Monument Healthcare Brigham City
Inspection history, citations, penalties and survey trends for this long-term care facility in Brigham City, Utah.
- Location
- 775 North 200 East, Brigham City, Utah 84302
- CMS Provider Number
- 465093
- Inspections on file
- 15
- Latest survey
- December 3, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Monument Healthcare Brigham City during CMS and state inspections, most recent first.
A resident with severe dementia and urinary incontinence was left in a wet brief for approximately eight hours, leading to a rash and excoriation. The assigned CNA failed to perform required two-hour checks, gave conflicting accounts of care provided, and blocked staff from entering the room. Staff interviews confirmed that the resident was unable to communicate her needs and required frequent incontinence care, which was not provided, resulting in physical harm.
A resident with dementia was found exiting a locked therapy room, appearing disoriented and sick, after allegedly engaging in sexual actions with a male staff member. The staff member was present in the facility after hours, and the therapy room was inaccessible to other staff, leading to an Immediate Jeopardy citation.
The facility failed to comply with food service safety standards as the dish machine's temperatures were below required levels, and there were no sanitizer strips available. The Dietary Manager acknowledged temperature fluctuations, and the Dietary Aide confirmed inaccurate temperature logging. A Vendor Consultant suggested changes to the logging process.
The facility failed to provide palatable and appetizing meals at safe temperatures. Residents reported dissatisfaction with food quality, citing issues such as unappealing presentation, excessive spiciness, and lack of substitutes. Observations revealed bland and improperly prepared meals, with food served at inadequate temperatures. The Dietary Manager and Vendor Consultant acknowledged issues with meal preparation and presentation.
The facility failed to provide suitable and nourishing alternative snacks for residents wanting to eat at non-traditional times. Observations showed that only saltine crackers were consistently available, with occasional fruits and other snacks not being restocked regularly. Residents expressed dissatisfaction with the limited snack options, and staff interviews revealed inconsistencies in snack restocking routines.
The facility failed to maintain a clean and homelike environment due to persistent strong odors, including urine and bowel movement smells, throughout various areas. Observations over several days confirmed these odors, with staff interviews indicating that certain residents contributed to the issue due to incontinence and refusal to be changed. Despite attempts to mitigate the odors, the facility did not adequately address the problem, resulting in a deficiency.
The facility failed to connect a Physical Therapy Assistant to the Direct Access Clearance System (DACS), despite having completed a background check. This oversight was discovered during a survey, revealing a lapse in the implementation of policies designed to prevent abuse, neglect, and exploitation of residents.
A resident at risk for falls experienced multiple unwitnessed falls, a skin tear, and hip pain due to the facility's failure to implement a comprehensive care plan. Despite being identified as needing a bariatric bed, this intervention was not executed, and staff were unaware of care plan updates. The lack of communication and follow-through on care plan interventions resulted in repeated falls and injuries.
A resident with a history of falls and health issues experienced multiple falls due to the facility's failure to provide a bariatric bed and timely interventions. Despite the resident's request for a larger bed, the facility did not provide it until after several incidents occurred, resulting in minor injuries and complaints of hip pain. Staff interviews revealed a lack of awareness and implementation of fall prevention measures.
Resident Left in Wet Brief for Extended Period Resulting in Skin Breakdown
Penalty
Summary
A deficiency occurred when a resident with severe dementia and urinary incontinence was left in a wet brief for an extended period, resulting in a rash and excoriation to the groin area. The resident was unable to communicate her needs and relied on staff for incontinence care. On the evening in question, the assigned CNA failed to perform the required two-hour checks and did not change the resident's brief for approximately eight hours. When oncoming staff arrived, they found the resident saturated with dried and wet urine up to her shoulders, and the nurse confirmed the resident's condition and documented skin breakdown. Multiple staff interviews revealed that the CNA assigned to the resident gave conflicting accounts of when care was last provided, initially claiming to have changed the resident multiple times, then admitting she had not done so since the afternoon. The CNA also blocked other staff from entering the resident's room and yelled at a coworker who confronted her about the lack of care. Other CNAs and nurses stated that routine practice was to check and change residents at least every two hours, and that leaving a resident in a wet brief could quickly lead to skin breakdown or infection. The facility's policy required regular incontinence care and monitoring to prevent neglect and harm. Staff interviews confirmed that the resident never refused care and that there were standing orders for frequent checks due to her incontinence and cognitive impairment. The failure to provide timely incontinence care directly resulted in physical harm to the resident, as evidenced by the documented skin issues and the observations of multiple staff members.
