Monument Healthcare Millcreek
Inspection history, citations, penalties and survey trends for this long-term care facility in Salt Lake City, Utah.
- Location
- 1201 East 4500 South, Salt Lake City, Utah 84117
- CMS Provider Number
- 465139
- Inspections on file
- 17
- Latest survey
- January 21, 2026
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Monument Healthcare Millcreek during CMS and state inspections, most recent first.
A resident with complex cardiac, renal, and nutritional conditions received evening TPN ordered with pharmacy instructions that conflicted between the electronic order summary and the pharmacy label regarding total volume, rate, and duration. An agency RN initiated the TPN, reported not finding an IV pump, and manually regulated the infusion via roller clamp instead of using the pump that was later confirmed to be in the room. The TPN, which was ordered to infuse over many hours with tapering, was instead delivered over roughly 3 hours, and the oncoming RN later found the bag empty and connected directly to the PICC line without the pump. Subsequent documentation showed marked changes in the resident’s neuro status and vital signs, including lethargy, altered mental status, elevated HR and BP, hyperglycemia, and complaints of chest pain, leading to EMS transfer and hospital admission. The facility’s investigation substantiated that the TPN was administered incorrectly as a bolus, and the PN policy requiring controlled, tapered infusion was not followed, while the transfer documentation did not note the TPN bolus when the resident was sent to the hospital.
A resident with sepsis and kidney stones was managed on PRN morphine for pain, but two concurrent PRN orders for morphine 15 mg (0.5 tablet q3h and 1 tablet q3h) were entered, creating a potential daily dose of up to 180 mg without clarification. Despite documentation of slurred speech, lethargy, low O2 sats, cough, and shortness of breath, and a provider note attributing intermittent dysarthria to morphine and indicating the need to reduce dosing unless pain exceeded 4, no updated morphine order was found. Nursing staff continued to administer 15 mg doses based largely on the resident’s requests and subjective pain scores, without resolving the conflicting orders or consistently consulting the provider, and the resident was ultimately transferred to the ED in critical condition, where opiate toxicity was diagnosed and treated with naloxone.
Three residents experienced deficiencies in medication management, including administration of blood pressure medications outside of physician-ordered parameters and missed doses of a diabetes medication due to pharmacy and documentation issues. The DON and LPN confirmed that medications were given when they should have been held or were not administered as scheduled, and that proper physician notification and documentation were lacking.
Seven public bathrooms accessible to residents were observed to lack call light systems, preventing residents from being able to call for staff assistance while using these facilities. The Director of Maintenance confirmed that these bathrooms were accessible to residents and did not have call lights installed, stating he was unaware of the requirement.
A resident with diabetes and other complex medical needs missed several scheduled doses of Trulicity due to pharmacy and supply issues, but the physician was not immediately notified of these missed doses. Documentation showed delays in both medication administration and provider notification, and staff interviews confirmed that the required immediate communication with the physician did not occur.
A resident admitted with surgical wounds and dressings on both feet did not receive wound care orders until nine days after admission, despite having a care plan noting the risk for skin breakdown and documented wounds. The admitting nurse did not obtain or verify wound care orders upon admission, and no wound care was documented until orders were finally received from the physician.
A resident with multiple serious health conditions did not receive several scheduled doses of IV Vancomycin, as ordered for treatment of bacterial arthritis and MRSA. The MAR showed missed or undocumented doses, with no corresponding nurse notes to explain the omissions. Nursing staff confirmed that missed doses should be documented and reported, but this was not done, resulting in a significant medication error.
A resident with multiple health conditions receiving IV Vancomycin had several high trough lab results, but there was no documentation that the physician was notified of these abnormal values. Staff interviews confirmed that the process required physician notification and documentation, but records did not show this occurred.
A resident with multiple complex diagnoses had a STAT KUB x-ray ordered and performed due to abdominal symptoms, but the signed and dated x-ray report was not filed in the clinical record. Staff interviews revealed inconsistencies in the process for handling and filing diagnostic results, resulting in the required documentation being unavailable in the resident's chart.
