescribed Trazodone and Depakote, but the facility failed to document a rationale for not attempting a gradual dose reduction (GDR) for Trazodone and did not attempt or document a GDR or clinical contraindication for Depakote. Staff interviews confirmed the medications were used for behaviors, but required documentation and rationale were missing.
Two residents were transferred to hospitals without proper documentation in their medical records of what information was sent to the receiving providers. Despite staff stating that they typically notify providers and send necessary paperwork, there was no record of transfer/discharge summaries or details such as practitioner contact, advanced directives, or care plan goals being communicated, resulting in incomplete transitions of care.
A resident with multiple chronic conditions experienced ongoing constipation, with documented periods of up to six days without a bowel movement. Although there were physician orders for Milk of Magnesia to treat constipation, the medication was not administered, and the care plan only addressed urinary elimination, omitting bowel elimination needs. The DON confirmed the care plan did not include interventions for constipation.
A resident with multiple chronic conditions experienced constipation that was not managed according to physician orders and the facility's bowel protocol. Despite documented periods of no bowel movement and standing orders for Milk of Magnesia (MOM) to be administered after three days without a BM, the medication was not given, and there was no documentation of administration, refusal, or follow-up interventions. Staff interviews revealed uncertainty about protocol implementation, and the resident's care plan did not address bowel management.
A resident with a history of heart disease and arthritis reported severe pain and requested more effective pain relief, but staff did not provide pain medication, alternative analgesics, or nonpharmaceutical interventions. Despite physician orders for acetaminophen and topical analgesics, there was no documentation that these were offered or administered, and the resident continued to report pain without relief. Documentation of pain assessments, interventions, and refusals was also lacking.
Surveyors found that an LPN and the DON did not ensure multi-use vials of Humalog and aplisol were properly labeled with open or discard dates. A resident's Humalog vial had an unclear date, and the aplisol vial lacked any labeling, both remaining available for use.
A resident with multiple complex diagnoses had a medication order incorrectly entered into the medical record, with hydroxyurea documented instead of hydroxyzine, and no corresponding diagnosis for sickle cell disease. Hydroxyzine was present in the medication cart, but there was no active order for it in the record. Interviews with an LPN and the DON confirmed that medication orders should be verified, but the error led to incomplete and inaccurate documentation.
A resident with multiple wounds and a PICC line did not have enhanced barrier precautions in place, and staff were unaware of the need for such precautions. During a meal, a plate guard that had fallen to the floor was reused without cleaning, contrary to facility expectations. These lapses resulted in a failure to maintain proper infection prevention and control practices.
A resident with multiple medical conditions experienced two incidents—elopement and an allegation of sexual abuse—where facility documentation failed to include the date APS was notified, despite forms indicating notification occurred. The administrator confirmed no further documentation was available to verify timely reporting.
A resident with severe cognitive impairment and a high risk for elopement was able to leave the facility unsupervised on two occasions due to inadequate supervision and unsecured exit points. Despite orders for a wander guard and frequent monitoring, the resident exited through a gate left open by visitors and, in another instance, through a side gate while the wander guard was attached to a wheelchair. Staff did not consistently check all areas when alarms sounded, and exit points were not always secured, resulting in the resident being found off facility grounds by police.
Failure to Employ Qualified Nutrition Services Director
Penalty
Summary
The facility failed to employ a clinically qualified full-time dietitian or another clinically qualified nutrition professional to serve as the director of nutrition services. During an initial walk-through of the kitchen, the Dietary Manager (DM) stated that he had not completed the required training to serve in his role and had only been working as DM for two months. The DM also confirmed that the Registered Dietitian (RD) did not work at the facility full-time and that he was in the process of obtaining necessary certifications. In a follow-up interview, the DM reiterated that he was scheduled to take his ServSafe test and would soon begin the Certified Dietary Manager course. The Administrator acknowledged awareness that the DM was not certified and had assumed the position after the previous DM resigned.
Failure to Maintain Complete Laboratory Records in Resident Files
Penalty
Summary
The facility failed to maintain complete, dated laboratory records in the clinical records of several residents. For four out of fourteen sampled residents, laboratory results for ordered tests were not filed in their medical records. Specifically, one resident with a history of cerebral infarction, hemiplegia, dysphagia, and hypertension had a physician order for a Prothrombin Time (PT) and International Normalized Ratio (INR) lab draw, but the results were not present in the medical record. The laboratory results were only provided later upon request. The Administrator confirmed that the process required the DON to upload lab results into the medical record within a week, but this was not done for the resident in question. Additional residents were also affected by this deficiency. One resident with respiratory failure, dementia, and muscle weakness had orders for a Vitamin B12, Folate, and Iron panel, but no results were found in the record. Another resident with diabetes, chronic kidney disease, and a history of traumatic amputation had orders for a Basic Metabolic Panel and magnesium level, but again, no results were present. A fourth resident with intracranial injury, diabetes, and mood disorders had multiple lab orders, including a complete blood count and metabolic panels, with no corresponding results in the medical record. In each case, documentation indicated that labs were ordered and sometimes reviewed, but the actual laboratory reports were missing from the residents' clinical records.
