Millcreek Rehabilitation And Nursing Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Salt Lake City, Utah.
- Location
- 3520 South Highland Drive, Salt Lake City, Utah 84106
- CMS Provider Number
- 465185
- Inspections on file
- 20
- Latest survey
- January 21, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Millcreek Rehabilitation And Nursing Llc during CMS and state inspections, most recent first.
A resident with multiple medical conditions fell backward in a wheelchair while being transported in a facility van, reportedly hitting his head and neck. The incident was not thoroughly investigated or reported to the State Survey Agency as required. Interviews revealed that staff did not follow proper procedures for incident assessment, documentation, or notification, and there was no evidence of an abuse investigation despite the resident's ongoing pain and concerns about the incident report's accuracy.
Two residents were not provided with adequate supervision or properly secured during transport, resulting in one resident falling backward in a facility van and sustaining a head and neck injury. Staff interviews revealed inconsistent and insufficient training on wheelchair securement and accident response, and the incident report did not accurately reflect the event. The deficiency was cited at the Immediate Jeopardy level due to the facility's failure to follow recommended safety practices.
A resident reported being sexually abused by another resident, with the facility failing to ensure separation or provide individualized interventions following the incident. Both residents had moderate cognitive impairment and psychiatric diagnoses. The capacity to consent to sexual activity was not assessed prior to the event, and care plan interventions addressing the altercation were delayed by several months. Staff interviews revealed a lack of timely communication and coordinated response to the abuse allegation.
Three residents with complex medical and psychosocial needs did not have comprehensive, individualized care plans addressing their specific conditions. One resident on dialysis lacked a care plan for fistula care and monitoring, another with repeated THC vape use had no substance use interventions in their care plan, and a third with frequent falls had care plan interventions that were not consistently implemented by staff, as observed and confirmed in interviews.
The facility did not consistently file laboratory reports in the clinical records for three residents, resulting in missing or misfiled lab results for routine and stat orders, including respiratory panels and metabolic panels. Staff interviews confirmed that some results were delayed, not uploaded, or placed in the wrong chart, leading to incomplete documentation.
Staff failed to maintain accurate and confidential medical records by documenting other residents' names in progress notes and misfiling discharge documentation, and did not ensure required physician rationale for ongoing PRN psychotropic medication was present in the chart. These actions resulted in incomplete, inaccurate, and insecure records for several residents with complex medical and psychiatric histories.
Staff failed to use proper infection control practices during snack distribution by handling food with bare hands, and did not implement Enhanced Barrier Precautions for two residents with indwelling medical devices or wounds. Staff interviews revealed a lack of awareness and adherence to required precautions, and there was no signage indicating EBP for affected residents.
Three handrails in resident corridors were found to be loose and not properly secured to the wall. The Maintenance and Housekeeping Supervisor reported that daily audits, including handrail inspections, were conducted but did not identify these deficiencies. The issue was confirmed during inspection with a State Surveyor.
The facility did not ensure timely reporting of alleged abuse, neglect, or injury to the administrator, SSA, APS, or law enforcement. In multiple cases, including incidents of sexual abuse and an injury during transportation, notifications to required authorities were delayed beyond the mandated 2-hour window. Staff and leadership interviews confirmed delays and uncertainty regarding reporting requirements.
A resident with multiple medical conditions reported fecal matter on the bathroom wall that remained unaddressed for an extended period, despite daily cleaning routines and available reporting mechanisms. Observations confirmed the substance persisted, indicating a failure to provide a safe, clean, and homelike environment.
A resident with complex medical needs did not have required routine laboratory tests, including CBC, CMP, and HbA1c, completed and documented as ordered by the facility physician. The DON reported that some labs were obtained from a dialysis center, but not all required tests were included, and results were not consistently documented in the resident's medical record.
A resident with no teeth and moderate cognitive impairment, who had reported difficulty chewing and swallowing, was served a minced and moist diet without physician approval after the Dietary Manager downgraded the diet based on the resident's complaints. Staff interviews revealed confusion about the resident's prescribed diet, and the Speech-Language Pathologist had not yet evaluated the resident. The facility failed to provide food in a form consistent with the physician's order.
A resident assessed as safe to smoke independently was restricted from accessing the secured outside smoking patio after 9:00 PM, except during set supervised times, due to facility policy and staffing limitations. The resident reported being unable to go outside at night as desired, and staff confirmed the door was locked and only opened at specific times, despite the resident's independent status.
Failure to Investigate and Report Resident Fall During Transport
Penalty
Summary
The facility failed to thoroughly investigate and report an incident involving a resident who sustained a fall while being transported in a facility van. The incident occurred when the resident, who had a history of heart failure, type 2 diabetes, osteomyelitis, and diarrhea, was being taken to a cardiology appointment. During the transport, the resident fell backward in his wheelchair, reportedly hitting his head and neck. The resident stated that his wheelchair was strapped in, but he was unsure about the seatbelt placement. Upon returning to the facility, the resident reported the accident and was provided an x-ray the following day. The resident also expressed concerns about the accuracy of the incident report and the timeliness of his medical assessment and follow-up care. Interviews and record reviews revealed that the facility did not conduct a thorough investigation of the incident or report it to the State Survey Agency (SSA) within the required five working days. The Director of Nursing (DON) and the Administrator (ADM) both acknowledged that the incident was not investigated as potential abuse or neglect, and there was no documentation of an abuse investigation. The ADM admitted that the process for handling such incidents, including immediate notification and assessment, was not followed. The transportation driver reported the incident after returning to the facility, but the ADM did not document the event or initiate an investigation, relying instead on the driver's account that no injuries occurred and that the wheelchair was secured. Further interviews with another resident who witnessed the incident indicated that the wheelchair may not have been properly secured, as something in the front came undone, causing the wheelchair to fall backward rapidly. The witness could not confirm if the resident hit his head but noted that the resident complained of neck pain and requested an x-ray. The facility's lack of investigation, failure to assess the resident immediately upon return, and omission of timely reporting to the SSA constituted a deficiency at the Immediate Jeopardy level.