Resident Found in Locked Therapy Room with Alleged Abuse by Staff
Penalty
Summary
The facility failed to protect a resident from abuse, resulting in an Immediate Jeopardy citation. A resident with a history of dementia and cognitive impairments was found missing by staff, and after a search, was discovered exiting a locked therapy room. The resident made statements indicating that a male staff member engaged in sexual actions with her. The therapy room was inaccessible to staff, and the resident was found pale, nauseated, and disoriented, with therapy paperwork in hand. Interviews with staff revealed that the therapy room was locked, and the resident was missing for approximately 20 minutes. Staff observed the resident exiting the therapy room, appearing sick and disoriented. The resident later disclosed to staff that she and a male staff member attempted to engage in sexual activity, which was reportedly consensual according to the resident. However, the resident's cognitive impairments raised concerns about her ability to consent. The male staff member, a Physical Therapy Assistant, was found in the facility after hours, contrary to previous instructions. Staff reported that the therapy room was usually unlocked, and the male staff member's presence in the facility after hours had been a concern. The facility's failure to ensure the safety and security of the resident, as well as the lack of access to the therapy room, contributed to the deficiency.
Removal Plan
- Resident and staff member were separated.
- Police contacted upon suspicion.
- Resident assessed; no injury noted.
- Notification to Physicians, POA, Incident reported by administrator to DHS, APS, Ombudsman.
- Resident interviewed with administrator.
- Hospital evaluation completed, no trauma noted.
- Resident care plan reviewed and updated as needed.
- Provider to assess/evaluate residents including medication review.
- Social Services wellness visits to be completed for resident and PRN.
- Behavioral health visit requested with local mental health provider.
- Therapy staff member was immediately placed on administrative leave, facility keys/badge provided to administrator.
- Therapy staff member was questioned and released by the police, pending potential charges.
- Employee file was reviewed.
- Therapy staff member will not return to the facility.
- Regional Director of Operations spoke to Therapy Regional Director and informed him that staff are not to stay in the facility after normal business hours without the approval of the facility administrator.
- Facility will ensure the therapy staff working in the facility have background checks (DACS) that are connected to the facility.
- All residents interviewed by administrator/designee to assess potential for abuse/neglect allegations.
- Locks will be removed from all doors and/or Master Key accessible to charge nurse on medication cart.
- Staff Members will not remain in the facility after normal business hours without the approval of the facility administrator.
- Administrator, DON and RNC reviewed Abuse & Neglect Policy.
- Administrator, DON and IDT were educated by RNC regarding Abuse & Neglect Policy.
- Administrator/DON/designee will complete Abuse & Neglect education with all staff.
- Education including post-test initiated for all facility staff on Abuse/Neglect.
- All employees will be educated at start of their next shift or if no scheduled shift by all staff meeting.
- The DON/designee will review incidents of sexually inappropriate behavior to ensure appropriate interventions are implemented and no trends are noted.
- The Administrator/designee will conduct random resident & staff interviews to ensure the Abuse & Neglect Policy have been followed and allegations have been investigated and reported.
- The facility administrator/designee will do random facility visits during off hours to ensure that only staff clocked in and assigned to be working are in the facility and that the charge nurse has a Master Key to all locked doors in the facility.
- The Administrator/designee will review employee files (including contracted therapist) to ensure they have completed abuse training, verification of license and background checks (DACS) is connected to the facility.
- Medical Director was informed of the incident and QAA Review & Recommendations.
- Results will be reported to the QAA committee from monitoring and follow-up.
Non-compliance with Food Service Safety Standards
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. During an initial tour of the kitchen, it was observed that the dish machine's washing and rinse temperatures were below the manufacturer's required levels, with washing temperatures recorded at 110°F and rinse temperatures at 120°F. The Dietary Manager (DM) acknowledged the issue, stating that the dish machine temperatures fluctuated, especially during resident showers, and that the machine needed to be run multiple times to reach the appropriate temperature. Additionally, there were no sanitizer strips available to test the solution, and the DM was unable to locate any strips. A follow-up tour revealed continued non-compliance, with dish machine temperatures still below the required levels, and the sanitizer level was recorded at 100 PPM. The Low Temperature Dish Machine Log showed inconsistencies, with the last recorded temperature on the 14th, despite the follow-up occurring on the 16th. The Dietary Aide (DA) confirmed the low temperatures and admitted to documenting temperatures inaccurately. The Vendor Consultant, who visits the facility monthly, confirmed the need for the dish machine to reach temperatures above 120°F for both wash and rinse cycles and suggested changes to the logging process to include temperatures for breakfast, lunch, and dinner.
Deficiency in Food Quality and Temperature
Penalty
Summary
The facility failed to provide food that was palatable, attractive, and at a safe and appetizing temperature for its residents. During interviews, several residents expressed dissatisfaction with the food quality. One resident found the food unappealing and unappetizing, while another resident, who was sensitive to spices, reported that the food had been too spicy. Another resident mentioned the lack of substitutes, and yet another resident expressed a need for better food and was restricted to a limited amount of juice per day. Observations of the facility's tray line revealed issues with food preparation and presentation. A test tray contained bland and slimy turkey and ham with marinara sauce, pureed broccoli with chunks, and a dessert with raw cake on top. Further observations on a different day showed that the food served was not at an appetizing temperature, with pork, stuffing, broccoli, and coffee all served below ideal temperatures. The pork was tough and bland, the stuffing was mushy, and the cake was dry. Interviews with the Dietary Manager and a Vendor Consultant revealed that the alternative meal was not served to residents, and the turkey and ham had been prepared days earlier. The Vendor Consultant noted that the cook ran out of gravy and added water to the stuffing after it had been sitting on the steam table. These actions and inactions contributed to the deficiency in providing quality meals to the residents.
