Below average — CMS composite of the measures below.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Meadow Brook Rehabilitation And Nursing during CMS and state inspections, most recent first.
Food service safety deficiencies were observed in the kitchen when the dishmachine wash temperature was below the documented rinse temperature while clean dishes were being removed, uncooked beef sirloins were stored on the same shelf as pizza crust and buttermilk biscuits, and the shelf above the steam table was soiled. A later observation found the trayline shelf soiled again.
The facility did not ensure that three residents with complex medical conditions were offered the COVID-19 vaccine or that their acceptance or refusal was documented. Record reviews and an interview with the DON confirmed the absence of required documentation for these residents.
Dirty wheelchairs, mechanical lifts, and carts were observed throughout the dining room area. A resident's wheelchair was soiled, two residents' wheelchairs were later observed dirty, and sit-to-stand lifts had soiled foot plates and debris. A med cart contained dead bugs, crumbs, and debris, and an emergency cart drawer with a suction machine had dust and debris. Staff interviews showed no clear cleaning schedule for the wheelchairs or lifts.
Missing Laboratory Results in Resident Records: The facility failed to maintain complete lab documentation in residents’ charts. For three residents, ordered labs such as CBC, CMP, BMP, urinalysis, wound culture, CRP, ESR, magnesium, ammonia, valproic acid, and a microalbumin creatinine ratio could not be located in the medical record. The DON and ADON stated the facility used a lab portal/website to access and print results, but the DON later could not locate one resident’s lab results in the record.
Food and drink were not served in a palatable, attractive, and appetizing manner. Several residents reported poor food quality, including cold food, bland taste, poor appearance, and blended meals that were hard to identify. Surveyors also found a test tray with multiple items that were bland, mushy, slimy, dull in color, or served at temperatures that were not appetizing. The RD stated she had not asked residents about food quality.
A resident with cognitive and mobility impairments was left unattended in a mechanical lift for about an hour after a CNA became frustrated, and in a separate incident, was subjected to a staff member raising her voice and making inappropriate comments during toileting assistance. Both incidents were reported, but investigations did not substantiate abuse or neglect, and documentation was incomplete.
Failure to timely report alleged abuse and neglect involving a resident with schizoaffective disorder, extrapyramidal and movement disorder, and dementia. A CNA left the resident unattended in a Hoyer lift after becoming frustrated, and another incident involved a CNA raising her voice during toileting assistance and making demeaning comments. The DON and Administrator stated both events should have been reported within 24 hours, but the reports were delayed.
A resident with poly neuropathy, systolic HF, atrial fibrillation, and CKD left the facility AMA to stay at a women's homeless shelter for help with low-income housing. The MD was notified, the resident signed an AMA form, and family picked up belongings, but the State Long-Term-Care Ombudsman notification was not documented. The Resident Advocate stated she emails the ombudsman for resident discharges but could not find proof that the ombudsman was notified for this discharge.
A resident with malnutrition, adult failure to thrive, dysphagia, and anemia had a 6.83% weight loss in about one month, but the RD missed the significant loss and dietary recommendations were not implemented in a timely manner. During a lunch observation, the resident was seen dropping drinks on the floor and lap, with no drink covers, and needed assistance before being set up for the meal. The RD later documented significant weight loss, decreased PO intake, puree diet, fortified diet, Medpass, and Magic Cup use, while the DON stated the RD did not usually attend weekly skin and weight meetings.
Failure to Obtain Ordered A1c Lab: A resident with diabetes and related diagnoses had a physician order for an A1c, but the lab result could not be located in the record. The DON stated the lab told her the A1c was drawn but not run, and described the facility's process for matching lab orders with portal results and filing them after NP sign-off.
A resident with schizoaffective disorder, movement disorder, diabetes, anxiety, and dementia had an ammonia level, CBC, and magnesium drawn without physician orders. The DON stated that lab draws need to be ordered by the physician and did not know why the resident’s lab values were obtained without orders.
Failure to provide ordered thickened liquids: A resident with dysphagia, dementia, pneumonia, and other diagnoses was ordered honey thick liquids and a modified diet, but surveyors observed coughing during meals and found beverages that were not consistently thickened to the ordered level. Staff gave conflicting accounts of how liquids were thickened, and one dietary aide reported using an amount of thickener that did not match the resident’s ordered consistency. The resident was also observed receiving whole pills despite a swallow evaluation recommending crushed medications in yogurt or applesauce.
A facility failed to monitor oxygen levels for a resident with pneumonia, despite having orders to maintain oxygen saturation above 90%. The resident had multiple diagnoses, including obstructive sleep apnea and pulmonary embolism. The DON could not find the missing oxygen saturation levels, indicating a lapse in the process of recording and maintaining vital information.
The facility failed to maintain a safe environment, resulting in multiple incidents of harm. A resident was injured due to improper wheelchair securement during transport, leading to a cervical spine injury. Additionally, other residents experienced falls, elopements, and injuries due to inadequate supervision and hazard management. The facility's deficiencies were exacerbated by insufficient staff training and documentation practices.
A resident in an LTC facility suffered a neck injury due to improper wheelchair securement during transport, resulting in central cord syndrome. The resident's cervical collar was later removed by CNAs during care, despite orders for it to remain on at all times. The facility failed to provide adequate training for staff on safe transport and medical device management, leading to compromised resident safety.
The facility failed to ensure a safe environment and adequate care for residents, resulting in incidents such as unsecured wheelchair transport leading to injury, multiple falls, unsafe discharges, and elopements. There was also a lack of sufficient nursing staff, failure to respect residents' rights to refuse treatment, inadequate pain management, and insufficient mental health services. These deficiencies were identified at harm levels, indicating significant negative impacts on resident well-being.
A resident with multiple serious health conditions had a signed advance directive indicating a preference for comfort care and a DNR status. Despite this, the resident received CPR after experiencing respiratory distress due to a lack of communication and training for agency staff. The agency nurse, unfamiliar with the facility's procedures, followed the DON's instructions to perform CPR, as the resident's POLST was unsigned.
Two residents experienced inadequate discharge planning, resulting in harm to one and potential harm to another. A resident with cognitive impairments was discharged to a hotel without a care plan and later found wandering, while another resident left on a leave of absence and was not properly oriented for discharge upon return. The facility failed to ensure safe transitions for both residents.
A facility failed to provide adequate incontinence care and skin management for residents, leading to moisture-associated skin damage and prolonged periods in soiled briefs. One resident with multiple diagnoses, including schizophrenia and dementia, reported being left in a soiled brief, resulting in skin irritation. Another resident with Alzheimer's was observed sitting in a soiled brief for nearly an hour, while a third resident with dementia was not repositioned or approached for toileting over a three-hour period.
Two residents experienced inadequate pain management in the facility. One resident with chronic conditions reported severe pain levels, and despite having pain medication orders, the pain was not effectively managed, and the physician was not notified promptly. Another resident with a history of traumatic brain injury also experienced ineffective pain relief, with no documentation of physician notification. The facility's policy for pain management was not followed, leading to a deficiency.
A resident with a history of mental health issues, including suicidal and homicidal ideation, did not receive necessary behavioral health services at the facility. Despite assessments recommending individual counseling and medication review, the facility failed to provide these services, leading to a deficiency cited at a harm level. The resident's care plan lacked adequate monitoring and safety measures, and there was confusion among staff regarding referrals to behavioral health providers.
The facility failed to address and resolve recurring concerns raised by the resident council over 14 months, including issues with staff turnover, dietary problems, and delayed call light responses. Interviews revealed a lack of documentation and follow-up on these concerns, indicating a deficiency in addressing resident grievances.
The facility failed to provide adequate housekeeping and maintenance services, resulting in unsanitary and unsafe conditions for residents. Observations revealed dirty resident areas, a lack of essential supplies, and significant maintenance issues. A resident fell due to a tripping hazard, and there were reports of cold showers and missing personal items. The facility's failure to maintain a clean, safe, and comfortable environment highlights significant deficiencies in care.
The facility failed to prevent abuse and neglect, as evidenced by incidents where residents were physically harmed during altercations. One resident was struck by a can thrown by another, following verbal disputes involving racial slurs. Another resident was cut by a razor during an altercation. The facility's delayed interventions and inconsistent monitoring contributed to these incidents.
The facility failed to implement timely reporting and investigation procedures for resident incidents, including a resident with cognitive impairment not returning from a LOA, another resident eloping by breaking a locked gate, and a third resident not returning after leaving with a friend. Delays in reporting to the SSA and inadequate staff response highlight deficiencies in managing resident safety.
The facility failed to report and investigate multiple incidents of alleged abuse, neglect, and resident safety concerns within the required timeframe. Incidents included verbal abuse towards a resident, a resident sharpening a knife with intent to harm, abuse involving water being thrown on a resident, an unreported fall leading to a resident's death, and delayed reporting of a resident's elopement and another resident's absence. These deficiencies highlight significant lapses in the facility's adherence to reporting protocols and resident safety measures.
The facility failed to thoroughly investigate abuse allegations for three residents, leading to deficiencies in handling potential abuse cases. A resident with cognitive impairment left the facility and was not reported missing promptly. Another resident alleged sexual abuse by a CNA, but the investigation lacked thoroughness and timely reporting. A third resident was involved in an alleged altercation, but the facility did not interview the witness for clarification.
The facility failed to implement PASRR Level II recommendations for mental health services for three residents, leading to a deficiency. One resident with a history of traumatic brain injury and major depressive disorder was not referred for mental health services despite multiple assessments indicating the need. Another resident with intellectual disabilities and major depressive disorder was not referred until months after admission, despite recurring depressive symptoms and behavioral issues. A third resident with hepatic failure and major depressive disorder was also not referred for mental health services until several months after admission.
The facility failed to provide scheduled showers to five residents, impacting their ability to perform activities of daily living. Residents with various health conditions, including cognitive impairments and physical disabilities, reported inconsistencies in receiving showers as per their care plans. Documentation issues and staff turnover contributed to the deficiency, with observations noting poor hygiene among affected residents.