Failure to Ensure Safe Resident Transport and Adequate Supervision
Penalty
Summary
Surveyors identified a deficiency in the facility's failure to ensure adequate supervision and the use of appropriate assistive devices to prevent accidents for two of 43 sampled residents. One resident, who had a history of heart failure, diabetes, bilateral below-knee amputations, and multiple wounds, fell backward while being transported in a facility van. The resident was not properly secured, resulting in a fall that caused injury to the head and neck. The incident was witnessed by another resident, and both the resident and the witness reported that the wheelchair tipped backward while the van was in motion. The transportation driver was unable to clearly recall or demonstrate the correct securement of the wheelchair and seatbelt, and there was inconsistency in staff training and understanding of proper transport procedures. The resident reported pain and symptoms consistent with a neck injury following the incident, including pain at the base of the skull and cracking sounds when turning the neck. Medical records confirmed that the resident received a cervical spine x-ray and was later referred for orthopedic evaluation, where a diagnosis of cervical spondylosis and whiplash injury was made. The resident and the witness both stated that the incident report provided by the facility was inaccurate, and the resident expressed dissatisfaction with the lack of immediate assessment upon return to the facility. The transportation driver and other staff interviews revealed gaps in training, inconsistent practices regarding the securement of wheelchairs and seatbelts, and a lack of clear protocols for responding to accidents during transport. Additionally, the facility failed to ensure that all staff involved in resident transport were adequately trained in safety procedures, including the proper securement of wheelchair-dependent residents and the appropriate response to accidents. Staff interviews indicated that training was often verbal, lacked documentation, and did not always include return demonstrations or specific guidance on accident protocols. The deficiency was determined to be at the Immediate Jeopardy level due to the facility's failure to implement CMS-recommended practices for hazard identification, risk evaluation, intervention implementation, and monitoring for effectiveness.
Failure to Protect Residents from Sexual Abuse and Inadequate Response to Allegation
Penalty
Summary
The facility failed to ensure that residents were protected from abuse, specifically sexual abuse, as evidenced by an incident involving inappropriate sexual contact between two residents. One resident reported waking up to another resident touching his genitals and attempting to penetrate his anus without consent. The incident was reported to the Resident Advocate and the police were contacted, but the alleged perpetrator was not arrested. The victim expressed ongoing anger and anxiety related to the incident and reported that the facility did not take sufficient action to keep the residents separated following the event. Documentation shows that the alleged perpetrator remained in the facility for several months after the incident, and the victim felt unsupported by staff in the aftermath. Medical records and interviews revealed that both residents involved had moderate cognitive impairments and significant psychiatric histories, including schizoaffective disorder, PTSD, and histories of trauma. The victim's care plan included trauma-informed care, but did not identify interventions specific to the sexual abuse incident. Additionally, the assessment of the resident's capacity to consent to sexual activity was not completed prior to the incident, and the care plan interventions addressing the altercation were not initiated until four months after the event. The facility's investigation was ultimately deemed inconclusive, with no conclusive evidence to verify the allegation, and the only interventions documented were the relocation of the alleged perpetrator and general monitoring. Interviews with facility staff, including the Resident Advocate, social worker, and administrator, indicated a lack of timely and coordinated response to the incident. The social worker was not informed of the sexual abuse allegation and did not address it in therapy or care planning. The administrator and Resident Advocate both acknowledged the incident and the subsequent anger and anxiety experienced by the victim, but could not recall or document any new or specific interventions implemented to support the resident or prevent further contact. The facility's failure to promptly assess capacity for consent, implement individualized interventions, and ensure separation of the residents contributed to the deficiency.
Failure to Develop and Implement Comprehensive Care Plans for Residents with Complex Needs
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for three residents with significant medical and psychosocial needs. One resident with end stage renal disease and an arteriovenous fistula for dialysis did not have a care plan addressing dialysis care, monitoring of the fistula, or interventions for potential complications. Despite regular assessments and communication with the dialysis center, there were no documented care plan focus areas or interventions specific to dialysis or fistula management in the resident's medical record. Another resident with a history of substance use, including repeated possession and use of THC vape devices, did not have a care plan addressing substance use or interventions to manage the associated risks. Multiple incidents were documented where the resident was found with THC vapes, and staff, including the DON and ADON, acknowledged awareness of the resident's substance use and the need for a care plan. However, no goals or interventions related to substance use were present in the care plan, despite ongoing issues and the potential impact on other residents. A third resident with a history of falls, cognitive impairment, and physical limitations had a care plan that included several interventions, such as the use of a Gerihip hip protector, pressure alarm mat, and education on using the call light. However, observations and staff interviews revealed that these interventions were not consistently implemented. The resident was repeatedly observed without the hip protector, and some staff were unaware of the intervention or its purpose. The pressure alarm mat was not always positioned correctly, and the resident was seen ambulating in socks, increasing fall risk. These lapses contributed to the facility's failure to ensure that care plan interventions were effectively carried out to meet the resident's needs.