A resident with MRSA, wounds, and a PICC line was not placed on appropriate contact precautions, as required by facility policy and CDC guidance. Staff were unclear about the differences between Enhanced Barrier Precautions and Contact Precautions, and the resident participated in therapy sessions outside their room without proper signage or PPE protocols in place, resulting in a breakdown of the infection prevention and control program.
Unsafe TPN Administration via Gravity Drip and Order Discrepancies
Penalty
Summary
The deficiency involves the unsafe and inappropriate administration of TPN/IV fluids to a cognitively intact resident with multiple complex medical conditions, including CHF, chronic pulmonary edema, chronic kidney disease, kidney transplant status, malnutrition, intestinal fistula, and electrolyte disorders. The resident had an order for evening TPN with pharmacy instructions specifying a compounded volume of 1800 ml, including start and end taper periods, and a total run period of 16 hours. However, the pharmacy label on the TPN bag directed infusion of 1800 ml at 125 ml/hr over 12 hours, and there were discrepancies between the pharmacy order summary (with tapering start and end rates and volumes) and the label directions. The DON later acknowledged that the label directions did not match the calculated infusion time for the stated volume and rate and that there was confusion in how the order was written. On the evening of the incident, an agency RN initiated the resident’s ordered TPN infusion between approximately 7:30 PM and 8:00 PM. The agency RN reported that an IV pump was not present in the room and manually calculated the drip rate, regulating the infusion via the roller clamp and counting drips per minute, rather than using an IV pump. It was later confirmed that an IV pump was in fact present in the room. The agency RN did not document or report the duration of infusion used to calculate the drip rate. Between 10:00 PM and 10:30 PM, the agency RN reported that the TPN bag was about half full before leaving the shift. At around 10:00 PM, the oncoming facility RN assumed care of the hallway and later, at approximately 11:01 PM, entered the resident’s room and found the TPN bag empty, connected directly to the PICC line and not routed through the IV pump. The progress note documented that the resident had already received the full TPN volume even though it was scheduled to run over 12 hours, and the facility’s abuse investigation determined that the TPN had infused over about 3 hours and 15 minutes instead of the ordered 12 hours. Following the rapid infusion, the resident’s condition changed. At about 11:01 PM, the resident’s blood sugar was documented as 450, and vital signs and neuro checks were performed, with subsequent neurological assessments showing elevated HR, elevated BP, increased RR, and progressive changes in level of consciousness and motor response from baseline over the night and into the morning. The resident became lethargic with altered mental status, was more difficult to arouse, and later complained of chest pain, headache, nausea, and confusion. A physiatry follow-up note described the resident as lethargic, arousable only to loud voice and tactile stimulation, and reporting constant sharp chest pain. EMS was called later that morning due to chest pain, low BP, fever, and high HR, and the resident was transferred to the hospital, where she was noted to be febrile, tachycardic, initially hypotensive, and confused, with differential diagnoses including sepsis and line sepsis. The facility’s emergency transfer form did not document that the resident had received a TPN bolus the prior night, and the hospital documentation did not reflect that the TPN bolus and associated change in condition had been communicated. The facility’s own investigation substantiated that the resident received TPN incorrectly as a bolus over a short period rather than as ordered. The facility’s PN policy required that PN be tapered up over 1–2 hours, run at a set rate for a determined time, and then tapered down over 1–2 hours, and specifically stated that PN should never be stopped suddenly and that tapering is needed to prevent hypoglycemia. The pharmacy order summary for this resident’s TPN included start and end taper periods and a total run period of 16 hours, but the pharmacy label and the way the order was presented created inconsistencies in the documented volume, rate, and duration. The DON acknowledged that the nurse should have clarified the discrepancies with the pharmacy and followed up with the physician. The DON also confirmed that the TPN label indicated infusion at 125 ml/hr with a total volume and duration that did not mathematically align, and that there was confusion with the order as written. Despite these documented inconsistencies and the presence of an IV pump in the room, the TPN was administered via gravity drip and infused in a fraction of the intended time, leading to a substantiated medication administration error and associated change in the resident’s condition.