The facility was found to have insufficient nursing staff, leading to delays in essential care such as showers, pain medication, and incontinence care. Residents reported being left alone for extended periods, resulting in falls and severe pain. A nurse left the facility to retrieve keys, leaving residents with inadequate supervision. These incidents highlight significant gaps in the facility's ability to meet resident needs.
The facility employed three NAs for over 120 days without certification, contrary to regulations. NA 2, NA 3, and NA 7 were hired between August and September 2023 and continued to provide care without certification. Interviews revealed that NA 2 was still pursuing certification, while NA 3 had not taken the test but was training others. The facility's policy delayed certification enrollment until 60 days of employment, contributing to this deficiency.
The facility failed to properly manage and monitor psychotropic medications for three residents. One resident did not receive required gradual dose reductions (GDR) for multiple medications, with no physician signature to confirm contraindications. Another resident's medications were not adjusted despite GDR reviews indicating a need. A third resident's sleep patterns were not monitored as ordered due to an entry error in the electronic medical record. These deficiencies highlight lapses in medication management and adherence to monitoring protocols.
A facility failed to store and label medications properly, with two medication fridges not maintaining safe temperatures. One fridge had a block of ice obstructing access to a locked medication box and causing water damage to medications. Some medications lacked resident information or were expired. Staff were unaware of how to address the ice issue or the purpose of certain medications. The facility's policy on proper storage and labeling was not followed.
The facility failed to provide palatable and adequately portioned food to several residents, as evidenced by interviews and resident council minutes. Residents expressed dissatisfaction with the quality, temperature, and variety of the food, with some reporting weight loss and the need to supplement meals with outside food. The resident council minutes consistently highlighted dietary concerns over a 14-month period, including small portions, cold food, and a lack of variety, with inconsistent responses from the facility.
The facility failed to maintain food safety and sanitation standards, with observations of soiled storage areas, improper food handling, and unsanitary meal tray distribution. Kitchen equipment was stored on dirty surfaces, and meal trays were exposed to contamination from a soiled plastic cover. Staff acknowledged the deficiencies, indicating a lack of adherence to cleaning protocols.
The facility failed to maintain an effective infection prevention and control program due to incomplete tracking and trending of infection data for several months. The absence of documentation for June through September 2023 hindered the ability to monitor and control infections, as revealed in interviews with the administrator and DON.
The facility's antibiotic stewardship program lacked complete documentation for infection control tracking and trending from June to September 2023. Interviews with the administrator and DON confirmed the absence of necessary records, hindering effective monitoring and analysis.
The facility was found to have inadequate ventilation, with strong odors in the shower room and a dusty vent in the kitchen's dry storage area. The temporary Corporate Maintenance staff noted algae in the shower room and the absence of caulking around toilets, which could lead to odors. The in-house maintenance team was responsible for vent maintenance.
The facility failed to ensure nursing assistants received adequate training, particularly in dementia management, and did not maintain proper orientation documentation. Inservice training records showed low attendance, and interviews revealed a lack of consistent training. Additionally, newly hired nursing assistants lacked completed orientation checklists, with some not yet certified but training others.
Two residents experienced a lack of dignity and privacy in their care. One resident was exposed during a brief change due to inadequate privacy measures, while another was given a cowbell to summon help when their call light was broken, which they found demeaning. Staff acknowledged these issues, and the DON recognized the dignity concerns raised by the use of cowbells.
A resident with a history of falls and complex medical conditions requested a bed cane to aid in mobility, but the LTC facility failed to provide the device. Despite the resident's cognitive intactness and multiple falls, the facility did not accommodate the request, leading the resident to purchase the device independently. Interviews with staff revealed a lack of communication and follow-through, resulting in the resident not receiving the necessary assistive device.
The facility failed to notify physicians of significant changes in the condition of two residents. One resident experienced severe pain that was not effectively managed, and the physician was not informed. Another resident did not receive prescribed Trulicity injections for two weeks due to pharmacy issues, and the physician was not notified. The facility's policies on reporting significant changes and medication issues were not followed, leading to deficiencies in care.
A resident's care plan was not reviewed by the full interdisciplinary team as required, with nursing staff absent from the meeting. The DON admitted to not attending and acknowledged the lack of a process for ensuring nursing representation. The Resident Advocate confirmed discrepancies in documentation, leading to a deficiency in care plan compliance.
A resident's discharge plan was not properly managed, as the facility failed to submit necessary paperwork for the New Choice Waiver (NCW) program. The resident, who was cognitively intact, wanted to return to the community but was denied due to incomplete application processes. The Resident Advocate, new to the role, was unfamiliar with the NCW process and did not provide timely assistance, leading to the closure of the application.
Two residents with moderate cognitive impairments did not receive adequate activity programming as per their care plans. One resident reported isolation and lacked documented one-on-one activities, while the other had no documented weekly visits. The facility's activity calendar lacked weekend activities, and residents were observed sitting idle, indicating a failure to meet their psychosocial and recreational needs.
A resident with multiple health conditions, including diabetes, did not receive necessary podiatry services or toenail care at the facility. Despite being cognitively intact and requiring assistance with daily activities, the resident's toenails were not trimmed, and no podiatry appointments were scheduled. Staff interviews revealed confusion and inaction regarding the scheduling of podiatry services.
A resident with severe malnutrition and a low BMI did not receive their ordered nutritional supplements for three days due to unavailability. Despite a care plan and physician orders, the facility failed to provide the necessary supplements, impacting the resident's nutritional status. Staff interviews highlighted the importance of these supplements for maintaining the resident's weight and nutritional health.
A resident with a PICC line for IV antibiotics experienced improper IV fluid administration and infection control lapses. The IV fluids were not hung on a pole, preventing proper infusion, and the PICC line lacked antiseptic barrier caps. The resident expressed concerns about infection control, noting inconsistent practices by nursing staff. Interviews with RNs and the DON highlighted discrepancies in infection prevention measures.
A resident with chronic respiratory conditions did not receive appropriate respiratory care due to the facility's failure to have physician's orders or documentation for changing oxygen tubing. Staff interviews revealed inconsistencies in the understanding and execution of tubing changes, and the DON confirmed the absence of a formal policy or documentation process, leading to the deficiency.
The facility failed to provide necessary social services for two residents seeking to transition to community-based settings through the New Choice Waiver (NCW) program. One resident's application was denied due to incomplete paperwork, while another was incorrectly informed of acceptance despite being denied. Both residents had significant medical histories and were cognitively intact, highlighting the facility's failure to manage the NCW application process effectively.
Food Storage, Dishmachine, and Trayline Sanitation Deficiencies
Penalty
Summary
Food was not stored, prepared, distributed, and served in accordance with professional standards for food service safety. During an initial kitchen tour, the dishmachine was observed operating with a wash temperature of 115 to 118 degrees Fahrenheit and a rinse temperature of 120 degrees Fahrenheit while a Dietary Aide removed bowls and dishes and placed them in the clean dish area. The Dietary Manager checked the sanitizer, which measured 50-100 parts per million of chlorine, and stated he was not sure if both wash and rinse temperatures needed to reach 120 degrees. The September 2025 dishwasher temperature log documented rinse temperatures of 120 degrees and sanitizer at 100 parts per million, but there was no column to record wash temperature. The steam table shelf above the food was observed to be soiled, and the Dietary Manager stated the shelf under the trayline was cleaned after each meal service. In the freezer, two boxes of beef sirloins were stored on the same shelf as pizza crust and buttermilk biscuits. The Dietary Manager removed the boxes and stated that uncooked meats should not be stored on the same shelf as pizza crust and buttermilk biscuits. On a later follow-up observation, the trayline shelf was again observed to be soiled.
Failure to Document COVID-19 Vaccine Offer and Refusal
Penalty
Summary
The facility failed to ensure that residents were offered the COVID-19 vaccine and that their acceptance or refusal was properly documented. During interviews and record reviews, it was found that for three out of five sampled residents, there was no documentation indicating whether the COVID-19 vaccine was offered or refused for the year 2024. The residents involved had significant medical conditions, including quadriplegia, protein-calorie malnutrition, anxiety disorder, type 2 diabetes mellitus, morbid obesity, schizoaffective disorder, major depressive disorder, dementia, and adult failure to thrive. The Director of Nursing confirmed that there was no documentation available to show that these residents were offered or refused the vaccine, and stated that a refusal form should be completed if a resident declines vaccination.
Dirty wheelchairs, lifts, and carts observed in dining room
Penalty
Summary
The facility did not maintain a clean, comfortable, and homelike environment because there was no process for cleaning dirty wheelchairs and mechanical lifts. On 9/22/25, resident 11's wheelchair was observed soiled with a white substance, and on 9/29/25, resident 1 and resident 11's wheelchairs were again observed soiled, with resident 11's wheelchair showing a white substance on the side and cushion. During interview, the Administrator stated the lifts and wheelchairs were cleaned regularly and that a cleaning plan was being developed, while CNA 1 stated she was not sure when the lifts were cleaned and did not know of a cleaning schedule for the wheelchairs or mechanical lifts. The dining room also contained equipment that was visibly dirty. A medication cart and emergency cart were observed in the dining room with dead bugs, crumbs, and debris in the side of the medication cart, and dust and debris in a drawer of the emergency cart where a suction machine was stored. Mechanical lifts in the dining room were observed with soiled foot plates and debris, including black substance on the foot plates and dirt at the bottom of one sit-to-stand lift. These observations were made on multiple dates and showed that the carts and lifts were not kept clean.