Failure to Maintain Complete Laboratory Records in Resident Charts
Penalty
Summary
The facility failed to maintain complete, dated laboratory records in the clinical records of three residents. For one resident with multiple chronic conditions, including diabetes, end stage renal disease, and hypertension, there was no documentation in the medical record for the results of a respiratory panel ordered due to influenza A exposure, nor for routine labs (CBC, CMP, HbA1c) ordered for a specific month. The Assistant Director of Nursing (ADON) indicated that the resident only allowed the dialysis center to obtain labs, and the results were not present in the facility's records until much later. The Director of Nursing (DON) confirmed that the laboratory results for the routine labs were only recently obtained from the dialysis center. Another resident with psychiatric and substance use diagnoses also had a respiratory panel ordered due to influenza A exposure, but the results were not found in the medical record. Staff interviews revealed that while lab results were typically faxed to the facility and uploaded into the medical record, the respiratory panel result remained in the fax queue and had not been uploaded. For a third resident with cardiac and renal diagnoses, a one-time basic metabolic panel was ordered, but the results were not present in the medical record; the DON later stated that the results had been uploaded to the wrong resident's chart. These findings demonstrate that laboratory reports were not consistently filed in the correct resident records as required.
Failure to Maintain Accurate and Confidential Medical Records
Penalty
Summary
The facility failed to maintain complete, accurate, and secure medical records for multiple residents. In several instances, staff documented other residents' names within a resident's medical record, rather than using appropriate identifiers such as room numbers. For example, in the medical record of a resident with schizoaffective disorder, PTSD, and other psychiatric diagnoses, progress notes included the full names of other residents involved in an altercation, contrary to facility policy and accepted standards. Additionally, another resident's discharge documentation was found in the wrong resident's medical record, and similar issues were identified in the records of other residents, where names of unrelated residents appeared in progress and event notes. Furthermore, the facility did not ensure that required physician documentation was present in the medical record for the ongoing use of a PRN psychotropic medication. In one case, a resident with PTSD and schizoaffective disorder had a PRN order for clonazepam extended, but the physician's rationale for this extension was not found in the medical record as required. The DON later located the missing document outside of the resident's chart, indicating a lapse in maintaining complete and accessible records. These deficiencies were identified through record review, staff interviews, and observation.
Failure to Implement Infection Control Practices and Enhanced Barrier Precautions
Penalty
Summary
A deficiency was identified when a Certified Nurse Assistant (CNA) was observed distributing snacks to residents in the hallway using bare hands, without the use of tongs or hand hygiene between residents. The Director of Nursing (DON) confirmed that staff are expected to use tongs and perform hand hygiene between each resident when handling food. This failure to follow proper infection control practices resulted in direct hand-to-food contact during snack distribution. Additionally, two residents with indwelling medical devices or wounds did not have Enhanced Barrier Precautions (EBP) in place as required. One resident with a wound vac for a right elbow wound and another with a foley catheter were not on EBP, and there was no signage indicating such precautions outside their rooms. Interviews with staff revealed a lack of awareness and implementation of EBP for residents with invasive devices, despite physician orders and care plans indicating the presence of these devices and associated infection risks.
Loose Handrails in Resident Corridors
Penalty
Summary
The facility failed to ensure that all corridors were equipped with firmly secured handrails, as required. During observations on multiple occasions, three separate handrails in resident corridors were found to be loose and not properly secured to the wall. These deficiencies were identified outside and between various resident rooms. In an interview, the Maintenance and Housekeeping Supervisor (MHS) stated that daily audits were conducted, including inspection of handrails, but acknowledged that the loose handrails had not been noticed during these audits. The MHS further confirmed during inspection with the State Surveyor that the handrails were loose and needed tightening or possible replacement. No information was provided regarding specific residents affected, their medical history, or their condition at the time of the deficiency.
Failure to Timely Report Alleged Abuse, Neglect, or Injury
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, or theft were reported immediately, but not later than 2 hours after the allegation was made, to the administrator, State Survey Agency (SSA), Adult Protective Services (APS), and local law enforcement. In several instances, staff did not notify the administrator or external agencies within the required timeframe after becoming aware of incidents involving residents. For example, after a resident reported being touched inappropriately by another resident, staff became aware of the incident at 5:51 AM, but the administrator was not notified until over 3 hours later, and notifications to SSA, APS, and law enforcement were delayed by more than 4 to 5 hours. In another case, two residents were found engaging in a sexual act in a bathroom. While the SSA was notified within an hour, notifications to APS and law enforcement were not made until four days after the facility became aware of the incident. The documentation did not include the exact time of these notifications, further indicating a lack of timely reporting as required by regulations. Additionally, a resident sustained an injury after falling in a transportation van. The incident was not reported to the SSA until several days later, and other agencies were not notified at the time of the incident. Interviews with the Director of Nursing and the administrator revealed uncertainty about whether the incident constituted neglect and acknowledged that the incident should have been reported. These failures demonstrate that the facility did not consistently follow required protocols for timely reporting of alleged abuse, neglect, or theft.
Failure to Maintain Clean and Homelike Resident Bathroom Environment
Penalty
Summary
A resident with a history of heart failure, type 2 diabetes, osteomyelitis, and diarrhea reported the presence of fecal matter on the wall next to the toilet in their bathroom, which had been there since admission. Multiple observations by the State Surveyor confirmed the presence of a brown substance on the wall near the toilet paper dispenser over several days, indicating the issue persisted throughout the survey period. Housekeeping staff interviewed stated that they cleaned the bathrooms daily, including the walls if needed, but did not notice the substance until it was pointed out. The Maintenance and Housekeeping Supervisor reported monitoring staff and addressing complaints as they arose, but was unaware of this specific issue until shown. Despite daily cleaning routines and available reporting mechanisms, the brown substance remained on the wall for an extended period, demonstrating a failure to maintain a safe, clean, and homelike environment for the resident.
