Meadow Brook Rehabilitation And Nursing
Inspection history, citations, penalties and survey trends for this long-term care facility in Salt Lake City, Utah.
- Location
- 433 East 2700 South, Salt Lake City, Utah 84115
- CMS Provider Number
- 465158
- Inspections on file
- 18
- Latest survey
- November 20, 2025
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Meadow Brook Rehabilitation And Nursing during CMS and state inspections, most recent first.
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.
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.
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.
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.
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 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.
A resident with a history of low blood pressure was administered oxycodone without the required blood pressure checks prior to administration, as ordered by the physician. The facility's charting system failed to alert nurses due to missing supplementary documentation, leading to 16 instances where the medication was given without proper monitoring.
A resident with type II diabetes mellitus did not receive their prescribed Trulicity medication for two consecutive weeks due to pharmacy delays. The facility's staff failed to notify the physician about the unavailability of the medication, and the Director of Nursing indicated that staff should have informed her and the Medical Director immediately about such critical issues.
A facility failed to obtain necessary lab tests for a resident with multiple health conditions, despite physician orders for HbA1c, GFR, and BMP tests. The DON confirmed the absence of lab results after reviewing medical records and contacting the lab.
The facility's dishwashing machine malfunctioned, causing water to spill onto the floor during cycles. Despite monthly servicing by Ecolab and maintenance efforts, the issue persisted. The Dietary Manager and Registered Dietitian were aware of the problem, which was due to the drain not keeping up with the dishwasher's output. Custodial staff had to mop up the spills, and there was no maintenance staff present at the facility.
The facility failed to maintain a functioning call system for two residents, leading to ineffective communication with staff. One resident's call light was non-functional for two days, while another did not use the call light and sought help in the hallway. Temporary fixes, such as cowbells, were provided but were not well-received by residents. Maintenance issues were not promptly addressed due to unclear responsibilities and communication lapses among staff.
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.
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 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.
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.
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.
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.
Failure to Monitor Blood Pressure Before Administering Pain Medication
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary drugs, specifically by not monitoring the resident's blood pressure before administering pain medication as ordered by the physician. Resident 16, who had multiple diagnoses including type 2 diabetes mellitus, stage 4 pressure ulcers, generalized anxiety disorder, and a history of low blood pressure, was prescribed oxycodone with a specific instruction to check blood pressure prior to administration. However, the Medication Administration Record (MAR) revealed that the resident received oxycodone 19 times over a seven-day period, with blood pressure being checked only three times within an hour before administration. Interviews with the nursing staff, including a Registered Nurse (RN) and the Director of Nursing (DON), indicated that the facility's charting system was supposed to alert staff when a vital check was required before medication administration. Despite this, the system did not prompt the nurses to check the resident's blood pressure due to a lack of supplementary documentation with the medication order. The DON acknowledged that the absence of such documentation meant the nurses were not aware of the need to check the resident's blood pressure, which was crucial to prevent potential adverse effects like hypotension and dizziness.
Medication Error Due to Pharmacy Delay
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically regarding the administration of Trulicity for a resident with type II diabetes mellitus. The resident, who had multiple diagnoses including hemiplegia, hemiparesis, and dementia, was admitted with an order for Trulicity to be administered weekly. However, the medication was not administered on two consecutive weeks due to unavailability from the pharmacy. There was no documentation indicating that the physician was notified about the missed doses. Interviews with RN 2 and the Director of Nursing (DON) revealed that the facility was experiencing delays with a new pharmacy, which affected medication availability. RN 2 stated that the DON was responsible for handling pharmacy issues and notifying the physician if a medication was unavailable. The DON confirmed that staff should have notified her and the Medical Director immediately about the unavailability of critical medications like insulin, and documented the notification in a progress note. The facility did not have Trulicity available in their Pixus overstock, which contributed to the medication error.
Failure to Obtain Ordered Laboratory Tests
Penalty
Summary
The facility failed to provide or obtain necessary laboratory services for a resident, identified as Resident 31, who was admitted with multiple diagnoses including hemiplegia, type II diabetes mellitus, and hypertension. On two separate occasions, 1/19/24 and 2/1/24, the resident's physician ordered specific laboratory tests, including Hemoglobin A1c (HbA1c), Glomerular Filtration Rate (GFR), and a Basic Metabolic Panel (BMP). However, a review of the resident's laboratory results showed no documentation of these tests being conducted. The Director of Nursing confirmed the absence of lab results after checking the medical records and contacting the laboratory, indicating a failure to meet the resident's laboratory needs as ordered by the physician.