Failure to Document Advance Directive and POLST Status
Penalty
Summary
A deficiency occurred when a resident was documented as full code in their medical record without having a completed Physician Orders for Life-Sustaining Treatment (POLST) or Advance Directive on file. The resident, who had multiple significant diagnoses including acute respiratory failure with hypoxia, chest pain, pleural effusion, COPD, asthma, atrial fibrillation, type 2 diabetes with complications, secondary hypertension, and shortness of breath, was admitted and readmitted to the facility. Despite the facility's policy requiring determination and documentation of advance directives upon admission, the resident's medical record lacked both a POLST and an Advance Directive, and the POLST status was left blank in the admission progress note. Interviews with the DON and Administrator confirmed that the required POLST form could not be located in the resident's record. The DON stated that completed POLST forms are to be turned in to her and then given to the Medical Director for signature, with monthly audits by the Resident Advocate. However, for this resident, the process was not completed as required, resulting in the absence of critical documentation regarding the resident's code status and advance directive preferences.
Failure to Promptly Resolve and Document Resident Grievance Regarding Missing Property
Penalty
Summary
A resident with a history of schizophrenia, tremor, stimulant abuse, COPD, peripheral vascular disease, and hypertension reported that his wallet containing identification and Medicaid card was missing. The resident informed the Resident Advocate (RA) and was told assistance would be provided to obtain new identification, but the resident stated that the RA never followed up. Review of the resident's personal inventory confirmed the wallet was previously documented, but the contents were not listed. Progress notes indicated the wallet was reported stolen, and the RA acknowledged the need to replace the wallet and obtain a new ID, but there was no documentation that this was completed. Further review of the facility's grievance binder revealed no record of a grievance or investigation related to the missing wallet and identification cards for this resident. The facility's grievance policy requires prompt efforts to resolve grievances and mandates documentation of the investigation and resolution, but no such evidence was maintained. The RA confirmed that a grievance investigation should have been initiated and documented, but none was found for this incident.
Failure to Document and Attempt Gradual Dose Reduction for Psychotropic Medications
Penalty
Summary
A deficiency was identified when a resident with multiple diagnoses, including cerebral infarction, cognitive communication deficit, hemiplegia, hemiparesis, dysphagia, aphasia, and hypertension, was not provided with appropriate gradual dose reductions (GDR) or behavioral interventions for psychotropic medications as required. The resident had physician orders for Trazodone for insomnia and Divalproex Sodium (Depakote) for increased behaviors. Documentation showed that a clinical contraindication form for GDR of Trazodone was completed, but the section specifying the reason for the contraindication was left blank. There was no documentation of an attempted GDR or a clinical contraindication for the use of Divalproex Sodium. Interviews with staff revealed that the resident exhibited behaviors such as impatience, yelling, and a history of physical and verbal aggression, which were being monitored. The Divalproex was reportedly used for these behaviors, but no GDR attempt or clinical contraindication was documented. The process for GDR and documentation was discussed among staff, but the required rationale for not attempting a GDR, particularly for Divalproex, was not provided in the resident's record.
Failure to Document and Communicate Required Information During Resident Transfers
Penalty
Summary
The facility failed to ensure that the transfer or discharge of two residents was properly documented in their medical records, and that all required information was communicated to the receiving provider. For both residents, there was no documentation of a transfer or discharge summary, nor was there evidence of what information was sent to the receiving provider at the time of transfer. This included missing details such as contact information for the practitioner responsible for the resident's care, resident representative contact information, advanced directive information, special instructions or precautions for ongoing care, comprehensive care plan goals, and other necessary information to ensure a safe and effective transition. One resident with diagnoses including HIV, anxiety disorder, schizophrenia, and hepatitis C was transferred to a hospital after calling 911 due to complaints of brain pain, but the medical record lacked documentation of what information was provided to the hospital. Another resident with multiple complex conditions, including diabetes, chronic kidney disease, traumatic amputation, bipolar disorder, and suicidal ideations, was transferred to the hospital on two occasions due to acute medical changes, but again, the medical record did not contain documentation of a transfer/discharge summary or what information was sent to the receiving provider. Interviews with staff confirmed that while there was a process for notifying providers and sending documentation, it was not consistently documented in the residents' records.