Inadequate Snack Provision for Residents
Penalty
Summary
The facility failed to provide suitable and nourishing alternative meals and snacks for residents who wanted to eat at non-traditional times or outside of scheduled meal service times. Observations revealed that for 5 out of 27 sampled residents, only saltine crackers were consistently offered as snacks. Containers at both the north and south nurses stations were observed to contain primarily saltine crackers, with some instances of crackers being open to air. Although there were occasional offerings of fruits and other snacks, these were not consistently available, and the restocking of snacks appeared to be irregular. Interviews with residents indicated dissatisfaction with the snack offerings. One resident mentioned that snacks were usually filled once a week and that the availability of better snacks seemed to coincide with visits from important individuals. Another resident expressed a desire for snacks to be offered at night to avoid going to bed hungry. Staff interviews revealed that the responsibility for restocking snacks was assigned to the evening shift, but there was no consistent routine for ensuring a variety of snacks were available. This inconsistency in snack availability and variety led to the deficiency noted by the surveyors.
Facility Fails to Maintain Clean and Homelike Environment Due to Persistent Odors
Penalty
Summary
The facility failed to provide a clean, comfortable, and homelike environment, as evidenced by persistent strong odors throughout various areas, including hallways and the dining room. Observations made over several days revealed a strong urine odor, as well as bowel movement and body odors, in multiple locations within the facility. Specific instances included a brown substance on a wheelchair seat and back, contributing to the unsanitary conditions. Interviews with staff, including a registered nurse, certified nursing assistants, and a housekeeper, confirmed the presence of these odors, with some staff acknowledging that certain residents contributed to the odors due to incontinence issues and refusal to be changed. Staff interviews revealed that the odors were a known issue, with some staff attempting to mitigate the smell using air fresheners. However, the odors persisted, particularly in areas where residents with incontinence issues were located. The housekeeper noted that certain rooms consistently had odors, often due to wet briefs being disposed of in bathroom trash cans. Despite these efforts, the facility's failure to adequately address and manage these odors resulted in a deficiency in maintaining a safe, clean, and homelike environment for residents.
Failure to Connect Staff to Facility in DACS
Penalty
Summary
The facility failed to develop and implement written policies and procedures that effectively prohibited and prevented abuse, neglect, and exploitation of residents. This deficiency was identified when a Physical Therapy Assistant (PTA) was found not to be connected to the facility through the Direct Access Clearance System (DACS), which is a requirement for ensuring that staff members are properly screened and linked to the facility. The PTA's employee file contained an offer letter for another facility, and there was no documentation indicating employment with the facility being surveyed. The information available was from a contract rehabilitation company, suggesting a lack of proper documentation and oversight. During an interview, the Administrator confirmed that a background screening was completed for the PTA, and no issues were found. However, the Background Processing Manager (BPM) at the State Survey Agency revealed that while the PTA was eligible for work, they had not been connected to the facility in the DACS. This oversight indicates a failure in the facility's process to ensure that all staff members are appropriately linked to the facility, which is a critical step in preventing abuse and ensuring resident safety. The facility's policy on preventing abuse, neglect, and exploitation, dated 11/2017 and revised in 9/2022, outlines comprehensive guidelines for screening, training, prevention, identification, investigation, protection, and reporting. Despite these guidelines, the failure to connect the PTA to the facility in the DACS represents a significant lapse in the implementation of these policies. This deficiency highlights the need for the facility to ensure that all staff, including contracted and temporary staff, are properly screened and documented in accordance with established procedures.
Failure to Implement Comprehensive Care Plan Leads to Resident Falls
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which resulted in multiple falls, a skin tear, and hip pain. The resident, who was admitted with several diagnoses including surgical amputation and chronic pain syndrome, was identified as being at risk for falls. Despite this, the care plan interventions, such as changing to a bariatric bed, were not implemented effectively. The resident experienced several unwitnessed falls, and although interventions like a floor mat and medication review were discussed, they were not timely or adequately executed. The resident's care plan was revised to include a bariatric bed, but this intervention was not implemented, as confirmed by staff interviews and the resident's own account. The resident continued to fall, sustaining injuries, and expressed frustration over not receiving the requested larger bed. Staff members, including CNAs and LPNs, were unaware of the care plan interventions, indicating a lack of communication and follow-through on the care plan updates. Interviews with the DON and other staff revealed discrepancies in the implementation of the care plan. The DON believed the resident had received a bariatric bed, but it was later discovered during the survey that this was not the case. The lack of proper communication and execution of the care plan interventions contributed to the resident's repeated falls and injuries, highlighting a deficiency in the facility's care planning and implementation processes.