Dishwasher Malfunction Leads to Water Spillage
Penalty
Summary
The facility failed to maintain its mechanical dishwashing machine in safe operating condition, resulting in water spilling onto the floor during dishwashing cycles. The Dietary Manager confirmed that the dish machine was serviced monthly by Ecolab, yet the issue persisted. Observations and interviews revealed that the water overflow was not normal, and custodial staff had to mop up the spills due to the absence of maintenance staff. The Registered Dietitian noted that both the Dietary Manager and maintenance were aware of the problem, which was attributed to the drain not keeping up with the dishwasher's output. Despite maintenance efforts, including snaking the drain and external plumbing services in January 2024, the issue remained unresolved.
Deficient Call System in Resident Rooms
Penalty
Summary
The facility failed to provide a functioning call system for two residents, identified as 26 and 30, which compromised their ability to communicate with staff effectively. Resident 26 reported that their call light had not been working for two days, causing confusion among staff about when assistance was needed. Resident 30, on the other hand, did not use the call light and instead sought help by going into the hallway. The maintenance log indicated that there was a known issue with the call light in their rooms, but it had not been addressed promptly. Interviews with staff revealed a lack of clear responsibility and communication regarding maintenance issues. The Corporate Maintenance staff, who was temporary, did not regularly check the maintenance log and relied on the administrator to inform them of necessary repairs. Nursing staff attempted temporary fixes, such as replacing cords or providing cowbells as an alternative, but these measures were not effective or well-received by residents. The Director of Nursing acknowledged that the use of cowbells was a dignity issue and that residents had expressed dissatisfaction with this temporary solution.
Latest citations in Utah
A resident with Parkinson’s Disease was being transferred from bed to a chair using a mechanical (Hoyer) lift operated by two CNAs when a sling strap snapped, causing the resident to fall and strike the back of the head. The resident sustained an abrasion, a 1 cm scalp laceration with bleeding, and severe back pain rated 9/10, and was sent to the hospital for evaluation. Manufacturer instructions required staff to inspect slings and straps for wear before each use, but there was no evidence the specific sling used in this transfer had been inspected for integrity, and the Administrator acknowledged that the strap breakage led to the resident’s fall and injury.
The facility failed to timely report alleged abuse to SSA and APS after staff twice observed a resident with dementia and acute systolic CHF receiving zealous, open-mouthed kisses on the mouth from her brother. On two separate occasions, a CNA and an LPN witnessed or were informed of these unusual kissing interactions, which they later described as awkward and not typical of a sibling relationship. Despite this, the nursing staff did not immediately report the incidents as potential abuse to the Administrator, and the allegation was not brought forward until a staff meeting days later, resulting in the required notifications to external authorities not being made within the mandated 2-hour timeframe.
A resident with muscle weakness, gait abnormalities, atrial fibrillation, and on a blood thinner sustained an unwitnessed bathroom fall, reported hitting her head, and developed rapidly worsening right facial swelling and a swollen‑shut eye that prevented pupillary assessment. Initial vitals and neuro checks were performed, oxygen was applied, and x‑rays were ordered, but despite the significant change in condition and the resident’s anticoagulation status, the provider was not notified of the worsening condition at the time it occurred and the resident was not sent to the hospital until the next day when an NP assessed her and ordered transfer. In the ED, the physician documented that no evaluation for the injuries had occurred the prior evening and CT imaging showed traumatic subdural and subarachnoid hemorrhages and a large facial hematoma, demonstrating that the facility failed to provide timely, standard‑of‑care treatment and hospital transfer after the fall and subsequent change in condition.
A resident with cognitive impairment, neurological conditions, and substance-related diagnoses was assessed as being at risk for elopement and documented as having poor safety awareness, poor judgment, and wandering behavior requiring frequent redirection. Nursing staff observed the resident wandering in the hall and behind the nurse’s station and communicated during shift report that a WanderGuard was recommended, but no device was applied because staff did not know where to obtain one. The resident later left the building through the front door, was not immediately detected as missing, and was ultimately found by a medication technician about a mile away walking on a sidewalk near a restaurant, demonstrating a failure to provide adequate supervision and timely elopement interventions.
