Monument Healthcare North Park
Inspection history, citations, penalties and survey trends for this long-term care facility in Bountiful, Utah.
- Location
- 350 South 400 East, Bountiful, Utah 84010
- CMS Provider Number
- 465163
- Inspections on file
- 14
- Latest survey
- February 6, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Monument Healthcare North Park during CMS and state inspections, most recent first.
The facility failed to ensure a safe environment for residents who smoke, with inadequate assessments and supervision leading to unsafe smoking practices. Residents with cognitive impairments and physical limitations were observed smoking without necessary safety measures, such as smoking aprons or supervision. Additionally, the facility did not conduct timely smoking assessments for new admissions, and failed to update care plans and implement interventions following falls, highlighting deficiencies in maintaining a safe environment.
A resident with severe cognitive impairment and a history of falls was repeatedly denied access to his room and placed under a beeping call light panel at a nurses' station. Despite expressing a need to use the bathroom, the resident was redirected multiple times due to safety concerns. The resident's family noted dissatisfaction with the situation, citing understaffing as a potential issue. Staff interviews revealed the resident was placed at the nurses' station for supervision, but the beeping call light was not addressed.
The facility failed to provide timely treatment for UTIs and did not implement bowel and bladder training programs for residents identified as candidates. Two residents experienced delays in receiving appropriate antibiotics for UTIs due to lapses in following up on lab results. Additionally, two other residents were not placed on scheduled toileting programs despite assessments indicating their suitability, leading to unmanaged incontinence.
A resident with PTSD and sensory processing disorder experienced undue stress due to the facility's failure to provide appropriate care. The resident was distressed by staff attempts to move them or assign a roommate, exacerbating their mental health symptoms. Despite needing female CNAs, male CNAs were assigned, and the resident had to self-administer medications due to delays. The facility's actions and lack of understanding of the resident's needs led to significant anxiety and distress.
The facility failed to promptly resolve grievances for several residents, including missing items and staff issues. Resident grievances were not documented or addressed in a timely manner, with some taking over a month to resolve. The facility's grievance policy was not followed, leading to unresolved issues and resident dissatisfaction.
The facility failed to notify two residents and their representatives of transfers or discharges, and did not inform the State Long-Term Care Ombudsman. One resident, with multiple health issues, was transferred to the hospital after being found lethargic outside, without written notification of the reason. Another resident was sent to the hospital due to respiratory distress, but the Ombudsman was not notified. The Administrator was unaware of the requirement to report hospital discharges.
The facility failed to develop comprehensive care plans for five residents, leading to deficiencies in addressing their medical and safety needs. A resident with involuntary hand movements was allowed to smoke unsupervised, while two residents requiring oxygen therapy did not have it included in their care plans. Another resident experienced multiple falls without effective interventions, and a smoker lacked a care plan addressing his smoking habits.
The facility failed to provide adequate respiratory care for five residents, lacking proper oxygen orders and failing to follow protocols for labeling and dating oxygen equipment. Residents with chronic respiratory conditions were observed with unlabeled and undated oxygen supplies, and inconsistencies were found in the execution of physician orders for equipment changes. This highlights a significant deficiency in adhering to professional standards and ensuring proper respiratory care.
The facility failed to provide meals at an appetizing temperature, with residents reporting cold and repetitive meals, particularly during dinner and weekends. Observations confirmed inconsistent use of plate warmers, leading to cold food being served. The Dietary Manager acknowledged the issue, noting that complaints were more frequent on weekends.
The facility was found to have multiple deficiencies in food storage, preparation, and sanitation practices. Observations revealed unclean kitchen conditions, improperly stored and labeled food items, and a lack of proper sanitation testing due to budgetary constraints. The Dietary Manager admitted to restrictions on ordering supplies and acknowledged the potential for foodborne illness due to inadequate sanitation practices. Staff were not consistently following standard kitchen attire protocols, and audits by the Regional Dietitian had not been conducted since November 2024.
The facility failed to correct quality deficiencies, including a lack of smoking safety assessment, resulting in a resident's burn hole in pants, and inadequate fall interventions leading to injuries. A resident was subjected to an alarming call light system and restricted room access, while another did not receive person-centered mental health care, causing psychological harm. Additionally, a resident with a UTI was untreated, and no bowel and bladder retraining program was in place. The Administrator admitted to not discussing critical issues in QAPI meetings and lacked experience in identifying trends.
The facility failed to implement an effective infection prevention and control program, as evidenced by the lack of Enhanced Barrier Precautions (EBP) for residents with wounds and indwelling devices. Staff were inadequately trained on EBP, leading to confusion and improper implementation. Additionally, a nurse handled medications with bare hands, and a CNA did not perform hand hygiene during meal service, further compromising infection control. The facility also lacked documentation for Legionella testing.