Failure to Provide Adequate Fall Prevention Measures
Penalty
Summary
The facility failed to ensure that the resident environment was free from accident hazards and did not provide adequate supervision and assistance devices to prevent accidents for one resident. This resident, who had a history of falls and was at risk due to gait and balance problems, experienced multiple falls. Despite the resident's request for a larger bed to prevent falls, the facility did not provide a bariatric bed until after several incidents occurred. The resident, who had a history of surgical amputation, diabetes, and other health issues, was admitted to the facility and had a care plan indicating a risk for falls. The care plan was revised to include a bed change to a bariatric bed, but this intervention was not implemented in a timely manner. The resident experienced several unwitnessed falls, resulting in minor injuries and complaints of hip pain, yet the facility did not provide the necessary assistance device promptly. Interviews with staff revealed a lack of awareness and implementation of interventions to prevent falls. The DON initially stated that a bariatric bed was provided, but later confirmed that the resident did not have one. The facility's failure to provide the appropriate bed and timely interventions contributed to the resident's repeated falls and injuries.
Latest citations in Utah
A resident with Parkinson’s Disease was being transferred from bed to a chair using a mechanical (Hoyer) lift operated by two CNAs when a sling strap snapped, causing the resident to fall and strike the back of the head. The resident sustained an abrasion, a 1 cm scalp laceration with bleeding, and severe back pain rated 9/10, and was sent to the hospital for evaluation. Manufacturer instructions required staff to inspect slings and straps for wear before each use, but there was no evidence the specific sling used in this transfer had been inspected for integrity, and the Administrator acknowledged that the strap breakage led to the resident’s fall and injury.
The facility failed to timely report alleged abuse to SSA and APS after staff twice observed a resident with dementia and acute systolic CHF receiving zealous, open-mouthed kisses on the mouth from her brother. On two separate occasions, a CNA and an LPN witnessed or were informed of these unusual kissing interactions, which they later described as awkward and not typical of a sibling relationship. Despite this, the nursing staff did not immediately report the incidents as potential abuse to the Administrator, and the allegation was not brought forward until a staff meeting days later, resulting in the required notifications to external authorities not being made within the mandated 2-hour timeframe.
A resident with muscle weakness, gait abnormalities, atrial fibrillation, and on a blood thinner sustained an unwitnessed bathroom fall, reported hitting her head, and developed rapidly worsening right facial swelling and a swollen‑shut eye that prevented pupillary assessment. Initial vitals and neuro checks were performed, oxygen was applied, and x‑rays were ordered, but despite the significant change in condition and the resident’s anticoagulation status, the provider was not notified of the worsening condition at the time it occurred and the resident was not sent to the hospital until the next day when an NP assessed her and ordered transfer. In the ED, the physician documented that no evaluation for the injuries had occurred the prior evening and CT imaging showed traumatic subdural and subarachnoid hemorrhages and a large facial hematoma, demonstrating that the facility failed to provide timely, standard‑of‑care treatment and hospital transfer after the fall and subsequent change in condition.
A resident with cognitive impairment, neurological conditions, and substance-related diagnoses was assessed as being at risk for elopement and documented as having poor safety awareness, poor judgment, and wandering behavior requiring frequent redirection. Nursing staff observed the resident wandering in the hall and behind the nurse’s station and communicated during shift report that a WanderGuard was recommended, but no device was applied because staff did not know where to obtain one. The resident later left the building through the front door, was not immediately detected as missing, and was ultimately found by a medication technician about a mile away walking on a sidewalk near a restaurant, demonstrating a failure to provide adequate supervision and timely elopement interventions.
A nurse failed to follow professional standards for medication administration by not properly identifying a resident before giving medications, resulting in the administration of Lorazepam and Carvedilol that were intended for another resident. The error was discovered and documented, with monitoring showing the resident remained stable and without distress, and the hospice nurse, NP, and family were notified. Leadership, including the DON and administrators, acknowledged that the failure to correctly verify the resident’s identity led to the wrong medications being administered.
A resident with multiple comorbidities and an above-knee amputation requested that staff heat prepackaged ramen soup in a microwave at the nutrition station; staff followed package directions and returned the hot soup, which the resident, who used a motorized wheelchair and insisted on carrying items independently, then spilled while turning, causing a third-degree burn to the palmar side of the left wrist. Staff interviews showed that, before this incident, CNAs and an LPN heated food based on package instructions and judged safety by touch without thermometers, and the DON confirmed that no thermometers were available and that staff relied on touch to determine if food was safe to serve.
The facility failed to provide sufficient nursing staff with appropriate skills to respond promptly to call lights and assist residents with toileting, resulting in multiple residents experiencing incontinence and being left unattended on the toilet. Several residents with significant mobility and medical issues reported waiting long periods, including up to 30–45 minutes or more, for call lights to be answered, particularly during evenings, nights, shift changes, and weekends. Surveyors directly observed call lights sounding for 8–13 minutes before staff responded. Staff reported that CNA hours had been cut after a change in ownership, many staff had quit, and they were unable to complete all care tasks due to understaffing. Grievances and resident council notes over several months documented repeated complaints about slow call light response times, residents being left on the toilet for extended periods, and delays in getting to meals, while leadership acknowledged staffing was based on census rather than acuity despite the written facility assessment describing an acuity-based approach.