A nurse failed to follow professional standards for medication administration by not properly identifying a resident before giving medications, resulting in the administration of Lorazepam and Carvedilol that were intended for another resident. The error was discovered and documented, with monitoring showing the resident remained stable and without distress, and the hospice nurse, NP, and family were notified. Leadership, including the DON and administrators, acknowledged that the failure to correctly verify the resident’s identity led to the wrong medications being administered.
A resident with multiple comorbidities and an above-knee amputation requested that staff heat prepackaged ramen soup in a microwave at the nutrition station; staff followed package directions and returned the hot soup, which the resident, who used a motorized wheelchair and insisted on carrying items independently, then spilled while turning, causing a third-degree burn to the palmar side of the left wrist. Staff interviews showed that, before this incident, CNAs and an LPN heated food based on package instructions and judged safety by touch without thermometers, and the DON confirmed that no thermometers were available and that staff relied on touch to determine if food was safe to serve.
The facility failed to provide sufficient nursing staff with appropriate skills to respond promptly to call lights and assist residents with toileting, resulting in multiple residents experiencing incontinence and being left unattended on the toilet. Several residents with significant mobility and medical issues reported waiting long periods, including up to 30–45 minutes or more, for call lights to be answered, particularly during evenings, nights, shift changes, and weekends. Surveyors directly observed call lights sounding for 8–13 minutes before staff responded. Staff reported that CNA hours had been cut after a change in ownership, many staff had quit, and they were unable to complete all care tasks due to understaffing. Grievances and resident council notes over several months documented repeated complaints about slow call light response times, residents being left on the toilet for extended periods, and delays in getting to meals, while leadership acknowledged staffing was based on census rather than acuity despite the written facility assessment describing an acuity-based approach.
Multiple residents and a family member reported that meals were bland, unappetizing, sometimes raw or over-roasted, difficult to chew, and often cold by the time they reached residents’ rooms, with no consistent offer of alternatives when food was disliked. Resident council minutes and grievances documented concerns about cold meals, limited variety, lack of fruit, and meals perceived as too high in carbohydrates. A test tray showed hot items, including chicken tenders and tater tots, were served at low temperatures, with mushy, cold textures and dry, tough meat, and there was no plate warmer used while CNAs, rather than dietary staff, passed trays on the halls after a change in kitchen operations.
A resident with a right humerus fracture, chronic right arm pain, dementia (BIMS 9), and impaired use of one upper extremity required setup/clean-up assistance with eating, including cut food and opened containers, as reflected in the MDS and care plan. Despite this, surveyors observed multiple meals where the resident’s food was not consistently cut into bite-sized pieces and containers (such as lidded bowls, syrup packets, and juice boxes) were left unopened, leading family members to cut food on at least one occasion. The diet order and meal card lacked instructions for cut-up food or setup assistance, and interviews with CNAs, the DM, the MDS coordinator, and an RN confirmed that the resident needed this help but that it was not incorporated into formal orders or consistently implemented.
Two residents on modified diets for dementia and chewing/swallowing concerns were given snacks that did not match their ordered textures. One resident on a pureed diet, ordered after staff observed food being held in the mouth and poor chewing, was repeatedly provided ham sandwiches, potato chips, and an ice cream cone. Another resident on a minced & moist Level 5 diet with cut‑up foods was served a peanut cluster and later offered a crunchy “bird’s nest” snack with chow mein noodles and candy. Staff interviews revealed that activities staff supplied their own snacks without verifying diet orders, that the ST had not been consulted for a swallow evaluation in at least one case, and that nursing and dietary staff expected physician diet orders to be followed.
Failure to Inspect Mechanical Lift Sling Results in Resident Fall and Injury
Penalty
Summary
The deficiency involved the facility’s failure to ensure a resident’s environment was free from accident hazards and that equipment used for transfers was in safe, functional condition. A resident with Parkinson’s Disease was being transferred from bed to a chair using a mechanical (Hoyer) lift operated by two CNAs. One CNA reported that when she arrived to assist, the resident was already positioned in the sling, and as the lift was raised, a sling strap snapped, causing the resident to fall and strike the back of the head. Review of the manufacturer’s instructions for the lift and slings showed that staff were required to inspect slings and lifting straps for signs of wear, fraying, or weakness prior to every use. Record review showed that the resident sustained an abrasion to the back of the head, a 1 cm scalp laceration, and reported pain in the shoulders and neck following the fall, and was transferred to the hospital for evaluation. Subsequent NP documentation confirmed the 1 cm scalp laceration was bleeding and that the resident rated back pain as 9/10 on a numeric pain scale. Although maintenance records reflected a general audit of equipment had been conducted several weeks before the incident, there was no evidence that the specific sling used for this transfer had been inspected for integrity prior to use. During interview, the Administrator acknowledged that the equipment failure and strap breakage resulted in the resident’s fall and injury.