Failure to Manage PRN Morphine Orders Safely Resulting in Opiate Toxicity
Penalty
Summary
The deficiency involves the facility’s failure to provide pain management in accordance with professional standards of practice for a resident receiving morphine, resulting in opiate toxicity and hospitalization. The resident was admitted with sepsis, obstructive and reflux uropathy, and kidney stones, and had an existing order for immediate-release morphine 7.5 mg every 6 hours as needed for dorsalgia. On admission, medication reconciliation was completed with the family and primary care physician records. Shortly after admission, the resident complained of ongoing pain and requested more morphine than he was receiving. On 1/3, nursing documentation reflected instructions to give 0.5 tablet by mouth every 3 hours for pain and 1 tablet by mouth every 3 hours as needed for pain, and physician orders were entered for morphine sulfate 15 mg, both 0.5 tablet every 3 hours PRN and 1 tablet every 3 hours PRN, creating two active PRN orders for the same opioid at different doses and the same frequency. The new morphine orders significantly increased the potential daily morphine exposure. Based on the prescribed frequency and dosage, there was a potential for up to 180 mg of morphine to be administered in a 24-hour period, representing an increase of 150 mg per 24 hours from the prior regimen. On 1/5, the physician documented that the resident’s family reported slurred speech, and the physician assessed that there was intermittent dysarthria likely caused by morphine and stated that the morphine should be reduced unless needed for pain levels higher than 4; however, no updated morphine order reflecting this change was found in the medical record. Subsequent nursing notes documented clinical changes, including lethargy, slurred or unclear speech, low oxygen saturations, cough, shortness of breath, and the need for supplemental oxygen and nebulizer treatments. Despite these changes and the physician’s concern about morphine-related dysarthria, the dual PRN morphine orders remained, and there was no documented clarification or consolidation of the opioid orders. In the days leading up to the resident’s transfer to the hospital, the MAR showed administration of 15 mg morphine tablets with pain scores of 10, 7, and 4, totaling 45 mg in a 24-hour period. On the morning of transfer, nursing documented that the resident appeared lethargic, had cold extremities, and that oxygen saturation could not be obtained despite oxygen being titrated up to 5 L/min, with staff reporting a significant decline compared to the prior day. The resident was transferred to the ED for further evaluation. In the ED, the provider documented that the resident arrived critically ill with hypoxia, slow respiratory rate, confusion, and minimal responsiveness, and noted that the resident had been receiving extra doses above the 0.5 tablet of morphine he was supposed to be getting at least once or twice a day. The ED provider diagnosed opiate toxicity along with hypoxia and sepsis, and the resident responded to naloxone with improvement in respiratory rate, oxygenation, and blood pressure. Interviews with an LPN and the DON revealed that nurses relied heavily on resident request and subjective pain reports to administer morphine, did not consistently question high-frequency opioid orders, and did not obtain provider clarification when two different PRN orders for the same opioid existed, contributing to the unsafe pain management that led to opiate toxicity. Interviews further clarified the facility’s practices and expectations around opioid administration and order management. The LPN stated that when receiving a physician order, he would repeat it back and then enter it into the record, and that he typically would follow up with a provider if he encountered a morphine order more frequent than every 4–6 hours. However, in this case, he did not follow up with the provider regarding the every-3-hour morphine orders because the resident had been on morphine for some time and appeared to be tolerating it. He also stated that he administered morphine based on resident request, even when pain levels were low, and that on the day of the resident’s decline he gave the higher dose at the resident’s request despite lethargy. The DON stated she expected nurses to use nursing judgment and to contact the physician when there were two different orders for the same opioid, and acknowledged that the morphine order should have been written as a range (0.5 to 1 tablet every 3 hours). The combination of unclarified duplicate PRN morphine orders, lack of documented adjustment after the physician’s concern about morphine-related dysarthria, and reliance on resident preference without adequate clinical reassessment or provider consultation led to excessive morphine dosing and the resident’s opiate toxicity.