Missing Laboratory Results in Resident Records
Penalty
Summary
The facility failed to keep complete, dated laboratory records in residents’ clinical records. For 3 of 29 sampled residents, laboratory reports that were completed were not filed in the medical record, and the reports were not available with the required date, laboratory name, and address. Resident 17, who had diagnoses including type 2 diabetes mellitus with hyperglycemia, diabetic chronic kidney disease, iron deficiency anemia, hypomagnesemia, acidosis, hyperkalemia, and diabetic polyneuropathy, had physician orders for a microalbumin creatinine ratio, a urinalysis with culture and sensitivity by PCR for ongoing UTI, and a BMP, but the lab results could not be located in the record. Resident 3, who had diagnoses including a stage 4 sacral pressure ulcer, cellulitis, and dehydration, had physician orders for a wound culture, CBC, CRP, ESR, CMP, and repeat CBC, ESR, and CRP, but the lab results could not be located in the medical record. Resident 15, who had diagnoses including schizoaffective disorder, extrapyramidal and movement disorder, diabetes mellitus, pseudobulbar, generalized anxiety disorder, and dementia, had physician orders for magnesium, urinalysis, CBC, ammonia, BMP, valproic acid, and CMP, but there were no laboratory results in the medical record. During interviews, the DON and ADON stated the facility used a lab portal or website to access results and that staff printed and downloaded results to the residents’ records, but the DON later stated she was unable to locate resident 15’s laboratory results in the medical record.
Food Served Was Not Palatable or Appetizing
Penalty
Summary
Food and drink were not served in a palatable, attractive, and safe and appetizing manner. Four of 29 sampled residents, identified as 2, 5, 13, and 25, complained about the quality of the food. Resident 25 stated the food was bad and that food quality was important. Resident 2 stated kitchen staff needed to check food temperatures because the food was served cold. Resident 13 stated the food tasted good that day but usually ate cereal because the food did not look or taste good. Resident 5 stated his food was usually blended and he did not know what he was served. A test tray obtained by surveyors showed meatloaf at 148.2 degrees with a bland taste and slimy texture, au gratin potatoes at 128.3 degrees with a bland taste and mushy texture, mixed vegetables at 125.0 degrees with dull color and mushy texture, corn bread at 103.2 degrees with an extra grainy texture, and dessert at 75.7 degrees with a bland taste. The Registered Dietitian stated she had done a test tray on 9/18/25 and did not have concerns regarding food quality, and she had not asked residents about food quality.
Resident Left Unattended in Mechanical Lift and Subjected to Verbal Abuse
Penalty
Summary
A resident with schizoaffective disorder, movement disorder, and dementia was left unattended in a mechanical lift for approximately one hour after a CNA became frustrated during a transfer. The resident required dependent assistance with two staff for transfers, as documented in the care plan. The incident was reported to the State Survey Agency, and interviews with staff and the resident's roommate confirmed that the resident was left alone in the lift, causing distress. The CNA involved refused to participate in the investigation and resigned immediately after the incident. There was no documentation of the incident in the resident's medical record, and the facility's investigation did not substantiate the event as abuse or neglect, with the rationale for this decision not fully documented. In a separate incident, the same resident requested toileting assistance and a CNA raised her voice, stating she was only required to provide assistance every two hours and told the resident she was not a child. Another CNA witnessed this event. There was no documentation of this verbal altercation in the resident's medical record. The facility reported the incident to the State Survey Agency, but the investigation did not verify the allegation of verbal abuse, and the reasoning for this decision was not fully documented. Interviews with staff, including the CNA coordinator and DON, confirmed that facility policy required two staff members for mechanical lift transfers and that residents should not be left unattended in lifts. The facility's policy defined abuse and neglect, including verbal and mental abuse, and required staff to recognize and prevent such incidents. Despite these policies, the incidents involving the resident were not substantiated as abuse or neglect in the facility's investigations, and documentation was incomplete.
Failure to Timely Report Alleged Abuse and Neglect
Penalty
Summary
The facility did not ensure that all alleged violations involving abuse or neglect were reported immediately, and not later than 24 hours when the events did not involve abuse. For one sampled resident, Resident 15, who was admitted with diagnoses including schizoaffective disorder, extrapyramidal and movement disorder, and dementia, the facility reported that the resident was left in a Hoyer lift for approximately one hour after a CNA became frustrated with the resident. The facility later reported this event to the State Survey Agency on 9/22/25, while the DON stated she had been notified of the incident on 8/8/25 and that the previous Administrator was the abuse coordinator. The DON stated she did not know why the incident was not reported sooner. The facility also reported a separate event involving Resident 15 in which a CNA raised her voice at the resident during a toileting request, told the resident she was only required to provide toileting assistance every two hours, and said the resident was not a child. Another CNA witnessed the interaction. The facility reported this verbal altercation to the State Survey Agency on 9/2/25. During interviews, the DON stated she was not aware of why the allegation of verbal abuse was not reported within 24 hours, and the Administrator stated the verbal altercation should have been reported within 24 hours.
Failure to Notify Ombudsman of AMA Discharge
Penalty
Summary
The facility did not provide the State Long-Term-Care Ombudsman notification when a resident was discharged from the facility. For 1 of 29 sampled residents, Resident 35 left the facility Against Medical Advice (AMA), and the ombudsman was not notified of the discharge. Resident 35 was admitted with diagnoses including poly neuropathy, systolic heart failure, atrial fibrillation, and chronic kidney disease. A nursing progress note documented that Resident 35 stated she was leaving AMA to go to a women's homeless shelter for a week or so so the shelter's social service worker could help her obtain low-income housing. The resident was educated that the facility could also help with this, but she remained determined to go to the shelter. The medical doctor was notified of the resident's decision, and the resident was sent with scheduled medications and a 14-day supply of PRN medications. Another nursing note documented that the resident's family came to pick up her belongings, and the resident signed an AMA form. During an interview, the Resident Advocate stated she emailed the ombudsman when residents were discharged, but she was unable to find the email showing that the ombudsman was notified of this AMA discharge.
Delayed Response to Significant Weight Loss
Penalty
Summary
Provide enough food and fluids to maintain a resident's health was not met for a resident with unspecified calorie protein malnutrition, adult failure to thrive, dysphagia, and anemia. The resident was admitted and later readmitted to the facility, and on 7/10/25 weighed 137.6 lbs. On 8/13/25, the resident weighed 128.2 lbs, reflecting a 6.83% weight loss in about one month. During a 9/22/25 lunch observation, the resident was seen dropping drinks on the floor and onto his lap, with no covers on the drinks, and was left with his feet up in his Geri chair for five minutes before the Resident Advocate assisted him with lunch. A Nutrition/Dietary note entered on 9/22/25 documented significant weight loss, decreased PO intake, recent downgrade to puree texture, use of fortified diet, Medpass 60 ml BID, and Magic Cup BID, and recommended documenting weight now, changing Medpass to 180 ml QID, and evaluating a PO stimulant. The recommendation was added about a month after the significant weight loss. The RD later stated the significant weight loss on 8/13/25 was missed, and the DON stated the RD did not usually attend the weekly skin and weight meetings and that the resident had been declining and was not doing well. The facility policy required weights to be monitored for undesirable weight loss, with 5% or more loss in one month considered significant and requiring confirmation and notification of the dietitian.
Failure to Obtain Ordered A1c Lab
Penalty
Summary
Provide timely, quality laboratory services/tests to meet the needs of residents was not met when the facility did not obtain a glycated hemoglobin (A1c) lab for Resident 17. Resident 17 was admitted with diagnoses including type 2 diabetes mellitus with hyperglycemia, diabetic chronic kidney disease, and diabetic polyneuropathy. The medical record showed a physician's order on 8/13/25 to obtain an A1c one time only, but the A1c lab could not be located in the record. During an interview on 9/24/25, the DON stated the facility used a lab portal to review results, printed lab orders to match them with completed labs, and said the lab told her they drew the A1c for Resident 17 but did not run it. The DON also stated that lab orders were printed for the next lab day and that once results were in the portal they were printed, placed in the lab book, and uploaded to the resident medical record after NP sign-off.
Lab Tests Obtained Without Physician Orders
Penalty
Summary
The facility did not provide or obtain laboratory services only when ordered by a physician. For one sampled resident, Resident 15, who was admitted and later readmitted with diagnoses including schizoaffective disorder, extrapyramidal and movement disorder, diabetes mellitus, pseudobulbar, generalized anxiety disorder, and dementia, the medical record showed an ammonia level drawn on 7/7/25, a CBC drawn on 7/9/25, and a magnesium and CBC drawn on 9/15/25. There were no physician orders for these laboratory tests. During an interview on 9/29/25, the DON stated that all laboratory draws need to be ordered by the physician and stated she did not know why there were no physician orders for Resident 15’s laboratory values.
Failure to Provide Ordered Thickened Liquids
Penalty
Summary
The facility did not ensure that each resident received food prepared in a form designed to meet individual needs. For one sampled resident with diagnoses including schizoaffective disorder, dementia, pneumonia, and moderate oropharyngeal dysphagia, the record showed orders for thickened liquids and a dysphagia evaluation recommending honey thick liquids with pureed and moist, soft foods. The resident’s care plan also identified the resident as being on a therapeutic diet with altered consistency and thickened liquids, and staff documented that the resident was often adamant about refusing the diet. During a lunch observation, the resident was fed a pink frozen substance identified by a CNA as a magic cup and was coughing after each bite. The resident was also observed with thickened milk and juice that appeared to be nectar consistency, and the resident coughed after drinking the liquids. On a later observation, the resident was again seen coughing while eating and drinking, and a CNA stated the resident needed mildly thickened liquids. The CNA then swirled the cranberry juice and stated it was not thickened. A dietary aide later stated he thickened the resident’s cranberry juice with three scoops of thickening powder into 18 ounces of juice. Additional interviews showed inconsistent understanding and preparation of the ordered liquid consistency. Staff stated that nurses, CNAs, and dietary staff could thicken beverages and that they followed a chart on the thickener container, while the dietary manager stated the resident required honey thick liquids. The assistant dietary manager stated she thickened to a moderate/mild thick consistency and used her best judgment when thickening beverages, and the thickener instructions observed by surveyors indicated a different amount for a moderately thick consistency than what was used for the resident’s cranberry juice. The resident was also observed receiving whole pills despite a dysphagia evaluation recommending medications be crushed in yogurt or applesauce.
