Monument Healthcare Bountiful
Inspection history, citations, penalties and survey trends for this long-term care facility in Bountiful, Utah.
- Location
- 460 West 2600 South, Bountiful, Utah 84010
- CMS Provider Number
- 465112
- Inspections on file
- 19
- Latest survey
- November 6, 2025
- Citations (last 12 mo.)
- 3 (1 serious)
Citation history
Health deficiencies cited at Monument Healthcare Bountiful during CMS and state inspections, most recent first.
A resident with significant mobility limitations fell from a Hoyer lift during a transfer when only one CNA assisted, contrary to policy requiring two staff. The lift was missing required safety latches, and the sling was not properly secured, resulting in the resident sustaining a fracture. Staff interviews and observations confirmed lapses in following procedures and equipment checks.
A resident with multiple medical conditions sustained a fall from a Hoyer lift resulting in a fracture, but the incident was not reported to the SSA within the required timeframe, and APS was not notified. The DON confirmed the delay in reporting and lack of investigation for possible neglect, leading to a deficiency in mandated reporting.
A resident with multiple medical conditions fell from a Hoyer lift during a transfer, resulting in pain and injury. The facility's abuse investigation lacked documentation of interviews with the staff involved and the resident, and the incident date was recorded incorrectly. The DON confirmed that the investigation records were incomplete and did not demonstrate a thorough review to rule out neglect.
A resident with cerebral palsy and functional quadriplegia was being pushed in a wheelchair by a CNA without footrests in place, resulting in the resident's foot catching on the ground and a fall that caused facial abrasions, a lip laceration, and other minor injuries. The incident highlighted a failure to provide adequate supervision and accident prevention during wheelchair transport.
A nurse mistakenly administered a resident's roommate's medications, including acetaminophen, senna, trazodone, and extended release morphine. The error was promptly reported, the resident was monitored for adverse effects, and no changes in condition were observed during follow-up assessments.
A resident with cognitive impairment and mobility issues slid out of her wheelchair during transport, resulting in a femur fracture. The van driver did not call emergency services and continued to the appointment. Upon return, the incident was reported to the Admissions Coordinator and a nurse, but the resident was not assessed or documented in the medical record. The injury was discovered days later after the resident complained of pain, revealing a lack of supervision and communication within the facility.
A resident with multiple diagnoses, including chronic pain and pressure ulcers, did not receive adequate pain management during wound care. Despite having orders for Acetaminophen and Morphine, the resident was not premedicated, leading to significant discomfort. Staff interviews and observations confirmed the oversight, with the RN admitting to not administering pain relief as per protocol. The DON acknowledged the failure to follow pain management procedures, resulting in a deficiency in care.
A resident with multiple health conditions fell from a wheelchair during transportation, resulting in a fracture. The facility failed to report the incident to the SSA within the required timeframe. Despite the resident's ongoing pain and eventual diagnosis of a fracture, the incident was not reported, highlighting a communication breakdown between the DON and the Administrator.
Two residents' MDS assessments were inaccurately completed, failing to reflect hospice services and PASRR Level II status. A resident receiving hospice care was not coded as such, and another with a PASRR Level II indicating serious mental illness was incorrectly documented. The MDS Coordinator did not thoroughly verify these statuses, leading to documentation errors.
A resident with a complex medical history experienced knee and hip pain, prompting x-rays to be ordered. While reports for the left knee and hips were documented, the right knee x-ray report was missing from the medical record, despite a critical fracture being reported. The DON acknowledged the oversight, and the missing report was later provided by the Regional Clinical Operations Director.
A facility failed to maintain proper infection control during a wound care procedure for a resident with pressure ulcers. The RN did not perform hand hygiene between glove changes and handled sterile supplies with bare hands, contrary to facility policy. The resident, who had multiple medical conditions and was dependent on staff, expressed pain during the procedure. The DON confirmed the breach in protocol, highlighting a deficiency in the infection prevention and control program.