Failure to Obtain and Document Required Laboratory Tests
Penalty
Summary
A deficiency was identified when a resident with multiple complex diagnoses, including type II diabetes mellitus, end stage renal disease, and hypertension, did not have required laboratory tests completed as ordered. The resident had physician orders for routine laboratory tests, specifically a Complete Blood Count (CBC), Comprehensive Metabolic Panel (CMP), and hemoglobin A1c (HbA1c) to be performed every six months in February and August. Upon review of the resident's medical records, there was no documentation of the CBC, CMP, or HbA1c results for the required periods. Interviews with the Director of Nursing (DON) revealed that while some laboratory results for CBC and CMP were eventually obtained from the dialysis center, the HbA1c was not included. The DON further explained that the dialysis center was conducting its own lab tests based on orders from their Nurse Practitioner, not the facility's physician orders, and that these results were not consistently communicated to or documented in the facility's medical records. Additionally, it was unclear if the facility's physician had access to the dialysis center's lab results, and the required lab results were not present in the resident's records.
Failure to Provide Physician-Ordered Diet Texture for Resident with Chewing and Swallowing Difficulties
Penalty
Summary
A deficiency occurred when a resident with no teeth, moderate cognitive impairment, and documented swallowing difficulties was served a modified diet that was not approved by the physician. The resident was observed eating chopped Lo Mein, chicken, vegetables, and whole French fries, despite a physician's order for a soft and bite-sized diet. The resident had previously reported difficulty chewing large chunks of food, prompting the Dietary Manager (DM) to downgrade the diet to minced and moist and notify the Speech-Language Pathologist (SLP) and the clinical team. However, this change was not approved by the physician, and the SLP had not yet evaluated the resident. Staff interviews revealed confusion regarding the resident's prescribed diet, with CNAs unsure of the current order and the DM stating that the meal card had been updated to minced and moist without physician approval. The Director of Nursing (DON) acknowledged being notified of the resident's difficulties and the dietary change but confirmed that any diet downgrade required provider approval and SLP evaluation, which had not occurred at the time of the survey. As a result, the facility failed to ensure that food was prepared and provided in a form designed to meet the resident's individual needs as ordered by the physician.
Failure to Support Resident Choice for Independent Smoking Access After Hours
Penalty
Summary
A deficiency was identified when a resident, who had been assessed as safe to smoke without supervision, was not allowed access to the secured outside smoking patio after 9:00 PM except during designated supervised smoking times at 11:00 PM and 3:00 AM. The resident expressed a desire to sit outside on the patio at night but was informed by staff that he had to be inside by 9:00 PM. The resident reported feeling treated like a child and unable to leave when he wanted. Review of the resident's smoking evaluations confirmed that he was considered safe to smoke independently. Facility staff, including the ADON, stated that the back interior door to the patio locked automatically at 9:00 PM and reopened at 6:00 AM, and that the policy required residents to wait for supervised smoking times at night, even if they were independent smokers. The ADON cited staffing limitations as the reason for this policy, noting that staff could not accommodate letting residents in and out at will during the night. The Administrator indicated that independent smokers should be allowed access as they pleased, but acknowledged there was no way for residents to alert staff to be let back in except by knocking, as the patio door lacked a doorbell.
Latest citations in Utah
A resident with Parkinson’s Disease was being transferred from bed to a chair using a mechanical (Hoyer) lift operated by two CNAs when a sling strap snapped, causing the resident to fall and strike the back of the head. The resident sustained an abrasion, a 1 cm scalp laceration with bleeding, and severe back pain rated 9/10, and was sent to the hospital for evaluation. Manufacturer instructions required staff to inspect slings and straps for wear before each use, but there was no evidence the specific sling used in this transfer had been inspected for integrity, and the Administrator acknowledged that the strap breakage led to the resident’s fall and injury.
The facility failed to timely report alleged abuse to SSA and APS after staff twice observed a resident with dementia and acute systolic CHF receiving zealous, open-mouthed kisses on the mouth from her brother. On two separate occasions, a CNA and an LPN witnessed or were informed of these unusual kissing interactions, which they later described as awkward and not typical of a sibling relationship. Despite this, the nursing staff did not immediately report the incidents as potential abuse to the Administrator, and the allegation was not brought forward until a staff meeting days later, resulting in the required notifications to external authorities not being made within the mandated 2-hour timeframe.
A resident with muscle weakness, gait abnormalities, atrial fibrillation, and on a blood thinner sustained an unwitnessed bathroom fall, reported hitting her head, and developed rapidly worsening right facial swelling and a swollen‑shut eye that prevented pupillary assessment. Initial vitals and neuro checks were performed, oxygen was applied, and x‑rays were ordered, but despite the significant change in condition and the resident’s anticoagulation status, the provider was not notified of the worsening condition at the time it occurred and the resident was not sent to the hospital until the next day when an NP assessed her and ordered transfer. In the ED, the physician documented that no evaluation for the injuries had occurred the prior evening and CT imaging showed traumatic subdural and subarachnoid hemorrhages and a large facial hematoma, demonstrating that the facility failed to provide timely, standard‑of‑care treatment and hospital transfer after the fall and subsequent change in condition.