Failure to Monitor Oxygen Levels for Resident with Pneumonia
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices. Specifically, the staff did not monitor oxygen levels for a resident who had a diagnosis of pneumonia. The resident was admitted with multiple diagnoses, including obstructive sleep apnea and pulmonary embolism, and had an order for oxygen via nasal cannula as needed, with a goal to maintain oxygen saturation levels above 90%. Despite these orders, the resident's medical record revealed that staff did not record oxygen saturation levels on several dates. The Director of Nursing (DON) explained that the process involved Certified Nursing Assistants (CNAs) checking and recording the resident's vitals on a vital sheet, which was then reviewed by nurses and turned in to the DON. However, the DON could not find the missing oxygen saturation levels for the resident, indicating a lapse in the process of recording and maintaining vital information in the resident's medical record. This deficiency highlights a failure in the facility's system to ensure that all residents receive appropriate monitoring and care as per their medical needs and care plans.
Facility's Failure to Ensure Resident Safety Leads to Multiple Incidents
Penalty
Summary
The facility failed to ensure a safe environment for its residents, resulting in multiple incidents of harm and immediate jeopardy. One significant incident involved a resident who was improperly secured in a wheelchair during transport in the facility van, leading to a fall that caused a hyperextension injury to the cervical spine, resulting in central cord syndrome. The resident's condition was further compromised when CNAs removed the cervical collar during grooming and bathing, which was against the medical order for the collar to be worn at all times. This lack of adherence to safety protocols and inadequate staff training on securing residents during transport and handling medical devices contributed to the resident's injury and subsequent complications. Additionally, the facility experienced several other incidents indicating a failure to maintain a hazard-free environment and provide adequate supervision. These included a resident sustaining a fractured hip after multiple falls, another resident tripping over a broken structural column, and a resident being unsafely discharged and found wandering. There were also instances of residents eloping from the facility, a resident being injured by another resident with a razor, and a resident being hit by a meal cart. These events highlight the facility's systemic issues in identifying and mitigating accident hazards and ensuring resident safety. The facility's deficiencies were compounded by inadequate staff training and oversight. The CNA Coordinator responsible for the transport incident had not received proper training on securing residents in the transport vehicle. Furthermore, the facility's documentation practices were insufficient, as evidenced by the lack of monitoring orders for the cervical collar and incomplete incident reports. These deficiencies underscore the need for comprehensive staff training and robust safety protocols to prevent future incidents and ensure resident well-being.
Removal Plan
- The Director of Nursing/Designee to do an audit of all residents to identify residents with medical devices or fixtures surgically placed, or otherwise applied to, or adjacent to their person. Identified devices reviewed to validate monitoring orders, care planning, and appropriate staff training are in place.
- The Director of Rehab/Designee to complete an assessment of all resident's transfer status, including type of transfer and number of staff to perform safely. Care Plans Reviewed and Updated as indicated to reflect current needs.
- The Director of Nursing/Designee to provide training on safe transfers and accident/hazards prevention to Facility Nurses and Nursing Assistants. Training to include proper transfer techniques utilized in the facility, the prohibition of using towel transfers, and where to find information in the care plan regarding individualized requirements for transfers. This training will be validated by a post-test to validate understanding of the material and Physical Therapist to complete return demonstration of transfer techniques with staff.
- The Director of Nursing to provide training to all Facility Nurses and Nursing Assistants on the definition of a fall and what documentation must be completed when a fall occurs. This training will be validated by a post-test to validate understanding of the material.
- The Administrator reviewed all individuals who perform transport duties and validated they have received training including securement of wheelchairs, securement of ambulatory residents, and securement of equipment in the transport van. A return demonstration checklist will be completed with transportation staff prior to their next transport.
- Any future staff member(s) providing transport services are to receive this training prior to beginning transport duties. Existing drivers to receive refresher training annually and as needed.
- The Chief Nursing Officer (CNO)/designee will provide education to the Inter-disciplinary team (IDT) about company policy on orientation and training to staff who provide direct patient care to residents of the facility and how to properly transfer residents.
- The Director of Nursing/Designee to review employees who have been hired in the past three months to verify orientation training has been completed. Any employee who does not have the orientation completed will meet with the Director of Nursing/Designee prior to the start of their next shift to create a plan to complete their training and review key interventions to keep residents safe.
- The Director of Nursing/Designee to create a summary of this training and put this in the agency binder, to provide agency staff resources to prevent accident/hazards.
- All Staff will receive training by Director of Nursing/Designee prior to their next working shift.
- The Director of Nursing/Designee to do interview with Charge Nurse(s) for each shift and review expectations for accident/hazards prevention and reporting until the IJ abatement is completed.
- The facility to review the 24-hour report in daily stand-up meetings, and as needed to validate that any accidents/hazards were followed up with in accordance with professional accepted standards of care. This audit to continue ongoing.
Inadequate Staff Training Leads to Resident Injury
Penalty
Summary
The deficiency involved a failure to ensure that nursing staff had the appropriate competencies and skill sets to provide safe and effective care for a resident, leading to a series of incidents that compromised the resident's well-being. A resident was transported in a facility van without proper securement of their wheelchair, resulting in the resident falling backward and sustaining a hyperextension injury to the neck. This incident led to a diagnosis of central cord syndrome and edema at the C6 and C7 levels of the cervical spine. The facility's failure to provide adequate training for staff responsible for transporting residents was a significant factor in this incident. Following the transport incident, the resident's care continued to be compromised. Upon returning to the facility, the resident's cervical collar, which was ordered to be worn at all times, was removed by CNAs during grooming and bathing. This removal occurred without proper supervision or understanding of the potential risks, as the CNAs were not adequately trained or informed about the necessity of the cervical collar. The resident was then unsuccessfully transferred to bed, resulting in the resident being assisted to the floor, further indicating a lack of competency in safe transfer techniques among the staff. The report highlights that the facility did not conduct proper orientation and training for newly hired nurse assistants and CNAs, which contributed to the inadequate care provided to the resident. The CNAs involved in the incidents were not properly trained on the use of medical devices such as the cervical collar, nor were they adequately supervised during critical care activities. This lack of training and supervision was a direct cause of the deficiencies observed, leading to the resident's compromised safety and well-being.
Removal Plan
- The Director of Nursing/Designee to do an audit of all residents to identify residents with medical devices or fixtures surgically placed, or otherwise applied to, or adjacent to their person. Identified devices reviewed to validate monitoring orders, care planning, and appropriate staff training are in place.
- The Director of Rehab/Designee to complete an assessment of all resident's transfer status, including type of transfer and number of staff to perform safely. Care Plans Reviewed and Updated as indicated to reflect current needs.
- The Director of Nursing/Designee to provide training on safe transfers and accident/hazards prevention to Facility Nurses and Nursing Assistants. Training to include proper transfer techniques utilized in the facility, the prohibition of using towel transfers, and where to find information in the care plan regarding individualized requirements for transfers. This training will be validated by a post-test to validate understanding of the material and Physical Therapist to complete return demonstration of transfer techniques with staff.
- The Director of Nursing to provide training to all Facility Nurses and Nursing Assistants on the definition of a fall and what documentation must be completed when a fall occurs. This training will be validated by a post-test to validate understanding of the material.
- The Administrator reviewed all individuals who perform transport duties and validated they have received training including securement of wheelchairs, securement of ambulatory residents, and securement of equipment in the transport van. A return demonstration checklist will be completed with transportation staff prior to their next transport.
- Any future staff member(s) providing transport services are to receive this training prior to beginning transport duties. Existing drivers to receive refresher training annually and as needed.
- The Chief Nursing Officer (CNO)/designee will provide education to the Inter-disciplinary team (IDT) about company policy on orientation and training to staff who provide direct patient care to residents of the facility and how to properly transfer residents.
- The Director of Nursing/Designee to review employees who have been hired in the past three months to verify orientation training has been completed. Any employee who does not have the orientation completed will meet with the Director of Nursing/Designee prior to the start of their next shift to create a plan to complete their training and review key interventions to keep residents safe.
- The Director of Nursing/Designee to create a summary of this training and put this in the agency binder, to provide agency staff resources to prevent accident/hazards.
- All Staff will receive training by Director of Nursing/Designee prior to their next working shift.
- The Director of Nursing/Designee to do interview with Charge Nurse(s) for each shift and review expectations for accident/hazards prevention and reporting until the IJ abatement is completed.
- The facility to review the 24-hour report in daily stand-up meetings, and as needed to validate that any accidents/hazards were followed up with in accordance with professional accepted standards of care. This audit to continue ongoing.
Multiple Deficiencies in Resident Safety and Care
Penalty
Summary
The facility failed to establish and implement written policies and procedures for feedback, data collection systems, and monitoring, including adverse event monitoring. This resulted in multiple areas of immediate jeopardy and harm identified during the recertification survey. Specifically, the facility did not ensure a safe environment for residents, leading to incidents such as a resident falling in a facility van due to an unsecured wheelchair, resulting in central cord syndrome and cervical spine edema. Additionally, residents experienced multiple falls, unsafe discharges, and elopements, with one resident being struck by another with a razor. The facility also lacked sufficient nursing staff with appropriate competencies and skill sets, which contributed to the unsafe transport of a resident and improper handling of a cervical collar. Furthermore, the facility failed to respect a resident's right to refuse medical treatment, as one resident received treatment against their documented wishes. There were also deficiencies in preparing residents for safe and orderly transfers or discharges, with one resident being discharged to a hotel room and subsequently becoming lost. Other deficiencies included the failure to incorporate PASRR level II recommendations for mental health services into resident care plans, inadequate treatment for residents with incontinence leading to urinary tract infections, and insufficient pain management for residents requiring such services. Additionally, a resident with suicidal and homicidal ideations did not receive the necessary behavioral health care services. These deficiencies were identified at harm levels, indicating significant negative impacts on resident well-being.
Failure to Honor Resident's Advance Directive
Penalty
Summary
The facility failed to honor a resident's advance directive, resulting in a deficiency. Resident 39, who had multiple serious health conditions, had a Utah Advance Health Care Directive indicating a preference for comfort care only and a Do Not Resuscitate (DNR) status. Despite this, the resident received CPR after experiencing respiratory distress and a drop in oxygen saturation. The Director of Nursing (DON) instructed staff to perform CPR because the resident's POLST was unsigned, although the resident had verbally expressed a DNR preference and had a signed advance directive on file. The incident occurred partly due to a lack of communication and training for agency staff. The agency nurse on duty was unfamiliar with the facility's procedures and the location of the advance directives, as he had only worked there twice. The Previous Director of Nursing (PDON) acknowledged that the nurse going off shift should have oriented the incoming agency nurse about where to find resident information. This oversight led to the failure to respect the resident's documented wishes, as the agency nurse relied on the PDON's instructions rather than the existing advance directive.