Multiple residents and a family member reported that meals were bland, unappetizing, sometimes raw or over-roasted, difficult to chew, and often cold by the time they reached residents’ rooms, with no consistent offer of alternatives when food was disliked. Resident council minutes and grievances documented concerns about cold meals, limited variety, lack of fruit, and meals perceived as too high in carbohydrates. A test tray showed hot items, including chicken tenders and tater tots, were served at low temperatures, with mushy, cold textures and dry, tough meat, and there was no plate warmer used while CNAs, rather than dietary staff, passed trays on the halls after a change in kitchen operations.
A resident with a right humerus fracture, chronic right arm pain, dementia (BIMS 9), and impaired use of one upper extremity required setup/clean-up assistance with eating, including cut food and opened containers, as reflected in the MDS and care plan. Despite this, surveyors observed multiple meals where the resident’s food was not consistently cut into bite-sized pieces and containers (such as lidded bowls, syrup packets, and juice boxes) were left unopened, leading family members to cut food on at least one occasion. The diet order and meal card lacked instructions for cut-up food or setup assistance, and interviews with CNAs, the DM, the MDS coordinator, and an RN confirmed that the resident needed this help but that it was not incorporated into formal orders or consistently implemented.
Two residents on modified diets for dementia and chewing/swallowing concerns were given snacks that did not match their ordered textures. One resident on a pureed diet, ordered after staff observed food being held in the mouth and poor chewing, was repeatedly provided ham sandwiches, potato chips, and an ice cream cone. Another resident on a minced & moist Level 5 diet with cut‑up foods was served a peanut cluster and later offered a crunchy “bird’s nest” snack with chow mein noodles and candy. Staff interviews revealed that activities staff supplied their own snacks without verifying diet orders, that the ST had not been consulted for a swallow evaluation in at least one case, and that nursing and dietary staff expected physician diet orders to be followed.
Failure to Inspect Mechanical Lift Sling Results in Resident Fall and Injury
Penalty
Summary
The deficiency involved the facility’s failure to ensure a resident’s environment was free from accident hazards and that equipment used for transfers was in safe, functional condition. A resident with Parkinson’s Disease was being transferred from bed to a chair using a mechanical (Hoyer) lift operated by two CNAs. One CNA reported that when she arrived to assist, the resident was already positioned in the sling, and as the lift was raised, a sling strap snapped, causing the resident to fall and strike the back of the head. Review of the manufacturer’s instructions for the lift and slings showed that staff were required to inspect slings and lifting straps for signs of wear, fraying, or weakness prior to every use. Record review showed that the resident sustained an abrasion to the back of the head, a 1 cm scalp laceration, and reported pain in the shoulders and neck following the fall, and was transferred to the hospital for evaluation. Subsequent NP documentation confirmed the 1 cm scalp laceration was bleeding and that the resident rated back pain as 9/10 on a numeric pain scale. Although maintenance records reflected a general audit of equipment had been conducted several weeks before the incident, there was no evidence that the specific sling used for this transfer had been inspected for integrity prior to use. During interview, the Administrator acknowledged that the equipment failure and strap breakage resulted in the resident’s fall and injury.
Failure to Timely Report Alleged Sexual Abuse to SSA and APS
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse and neglect were reported immediately, but no later than two hours after the allegation was made, to the State Survey Agency (SSA) and Adult Protective Services (APS). Resident 3, who was admitted with unspecified dementia and acute systolic congestive heart failure, was involved in two separate incidents in which her brother was observed kissing her on the mouth in a manner staff described as zealous, enthusiastic, sloppy, and not typical of a brother-sister interaction. On 12/28/25, CNA 1 observed a well-dressed man enter Resident 3's room, hug her, and give her a zealous kiss on the mouth. CNA 1 assumed the man was the resident's husband and reported this to LPN 1, who knew the visitor was the resident's brother. LPN 1 looked into the room and did not see anything out of the ordinary, and neither CNA 1 nor LPN 1 reported this incident as a potential allegation of abuse to the Administrator at that time. On 1/4/26, LPN 1 and CNA 1 entered Resident 3's room to address the resident's pain and request for catheter removal and to assist with a brief and linen change. Resident 3 had two visitors present, including her brother. When asked to step out for privacy, the female visitor left, but the brother hesitated and then gave Resident 3 a sloppy, open-mouthed kiss on the mouth lasting about three seconds, again in the presence of staff. The brother stated that Resident 3 was his older sister and that she had taken care of him since they were very small. LPN 1 did not report either the 12/28/25 or 1/4/26 kissing incidents to the Administrator. The Administrator later stated that the alleged abuse was first mentioned during a meeting on 1/6/26, at which time staff described the kiss as a weird, awkward kiss and not a typical brother-sister kiss, and acknowledged that nursing staff had not reported the suspicious activity in a timely manner, resulting in failure to notify SSA and APS within two hours of the allegation.