Failure to Adhere to Physician-Ordered Medication Parameters and Timely Administration
Penalty
Summary
The facility failed to ensure that each resident’s drug regimen was free from unnecessary drugs, as defined by administration outside of physician-ordered parameters, missed doses, and lack of adequate monitoring. For three residents, there were documented instances where blood pressure medications were administered despite vital signs being outside the prescribed hold parameters. Specifically, one resident with hypertensive chronic kidney disease, hemiplegia, and atrial fibrillation received Metoprolol Tartrate on six occasions when either systolic blood pressure or heart rate was below the physician’s specified threshold for holding the medication. Another resident with diagnoses including orthopedic aftercare, diabetes, and morbid obesity did not receive her prescribed Dulaglutide injections as scheduled for three weeks following admission. The delay was attributed to pharmacy delivery issues and insurance coverage, with documentation showing missed doses and late administration. The resident reported the missed doses, and the nurse confirmed difficulties in obtaining the medication, but there was inconsistent documentation of physician notification and follow-up. A third resident with multiple cardiac conditions, including atrial fibrillation and congestive heart failure, received both Metoprolol Succinate ER and Amiodarone HCl on several occasions when blood pressure or heart rate was below the ordered parameters for holding the medications. Interviews with the DON confirmed that medications should have been held according to the physician’s orders, and that the administration outside of these parameters was not in compliance with the prescribed regimen.
Lack of Call Light Systems in Public Bathrooms
Penalty
Summary
The facility was found to be inadequately equipped to allow residents to call for staff assistance in public bathrooms, as none of the seven public bathrooms accessible to residents were equipped with a call light system. Observations on 11/20/25 revealed that multiple public bathrooms, including those in the 300 and 400 hallways, near the nurse's station, staff break room, Human Resource office, front desk, Administration hallway, and activities room, did not contain call lights. These bathrooms were not locked, making them accessible to residents at any time. During an interview, the Director of Maintenance confirmed the absence of call lights in these bathrooms and stated that he was unaware of the requirement to have them installed.
Failure to Immediately Notify Physician of Missed Diabetes Medication
Penalty
Summary
A deficiency was identified when the facility failed to immediately inform or consult with a resident's physician regarding a significant change in the resident's treatment, specifically related to the administration of Trulicity (Dulaglutide) for diabetes management. The resident, who had diagnoses including orthopedic aftercare following amputation, Type 2 diabetes mellitus, and morbid obesity, reported missing three weeks of Trulicity injections upon admission. Medical record review showed that the medication was not administered as scheduled on multiple occasions due to pharmacy delivery issues and lab results, with documentation indicating delays and missed doses. Despite these missed doses, there was no immediate notification to the resident's physician at the time the medication was unavailable. Provider notification occurred 24 hours after a scheduled dose was missed, and in other instances, the medication was either awaited from the pharmacy or arrangements were made for a family member to bring it in. Interviews with facility staff, including an LPN and the DON, confirmed that the physician was not promptly notified as required when the medication was not available, and the DON was unaware that multiple doses had been missed.
Delay in Initiation of Wound Care Orders for Newly Admitted Resident
Penalty
Summary
A deficiency was identified when a resident was admitted with wounds and dressings on both feet, but did not have wound care orders initiated until nine days after admission. The resident had a complex medical history, including arthritis due to bacteria in the left ankle and foot, MRSA, diabetes mellitus, chronic kidney disease, congestive heart failure, pain, and edema. Upon admission, the resident's hospital discharge orders did not include wound care instructions, but the nursing assessment documented the presence of surgical incisions and dressings. The care plan noted the potential for skin breakdown and included interventions to administer treatments as ordered and monitor for effectiveness. Despite these documented needs, there was no evidence that wound care was provided or that orders were obtained until nine days after admission, when a physician finally ordered specific wound care procedures. Interviews with staff revealed that the admitting nurse is responsible for reviewing discharge orders, documenting wounds, and obtaining necessary wound care orders, but this process was not followed in this case. The Director of Nursing confirmed that the expectation is for the admitting nurse to follow up with the physician for wound care orders if they are not present at admission.