A resident with cognitive impairment, neurological conditions, and substance-related diagnoses was assessed as being at risk for elopement and documented as having poor safety awareness, poor judgment, and wandering behavior requiring frequent redirection. Nursing staff observed the resident wandering in the hall and behind the nurse’s station and communicated during shift report that a WanderGuard was recommended, but no device was applied because staff did not know where to obtain one. The resident later left the building through the front door, was not immediately detected as missing, and was ultimately found by a medication technician about a mile away walking on a sidewalk near a restaurant, demonstrating a failure to provide adequate supervision and timely elopement interventions.
A nurse failed to follow professional standards for medication administration by not properly identifying a resident before giving medications, resulting in the administration of Lorazepam and Carvedilol that were intended for another resident. The error was discovered and documented, with monitoring showing the resident remained stable and without distress, and the hospice nurse, NP, and family were notified. Leadership, including the DON and administrators, acknowledged that the failure to correctly verify the resident’s identity led to the wrong medications being administered.
A resident with multiple comorbidities and an above-knee amputation requested that staff heat prepackaged ramen soup in a microwave at the nutrition station; staff followed package directions and returned the hot soup, which the resident, who used a motorized wheelchair and insisted on carrying items independently, then spilled while turning, causing a third-degree burn to the palmar side of the left wrist. Staff interviews showed that, before this incident, CNAs and an LPN heated food based on package instructions and judged safety by touch without thermometers, and the DON confirmed that no thermometers were available and that staff relied on touch to determine if food was safe to serve.
The facility failed to provide sufficient nursing staff with appropriate skills to respond promptly to call lights and assist residents with toileting, resulting in multiple residents experiencing incontinence and being left unattended on the toilet. Several residents with significant mobility and medical issues reported waiting long periods, including up to 30–45 minutes or more, for call lights to be answered, particularly during evenings, nights, shift changes, and weekends. Surveyors directly observed call lights sounding for 8–13 minutes before staff responded. Staff reported that CNA hours had been cut after a change in ownership, many staff had quit, and they were unable to complete all care tasks due to understaffing. Grievances and resident council notes over several months documented repeated complaints about slow call light response times, residents being left on the toilet for extended periods, and delays in getting to meals, while leadership acknowledged staffing was based on census rather than acuity despite the written facility assessment describing an acuity-based approach.
Multiple residents and a family member reported that meals were bland, unappetizing, sometimes raw or over-roasted, difficult to chew, and often cold by the time they reached residents’ rooms, with no consistent offer of alternatives when food was disliked. Resident council minutes and grievances documented concerns about cold meals, limited variety, lack of fruit, and meals perceived as too high in carbohydrates. A test tray showed hot items, including chicken tenders and tater tots, were served at low temperatures, with mushy, cold textures and dry, tough meat, and there was no plate warmer used while CNAs, rather than dietary staff, passed trays on the halls after a change in kitchen operations.
A resident with a right humerus fracture, chronic right arm pain, dementia (BIMS 9), and impaired use of one upper extremity required setup/clean-up assistance with eating, including cut food and opened containers, as reflected in the MDS and care plan. Despite this, surveyors observed multiple meals where the resident’s food was not consistently cut into bite-sized pieces and containers (such as lidded bowls, syrup packets, and juice boxes) were left unopened, leading family members to cut food on at least one occasion. The diet order and meal card lacked instructions for cut-up food or setup assistance, and interviews with CNAs, the DM, the MDS coordinator, and an RN confirmed that the resident needed this help but that it was not incorporated into formal orders or consistently implemented.
Two residents on modified diets for dementia and chewing/swallowing concerns were given snacks that did not match their ordered textures. One resident on a pureed diet, ordered after staff observed food being held in the mouth and poor chewing, was repeatedly provided ham sandwiches, potato chips, and an ice cream cone. Another resident on a minced & moist Level 5 diet with cut‑up foods was served a peanut cluster and later offered a crunchy “bird’s nest” snack with chow mein noodles and candy. Staff interviews revealed that activities staff supplied their own snacks without verifying diet orders, that the ST had not been consulted for a swallow evaluation in at least one case, and that nursing and dietary staff expected physician diet orders to be followed.
Failure to Inspect Mechanical Lift Sling Results in Resident Fall and Injury
Penalty
Summary
The deficiency involved the facility’s failure to ensure a resident’s environment was free from accident hazards and that equipment used for transfers was in safe, functional condition. A resident with Parkinson’s Disease was being transferred from bed to a chair using a mechanical (Hoyer) lift operated by two CNAs. One CNA reported that when she arrived to assist, the resident was already positioned in the sling, and as the lift was raised, a sling strap snapped, causing the resident to fall and strike the back of the head. Review of the manufacturer’s instructions for the lift and slings showed that staff were required to inspect slings and lifting straps for signs of wear, fraying, or weakness prior to every use. Record review showed that the resident sustained an abrasion to the back of the head, a 1 cm scalp laceration, and reported pain in the shoulders and neck following the fall, and was transferred to the hospital for evaluation. Subsequent NP documentation confirmed the 1 cm scalp laceration was bleeding and that the resident rated back pain as 9/10 on a numeric pain scale. Although maintenance records reflected a general audit of equipment had been conducted several weeks before the incident, there was no evidence that the specific sling used for this transfer had been inspected for integrity prior to use. During interview, the Administrator acknowledged that the equipment failure and strap breakage resulted in the resident’s fall and injury.