Failure to Timely Report Alleged Sexual Abuse to SSA and APS
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse and neglect were reported immediately, but no later than two hours after the allegation was made, to the State Survey Agency (SSA) and Adult Protective Services (APS). Resident 3, who was admitted with unspecified dementia and acute systolic congestive heart failure, was involved in two separate incidents in which her brother was observed kissing her on the mouth in a manner staff described as zealous, enthusiastic, sloppy, and not typical of a brother-sister interaction. On 12/28/25, CNA 1 observed a well-dressed man enter Resident 3's room, hug her, and give her a zealous kiss on the mouth. CNA 1 assumed the man was the resident's husband and reported this to LPN 1, who knew the visitor was the resident's brother. LPN 1 looked into the room and did not see anything out of the ordinary, and neither CNA 1 nor LPN 1 reported this incident as a potential allegation of abuse to the Administrator at that time. On 1/4/26, LPN 1 and CNA 1 entered Resident 3's room to address the resident's pain and request for catheter removal and to assist with a brief and linen change. Resident 3 had two visitors present, including her brother. When asked to step out for privacy, the female visitor left, but the brother hesitated and then gave Resident 3 a sloppy, open-mouthed kiss on the mouth lasting about three seconds, again in the presence of staff. The brother stated that Resident 3 was his older sister and that she had taken care of him since they were very small. LPN 1 did not report either the 12/28/25 or 1/4/26 kissing incidents to the Administrator. The Administrator later stated that the alleged abuse was first mentioned during a meeting on 1/6/26, at which time staff described the kiss as a weird, awkward kiss and not a typical brother-sister kiss, and acknowledged that nursing staff had not reported the suspicious activity in a timely manner, resulting in failure to notify SSA and APS within two hours of the allegation.
Delayed Hospital Transfer After Fall With Head Trauma and Anticoagulation
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident who experienced a fall with head trauma and was on anticoagulation received timely treatment and care in accordance with professional standards of practice. The resident had diagnoses including generalized muscle weakness, gait and mobility abnormalities, and unspecified atrial fibrillation, and was on a blood thinner. On the evening of the fall, nursing documentation showed that the resident was found on the bathroom floor after her roommate called out. The resident reported hitting her head, had facial pain rated 5/10, and initial vital signs showed an O2 saturation of 88–90% with other vitals within normal limits. A neurological assessment was initiated, oxygen was applied, and the on‑call provider was notified, who ordered x‑rays of the resident’s head and left hand. As the evening progressed, the resident’s condition changed. The nurse documented that the resident’s right eye became increasingly swollen to the point that by 9:15 PM it was swollen shut and pupillary reactivity could no longer be assessed, while the left eye remained equal and reactive to light. The neurological exam form recorded that the provider was notified of the fall at 8:00 PM, but did not indicate that the provider was notified when the right eye became swollen shut at 9:15 PM. The DON later stated that this change in the resident’s condition occurred at 9:15 PM and that the medical provider was not notified of this change until the provider came to the facility the following day. The DON also stated that if a resident on a blood thinner experienced a fall with head strike, she expected staff to send the resident to the hospital, and that she was not sure why this resident was not immediately sent. The resident remained in the facility overnight while x‑rays were obtained around 1:00–1:30 AM, with results reportedly available sometime between early morning hours and mid‑morning. The next morning, the NP assessed the resident due to the fall and documented significant right facial swelling, focal tenderness over the zygoma, difficulty visualizing the right eye, and concern for occult injury and possible orbital blowout fracture in the context of anticoagulation. The NP ordered transfer to the emergency department for CT imaging of the head and face. In the emergency department, the physician documented that no evaluation for the resident’s injuries had occurred the previous evening and that the facility had reported the resident seemed slightly altered the prior night and had worsening swelling by the time EMS was called. CT imaging revealed traumatic small subdural and subarachnoid hemorrhages without mass effect and a large facial hematoma. Interviews with nursing staff showed that the RN on duty was very concerned about the resident’s rapidly increasing facial swelling and difficulty administering medications due to lip swelling, but was waiting for a physician order to send the resident to the hospital and was unaware at the time that she could initiate a hospital transfer without such an order. These actions and inactions resulted in a delay in sending the resident to the hospital after a significant change in condition following a fall with head trauma while on a blood thinner. The facility’s Change of Condition/SBAR Evaluation Policy outlined expectations for describing changes in condition, documenting vital signs, identifying changes from baseline (including neurological status changes), and notifying the provider and responsible party, as well as documenting immediate actions and outcomes such as transfer to the hospital. Despite this policy, the neurological exam form did not reflect timely provider notification when the resident’s right eye became swollen shut, and the resident was not transferred until the following day after the NP’s in‑person assessment. The DON confirmed that the change in condition at 9:15 PM was not communicated to the provider until the next day. The surveyors determined that, for this resident, the facility did not ensure timely hospital transfer and did not provide treatment and care in accordance with professional standards of practice after a fall with head injury and subsequent change in condition.