Delayed Hospital Transfer After Fall With Head Trauma and Anticoagulation
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident who experienced a fall with head trauma and was on anticoagulation received timely treatment and care in accordance with professional standards of practice. The resident had diagnoses including generalized muscle weakness, gait and mobility abnormalities, and unspecified atrial fibrillation, and was on a blood thinner. On the evening of the fall, nursing documentation showed that the resident was found on the bathroom floor after her roommate called out. The resident reported hitting her head, had facial pain rated 5/10, and initial vital signs showed an O2 saturation of 88–90% with other vitals within normal limits. A neurological assessment was initiated, oxygen was applied, and the on‑call provider was notified, who ordered x‑rays of the resident’s head and left hand. As the evening progressed, the resident’s condition changed. The nurse documented that the resident’s right eye became increasingly swollen to the point that by 9:15 PM it was swollen shut and pupillary reactivity could no longer be assessed, while the left eye remained equal and reactive to light. The neurological exam form recorded that the provider was notified of the fall at 8:00 PM, but did not indicate that the provider was notified when the right eye became swollen shut at 9:15 PM. The DON later stated that this change in the resident’s condition occurred at 9:15 PM and that the medical provider was not notified of this change until the provider came to the facility the following day. The DON also stated that if a resident on a blood thinner experienced a fall with head strike, she expected staff to send the resident to the hospital, and that she was not sure why this resident was not immediately sent. The resident remained in the facility overnight while x‑rays were obtained around 1:00–1:30 AM, with results reportedly available sometime between early morning hours and mid‑morning. The next morning, the NP assessed the resident due to the fall and documented significant right facial swelling, focal tenderness over the zygoma, difficulty visualizing the right eye, and concern for occult injury and possible orbital blowout fracture in the context of anticoagulation. The NP ordered transfer to the emergency department for CT imaging of the head and face. In the emergency department, the physician documented that no evaluation for the resident’s injuries had occurred the previous evening and that the facility had reported the resident seemed slightly altered the prior night and had worsening swelling by the time EMS was called. CT imaging revealed traumatic small subdural and subarachnoid hemorrhages without mass effect and a large facial hematoma. Interviews with nursing staff showed that the RN on duty was very concerned about the resident’s rapidly increasing facial swelling and difficulty administering medications due to lip swelling, but was waiting for a physician order to send the resident to the hospital and was unaware at the time that she could initiate a hospital transfer without such an order. These actions and inactions resulted in a delay in sending the resident to the hospital after a significant change in condition following a fall with head trauma while on a blood thinner. The facility’s Change of Condition/SBAR Evaluation Policy outlined expectations for describing changes in condition, documenting vital signs, identifying changes from baseline (including neurological status changes), and notifying the provider and responsible party, as well as documenting immediate actions and outcomes such as transfer to the hospital. Despite this policy, the neurological exam form did not reflect timely provider notification when the resident’s right eye became swollen shut, and the resident was not transferred until the following day after the NP’s in‑person assessment. The DON confirmed that the change in condition at 9:15 PM was not communicated to the provider until the next day. The surveyors determined that, for this resident, the facility did not ensure timely hospital transfer and did not provide treatment and care in accordance with professional standards of practice after a fall with head injury and subsequent change in condition.
Failure to Implement Elopement Precautions and Supervision for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and implement elopement precautions for a cognitively impaired resident who was identified as being at risk for elopement. The resident was admitted with multiple neurological and substance-related diagnoses, including cerebral infarction, ataxia, Wernicke’s encephalopathy, alcohol and opioid dependence, and traumatic subdural hemorrhage. On admission, the resident’s elopement risk screening showed a score of 12, indicating elopement risk, and nursing documentation described poor safety awareness, poor judgment, and a need for continuous cues with self-care and ADLs. The resident was also noted to require 1:1 supervision during meals due to quick eating behavior. In the hours leading up to the elopement, nursing staff observed the resident wandering in the hallway and behind the nurse’s station and reported that he required constant redirection. The night shift RN informed the day shift LPN during report that the resident had been wandering since early morning and that a WanderGuard was recommended. Despite this, no WanderGuard was applied before the resident left the building. The LPN later stated that she did not know where to obtain a WanderGuard, and the DON confirmed that both the RN and LPN had not placed a WanderGuard because they did not know its location. On the day of the incident, the resident went to the kitchen and requested water, and kitchen staff noticed a fall risk bracelet on his wrist. After this interaction, staff discovered that the resident was no longer in the building. Facility investigation determined that the resident exited through the front door at approximately 9:37 AM and was later found off premises, about one mile away, walking on a sidewalk near a restaurant. A medication technician, who had previously seen the resident wandering in only a gown and had informed the nurse, located the resident and returned him to the facility. These events demonstrate that, despite known elopement risk and observed wandering behavior, the facility did not implement timely elopement precautions or ensure adequate supervision to prevent the resident from eloping.