Failure to Timely Report Alleged Sexual Abuse to SSA and APS
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse and neglect were reported immediately, but no later than two hours after the allegation was made, to the State Survey Agency (SSA) and Adult Protective Services (APS). Resident 3, who was admitted with unspecified dementia and acute systolic congestive heart failure, was involved in two separate incidents in which her brother was observed kissing her on the mouth in a manner staff described as zealous, enthusiastic, sloppy, and not typical of a brother-sister interaction. On 12/28/25, CNA 1 observed a well-dressed man enter Resident 3's room, hug her, and give her a zealous kiss on the mouth. CNA 1 assumed the man was the resident's husband and reported this to LPN 1, who knew the visitor was the resident's brother. LPN 1 looked into the room and did not see anything out of the ordinary, and neither CNA 1 nor LPN 1 reported this incident as a potential allegation of abuse to the Administrator at that time. On 1/4/26, LPN 1 and CNA 1 entered Resident 3's room to address the resident's pain and request for catheter removal and to assist with a brief and linen change. Resident 3 had two visitors present, including her brother. When asked to step out for privacy, the female visitor left, but the brother hesitated and then gave Resident 3 a sloppy, open-mouthed kiss on the mouth lasting about three seconds, again in the presence of staff. The brother stated that Resident 3 was his older sister and that she had taken care of him since they were very small. LPN 1 did not report either the 12/28/25 or 1/4/26 kissing incidents to the Administrator. The Administrator later stated that the alleged abuse was first mentioned during a meeting on 1/6/26, at which time staff described the kiss as a weird, awkward kiss and not a typical brother-sister kiss, and acknowledged that nursing staff had not reported the suspicious activity in a timely manner, resulting in failure to notify SSA and APS within two hours of the allegation.
Delayed Hospital Transfer After Fall With Head Trauma and Anticoagulation
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident who experienced a fall with head trauma and was on anticoagulation received timely treatment and care in accordance with professional standards of practice. The resident had diagnoses including generalized muscle weakness, gait and mobility abnormalities, and unspecified atrial fibrillation, and was on a blood thinner. On the evening of the fall, nursing documentation showed that the resident was found on the bathroom floor after her roommate called out. The resident reported hitting her head, had facial pain rated 5/10, and initial vital signs showed an O2 saturation of 88–90% with other vitals within normal limits. A neurological assessment was initiated, oxygen was applied, and the on‑call provider was notified, who ordered x‑rays of the resident’s head and left hand. As the evening progressed, the resident’s condition changed. The nurse documented that the resident’s right eye became increasingly swollen to the point that by 9:15 PM it was swollen shut and pupillary reactivity could no longer be assessed, while the left eye remained equal and reactive to light. The neurological exam form recorded that the provider was notified of the fall at 8:00 PM, but did not indicate that the provider was notified when the right eye became swollen shut at 9:15 PM. The DON later stated that this change in the resident’s condition occurred at 9:15 PM and that the medical provider was not notified of this change until the provider came to the facility the following day. The DON also stated that if a resident on a blood thinner experienced a fall with head strike, she expected staff to send the resident to the hospital, and that she was not sure why this resident was not immediately sent. The resident remained in the facility overnight while x‑rays were obtained around 1:00–1:30 AM, with results reportedly available sometime between early morning hours and mid‑morning. The next morning, the NP assessed the resident due to the fall and documented significant right facial swelling, focal tenderness over the zygoma, difficulty visualizing the right eye, and concern for occult injury and possible orbital blowout fracture in the context of anticoagulation. The NP ordered transfer to the emergency department for CT imaging of the head and face. In the emergency department, the physician documented that no evaluation for the resident’s injuries had occurred the previous evening and that the facility had reported the resident seemed slightly altered the prior night and had worsening swelling by the time EMS was called. CT imaging revealed traumatic small subdural and subarachnoid hemorrhages without mass effect and a large facial hematoma. Interviews with nursing staff showed that the RN on duty was very concerned about the resident’s rapidly increasing facial swelling and difficulty administering medications due to lip swelling, but was waiting for a physician order to send the resident to the hospital and was unaware at the time that she could initiate a hospital transfer without such an order. These actions and inactions resulted in a delay in sending the resident to the hospital after a significant change in condition following a fall with head trauma while on a blood thinner. The facility’s Change of Condition/SBAR Evaluation Policy outlined expectations for describing changes in condition, documenting vital signs, identifying changes from baseline (including neurological status changes), and notifying the provider and responsible party, as well as documenting immediate actions and outcomes such as transfer to the hospital. Despite this policy, the neurological exam form did not reflect timely provider notification when the resident’s right eye became swollen shut, and the resident was not transferred until the following day after the NP’s in‑person assessment. The DON confirmed that the change in condition at 9:15 PM was not communicated to the provider until the next day. The surveyors determined that, for this resident, the facility did not ensure timely hospital transfer and did not provide treatment and care in accordance with professional standards of practice after a fall with head injury and subsequent change in condition.