Inadequate Discharge Planning Leads to Harm and Potential Harm
Penalty
Summary
The facility failed to provide and document adequate preparation for the safe transfer or discharge of two residents, resulting in harm to one and potential harm to another. Resident 94, who had a history of cognitive impairments including Wernicke's encephalopathy, dementia, and traumatic brain injury, was discharged to a hotel room without a proper discharge care plan. This resident was later found wandering and confused, leading to an emergency room visit where it was determined that he lacked the capacity to make decisions about his living situation. Despite multiple assessments indicating his need for a structured environment, the facility discharged him based on a physician's opinion that conflicted with previous evaluations. Resident 94's medical records and assessments highlighted his moderate cognitive impairment, elopement risk, and need for assistance with activities of daily living. Despite these documented needs, the facility did not create a discharge plan or ensure a safe transition, resulting in the resident being found in a vulnerable state. The previous administrator acknowledged the resident's cognitive impairment but relied on a physician's assessment that the resident could make his own decisions, leading to the inappropriate discharge. Resident 97, who also had moderate cognitive impairment, left the facility on a leave of absence to look at apartments but did not return as expected. The facility did not report him missing until several days later, and when he returned, he was not appropriately oriented for discharge. The facility's handling of Resident 97's leave of absence and subsequent discharge was inadequate, as they failed to ensure his safe return and did not conduct a thorough investigation into his absence. The previous administrator admitted to discharging the resident without proper orientation or investigation, citing the resident's substance use issues as a factor.
Inadequate Incontinence Care and Skin Management
Penalty
Summary
The facility failed to provide appropriate care for residents who were incontinent of bowel and bladder, leading to moisture-associated skin damage (MASD) and inadequate toileting services. Resident 6, who had multiple diagnoses including schizophrenia, diabetes, and dementia, reported being left in a soiled brief for extended periods, resulting in erythematous skin with red dots. Observations confirmed that Resident 6's skin was irritated, and the care plan included interventions such as frequent brief changes and the application of barrier ointment. However, the staff did not consistently adhere to these interventions, as evidenced by the resident's complaints and the presence of MASD. Resident 17, diagnosed with Alzheimer's disease and dementia, was observed sitting in a soiled brief for nearly an hour in the dining room. Despite the strong smell of feces, it took staff almost an hour to assist the resident with changing. The care plan for Resident 17 required frequent checks and changes, but the electronic medical record indicated that toileting assistance was provided only one to three times a day, which was insufficient given the resident's needs. Resident 28, with diagnoses including dementia and muscle weakness, was observed for three hours without being repositioned or approached for toileting. The care plan highlighted the risk of skin breakdown due to incontinence and impaired mobility, yet staff failed to provide necessary assistance during the observation period. This lack of attention to the residents' toileting needs and skin care contributed to the deficiencies identified in the facility's care practices.
Inadequate Pain Management for Residents
Penalty
Summary
The facility failed to provide adequate pain management for two residents, resulting in a deficiency. Resident 90, who was admitted with multiple diagnoses including cellulitis, chronic venous hypertension, and chronic ulcers, reported severe pain levels consistently at 10 out of 10. Despite having orders for Oxycodone and Acetaminophen, the resident's pain was not effectively managed, and the physician was not notified in a timely manner. Observations revealed that Resident 90 did not receive pain medication prior to wound care, as outlined in the care plan, leading to significant distress during the procedure. Resident 29, with a history of traumatic brain injury and other chronic conditions, also experienced ineffective pain management. The resident reported severe pain levels, and despite receiving Oxycodone, the pain relief was documented as ineffective. There was no documentation indicating that the physician was notified of the ineffective pain control, and no additional pain management interventions were provided. The facility's policy required staff to evaluate and document the effectiveness of pain interventions and notify the physician if pain was not controlled, which was not adhered to in this case. Interviews with staff, including the Director of Nursing, confirmed that the facility's expectations for pain management were not met. The DON stated that uncontrolled pain should prompt immediate notification to the physician, which did not occur for either resident. The failure to administer pain medication prior to painful procedures and the lack of timely physician notification contributed to the deficiency in pain management for these residents.
Failure to Provide Necessary Behavioral Health Services
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to a resident with a history of mental health issues, including suicidal ideation, suicidal attempts, and homicidal ideation. The resident, who had a traumatic brain injury and multiple psychiatric diagnoses, was assessed as requiring mental health services, including individual counseling and a review of psychotropic medications. Despite these assessments and recommendations, the facility did not ensure that these services were provided, leading to a deficiency cited at a harm level. The resident had a history of depression and anxiety dating back to childhood, with multiple hospitalizations for mental health issues and suicide attempts. The resident expressed suicidal thoughts and had a plan to harm another resident, which was not adequately addressed by the facility. The facility's documentation revealed gaps in monitoring and providing mental health services, as well as a lack of investigation into incidents involving the resident's suicidal and homicidal ideations. Interviews with facility staff indicated a lack of clarity and coordination in providing mental health services. The facility had been without a social service worker for a period, and there was confusion about referrals to behavioral health providers. The resident's care plan did not adequately address the need for increased supervision and monitoring for suicidal ideation, and there was no documentation of safety measures to prevent access to sharp objects. These deficiencies contributed to the facility's failure to provide the necessary behavioral health care and services to the resident.
Failure to Address Resident Council Concerns
Penalty
Summary
The facility failed to promptly address and resolve grievances and recommendations made by the resident council concerning issues of resident care and life in the facility. Over a period of approximately 14 months, recurring concerns were raised by the resident council without follow-up or resolution. These concerns included issues with the parking lot being dangerous, high turnover of agency staff affecting care, dietary issues such as small portions and cold food, and call lights not being answered promptly. Residents also reported problems with laundry, such as missing clothes, and housekeeping issues, including unclean floors and the presence of cockroaches. Additionally, there were complaints about the lack of timely assistance from nurses and CNAs, with some residents feeling neglected and not receiving the care they needed. The facility was unable to demonstrate their response and rationale for these resident concerns, as there was no documentation indicating the facility's response to the resident council concerns for several months. Interviews with facility staff revealed that prior to October 2023, there were no response forms being completed by facility staff in regard to concerns voiced at resident council meetings. The facility's Administrator acknowledged that recurring issues raised in resident council meetings had not been incorporated into the facility's Quality Assurance program. This lack of documentation and follow-up on resident council concerns indicates a deficiency in the facility's ability to address and resolve resident grievances effectively.
Facility Fails to Maintain Sanitary and Safe Environment
Penalty
Summary
The facility failed to provide adequate housekeeping and maintenance services, resulting in unsanitary and unsafe conditions for residents. Observations revealed that resident areas were dirty, with issues such as filthy dining room tables, bad odors, and a sewer smell from the drinking fountain. Residents reported running out of essential supplies like toilet paper, and there were significant maintenance issues, including a gap in a heating unit that allowed cold air and spiders to enter a resident's room. The facility lacked a full-time maintenance worker, and the absence of weekend housekeeping staff led to unclean conditions, particularly in shared restrooms and the communal shower room, which had mold, soiled items, and non-functional toilets. The facility also failed to maintain a safe environment, as evidenced by a resident's fall caused by a loose metal base from a gazebo column. This incident resulted in a laceration requiring stitches. The resident had a history of falls and cognitive impairment, which necessitated supervision and safety awareness training. However, the facility did not adequately address the tripping hazard posed by the loose metal base, which was in a high-traffic area. Interviews with staff revealed that the maintenance issues were known but not promptly addressed, contributing to the unsafe conditions. Additionally, the facility did not ensure the availability of hot water for residents, with reports of cold showers and sinks lacking warm water. The water temperature in various locations was found to be below acceptable levels, and the facility's water heater settings were not sufficient to provide consistent hot water. Furthermore, there were issues with missing personal items for residents, with inadequate documentation and follow-up on reported grievances. The facility's failure to maintain a clean, safe, and comfortable environment, along with inadequate response to maintenance and personal property concerns, highlights significant deficiencies in the care provided to residents.
Failure to Prevent Resident-to-Resident Abuse and Neglect
Penalty
Summary
The facility failed to protect residents from abuse and neglect, as evidenced by multiple incidents involving resident-to-resident altercations. One incident involved a resident with a history of traumatic subdural hemorrhage and moderate cognitive impairment, who was struck in the leg by a can of food thrown by another resident. This altercation followed a series of verbal disputes, including racial slurs and accusations of physical assault, which were not adequately addressed by the facility. Despite the facility's awareness of these ongoing conflicts, interventions such as room changes were delayed, contributing to the escalation of the situation. Another incident involved a resident with severe cognitive impairment who was cut on the hand during an altercation with another resident. The cognitively intact resident involved in the altercation was found to have used a razor to scratch the other resident. The facility's investigation confirmed the physical abuse, yet there was a lack of immediate and effective measures to prevent access to sharp objects or to monitor the resident's behavior closely. The facility's failure to implement timely interventions and restrictions allowed the situation to escalate to physical harm. The facility's policies on abuse prevention and reporting were not effectively implemented, as evidenced by staff interviews indicating a lack of awareness and communication regarding resident behaviors and restrictions. Staff members reported inconsistent practices in documenting and reporting incidents, with some incidents not being escalated to the Director of Nursing unless deemed significant. This lack of consistent monitoring and communication contributed to the facility's inability to prevent and address abuse and neglect effectively.