Resident Fall Due to Improper Hoyer Lift Use and Missing Safety Latches
Penalty
Summary
A deficiency occurred when a resident, who was dependent on staff for all transfers and activities of daily living due to multiple medical conditions including hemiplegia, diabetes, and a history of stroke, sustained a fall from a Hoyer lift during a transfer from bed to wheelchair. The incident happened during a one-person assisted transfer, despite facility policy and manufacturer guidelines requiring at least two staff members for safe operation of the mechanical lift. The resident was found on the floor with pain in the hip and knee, and later diagnosed with a fracture after being transferred to the hospital due to persistent, severe pain. Investigation revealed that the Hoyer lift used during the incident was missing safety latches on the cradle hooks, which are required by the manufacturer to prevent sling straps from slipping off. Staff interviews confirmed that the sling was not properly secured, with one of the straps not attached to the lift, and that the CNA operating the lift did not request assistance or verify the secure placement of all straps. The CNA involved admitted to not being familiar with the sling and noted that the absence of safety latches made it easier for straps to come off the hooks. Another CNA present at the time also failed to inspect the sling for proper placement, assuming the other staff member had done so. Observations and interviews further confirmed that both Hoyer lifts in the facility were missing some or all of the required safety latches, and that staff were not consistently following procedures to ensure equipment was in good working condition and that transfers were performed with adequate supervision. The facility's own policy and the manufacturer's instructions both require thorough inspection of the lift and sling, proper attachment of all straps, and the presence of two trained staff during transfers. These requirements were not met at the time of the incident, directly leading to the resident's fall and injury.
Failure to Timely Report Suspected Neglect Following Resident Fall
Penalty
Summary
A deficiency occurred when the facility failed to report an alleged violation involving neglect within the required 24-hour timeframe. Specifically, a resident with multiple complex medical conditions, including type 2 diabetes mellitus, right femur fracture, hemiplegia, and respiratory failure, sustained a fall from a Hoyer lift during a one-person assisted transfer. The incident resulted in a fracture, and the event was documented by the Interdisciplinary Team as a fall from the lift. However, the State Survey Agency (SSA) was not notified of the incident until approximately seven days after it occurred, and there was no documentation indicating that Adult Protective Services (APS) had been notified at all. During an interview, the Director of Nursing (DON) acknowledged the regulatory requirement to report suspected abuse or neglect to the state within two hours and confirmed that the facility did not investigate the incident for possible neglect in a timely manner. The DON also stated that APS was not notified and could not provide a reason for this omission. The failure to report the incident as required and to notify the appropriate authorities constituted a violation of mandated reporting protocols.
Failure to Document Thorough Investigation After Resident Fall
Penalty
Summary
A deficiency was identified when the facility failed to provide evidence of a thorough investigation into an allegation of neglect following a fall incident involving a resident. The resident, who had multiple complex medical diagnoses including type 2 diabetes, right femur fracture, asthma, major depressive disorder, hemiplegia, respiratory failure, and cognitive communication deficit, sustained a fall from a Hoyer lift during a one-person assisted transfer. The incident resulted in complaints of pain and a visible injury, prompting an abuse investigation and notification to the State Survey Agency. The facility's abuse investigation documentation was incomplete, lacking records of interviews with the staff members involved in the transfer and the resident. Additionally, the investigation summary referenced an interview with the resident, but no documentation of this interview was found. The date of the incident was also incorrectly documented in the investigation. The Director of Nursing confirmed that the investigation records did not contain the necessary interviews to rule out neglect, and it was not evident from the documentation that a thorough investigation had been conducted.
Resident Fall Due to Lack of Wheelchair Footrests During Transport
Penalty
Summary
A deficiency occurred when a resident with a history of cerebral palsy, functional quadriplegia, contractures, and balance deficits was being transported in a wheelchair by a CNA without the use of footrests. The resident, who was able to self-propel using one foot, was being pushed by staff when her foot caught on the ground, causing her to fall forward out of the wheelchair. As a result, the resident sustained abrasions to her face and wrist, a skin tear, and a laceration to her lip. She also experienced pain in her back, mouth, face, and chest, and exhibited shallow breathing following the incident. Medical records indicated that the resident was unable to brace herself during the fall due to her physical limitations. The incident required emergency medical services, and the resident was transferred to a hospital for evaluation. Subsequent assessments confirmed no fractures, but superficial injuries were present. The deficiency was identified through observation, interviews, and record review, which confirmed that the resident did not have appropriate supervision and safety measures in place to prevent the accident during wheelchair transport.