Medication Administration Error Due to Failure to Verify Resident Identity
Penalty
Summary
The deficiency involves a failure to provide necessary care and services in accordance with professional standards of practice during medication administration. For one resident reviewed for medication administration, a nurse did not follow the Five Rights of medication administration, specifically failing to properly identify the resident before giving medications. As a result, the nurse administered 0.25 mL of Lorazepam, an anti-anxiety medication, and 25 mg of Carvedilol, a beta-blocker used for blood pressure, that were intended for a different resident to Resident #1. Following the administration error, Resident #1’s vital signs were monitored throughout the night, and documentation indicated the resident remained stable, alert, and without signs of distress during the shift. The hospice nurse, nurse practitioner, and family were notified of the error. During interviews, the Administrator and DON acknowledged the medication error, and the DON confirmed that the nurse’s failure to correctly identify the resident prior to administering the medications was the cause of the wrong medications being given.
Burn Injury from Hot Soup Due to Inadequate Supervision and Temperature Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and accident prevention for a resident who sustained a burn injury from hot food. One resident with end stage renal disease, type 2 diabetes mellitus, pericardial effusion, chronic obstructive pulmonary disease, and an above-knee amputation of the left leg requested that staff heat a prepackaged ramen soup. Facility staff heated the soup in a microwave located in the nutrition station behind the nurse’s station according to the package directions and then returned the hot soup to the resident. After receiving the heated soup, the resident, who used a motorized wheelchair and was described as very independent, turned in his power wheelchair, causing the ramen to spill and the hot liquid to burn the palmar side of his left wrist. A progress note documented that the resident received a burn to his left wrist after spilling the hot soup, that the wound was assessed, wound care was provided, and new orders were placed following consultation with a wound provider. The resident reportedly tolerated treatment well and denied pain or other concerns at that time. Subsequent documentation by a wound provider classified the burn on the resident’s left wrist as a third-degree burn. Staff interviews revealed that, prior to this incident, staff heated residents’ food according to package directions and determined whether it was safe to return based on touch, without using thermometers to verify temperature. A CNA reported that the resident often asked CNAs to heat food and insisted on carrying it himself, and that staff declined to heat his food when he refused to allow them to carry it due to safety concerns. An LPN and the DON both confirmed that thermometers were not available for use before the burn occurred and that staff relied on touch to judge food temperature.
Insufficient Nursing Staff and Delayed Call Light Response Leading to Incontinence and Unattended Toileting
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff with appropriate competencies and skills to meet residents’ needs, particularly in timely response to call lights and assistance with toileting, which resulted in incontinent episodes and residents being left unattended. Multiple residents reported long call light wait times, especially during evening and night shifts and on weekends, when there were as few as three CNAs for the entire building. Residents with significant physical limitations, including recent hip fractures, hemiplegia, and other serious conditions, described being unable to get to the bathroom without staff assistance and experiencing incontinence because staff did not respond promptly to their call lights. One resident with a periprosthetic hip fracture, hemiplegia, an artificial hip joint, major depressive disorder, and anxiety reported that from 6:00 PM to 6:00 AM there were only three CNAs for three hallways, resulting in long waits for call light responses. This resident stated she had incontinent bladder episodes when she first arrived because she could not hold her urine while waiting for help, including one instance where she waited 35 minutes for a response. Another resident with a left femur fracture, chronic pain, lupus, and epilepsy reported waiting an hour for her call light to be answered, leading to urinating in her brief because staff did not arrive in time to take her to the bathroom. A third resident with metabolic encephalopathy, acute respiratory failure with hypoxia, pneumonia, UTI, and end-stage renal disease on dialysis stated she had been left on the toilet and had to get herself off and back to bed due to lack of staff. CNA documentation showed multiple incontinent episodes for these residents despite staff describing them as continent of bowel and bladder. Additional residents and a family member reported frequent long call light wait times, including waits of 30–45 minutes, particularly during shift changes and on weekends. The Resident Council President reported that since a change in ownership, residents complained that call lights took 30–40 minutes to be answered and that there were not enough CNAs on the night shift to handle residents’ needs during evening and bedtime hours. Direct observations by surveyors documented call lights sounding for 8 to 13 minutes before being answered on multiple occasions. Staff interviews confirmed that CNA hours had been cut after the ownership change, that many staff had quit, and that staff were asked to work a lot of overtime and were sometimes unable to complete showers due to understaffing. One staff member reported a resident had an incontinent episode after waiting about 45 minutes for a call light response. Grievance records and resident council notes showed a repeated pattern of complaints over several months about slow call light response times, residents being left on the toilet for extended periods, and delays in getting to meals due to insufficient staff. Grievances included reports of residents waiting over an hour to be taken to breakfast, feeling ignored when requests were not fulfilled, and being left on the toilet for almost three hours, causing discomfort. Resident council notes repeatedly documented concerns about call lights taking a long time to be answered, not enough CNAs in the dining room at mealtimes, and residents being left on the toilet or not getting to breakfast on time. Although the facility’s written facility assessment and staffing plan referenced using acuity and tools such as the MDS and RAI to determine staffing, the DON stated that in practice staffing coverage was based on census rather than acuity and acknowledged there had been many issues with call lights since staffing was cut after the change in ownership.