Failure to Report and Investigate Resident Incidents Timely
Penalty
Summary
The facility failed to implement policies and procedures to ensure timely reporting and investigation of allegations of neglect and abuse for several residents. For instance, Resident 38, who had a history of cognitive impairment and was known to leave the facility for extended periods, did not return from a Leave of Absence (LOA) as expected. The facility delayed reporting this incident to the State Survey Agency (SSA), and the staff did not follow the protocol of notifying the Director of Nursing (DON) immediately when the resident did not return. This lack of timely communication and reporting highlights a deficiency in the facility's handling of resident safety and accountability. Another incident involved Resident 94, who eloped from the facility by breaking through a locked gate. Although the staff attempted to locate the resident and involved the police, the facility failed to submit the required follow-up report to the SSA within the mandated timeframe. This delay in reporting and the lack of immediate staff training on elopement prevention after the incident further demonstrate the facility's inadequate response to critical safety issues. Additionally, Resident 97 left the facility with a friend and did not return as expected. The facility delayed reporting the resident as missing and did not conduct a thorough investigation into the incident. The staff's assumption that the resident would return on his own, despite his history of substance abuse and extended absences, reflects a failure to adhere to proper procedures for resident monitoring and safety. These incidents collectively indicate systemic issues in the facility's ability to manage and report resident safety concerns effectively.
Failure to Report and Investigate Alleged Abuse and Neglect
Penalty
Summary
The facility failed to report alleged violations involving abuse, neglect, exploitation, injuries of unknown source, and misappropriation of resident property to the State Survey Agency (SSA), Adult Protective Services (APS), and law enforcement within the required two-hour timeframe. For instance, Resident 4 experienced two separate allegations of verbal abuse by staff, which were not reported to the SSA and APS within the mandated timeframe. Additionally, Resident 29 was involved in an incident where he sharpened a butter knife with the intent to harm another resident, yet this incident was not documented or reported to the SSA or APS. Another deficiency involved Resident 92, who was subjected to abuse by fellow residents 7 and 29, who threw water on him to quiet him down after he fell and broke his hip. This incident was witnessed by the Certified Nurse Assistant Coordinator (CNAC) but was not reported or documented as required. Similarly, Resident 96 experienced a fall during transportation, which was not investigated or reported, and subsequently passed away unexpectedly. The facility also failed to report the elopement of Resident 94 in a timely manner, with the required form being submitted approximately two months after the incident. Furthermore, Resident 97 left the facility on a leave of absence and did not return as expected. The facility delayed reporting the resident as missing and did not conduct a thorough investigation, as only one staff member was interviewed. The facility's failure to adhere to reporting protocols and conduct timely investigations into these incidents highlights significant deficiencies in their handling of abuse, neglect, and resident safety concerns.
Inadequate Investigation of Abuse Allegations
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse for three residents, leading to deficiencies in handling potential abuse cases. Resident 97, who had moderate cognitive impairment, left the facility with a friend and did not return as expected. The facility delayed reporting the resident as missing and did not conduct a comprehensive investigation, as only one staff member was interviewed. The previous administrator admitted to not reporting the resident missing sooner and failing to orient the resident for discharge upon their return. Resident 16, with a history of abuse and suicidal ideation, alleged sexual abuse by a male CNA. The facility's investigation was inadequate, as there was no documentation of interviews with all relevant staff, and the accused CNA was not interviewed by the administrator. The investigation findings were inconclusive, and there was no detailed assessment to rule out rape or trauma. The facility failed to report the incident to the State Survey Agency in a timely manner. Resident 33, with moderate cognitive impairment, was involved in an alleged physical altercation with another resident. The facility's investigation lacked thoroughness, as the CNA who witnessed the incident was not interviewed for clarification. The facility concluded that the contact was accidental based on the resident's statement, but failed to substantiate the findings with witness testimony. The administrator acknowledged the need for more clarification from the witness statement.
Failure to Implement PASRR Recommendations for Mental Health Services
Penalty
Summary
The facility failed to incorporate the recommendations from the Pre-Admission Screening and Resident Review (PASRR) Level II determination into the resident assessment, care planning, and transitions of care for three residents. These residents had PASRR Level II recommendations for mental health services, which were not provided. Resident 29, with a history of traumatic brain injury, major depressive disorder, and anxiety, was not referred to mental health services despite multiple assessments indicating the need for individual counseling and psychotropic medication review. The facility lacked documentation of any referrals made for Resident 29, and interviews revealed confusion and delays in coordinating mental health services due to staff changes and the transition to a new behavioral health provider. Resident 34, diagnosed with intellectual disabilities and major depressive disorder, also did not receive the recommended mental health services. Despite a history of recurring depressive symptoms and behavioral issues, including suicidal ideation and aggression, Resident 34 was not referred to mental health services until February 2024. The facility's failure to act on the PASRR recommendations and the resident's care plan interventions contributed to the deficiency. Similarly, Resident 21, with diagnoses including hepatic failure and major depressive disorder, was not referred for mental health services until January 2024, despite being admitted in May 2023. The PASRR Level II evaluation and care plans indicated the need for mental health services, but there was no evidence of referrals being made until several months later. The facility's inaction in coordinating and documenting the necessary mental health services for these residents led to the identified deficiency.
Deficiency in Scheduled Shower Provision for Residents
Penalty
Summary
The facility failed to provide appropriate treatment and services to maintain or improve the ability of five residents to carry out activities of daily living, specifically in the provision of scheduled showers. Resident 7, who required substantial assistance due to multiple health conditions, reported inconsistencies in receiving scheduled showers. Despite having a care plan that required assistance from two staff members due to behavioral issues, documentation showed a lack of showers over a 30-day period, and staff interviews confirmed difficulties in completing shower schedules due to staff turnover. Resident 31, with a history of hemiplegia and other health issues, also experienced inconsistencies in receiving scheduled showers. Although her care plan required supervision and assistance, documentation indicated she received only two showers in December and January, despite a schedule of twice-weekly showers. Interviews with staff revealed issues with documentation and adherence to the shower schedule, with the CNAC acknowledging the lack of proper record-keeping. Similarly, Resident 34, who required assistance for showers, reported not receiving daily showers as preferred and had only one documented shower in the previous 30 days. Observations noted an odor of stale urine, indicating poor hygiene. Resident 28, with dementia and other health issues, also lacked documented showers in the past 30 days, and Resident 8, who desired more frequent showers, was observed with greasy and matted hair, indicating missed scheduled showers. The facility's failure to adhere to shower schedules and properly document care contributed to the deficiency in maintaining residents' abilities to perform activities of daily living.
Staffing Deficiencies and Delayed Care in LTC Facility
Penalty
Summary
The facility was found to have insufficient nursing staff with the necessary competencies and skills to ensure resident safety and well-being. Multiple residents expressed concerns about the staffing levels, which led to delays in providing essential care such as showers, pain medication, and incontinence care. One resident reported being left alone in the shower for an extended period, resulting in a fall and an embarrassing incident. Another resident mentioned the facility's reliance on agency staff due to understaffing, which affected the quality of care. The report highlights specific incidents where residents did not receive timely care. For instance, a resident with severe pain due to multiple health conditions, including cellulitis and chronic ulcers, did not receive pain medication promptly, leading to prolonged periods of severe pain. The resident's care plan required pain management before wound care, but this was not consistently followed, resulting in the resident experiencing significant pain during wound care procedures. The Director of Nursing acknowledged the issue, stating that the nurses were busy and could not administer pain medication in a timely manner. Additionally, the report details an incident where a nurse left the facility to retrieve keys to the medication cart, leaving residents with only one aide for an extended period. This incident further underscores the staffing issues and the lack of proper protocols to handle such situations. The Director of Nursing admitted that the nurse should not have left the facility and that there should have been a spare key available. These deficiencies in staffing and care delivery highlight significant gaps in the facility's ability to meet the needs of its residents.
Nurse Aides Worked Beyond 120 Days Without Certification
Penalty
Summary
The facility was found to be using individuals as nurse aides for more than 120 days without ensuring they were certified. Specifically, three Nursing Assistants (NAs) were identified as having worked at the facility beyond the 120-day period without obtaining certification. The review of their files showed that NA 2 was hired on 9/25/23, NA 3 on 9/1/23, and NA 7 on 8/7/23. Despite this, they were scheduled to provide care to residents during the week of 2/4/24 through 2/10/24. Interviews with the NAs revealed that NA 2 was still working on obtaining his certificate, and NA 3 had not yet taken the certification test but was involved in training other NAs and CNAs. The Business Office Manager confirmed that these NAs had been employed for more than 120 days and were not yet certified. The facility's policy, as explained by the Administrator, was to delay enrolling NAs in certification programs until they had been employed for at least 60 days due to high staff turnover. This policy resulted in NAs working beyond the allowed period without certification. The Administrator acknowledged that it was the responsibility of the Certified Nursing Assistant Coordinator to ensure NAs were certified before reaching the 120-day employment mark.
Deficiencies in Psychotropic Medication Management and Monitoring
Penalty
Summary
The deficiency report highlights issues with the administration and monitoring of psychotropic medications for three residents in the facility. Resident 2, who has multiple mental health diagnoses, was not provided with a gradual dose reduction (GDR) for several psychotropic medications, including Aracept, mirtazapine, Ativan, gabapentin, Seroquel, and duloxetine, despite a documented need for such a review. The facility's psychotropic medication monthly review indicated that a GDR was due, but it was marked as clinically contraindicated without a physician's signature to confirm this decision. The Director of Nursing (DON) confirmed that the absence of a physician's signature meant there was no way to verify the physician's involvement in the decision-making process. Resident 31, who has a complex medical history including hemiplegia, diabetes, and major depressive disorder, was prescribed multiple psychotropic medications such as Clonazepam, Escitalopram, and Trazodone. Despite reviews indicating that a GDR was due, no changes were made to these medications. The DON acknowledged that there were no attempts or documentation of contraindications for a GDR for these medications, indicating a lapse in the facility's medication management process. Resident 7, with diagnoses including narcolepsy and major depressive disorder, was prescribed Trazodone for insomnia. However, the facility failed to monitor the resident's sleeping patterns as ordered, due to an error in entering the order into the electronic medical record. The DON admitted that the order for monitoring hours of sleep was not correctly entered, resulting in the nursing staff not documenting the resident's sleep patterns. This oversight highlights a gap in the facility's adherence to physician orders and monitoring protocols.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored and labeled in accordance with accepted professional principles. During an observation, it was found that the temperature in both medication refrigerators was not within a safe range for medication storage. The first fridge had a temperature of 49°F and contained a large block of ice obstructing the door from closing properly. This ice blocked access to a locked medication box and caused water to drip onto medications, including a box of Biscodyl suppositories belonging to a resident. Additionally, a Tresiba flex touch pen was found frozen to the ice block, and a Cathflo Activase package lacked resident information and was expired. The second fridge had a temperature of 27.7°F and contained medications for a resident, including Meropenem and Vancomycin, without proper temperature control. Interviews with nursing staff revealed a lack of knowledge about the medications and how to address the ice issue. RN 2 and RN 3 were unaware of the purpose of Cathflo Activase and how to remove the ice. The Director of Nursing (DON) and Chief Nursing Officer (CNO) were also involved, with the DON contacting the facility pharmacist for guidance. The pharmacist provided information on the safety of some medications but needed to verify others. The facility's policy required drugs to be stored under proper conditions and returned to the pharmacy if improperly labeled or expired, which was not adhered to in this case.