Failure to Implement Elopement Precautions and Supervision for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and implement elopement precautions for a cognitively impaired resident who was identified as being at risk for elopement. The resident was admitted with multiple neurological and substance-related diagnoses, including cerebral infarction, ataxia, Wernicke’s encephalopathy, alcohol and opioid dependence, and traumatic subdural hemorrhage. On admission, the resident’s elopement risk screening showed a score of 12, indicating elopement risk, and nursing documentation described poor safety awareness, poor judgment, and a need for continuous cues with self-care and ADLs. The resident was also noted to require 1:1 supervision during meals due to quick eating behavior. In the hours leading up to the elopement, nursing staff observed the resident wandering in the hallway and behind the nurse’s station and reported that he required constant redirection. The night shift RN informed the day shift LPN during report that the resident had been wandering since early morning and that a WanderGuard was recommended. Despite this, no WanderGuard was applied before the resident left the building. The LPN later stated that she did not know where to obtain a WanderGuard, and the DON confirmed that both the RN and LPN had not placed a WanderGuard because they did not know its location. On the day of the incident, the resident went to the kitchen and requested water, and kitchen staff noticed a fall risk bracelet on his wrist. After this interaction, staff discovered that the resident was no longer in the building. Facility investigation determined that the resident exited through the front door at approximately 9:37 AM and was later found off premises, about one mile away, walking on a sidewalk near a restaurant. A medication technician, who had previously seen the resident wandering in only a gown and had informed the nurse, located the resident and returned him to the facility. These events demonstrate that, despite known elopement risk and observed wandering behavior, the facility did not implement timely elopement precautions or ensure adequate supervision to prevent the resident from eloping.
Medication Administration Error Due to Failure to Verify Resident Identity
Penalty
Summary
The deficiency involves a failure to provide necessary care and services in accordance with professional standards of practice during medication administration. For one resident reviewed for medication administration, a nurse did not follow the Five Rights of medication administration, specifically failing to properly identify the resident before giving medications. As a result, the nurse administered 0.25 mL of Lorazepam, an anti-anxiety medication, and 25 mg of Carvedilol, a beta-blocker used for blood pressure, that were intended for a different resident to Resident #1. Following the administration error, Resident #1’s vital signs were monitored throughout the night, and documentation indicated the resident remained stable, alert, and without signs of distress during the shift. The hospice nurse, nurse practitioner, and family were notified of the error. During interviews, the Administrator and DON acknowledged the medication error, and the DON confirmed that the nurse’s failure to correctly identify the resident prior to administering the medications was the cause of the wrong medications being given.