Failure to Provide Palatable, Attractive Meals at Appropriate Temperatures
Penalty
Summary
The deficiency involves the facility’s failure to consistently provide food and drink that were palatable, attractive, and served at safe and appetizing temperatures for multiple residents. Several residents reported that the food was bland, horrible, disgusting, or generally “not good,” and one resident stated that if she did not like what was served, staff did not offer an alternative and that she repeatedly received dark meat she did not like. A family member reported that a resident with a poor appetite received chicken that was dry and needed more moisture. Resident council minutes documented concerns that hamburgers were sometimes too raw, vegetables were roasted to the point of tasting burned, pork chops were difficult to cut or chew, and that food delivered to rooms was cold by the time it arrived when CNAs passed trays. Surveyors’ direct observation of a test tray showed that hot items were not maintained at appetizing temperatures and were of poor quality. After the last tray was plated and placed in the cart, CNAs—not dietary staff—were responsible for passing trays to residents, and there was no plate warmer between the plate and the plastic base. When the test tray was checked, the chicken tender and tater tots were below typical hot-holding temperatures, with the tater tots described as mushy and cold and the chicken tender as dry, tough to chew, and salty. The cold item, a carrot coin salad, was measured at a chilled temperature. Grievances documented that meals were served too cold and that residents were dissatisfied with the variety, fruit options, and perceived high carbohydrate content of the meals. The Dietary Manager acknowledged that dietary staff no longer delivered trays to residents after a change in ownership and attributed cold food to CNAs not passing trays quickly enough, while the Administrator acknowledged there had been complaints about food quality.
Failure to Provide Required Meal Setup and Cut Food Assistance for Resident With Upper Extremity Impairment
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate treatment and services to maintain or improve a resident’s ability to perform ADLs related to dining and eating, specifically cutting food into bite-sized pieces and opening containers as assessed and care planned. A resident with a right humerus fracture, chronic right arm pain, dementia with moderate cognitive impairment (BIMS 9), polyneuropathy, osteoarthritis, chronic pain syndrome, and a right artificial shoulder joint reported being unable to cut her own food and demonstrated that she had to guide her right arm with her left hand. Surveyors observed on multiple occasions that her meals were not consistently prepared or set up to match her assessed need for setup/clean-up assistance with eating. At one meal, her family reported they had to cut up her food and that this was not the first time. At another meal, her breakfast tray included whole sausage links, a lidded bowl, an unopened syrup packet, and a closed juice box with the straw still wrapped, despite her limited use of one arm. The resident’s MDS indicated impairment in one upper extremity and a need for setup or clean-up assistance with eating, and her care plan documented a focus on ADL self-care performance deficit related to dementia and impaired balance, with an intervention that she required setup or clean-up assistance to eat. However, her physician’s diet order specified only a regular diet with regular texture and consistency, with no instruction for cut-up food or meal setup assistance. The Dietary Manager confirmed there were no directions on the resident’s meal card to cut up her food and stated that food was sometimes cut into strips, including pork cutlets, based on the type of food. The MDS Coordinator and an RN both stated that the resident needed her food cut up and lids removed for meal setup and that it would be too difficult for her to manage with one arm, but acknowledged these needs were not reflected in physician orders. Staff also noted that the resident likely could not cut her own food due to right arm pain and limited function and that she would not usually ask for help even when needed, yet the kitchen and nursing staff did not consistently ensure her food was cut into bite-sized pieces or that containers were opened for her.
Failure to Provide Ordered Diet Textures During Nursing and Activities Snacks
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents received food in the texture ordered to meet their individual needs. One resident with dementia and Alzheimer’s disease had a physician’s order for a pureed diet after nursing, the DON, and the nurse practitioner observed that she was not eating well on a regular diet, was cheeking food, holding it in her mouth, and not chewing. Despite this pureed diet order, multiple nursing progress notes documented that she was given ham sandwiches and potato chips on several nights, and an activities note documented that she ate an ice cream cone. Staff interviews confirmed that she was on a pureed diet because she would let food sit in her mouth and that chips and sandwiches are not part of a pureed diet. The speech therapist stated he had not been asked to evaluate her swallowing, that he normally would want to screen residents whose diets were downgraded, and that non‑pureed foods for someone who holds food in their mouth would be a choking concern. Another resident with dementia and a severe cognitive impairment, as evidenced by a BIMS score of 3, had a physician’s order for a regular diet with minced and moist (Level 5) texture and cut‑up foods due to loose teeth. Nonetheless, an activities progress note documented that she ate a peanut cluster during a cooking social, and the Activities Director later reported that she was also given a “bird’s nest” snack made of crunchy chow mein noodles with candy on top, which she did not eat. Nursing staff stated that this resident did not have the mental capacity to chew, required extensive cueing, and that they would be concerned about choking if she were served non‑minced and moist foods. The Dietary Manager reported that the Activities Department provided its own snacks and did not ensure residents received the correct diet textures, and the DON stated that staff were expected to follow physician orders for diet textures despite limited availability of the speech therapist.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