Failure to Address Bowel Elimination in Resident Care Plan
Penalty
Summary
A deficiency was identified when the facility failed to develop and implement a comprehensive, person-centered care plan that addressed all of a resident's needs, specifically regarding bowel elimination. The resident, who had multiple diagnoses including schizophrenia, Parkinsonism, generalized anxiety disorder, obsessive-compulsive disorder, major depressive disorder, congestive heart failure, and peripheral vascular disease, reported experiencing constipation over the previous two months, with extended periods without a bowel movement. Medical records confirmed physician orders for Milk of Magnesia to treat constipation, but the medication was not administered during the month reviewed. Documentation showed the resident went up to six days without a bowel movement on one occasion and three days on another within a 30-day period. The resident's care plan, initially created for ADL self-care performance deficits related to schizophrenia, only addressed urinary elimination and did not include any interventions or monitoring for bowel elimination or constipation. The care plan's toileting focus area had not been updated to reflect the resident's bowel elimination needs, despite evidence of ongoing constipation and physician orders for treatment. The DON confirmed that the care plan only addressed urinary elimination and not bowel elimination.
Failure to Follow Bowel Protocol for Resident with Constipation
Penalty
Summary
A deficiency was identified when a resident with multiple medical diagnoses, including schizophrenia, Parkinsonism, generalized anxiety disorder, obsessive-compulsive disorder, major depressive disorder, congestive heart failure, and peripheral vascular disease, experienced episodes of constipation that were not managed according to the facility's established bowel protocol. The resident reported experiencing constipation over the previous two months and indicated that he had gone extended periods without a bowel movement. Despite having physician orders for Milk of Magnesia (MOM) to be administered as needed for constipation, and a specific order to administer MOM on the third day without a bowel movement, the medication was not given during the month in question, as documented in the Medication Administration Record (MAR). Review of the resident's bowel elimination records showed multiple instances where the resident went three or more days without a bowel movement, including a six-day period and a three-day period. The facility's bowel protocol required staff to initiate treatment with MOM after three days without a bowel movement, followed by additional interventions if the initial treatment was ineffective. However, there was no documentation that the protocol was followed, that MOM was administered or refused, or that subsequent steps were taken as required by the protocol. Interviews with facility staff, including an LPN, a CNA, and the DON, revealed a lack of clarity regarding the location and implementation of the bowel protocol. The DON confirmed that the protocol should have been initiated and that documentation of administration or refusal should have been present in the MAR or nurse progress notes. The resident's care plan also did not address bowel elimination patterns or treatment for constipation, and there was no evidence that the required interventions were provided or documented during the periods of constipation.
Failure to Provide Timely and Appropriate Pain Management
Penalty
Summary
A deficiency was identified when a resident with a history of atherosclerotic heart disease, arthritis, and a childhood neck injury reported significant pain to facility staff. The resident expressed that he was experiencing severe neck and back pain, requested to go to the hospital, and stated that his current pain management regimen of two Tylenol was ineffective. Despite these complaints, the resident was not provided with any pain medication, alternative pain relievers, or nonpharmaceutical pain interventions at the time of his request. Staff responses included relaying the complaint to a nurse, who indicated she would contact the Medical Director, and instructing the resident to rest, but no immediate pain relief measures were implemented. Review of the resident's care plan revealed it was focused on headache pain and included interventions such as medication and rest, anticipating pain relief needs, and documenting pain history and management. The care plan also noted the resident's preference for Tylenol, but did not address his arthritis or neck pain specifically. The resident's recent pain assessment documented frequent pain, with significant interference in sleep and activities, and a high pain score. Orders for acetaminophen and topical analgesics were present, but there was no documentation that these were offered or administered during the pain episode in question, nor was there documentation of refusal. Interviews with the resident confirmed that he had not received any pain relief or intervention following his complaints. The DON stated that the Medical Director was contacted, but the response was delayed by several hours, and there was no evidence of alternative pain management strategies being discussed or implemented. Documentation was lacking regarding pain assessments, interventions offered, and resident refusals, contributing to the failure to provide appropriate pain management as required.
Failure to Properly Label Multi-Use Medication Vials
Penalty
Summary
Surveyors observed that the facility failed to ensure drugs and biologicals were labeled in accordance with accepted professional principles, specifically regarding the inclusion of expiration, open, or discard dates. During an inspection of the medication fridge at the nurses station with an LPN, an open multi-use vial of Humalog was found with a date on the box, but the LPN was unsure if it represented the open or discard date. This vial was available for use and belonged to a resident. Additionally, an open multi-use vial of aplisol was present in the fridge without any open or discard date labeled. The DON confirmed that multi-use vials are typically labeled with an open date and that both Humalog and aplisol are considered good for 30 days after opening, but this practice was not followed for the vials in question.