Missed Vancomycin Doses and Lack of Documentation
Penalty
Summary
A deficiency occurred when a resident with multiple complex medical conditions, including bacterial arthritis, MRSA, diabetes, chronic kidney disease, and congestive heart failure, did not receive several scheduled doses of Vancomycin as ordered by their physician. The resident, who had a PICC line for intravenous antibiotics, reported that three doses of Vancomycin were missed. Review of the Medication Administration Record (MAR) showed that on four occasions, Vancomycin doses were either marked with codes indicating 'see Nurse Note' or 'HOLD see Nurse Note,' or lacked any documentation of administration or reason for omission. No corresponding nurse progress notes were found to explain why the medication was not given or held on these dates. Interviews with nursing staff and the Director of Nursing revealed that the expected protocol was to notify the physician of any missed medication doses and document the reason in a progress note. The LPN interviewed stated that a code indicating a missed dose should be accompanied by a detailed progress note, and that missing documentation in the MAR should be flagged for review by nursing leadership. Despite these expectations, there was no documentation to account for the missed Vancomycin doses, resulting in the resident not being free from significant medication errors.
Failure to Notify Physician of Critical Lab Results
Penalty
Summary
A deficiency was identified when the facility failed to notify the ordering physician of laboratory results that were outside the clinical reference ranges for one resident. The resident, who had a complex medical history including bacterial arthritis, MRSA, diabetes, chronic kidney disease, congestive heart failure, pain, and edema, was receiving intravenous Vancomycin therapy via a PICC line. Multiple Vancomycin trough levels were reported as high on several occasions, but there was no documentation that the physician was notified of these abnormal results. Interviews with staff confirmed that the process required notification of the physician and documentation in the progress notes when lab results were abnormal. However, review of the resident's records did not show any evidence that the physician was informed of the high Vancomycin trough levels, nor was there documentation of any pharmacy recommendations for dose adjustment. The DON confirmed that such notifications and documentation should have occurred.
Failure to File Signed and Dated Diagnostic Report in Resident Record
Penalty
Summary
A deficiency was identified when the facility failed to file a signed and dated report of a radiological diagnostic service in a resident's clinical record. The resident, who had a history of traumatic subdural hemorrhage with loss of consciousness, quadriplegia, spinal stenosis, and post-traumatic stress disorder, was admitted to the facility and later had a physician's order for an immediate (STAT) Kidney, Ureter, and Bladder (KUB) x-ray due to abdominal symptoms. Although nursing notes referenced the x-ray and its impression, the actual documentation of the x-ray results could not be located in the resident's medical record during the review period. Interviews with multiple staff members, including LPNs, the Regional Compliance Nurse, the DON, and the Administrator, revealed that the process for handling x-ray results involved receiving faxed reports from the x-ray company, notifying the physician, and distributing copies to various offices before forwarding the results to medical records for scanning and attachment to the resident's chart. However, there was a lack of clarity and consistency in the process, and the KUB x-ray result for the resident in question was not found in the clinical record as required.
Failure to Implement Proper Contact Precautions for Resident with MRSA
Penalty
Summary
A deficiency was identified when a resident with a history of MRSA septic arthritis, bacteremia, and a PICC line for intravenous antibiotics was not placed on proper contact precautions. The resident had undergone surgical cleaning of both ankles, with the left foot confirmed to have MRSA. Despite the presence of a PPE cart in the room and a magnet indicator on the doorframe, there was no signage specifying the type of transmission-based precautions required. The resident's medical records indicated orders for both Enhanced Barrier Precautions (EBP) and Contact Precautions due to wounds and the PICC line, and the care plan included interventions for EBP related to these conditions. Interviews with staff revealed confusion and lack of clarity regarding the implementation and distinction between EBP and Contact Precautions. An LPN was unable to clearly differentiate between the two types of precautions or specify the required PPE for each. The Director of Rehabilitation was unaware that the resident was on any transmission-based precautions and allowed the resident to participate in therapy sessions in the gym, stating that if the wound was contained, gym attendance was permitted. The DON confirmed that a number 6 magnet was used to indicate EBP, but that Contact Precautions would require additional signage, which was not present for this resident. Facility policies and CDC guidance reviewed during the survey specified that residents with MRSA infections should be placed on Contact Precautions, with clear signage and appropriate use of gowns and gloves upon room entry. The lack of proper signage, inconsistent staff knowledge, and failure to implement the correct precautions for a resident with an active MRSA infection led to the deficiency. The resident was observed participating in group therapy without the required precautions in place, further demonstrating the facility's failure to maintain an effective 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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