Medication Error: Resident Administered Roommate's Medications
Penalty
Summary
A nurse administered the incorrect medications to a resident by giving her the medications intended for her roommate. The medications given in error included acetaminophen 325mg, senna 8.6mg, trazodone 50mg, and extended release morphine 15mg. The incident was documented in the resident's medical record, and the nurse notified the physician, who provided instructions to hold the resident's scheduled Tylenol, senna, and trazodone. The nurse also contacted the resident's emergency contact and initiated monitoring for any adverse effects. Following the medication error, nursing staff conducted additional assessments each shift to monitor the resident for any changes in condition. Throughout the monitoring period, the resident's condition remained at baseline with no noted changes. The nurse involved reported the error to the nurse manager and followed instructions to check for allergies and perform neurological checks. The incident was the only medication error reported in the facility within the past 60 days.
Resident Injury Due to Inadequate Supervision During Transport
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices to prevent accidents for a resident, who slid out of her wheelchair during transport and sustained a femur fracture. The resident, who had a history of hemiplegia, hemiparesis, and moderate cognitive impairment, was being transported to a medical appointment when the incident occurred. The van driver reported that the resident informed him she was sliding out of her wheelchair, prompting him to stop and seek assistance from a nearby school. Despite the resident being partially suspended by the seatbelt, the driver did not call emergency services, as per company policy, and continued to the appointment. Upon returning to the facility, the van driver informed the Admissions Coordinator and a nurse about the incident. However, the nurse did not assess the resident or document the occurrence in the medical record. The resident later complained of pain, leading to x-rays that revealed a fracture. The facility's staff, including the DON and ADON, were not immediately informed of the incident, and the resident's condition was not promptly addressed, resulting in a delay in identifying the injury. Interviews with facility staff revealed communication breakdowns and a lack of proper documentation and assessment following the incident. The SLP was informed by the resident about the fall and reported it to the DON, but did not document this communication. The RN on duty at the time of the incident did not perform an assessment or document the event, contributing to the oversight. The facility's failure to ensure proper supervision and communication led to the resident's injury going unaddressed for several days.
Inadequate Pain Management for Resident During Wound Care
Penalty
Summary
The facility failed to provide adequate pain management for a resident, identified as Resident 42, who required such services. Resident 42 was admitted with multiple diagnoses, including chronic pain and pressure ulcers. Despite having physician orders for pain management, including Acetaminophen and Morphine, the resident did not receive pain medication prior to or after wound care treatments. The resident reported a pain level of 8 out of 10, yet the medication administration record showed inconsistent documentation of pain scores and administration of pain relief. During an observation, Resident 42 expressed pain during wound care, moaning and vocalizing discomfort, yet was not premedicated with pain relief as per the facility's protocol. The Registered Nurse (RN) involved acknowledged the oversight and admitted to not administering pain medication before or after the wound care session. The Director of Nursing (DON) confirmed that pain medication should be administered 30 to 40 minutes prior to wound care, but this protocol was not followed. Interviews with staff revealed that Resident 42 was dependent on staff for care and experienced pain with movement, particularly in the right knee and heels. Despite having orders for pain evaluations every shift and the availability of Morphine for severe pain, the resident's pain management was inadequate, leading to unnecessary suffering during wound care procedures. The facility's failure to adhere to pain management protocols and physician orders resulted in a deficiency in providing appropriate care for Resident 42.