Burn Injury from Hot Soup Due to Inadequate Supervision and Temperature Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and accident prevention for a resident who sustained a burn injury from hot food. One resident with end stage renal disease, type 2 diabetes mellitus, pericardial effusion, chronic obstructive pulmonary disease, and an above-knee amputation of the left leg requested that staff heat a prepackaged ramen soup. Facility staff heated the soup in a microwave located in the nutrition station behind the nurse’s station according to the package directions and then returned the hot soup to the resident. After receiving the heated soup, the resident, who used a motorized wheelchair and was described as very independent, turned in his power wheelchair, causing the ramen to spill and the hot liquid to burn the palmar side of his left wrist. A progress note documented that the resident received a burn to his left wrist after spilling the hot soup, that the wound was assessed, wound care was provided, and new orders were placed following consultation with a wound provider. The resident reportedly tolerated treatment well and denied pain or other concerns at that time. Subsequent documentation by a wound provider classified the burn on the resident’s left wrist as a third-degree burn. Staff interviews revealed that, prior to this incident, staff heated residents’ food according to package directions and determined whether it was safe to return based on touch, without using thermometers to verify temperature. A CNA reported that the resident often asked CNAs to heat food and insisted on carrying it himself, and that staff declined to heat his food when he refused to allow them to carry it due to safety concerns. An LPN and the DON both confirmed that thermometers were not available for use before the burn occurred and that staff relied on touch to judge food temperature.
Insufficient Nursing Staff and Delayed Call Light Response Leading to Incontinence and Unattended Toileting
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff with appropriate competencies and skills to meet residents’ needs, particularly in timely response to call lights and assistance with toileting, which resulted in incontinent episodes and residents being left unattended. Multiple residents reported long call light wait times, especially during evening and night shifts and on weekends, when there were as few as three CNAs for the entire building. Residents with significant physical limitations, including recent hip fractures, hemiplegia, and other serious conditions, described being unable to get to the bathroom without staff assistance and experiencing incontinence because staff did not respond promptly to their call lights. One resident with a periprosthetic hip fracture, hemiplegia, an artificial hip joint, major depressive disorder, and anxiety reported that from 6:00 PM to 6:00 AM there were only three CNAs for three hallways, resulting in long waits for call light responses. This resident stated she had incontinent bladder episodes when she first arrived because she could not hold her urine while waiting for help, including one instance where she waited 35 minutes for a response. Another resident with a left femur fracture, chronic pain, lupus, and epilepsy reported waiting an hour for her call light to be answered, leading to urinating in her brief because staff did not arrive in time to take her to the bathroom. A third resident with metabolic encephalopathy, acute respiratory failure with hypoxia, pneumonia, UTI, and end-stage renal disease on dialysis stated she had been left on the toilet and had to get herself off and back to bed due to lack of staff. CNA documentation showed multiple incontinent episodes for these residents despite staff describing them as continent of bowel and bladder. Additional residents and a family member reported frequent long call light wait times, including waits of 30–45 minutes, particularly during shift changes and on weekends. The Resident Council President reported that since a change in ownership, residents complained that call lights took 30–40 minutes to be answered and that there were not enough CNAs on the night shift to handle residents’ needs during evening and bedtime hours. Direct observations by surveyors documented call lights sounding for 8 to 13 minutes before being answered on multiple occasions. Staff interviews confirmed that CNA hours had been cut after the ownership change, that many staff had quit, and that staff were asked to work a lot of overtime and were sometimes unable to complete showers due to understaffing. One staff member reported a resident had an incontinent episode after waiting about 45 minutes for a call light response. Grievance records and resident council notes showed a repeated pattern of complaints over several months about slow call light response times, residents being left on the toilet for extended periods, and delays in getting to meals due to insufficient staff. Grievances included reports of residents waiting over an hour to be taken to breakfast, feeling ignored when requests were not fulfilled, and being left on the toilet for almost three hours, causing discomfort. Resident council notes repeatedly documented concerns about call lights taking a long time to be answered, not enough CNAs in the dining room at mealtimes, and residents being left on the toilet or not getting to breakfast on time. Although the facility’s written facility assessment and staffing plan referenced using acuity and tools such as the MDS and RAI to determine staffing, the DON stated that in practice staffing coverage was based on census rather than acuity and acknowledged there had been many issues with call lights since staffing was cut after the change in ownership.