Deficiency in Food Quality and Portion Sizes
Penalty
Summary
The facility failed to provide palatable and adequately portioned food to 10 out of 40 residents, as evidenced by interviews and resident council minutes. Residents expressed dissatisfaction with the quality, temperature, and variety of the food. Specific complaints included food being served cold, repetitive menus, and insufficient portion sizes. Some residents reported having to supplement their meals with outside food or baby food due to inadequate portions. Additionally, residents noted that snacks were limited and lacked variety, often consisting of peanut butter and jelly sandwiches or bologna and cheese sandwiches. The resident council minutes over a 14-month period consistently highlighted dietary concerns, including small portions, cold food, and a lack of variety. Residents also reported issues with the distribution of water and the timeliness of meal service. Despite these ongoing complaints, the facility's responses to the resident council's concerns were inconsistent, with some months lacking a documented response. The Dietary Manager stated that individual complaints were addressed by updating dietary profiles or care plans, but there was no evidence of a comprehensive approach to resolving the widespread issues reported by the residents. Interviews with residents revealed that some had experienced weight loss due to the poor quality and insufficient quantity of food. One resident, who was diabetic, expressed frustration over the lack of healthy food options and the inability to receive extra portions. Another resident mentioned being hospitalized previously due to eating problems and expressed concern about the facility's food quality. The facility's failure to address these dietary concerns adequately resulted in a deficiency in providing palatable and appropriately portioned meals to its residents.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility was found to have deficiencies in food storage, preparation, distribution, and serving practices, which did not meet professional standards for food safety. During a walkthrough of the kitchen, it was observed that hotel pans were stored on visibly soiled shelves, and metal colanders were placed on top of the ice machine. A carafe was stored upside down on a chipped laminate shelf, with a watery pink liquid dripping into the chips, indicating that the storage space could not be fully sanitized. The counter where the coffee machine was stored was stained with coffee, and a window air conditioning unit was blowing cold air across uncovered cake slices. Additionally, a vent in the dry storage area was covered in dust, and crumbs were found on the bottom shelves of refrigerators. Cleaning chemicals were improperly stored in the dry storage area. The meal tray distribution process was also found to be unsanitary. The tray cart used to pass meal trays to residents was covered with a visibly soiled plastic cover, which made contact with uncovered food on the trays. The Dietary Manager acknowledged that the plastic covers should be cleaned after each meal, and shelves storing utensils should be cleaned every other day. Nursing staff confirmed that it was unacceptable for the plastic covering to brush against uncovered food on resident meal trays. These observations and interviews highlight the facility's failure to maintain a clean and sanitary environment for food service, leading to potential physical contamination of resident meals.
Incomplete Infection Control Tracking and Trending
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by incomplete tracking and trending of infection data for several months. Specifically, the facility's infection control tracking and trending log lacked mapping, tracking, trending, or analysis of data for June, July, August, and September of 2023. This deficiency was identified during a review of the facility's infection prevention policy and procedure, which outlined goals such as decreasing infection risk, monitoring infection occurrences, and maintaining compliance with regulations. However, the absence of documentation for the specified months indicated a failure to adhere to these goals. Interviews with the facility's administrator and Director of Nursing revealed that they were unable to locate the infection control information for the missing months, which hindered their ability to track and trend infections effectively. The Director of Nursing acknowledged the difficulty in performing tracking and trending without the necessary documentation. This lack of documentation and analysis compromised the facility's ability to monitor and control infections, as required by their infection prevention and control program.
Incomplete Antibiotic Stewardship Program Documentation
Penalty
Summary
The facility failed to ensure that its antibiotic stewardship program included protocols and a system to monitor antibiotic use. Specifically, the infection control tracking and trending log was incomplete, lacking mapping, tracking, trending, or analysis of data for June, July, August, and September of 2023. This deficiency was identified during a review of the facility's infection control tracking and trending log, which revealed the absence of necessary documentation for these months. Interviews with the facility's administrator and Director of Nursing confirmed the inability to locate the infection control information for the specified months. The Director of Nursing acknowledged that tracking and trending would be challenging without the necessary documentation. The facility's infection prevention policy outlined goals such as decreasing infection risk, monitoring infection occurrences, and maintaining compliance with regulations, but these were not met due to the missing documentation.
Inadequate Ventilation and Maintenance Issues
Penalty
Summary
The facility was found to have inadequate outside ventilation, as evidenced by persistent odors throughout the building. During an observation of the shower room, a strong odor of feces and urine was detected. Additionally, a walkthrough of the facility's kitchen revealed a vent in the dry storage area that was visibly covered in dust, indicating a lack of proper maintenance and potentially restricted airflow. An interview with the Corporate Maintenance (CM) personnel revealed that he was temporary and had been at the facility for only three days. The CM was responsible for overseeing large projects but not day-to-day maintenance tasks. He noted the presence of black material in the main shower room, which he identified as algae rather than mold, and stated it could be removed with cleaning. The CM also mentioned that the absence of caulking around toilets could allow fluids to seep underneath, potentially causing odors. He acknowledged that the in-house maintenance staff was responsible for changing vents and that dusty vents could restrict airflow, reducing their efficiency.
Deficiency in Training and Orientation for Nursing Assistants
Penalty
Summary
The facility failed to ensure that nursing assistants received adequate training to maintain ongoing competence, particularly in dementia management. A review of inservice training records revealed that only a small number of staff members attended the training sessions on various topics, including wandering residents, elopements, infection prevention, and abuse training. Interviews with the facility Administrator and the CNA Coordinator indicated a lack of consistent training, with the CNA Coordinator admitting that no dementia or trauma-informed care training had been provided. Additionally, the facility could not provide documentation of inservices prior to a certain date, highlighting a gap in training records. Furthermore, the facility did not maintain proper orientation documentation for newly hired nursing assistants. A review of employee files for four nursing assistants showed that none had a completed orientation checklist, and some had not even started their certification process. Interviews with the nursing assistants revealed that they had not completed orientation packets, and some were training others without being certified themselves. The facility Administrator acknowledged that orientation checklists were supposed to be completed and returned to the Business Office Manager, but this process was not followed, resulting in incomplete or missing documentation.
Privacy and Dignity Concerns in Resident Care
Penalty
Summary
The facility failed to uphold the dignity and privacy of its residents, as evidenced by two specific incidents involving residents 6 and 26. Resident 6, who has multiple diagnoses including schizophrenia, dementia, and overactive bladder, was observed during a brief change without adequate privacy. The Certified Nursing Assistant (CNA) assisting the resident left the door open and did not fully close the curtain, exposing the resident during the procedure. The CNA acknowledged the importance of privacy but did not close the door due to the resident's preference for it to remain open to avoid overheating. The Director of Nursing (DON) confirmed that privacy should be maintained during such care activities to protect resident dignity. Resident 26, with conditions such as osteomyelitis and diabetes-related foot ulcers, experienced a lack of respect and dignity when their call light was non-functional for two days. Instead of a timely repair, the resident was provided with a cowbell as an alternative means to summon assistance, which made the resident feel demeaned. Staff interviews revealed that cowbells were used as a temporary solution when call lights malfunctioned, despite residents expressing dissatisfaction with this method. The DON acknowledged the residents' concerns about the cowbells and recognized the dignity issues they presented.
Failure to Provide Assistive Device for Resident Mobility
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of a resident who requested a bed cane to aid in mobility. The resident, who was cognitively intact with a BIMS score of 14, had a history of multiple falls and had requested the assistive device after experiencing two falls. Despite the resident's request, the facility did not provide the bed cane, leading the resident to purchase one independently. The resident had a complex medical history, including chronic obstructive pulmonary disease, morbid obesity, and several other conditions that affected his mobility. The resident's care plan included the use of a 1/4 repositioning bar for bed mobility, but the order for a bed rail was not initiated until two months after the care plan was created. The resident experienced several falls, with incident reports documenting injuries and interventions that did not include the provision of the requested bed cane. Interviews with facility staff, including the CNAC, DON, DOT, and ADM, revealed a lack of communication and follow-through regarding the resident's request for a bed cane. The DOT was not consulted for an evaluation, and the ADM did not recall an IDT meeting or evaluation for the device. The ADM acknowledged the resident's purchase of a bed rail but did not reimburse the resident or provide a facility-approved device, citing difficulties with the existing beds. This lack of action and coordination resulted in the resident not receiving the necessary assistive device in a timely manner.
Failure to Notify Physician of Significant Changes in Resident Condition
Penalty
Summary
The facility failed to notify the physician of significant changes in the condition of two residents, leading to deficiencies in care. Resident 29, who had a complex medical history including traumatic brain injury and chronic pain, reported severe pain that was not effectively managed with prescribed Oxycodone. Despite the resident's pain levels remaining high after medication administration, there was no documentation that the physician was notified of the ineffective pain control, nor were additional pain management interventions provided. Interviews with nursing staff and the Director of Nursing (DON) confirmed that the expectation was to notify the physician immediately in cases of unresolved pain, which was not adhered to in this instance. Resident 31, diagnosed with type II diabetes mellitus among other conditions, did not receive the prescribed Trulicity injections for two consecutive weeks due to unavailability from the pharmacy. The facility's records showed that the medication was not administered, and there was no documentation that the physician was informed of this lapse. Interviews revealed that the DON was responsible for handling medication availability issues, but the staff failed to notify the physician or the interim DON about the critical medication shortage, which was necessary to ensure timely intervention. The facility's policies required staff to document and report significant changes in residents' conditions and the effectiveness of interventions, which were not followed in these cases. The lack of communication with the physicians regarding the residents' pain management and medication administration issues resulted in deficiencies in the care provided to these residents.