Failure to Implement Elopement Precautions and Supervision for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and implement elopement precautions for a cognitively impaired resident who was identified as being at risk for elopement. The resident was admitted with multiple neurological and substance-related diagnoses, including cerebral infarction, ataxia, Wernicke’s encephalopathy, alcohol and opioid dependence, and traumatic subdural hemorrhage. On admission, the resident’s elopement risk screening showed a score of 12, indicating elopement risk, and nursing documentation described poor safety awareness, poor judgment, and a need for continuous cues with self-care and ADLs. The resident was also noted to require 1:1 supervision during meals due to quick eating behavior. In the hours leading up to the elopement, nursing staff observed the resident wandering in the hallway and behind the nurse’s station and reported that he required constant redirection. The night shift RN informed the day shift LPN during report that the resident had been wandering since early morning and that a WanderGuard was recommended. Despite this, no WanderGuard was applied before the resident left the building. The LPN later stated that she did not know where to obtain a WanderGuard, and the DON confirmed that both the RN and LPN had not placed a WanderGuard because they did not know its location. On the day of the incident, the resident went to the kitchen and requested water, and kitchen staff noticed a fall risk bracelet on his wrist. After this interaction, staff discovered that the resident was no longer in the building. Facility investigation determined that the resident exited through the front door at approximately 9:37 AM and was later found off premises, about one mile away, walking on a sidewalk near a restaurant. A medication technician, who had previously seen the resident wandering in only a gown and had informed the nurse, located the resident and returned him to the facility. These events demonstrate that, despite known elopement risk and observed wandering behavior, the facility did not implement timely elopement precautions or ensure adequate supervision to prevent the resident from eloping.
Medication Administration Error Due to Failure to Verify Resident Identity
Penalty
Summary
The deficiency involves a failure to provide necessary care and services in accordance with professional standards of practice during medication administration. For one resident reviewed for medication administration, a nurse did not follow the Five Rights of medication administration, specifically failing to properly identify the resident before giving medications. As a result, the nurse administered 0.25 mL of Lorazepam, an anti-anxiety medication, and 25 mg of Carvedilol, a beta-blocker used for blood pressure, that were intended for a different resident to Resident #1. Following the administration error, Resident #1’s vital signs were monitored throughout the night, and documentation indicated the resident remained stable, alert, and without signs of distress during the shift. The hospice nurse, nurse practitioner, and family were notified of the error. During interviews, the Administrator and DON acknowledged the medication error, and the DON confirmed that the nurse’s failure to correctly identify the resident prior to administering the medications was the cause of the wrong medications being given.
Burn Injury from Hot Soup Due to Inadequate Supervision and Temperature Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and accident prevention for a resident who sustained a burn injury from hot food. One resident with end stage renal disease, type 2 diabetes mellitus, pericardial effusion, chronic obstructive pulmonary disease, and an above-knee amputation of the left leg requested that staff heat a prepackaged ramen soup. Facility staff heated the soup in a microwave located in the nutrition station behind the nurse’s station according to the package directions and then returned the hot soup to the resident. After receiving the heated soup, the resident, who used a motorized wheelchair and was described as very independent, turned in his power wheelchair, causing the ramen to spill and the hot liquid to burn the palmar side of his left wrist. A progress note documented that the resident received a burn to his left wrist after spilling the hot soup, that the wound was assessed, wound care was provided, and new orders were placed following consultation with a wound provider. The resident reportedly tolerated treatment well and denied pain or other concerns at that time. Subsequent documentation by a wound provider classified the burn on the resident’s left wrist as a third-degree burn. Staff interviews revealed that, prior to this incident, staff heated residents’ food according to package directions and determined whether it was safe to return based on touch, without using thermometers to verify temperature. A CNA reported that the resident often asked CNAs to heat food and insisted on carrying it himself, and that staff declined to heat his food when he refused to allow them to carry it due to safety concerns. An LPN and the DON both confirmed that thermometers were not available for use before the burn occurred and that staff relied on touch to judge food temperature.
Insufficient Nursing Staff and Delayed Call Light Response Leading to Incontinence and Unattended Toileting
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff with appropriate competencies and skills to meet residents’ needs, particularly in timely response to call lights and assistance with toileting, which resulted in incontinent episodes and residents being left unattended. Multiple residents reported long call light wait times, especially during evening and night shifts and on weekends, when there were as few as three CNAs for the entire building. Residents with significant physical limitations, including recent hip fractures, hemiplegia, and other serious conditions, described being unable to get to the bathroom without staff assistance and experiencing incontinence because staff did not respond promptly to their call lights. One resident with a periprosthetic hip fracture, hemiplegia, an artificial hip joint, major depressive disorder, and anxiety reported that from 6:00 PM to 6:00 AM there were only three CNAs for three hallways, resulting in long waits for call light responses. This resident stated she had incontinent bladder episodes when she first arrived because she could not hold her urine while waiting for help, including one instance where she waited 35 minutes for a response. Another resident with a left femur fracture, chronic pain, lupus, and epilepsy reported waiting an hour for her call light to be answered, leading to urinating in her brief because staff did not arrive in time to take her to the bathroom. A third resident with metabolic encephalopathy, acute respiratory failure with hypoxia, pneumonia, UTI, and end-stage renal disease on dialysis stated she had been left on the toilet and had to get herself off and back to bed due to lack of staff. CNA documentation showed multiple incontinent episodes for these residents despite staff describing them as continent of bowel and bladder. Additional residents and a family member reported frequent long call light wait times, including waits of 30–45 minutes, particularly during shift changes and on weekends. The Resident Council President reported that since a change in ownership, residents complained that call lights took 30–40 minutes to be answered and that there were not enough CNAs on the night shift to handle residents’ needs during evening and bedtime hours. Direct observations by surveyors documented call lights sounding for 8 to 13 minutes before being answered on multiple occasions. Staff interviews confirmed that CNA hours had been cut after the ownership change, that many staff had quit, and that staff were asked to work a lot of overtime and were sometimes unable to complete showers due to understaffing. One staff member reported a resident had an incontinent episode after waiting about 45 minutes for a call light response. Grievance records and resident council notes showed a repeated pattern of complaints over several months about slow call light response times, residents being left on the toilet for extended periods, and delays in getting to meals due to insufficient staff. Grievances included reports of residents waiting over an hour to be taken to breakfast, feeling ignored when requests were not fulfilled, and being left on the toilet for almost three hours, causing discomfort. Resident council notes repeatedly documented concerns about call lights taking a long time to be answered, not enough CNAs in the dining room at mealtimes, and residents being left on the toilet or not getting to breakfast on time. Although the facility’s written facility assessment and staffing plan referenced using acuity and tools such as the MDS and RAI to determine staffing, the DON stated that in practice staffing coverage was based on census rather than acuity and acknowledged there had been many issues with call lights since staffing was cut after the change in ownership.