Failure to Provide Palatable, Attractive Meals at Appropriate Temperatures
Penalty
Summary
The deficiency involves the facility’s failure to consistently provide food and drink that were palatable, attractive, and served at safe and appetizing temperatures for multiple residents. Several residents reported that the food was bland, horrible, disgusting, or generally “not good,” and one resident stated that if she did not like what was served, staff did not offer an alternative and that she repeatedly received dark meat she did not like. A family member reported that a resident with a poor appetite received chicken that was dry and needed more moisture. Resident council minutes documented concerns that hamburgers were sometimes too raw, vegetables were roasted to the point of tasting burned, pork chops were difficult to cut or chew, and that food delivered to rooms was cold by the time it arrived when CNAs passed trays. Surveyors’ direct observation of a test tray showed that hot items were not maintained at appetizing temperatures and were of poor quality. After the last tray was plated and placed in the cart, CNAs—not dietary staff—were responsible for passing trays to residents, and there was no plate warmer between the plate and the plastic base. When the test tray was checked, the chicken tender and tater tots were below typical hot-holding temperatures, with the tater tots described as mushy and cold and the chicken tender as dry, tough to chew, and salty. The cold item, a carrot coin salad, was measured at a chilled temperature. Grievances documented that meals were served too cold and that residents were dissatisfied with the variety, fruit options, and perceived high carbohydrate content of the meals. The Dietary Manager acknowledged that dietary staff no longer delivered trays to residents after a change in ownership and attributed cold food to CNAs not passing trays quickly enough, while the Administrator acknowledged there had been complaints about food quality.
Failure to Provide Required Meal Setup and Cut Food Assistance for Resident With Upper Extremity Impairment
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate treatment and services to maintain or improve a resident’s ability to perform ADLs related to dining and eating, specifically cutting food into bite-sized pieces and opening containers as assessed and care planned. A resident with a right humerus fracture, chronic right arm pain, dementia with moderate cognitive impairment (BIMS 9), polyneuropathy, osteoarthritis, chronic pain syndrome, and a right artificial shoulder joint reported being unable to cut her own food and demonstrated that she had to guide her right arm with her left hand. Surveyors observed on multiple occasions that her meals were not consistently prepared or set up to match her assessed need for setup/clean-up assistance with eating. At one meal, her family reported they had to cut up her food and that this was not the first time. At another meal, her breakfast tray included whole sausage links, a lidded bowl, an unopened syrup packet, and a closed juice box with the straw still wrapped, despite her limited use of one arm. The resident’s MDS indicated impairment in one upper extremity and a need for setup or clean-up assistance with eating, and her care plan documented a focus on ADL self-care performance deficit related to dementia and impaired balance, with an intervention that she required setup or clean-up assistance to eat. However, her physician’s diet order specified only a regular diet with regular texture and consistency, with no instruction for cut-up food or meal setup assistance. The Dietary Manager confirmed there were no directions on the resident’s meal card to cut up her food and stated that food was sometimes cut into strips, including pork cutlets, based on the type of food. The MDS Coordinator and an RN both stated that the resident needed her food cut up and lids removed for meal setup and that it would be too difficult for her to manage with one arm, but acknowledged these needs were not reflected in physician orders. Staff also noted that the resident likely could not cut her own food due to right arm pain and limited function and that she would not usually ask for help even when needed, yet the kitchen and nursing staff did not consistently ensure her food was cut into bite-sized pieces or that containers were opened for her.
Failure to Provide Ordered Diet Textures During Nursing and Activities Snacks
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents received food in the texture ordered to meet their individual needs. One resident with dementia and Alzheimer’s disease had a physician’s order for a pureed diet after nursing, the DON, and the nurse practitioner observed that she was not eating well on a regular diet, was cheeking food, holding it in her mouth, and not chewing. Despite this pureed diet order, multiple nursing progress notes documented that she was given ham sandwiches and potato chips on several nights, and an activities note documented that she ate an ice cream cone. Staff interviews confirmed that she was on a pureed diet because she would let food sit in her mouth and that chips and sandwiches are not part of a pureed diet. The speech therapist stated he had not been asked to evaluate her swallowing, that he normally would want to screen residents whose diets were downgraded, and that non‑pureed foods for someone who holds food in their mouth would be a choking concern. Another resident with dementia and a severe cognitive impairment, as evidenced by a BIMS score of 3, had a physician’s order for a regular diet with minced and moist (Level 5) texture and cut‑up foods due to loose teeth. Nonetheless, an activities progress note documented that she ate a peanut cluster during a cooking social, and the Activities Director later reported that she was also given a “bird’s nest” snack made of crunchy chow mein noodles with candy on top, which she did not eat. Nursing staff stated that this resident did not have the mental capacity to chew, required extensive cueing, and that they would be concerned about choking if she were served non‑minced and moist foods. The Dietary Manager reported that the Activities Department provided its own snacks and did not ensure residents received the correct diet textures, and the DON stated that staff were expected to follow physician orders for diet textures despite limited availability of the speech therapist.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