Incorrect Medication Order Entry and Incomplete Medical Record Documentation
Penalty
Summary
A deficiency was identified when a resident's medication order was incorrectly entered into the medical record. The resident, who had a complex medical history including type 1 diabetes mellitus, generalized anxiety disorder, chronic kidney disease stage 3, traumatic amputation of toes, bipolar disorder, and suicidal ideations, was admitted and readmitted to the facility. During a review of the resident's records, it was found that a physician's order for Hydroxyurea 25 mg by mouth every 12 hours as needed for anti-anxiety was documented, despite no diagnosis of sickle cell disease being present in the resident's record. Additionally, a nursing progress note indicated a verbal order to restart hydroxyzine 25 mg by mouth twice a day and as needed, but there was no active order for hydroxyzine in the medical record. Upon observation, hydroxyzine 25 mg was found in the medication cart for the resident, while hydroxyurea was not present. Interviews with an LPN revealed that medication orders were supposed to be double-checked and verified against the medication card, and the DON confirmed that nurses were expected to verify the correct medication was entered into the medical record. The incorrect entry of the medication order resulted in incomplete and inaccurate documentation in the resident's medical record.
Failure to Implement Enhanced Barrier Precautions and Maintain Infection Control
Penalty
Summary
A deficiency was identified when a resident with multiple wounds and a peripherally inserted central catheter (PICC) line did not have enhanced barrier precautions (EBP) implemented as required. Despite physician orders for wound care and PICC line monitoring, there was no EBP signage or supplies outside the resident's room. Interviews with staff, including a CNA, LPN, and the Director of Nursing, revealed a lack of awareness and implementation of EBP for residents with wounds and indwelling catheters, including PICC lines. Staff reported not using gowns during care and were unsure about the need for EBP in such cases. Additionally, during a meal service, a plate guard that had fallen to the floor was picked up and placed back on the resident's plate by a CNA, without being cleaned or replaced. The CNA was unaware that the plate guard had been on the floor, and the Administrator later confirmed that the expectation was for dropped items to be replaced with clean ones and not reused. These actions demonstrated a failure to maintain proper infection prevention and control practices for the resident.
Failure to Document Timely APS Notification for Abuse and Neglect Allegations
Penalty
Summary
A deficiency was identified when the facility failed to ensure that all alleged violations involving abuse and neglect were reported immediately, but not later than two hours after the allegation was made, to the administrator, State Survey Agency (SSA), and Adult Protective Services (APS). Specifically, for one resident with a history of anoxic brain damage, unspecified convulsions, diabetes mellitus, asthma, hypothyroidism, restless leg syndrome, and dysphagia, the facility's documentation of two separate incidents—an elopement and an allegation of sexual abuse—did not include a documented date that APS was notified. In the first incident, the local police found the resident wandering outside the facility and transported him to a hospital; the facility's form indicated APS was notified, but no date was recorded. In the second incident, the resident reported rectal pain and alleged rape to a nurse, but again, while the form stated APS was notified, no date was documented. The current administrator confirmed that there was no additional documentation available to verify the timing of APS notification for either event.
Failure to Prevent Resident Elopement Due to Inadequate Supervision and Unsecured Exit
Penalty
Summary
A deficiency occurred when a resident with a known history of elopement risk and severe cognitive impairment was not adequately supervised, resulting in two separate elopement incidents. The resident, who had diagnoses including anoxic brain damage, unspecified convulsions, diabetes mellitus, asthma, hypothyroidism, restless leg syndrome, and dysphagia, was assessed as high risk for wandering and elopement. Physician orders and care plans specified the use of a wander guard device, frequent monitoring, and supervision, especially during exit-seeking behaviors. Despite these interventions, the resident was able to leave the facility unsupervised on two occasions. On one occasion, the resident exited through a gate that was left slightly open by visitors who had attended a church service at the facility. The gate, which required a code to enter, was not properly secured after the visitors left. The resident was found by local police wandering on a street near the facility and was transported to a hospital for evaluation. Staff interviews and documentation revealed that the wander guard alarm system was in place, but staff did not check the entire courtyard when the alarm sounded, and the gate was not secured as required. In another incident, the resident was able to leave the facility through the side gate of the courtyard. At the time, the wander guard was attached to the resident's wheelchair rather than his person, as he had previously removed the device from his leg. Documentation indicated that the resident was exit-seeking, and staff were aware of his behaviors, but the supervision and monitoring in place were insufficient to prevent his elopement. These lapses in supervision and failure to secure exit points directly contributed to the resident's ability to leave the facility unsupervised.
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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