Failure to Report Resident Fracture Incident
Penalty
Summary
The facility failed to report an incident involving a resident who sustained a fracture during transportation. Resident 20, who has a medical history including hemiplegia, heart disease, diabetes, and cognitive deficits, fell out of a wheelchair while being transported to an appointment. The incident was initially noted by a speech language pathologist and later by the Assistant Director of Nursing (ADON), who observed an abrasion on the resident's knee. Despite these observations, the incident was not reported to the State Survey Agency (SSA) as required. The resident continued to experience pain, leading to further assessments and x-rays. Initially, x-rays of the left knee and hips showed normal results, but subsequent x-rays revealed a critical fracture in the right leg/knee. The resident was then sent to the emergency room for treatment. Despite the discovery of the fracture, the facility did not report the incident to the SSA within the required timeframe. Interviews with the Director of Nursing (DON) and the Administrator revealed a lack of communication and understanding regarding the reporting requirements. The DON believed the incident was not reportable until the fracture was confirmed, and the Administrator acknowledged that no report was filed with the SSA. The Administrator stated that the incident should have been reported within 24 hours once the fracture was identified, but this did not occur.
Inaccurate MDS Assessments for Hospice and PASRR Status
Penalty
Summary
The facility failed to accurately reflect the status of two residents in their Minimum Data Set (MDS) assessments, leading to deficiencies in the documentation of hospice services and Preadmission Screening and Resident Review (PASRR) Level II status. Resident 22, who was receiving hospice services, was not coded as such on two quarterly MDS assessments and an annual MDS assessment. Despite the hospice start of care date being documented in the resident's medical record, the MDS Coordinator did not identify this in the daily census or the resident's medical record, where the resident was listed as private pay. Resident 27, who had a PASRR Level II assessment indicating serious mental illness, was not accurately coded in the MDS assessment. The MDS Coordinator relied solely on the PASRR Letter of Determination, which did not explicitly state the presence of a serious mental illness, rather than reviewing the full PASRR Level II evaluation. This led to an incorrect 'No' response in the MDS assessment regarding the resident's PASRR status, despite the evaluation documenting a serious mental illness. The MDS Coordinator's process for completing assessments involved a schedule distributed to department heads, with various sections of the MDS being completed by different staff members. However, the MDS Coordinator did not verify the hospice status or PASRR Level II status through comprehensive review of the residents' medical records, leading to inaccuracies in the MDS assessments for both residents.
Missing X-ray Report in Resident's Medical Record
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for a resident, specifically by not filing a signed and dated x-ray report for the resident's right knee. The resident, who had a complex medical history including hemiplegia, atherosclerotic heart disease, and type 2 diabetes, was experiencing bilateral knee and hip pain. An x-ray was ordered for both knees and hips, and while the results for the left knee and hips were documented, the report for the right knee was missing from the medical record. The deficiency was identified during a review of the resident's medical records, which revealed that the x-ray report for the right knee was not present, despite a critical fracture being reported to the facility. The Director of Nursing acknowledged the oversight, stating that the facility had not received a printed report for the right knee, although the Regional Clinical Operations Director later provided a copy of the missing report. This lapse in documentation highlights a failure in the facility's process for ensuring all diagnostic reports are properly filed in the resident's medical record.
Infection Control Deficiency in Wound Care Procedure
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by improper hand hygiene and PPE usage during a wound care treatment for a resident. The resident, who had multiple medical conditions including dementia and pressure ulcers on both heels, was observed receiving wound care from a registered nurse (RN). During the procedure, the RN did not adhere to proper hand hygiene protocols, such as failing to perform hand hygiene between glove changes and handling sterile supplies with bare hands. The resident, who was dependent on staff for care and had a moderate cognitive impairment, expressed pain during the wound care procedure. The RN was observed to don and doff gloves without performing hand hygiene in between, and handled sterile gauze with bare hands, which compromised the sterility of the supplies. The RN acknowledged the need for hand hygiene between glove changes but did not follow through during the procedure. The Director of Nursing (DON) confirmed that the facility's policy required hand hygiene before donning gloves and between glove changes, especially when moving from a dirty to a clean area. The facility's policy on hand hygiene, which was last revised in February 2024, was not adhered to during the observed wound care, leading to a deficiency in the infection prevention and control program.
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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