Failure to Provide Palatable, Attractive Meals at Appropriate Temperatures
Penalty
Summary
The deficiency involves the facility’s failure to consistently provide food and drink that were palatable, attractive, and served at safe and appetizing temperatures for multiple residents. Several residents reported that the food was bland, horrible, disgusting, or generally “not good,” and one resident stated that if she did not like what was served, staff did not offer an alternative and that she repeatedly received dark meat she did not like. A family member reported that a resident with a poor appetite received chicken that was dry and needed more moisture. Resident council minutes documented concerns that hamburgers were sometimes too raw, vegetables were roasted to the point of tasting burned, pork chops were difficult to cut or chew, and that food delivered to rooms was cold by the time it arrived when CNAs passed trays. Surveyors’ direct observation of a test tray showed that hot items were not maintained at appetizing temperatures and were of poor quality. After the last tray was plated and placed in the cart, CNAs—not dietary staff—were responsible for passing trays to residents, and there was no plate warmer between the plate and the plastic base. When the test tray was checked, the chicken tender and tater tots were below typical hot-holding temperatures, with the tater tots described as mushy and cold and the chicken tender as dry, tough to chew, and salty. The cold item, a carrot coin salad, was measured at a chilled temperature. Grievances documented that meals were served too cold and that residents were dissatisfied with the variety, fruit options, and perceived high carbohydrate content of the meals. The Dietary Manager acknowledged that dietary staff no longer delivered trays to residents after a change in ownership and attributed cold food to CNAs not passing trays quickly enough, while the Administrator acknowledged there had been complaints about food quality.
Failure to Provide Required Meal Setup and Cut Food Assistance for Resident With Upper Extremity Impairment
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate treatment and services to maintain or improve a resident’s ability to perform ADLs related to dining and eating, specifically cutting food into bite-sized pieces and opening containers as assessed and care planned. A resident with a right humerus fracture, chronic right arm pain, dementia with moderate cognitive impairment (BIMS 9), polyneuropathy, osteoarthritis, chronic pain syndrome, and a right artificial shoulder joint reported being unable to cut her own food and demonstrated that she had to guide her right arm with her left hand. Surveyors observed on multiple occasions that her meals were not consistently prepared or set up to match her assessed need for setup/clean-up assistance with eating. At one meal, her family reported they had to cut up her food and that this was not the first time. At another meal, her breakfast tray included whole sausage links, a lidded bowl, an unopened syrup packet, and a closed juice box with the straw still wrapped, despite her limited use of one arm. The resident’s MDS indicated impairment in one upper extremity and a need for setup or clean-up assistance with eating, and her care plan documented a focus on ADL self-care performance deficit related to dementia and impaired balance, with an intervention that she required setup or clean-up assistance to eat. However, her physician’s diet order specified only a regular diet with regular texture and consistency, with no instruction for cut-up food or meal setup assistance. The Dietary Manager confirmed there were no directions on the resident’s meal card to cut up her food and stated that food was sometimes cut into strips, including pork cutlets, based on the type of food. The MDS Coordinator and an RN both stated that the resident needed her food cut up and lids removed for meal setup and that it would be too difficult for her to manage with one arm, but acknowledged these needs were not reflected in physician orders. Staff also noted that the resident likely could not cut her own food due to right arm pain and limited function and that she would not usually ask for help even when needed, yet the kitchen and nursing staff did not consistently ensure her food was cut into bite-sized pieces or that containers were opened for her.
Failure to Provide Ordered Diet Textures During Nursing and Activities Snacks
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents received food in the texture ordered to meet their individual needs. One resident with dementia and Alzheimer’s disease had a physician’s order for a pureed diet after nursing, the DON, and the nurse practitioner observed that she was not eating well on a regular diet, was cheeking food, holding it in her mouth, and not chewing. Despite this pureed diet order, multiple nursing progress notes documented that she was given ham sandwiches and potato chips on several nights, and an activities note documented that she ate an ice cream cone. Staff interviews confirmed that she was on a pureed diet because she would let food sit in her mouth and that chips and sandwiches are not part of a pureed diet. The speech therapist stated he had not been asked to evaluate her swallowing, that he normally would want to screen residents whose diets were downgraded, and that non‑pureed foods for someone who holds food in their mouth would be a choking concern. Another resident with dementia and a severe cognitive impairment, as evidenced by a BIMS score of 3, had a physician’s order for a regular diet with minced and moist (Level 5) texture and cut‑up foods due to loose teeth. Nonetheless, an activities progress note documented that she ate a peanut cluster during a cooking social, and the Activities Director later reported that she was also given a “bird’s nest” snack made of crunchy chow mein noodles with candy on top, which she did not eat. Nursing staff stated that this resident did not have the mental capacity to chew, required extensive cueing, and that they would be concerned about choking if she were served non‑minced and moist foods. The Dietary Manager reported that the Activities Department provided its own snacks and did not ensure residents received the correct diet textures, and the DON stated that staff were expected to follow physician orders for diet textures despite limited availability of the speech therapist.
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