Deficiency in Interdisciplinary Care Plan Review
Penalty
Summary
The facility failed to ensure that the comprehensive care plan for a resident was prepared and reviewed by the interdisciplinary team (IDT) as required. Specifically, during a quarterly care conference for a resident with multiple complex medical conditions, including mononeuropathy, chronic respiratory failure, and schizoaffective disorder, among others, the nursing staff were not present. The resident reported that only the Resident Advocate, Activities, and therapy staff attended the meeting, contrary to the expectation that the Administrator, Director of Nursing (DON), and Human Resources should also be present. The Director of Nursing admitted to not attending the care conference due to being late and acknowledged that no nursing staff were present in her absence. The DON stated that there was no established process or policy for IDT meetings and that nursing representation was necessary to discuss care and medication. The Resident Advocate confirmed the absence of nursing staff and noted discrepancies in the documentation of attendees, which inaccurately reflected the presence of various departments. This lack of nursing involvement in the care planning process led to a deficiency in the facility's compliance with care plan preparation and review requirements.
Failure to Submit Required Paperwork for Resident's Discharge Plan
Penalty
Summary
The facility failed to ensure that the discharge needs of a resident were identified and addressed, resulting in the absence of a proper discharge plan. The resident, who was cognitively intact, expressed a desire to return to the community through the New Choice Waiver (NCW) program. However, the facility did not submit the necessary paperwork, leading to the resident's application being denied. The resident had requested assistance from the Resident Advocate (RA) to reapply, but the paperwork was not provided in a timely manner. The RA, who had recently started at the facility, was unfamiliar with the NCW application process and had not received adequate guidance on managing these applications. The RA discovered that the resident's application had been closed due to the facility's failure to submit additional requested information. The RA had only recently gained access to the NCW login system, which did not clearly indicate the status of applications. This lack of proper tracking and submission of required documents contributed to the deficiency in meeting the resident's discharge needs.
Failure to Provide Adequate Resident Activities
Penalty
Summary
The facility failed to provide an ongoing program of activities that met the needs and preferences of two residents, as required by their comprehensive assessments and care plans. Resident 21, who has moderate cognitive impairment and a history of mental health issues, reported feeling isolated and not receiving activities. The resident's care plan included goals for participation in leisure activities and social engagement, but there was no documentation of one-on-one activities for several weeks. Additionally, the resident's activity preferences assessment was overdue by 89 days, indicating a lack of timely evaluation of the resident's needs. Resident 22, who also has moderate cognitive impairment and other health issues, had a care plan that required weekly one-on-one visits for social engagement. However, there was no documentation of these visits for several weeks, and the resident declined participation in activities during one documented week. The Activities Director acknowledged the lack of documentation and stated that there was no set schedule for one-on-one visits, which were supposed to occur weekly. The director also mentioned being unable to locate documentation prior to their hire date and cited illness as a reason for missing documentation in one week. The facility's activity calendar for February 2024 showed no scheduled activities on weekends, only listing "at your leisure" options. An observation noted residents sitting idle in the dining room, indicating a lack of engagement. The Activities Director admitted that initial activity assessments should be completed within 24 hours of admission, but there was no reason provided for the delay in assessing new residents' activity preferences. This lack of structured activity programming and documentation highlights the facility's failure to meet the residents' psychosocial and recreational needs as outlined in their care plans.
Failure to Provide Podiatry Services
Penalty
Summary
The facility failed to provide appropriate foot care for a resident, identified as Resident 7, who was admitted with multiple diagnoses including type II diabetes mellitus with polyneuropathy. Despite the resident's cognitive intactness and need for substantial assistance with activities of daily living, the facility did not ensure that his toenails were trimmed or that he received podiatry services. During an interview, Resident 7 expressed that staff refused to cut his toenails, stating that a podiatrist was required, yet he had not seen one since his admission. The facility's records lacked documentation of any podiatry services or foot care provided to Resident 7. Interviews with staff revealed a lack of clarity and action regarding the scheduling of podiatry appointments. A Registered Nurse was unsure of the podiatrist's visitation schedule, and the Resident Advocate admitted to not having scheduled any appointments, despite being responsible for doing so. The Resident Advocate also noted a lack of communication with the previous facility podiatrist, further contributing to the deficiency in care.
Failure to Provide Ordered Nutritional Supplements
Penalty
Summary
The facility failed to ensure that a resident maintained acceptable nutritional status by not providing the ordered supplement for three consecutive days. The resident, who was initially admitted with severe protein-calorie malnutrition, alcoholic cirrhosis, dementia, and other health issues, had a documented weight of 86 pounds and a low BMI. A nutrition care plan was in place, recommending supplements to address the resident's malnutrition and low BMI. Despite these orders, the facility did not provide the required supplements from January 28 to January 30, as documented in the administration notes, which repeatedly stated that the supplements were unavailable. Interviews with facility staff, including a Registered Nurse (RN) and the Director of Nursing (DON), revealed that the resident was frail and required all available nutrition, including supplements, to maintain and build body mass. The RN expressed frustration over the missed doses, noting that the supplements were crucial for residents like this one, who struggled to gain or maintain weight. The DON acknowledged that there was a backorder on the medpass supplement but stated that other supplements should have been available. The Registered Dietician (RD) confirmed that the supplements were intended to help the resident gain weight due to their low BMI, which had shown some improvement with the interventions in place.
Improper IV Therapy Administration and Infection Control Lapses
Penalty
Summary
The facility failed to ensure the safe and appropriate administration of intravenous (IV) therapy for a resident, identified as Resident 26, who was observed with IV fluids improperly placed on a flat surface rather than being hung on a pole. This improper setup prevented the IV fluids from being administered correctly. Additionally, the resident's peripherally inserted central catheter (PICC) line was not covered with alcohol caps, which are essential for infection prevention. The resident expressed frustration over the lack of infection control measures, noting that nurses sometimes handled the PICC line without gloves and did not clean the port properly. Resident 26 was admitted with multiple serious health conditions, including osteomyelitis, generalized muscle weakness, polyneuropathy, type 2 diabetes mellitus with a foot ulcer, and necrotizing fasciitis. The resident required a PICC line for IV antibiotics to treat an infection in the right foot. Observations revealed that the nursing staff did not consistently follow professional standards of practice for IV therapy, as evidenced by the improper handling of the IV fluids and the lack of antiseptic barrier caps on the PICC line ports. Interviews with nursing staff, including RN 3 and RN 2, highlighted inconsistencies in infection control practices. RN 3 acknowledged the need for proper disinfection of the PICC line port and the use of a pole for IV fluid administration, while RN 2 downplayed the necessity of using antiseptic caps, citing studies that questioned their effectiveness. The Director of Nursing (DON) confirmed the oversight regarding the IV fluid placement and emphasized the nurse's responsibility to ensure proper medication administration. A referenced study underscored the importance of antiseptic barrier caps in preventing central line-associated bloodstream infections (CLABSIs).
Deficiency in Respiratory Care Due to Lack of Oxygen Tubing Management
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident who required supplemental oxygen, as there were no physician's orders for changing the resident's oxygen tubing, nor was there documentation of such changes. The resident, who had chronic respiratory conditions and was dependent on supplemental oxygen, was observed using an oxygen concentrator with undated tubing. Despite the presence of orders to monitor oxygen saturation and shortness of breath, there was a lack of specific orders or documentation regarding the maintenance of the oxygen equipment. Interviews with staff revealed inconsistencies in the understanding and execution of oxygen tubing changes. Nursing staff, including a Nursing Assistant, a Certified Nursing Assistant Coordinator, and a Registered Nurse, provided conflicting information about the frequency and responsibility for changing the tubing. The Director of Nursing confirmed that the tubing should be changed weekly, but acknowledged the absence of a formal policy or documentation process for these changes. This lack of clarity and documentation led to the deficiency in providing safe and appropriate respiratory care for the resident.
Failure to Provide Medically-Related Social Services for NCW Program
Penalty
Summary
The facility failed to provide medically-related social services to two residents, preventing them from achieving the highest practicable physical, mental, and psychosocial well-being. Resident 4, who was cognitively intact, expressed a desire to discharge with the New Choice Waiver (NCW) program, but the facility did not submit the necessary paperwork, resulting in a denial. The Resident Advocate (RA) admitted to not knowing the application process and stated that the application was closed due to the facility's failure to submit additional requested information. Resident 31, also cognitively intact, expressed a desire to move to her own place and had signed up for the NCW program. However, the facility did not submit all the required paperwork, and despite progress notes indicating approval, the RA later confirmed that the resident was denied due to not meeting the level of care requirements. The RA was unaware of why the progress notes incorrectly stated that the resident was accepted into the program. Both residents had significant medical histories, including conditions such as diabetes, obesity, and mental health disorders. The facility's failure to properly manage the NCW application process and follow up on required documentation led to the deficiency, impacting the residents' ability to transition to community-based settings as desired.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 140 citations issued within 25 miles in the last 12 months — including the 3 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Salt Lake City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Monument Healthcare South Salt Lake | 0.3 mi | ★★★★★ | 0 | 0 |
| Little Cottonwood Rehabilitation And Nursing | 0.8 mi | ★★★★★ | 5 | 0 |
| St Joseph Villa | 1.1 mi | ★★★★★ | 0 | 0 |
| Millcreek Rehabilitation And Nursing | 1.6 mi | ★★★★★ | 3 | 0 |
| Monument Healthcare Murray Creek | 1.8 mi | ★★★★★ | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.