A facility failed to ensure a resident's right to self-administer medications was properly evaluated and documented by the IDT before allowing the practice. A resident was observed with a fluticasone propionate inhaler on her bedside table and reported having an emergency inhaler in her purse. Although a nursing note and self-administration evaluation were completed, the care plan and physician orders were not initiated until after the observation, leading to the deficiency.
A resident with hemiplegia and hemiparesis following a cerebral infarction did not receive a timely evaluation for a tilt wheelchair, as ordered by a physician. The evaluation was delayed for five months, during which the resident was not observed out of bed or in a wheelchair, and reported falling from bed and injuring his shoulder. The delay in addressing the physician's order resulted in the resident not receiving necessary equipment to accommodate his needs and preferences.
A resident with severe cognitive impairment and chronic pain experienced frequent misappropriation of fentanyl patches in an LTC facility. Despite orders to check patch placement every two hours, the patches often went missing, leading to unmanaged pain and increased agitation. The facility's documentation was inconsistent, and staff lacked education on handling and disposing of the patches, resulting in a deficiency in protecting the resident's belongings and managing their pain.
A facility failed to review and revise a resident's care plan for seven months, despite the resident's intact cognitive status and multiple diagnoses. The resident and her family were not involved in any care plan meetings after the initial admission meeting. Staff interviews revealed a lack of documentation and follow-up regarding interdisciplinary team meetings, with the MDS Coordinator and Social Services Director acknowledging inconsistencies in scheduling and documentation.
Two residents did not receive appropriate bathing services as scheduled, with one resident reporting rushed showers and another resorting to self-cleaning due to lack of assistance. Staff interviews revealed inconsistencies in documentation and adherence to shower schedules.
A resident with severe cognitive impairment and extensive assistance needs was not consistently offered showers twice a week as preferred. Despite a system for scheduling showers, documentation was inconsistent, and follow-up on refusals was inadequately managed, leading to a deficiency in maintaining the resident's personal hygiene.
Two residents with limited range of motion did not receive consistent restorative nursing services to maintain or improve their mobility. One resident, with multiple diagnoses including diabetes and muscle weakness, lacked a structured program after physical therapy discharge due to the retirement of the Restorative Nursing Assistant. Another resident, with conditions like malignant neoplasm and lupus, only began a walking program three weeks before the survey, managed by a Lead CNA without consistent support. The facility's failure to implement these programs resulted in deficiencies.
A resident with a PICC line did not have physician orders for its care for 10 days after placement, leading to a deficiency in the facility's adherence to professional standards. Nursing staff were unaware of the necessary care procedures, and the facility's policy for parenteral fluid administration was not followed.
The facility failed to provide appropriate dialysis care for two residents by not implementing fluid restrictions as required. One resident had a care plan indicating a fluid restriction but lacked a physician's order, and the facility did not track fluid intake. Another resident did not have a formal fluid restriction despite dialysis reports reinforcing the need. Communication and documentation issues contributed to the deficiency.
A resident with multiple health conditions, including hypertension, was administered Metoprolol Succinate ER despite having a blood pressure reading below the physician's specified parameters. The medication was given when the resident's blood pressure was 100/59, contrary to the order to hold the medication if systolic blood pressure was less than 105. The DON acknowledged the error during an interview.
Two residents were inappropriately administered psychotropic medications. One resident was given an antipsychotic without a proper diagnosis, and another received PRN anti-anxiety medication beyond the 14-day limit without necessary documentation. Staff interviews and record reviews revealed a lack of adherence to facility policies regarding psychotropic medication administration.
Two residents experienced significant medication errors due to inconsistent administration and documentation of Vancomycin and Midodrine. Resident 3, with MRSA and renal disease, had Vancomycin doses missed and trough levels not monitored as ordered. Resident 32, with renal disease, had inconsistent documentation of Midodrine administration for low blood pressure during dialysis. These errors highlight failures in medication management processes.
A resident with MRSA and end-stage renal disease did not receive timely lab services for vancomycin trough levels, as ordered by the physician. The lab sample was not picked up on time, leading to a delay in obtaining necessary results for proper medication dosing.
Two residents with dysphagia were served beverages not thickened to the required consistency, as dietary staff failed to follow proper procedures. The dietary aides prepared the drinks the day before, but did not adhere to the instructions on the thickener bottle, resulting in slightly thick liquids instead of the required mildly thick/nectar consistency. This failure was identified through observations and interviews with the Dietary Manager and Speech Language Pathologist.
The facility failed to maintain complete and accurate medical records for three residents, leading to discrepancies in wound care orders and missing documentation of showers. A resident's wound care orders did not match those documented by the Wound PA-C, and two residents' shower records were incomplete, with shower sheets not included in their medical records. The Lead CNA confirmed that shower sheets were stored on a computer file rather than being added to the residents' medical records.
The facility did not provide required behavioral health training to four staff members, despite the Facility Assessment identifying the need for such training due to the resident population's psychiatric and mood disorders. The Administrator and DON acknowledged the necessity for training but were unclear about its implementation, with corporate determining the training content.
Inadequate Smoking Safety and Fall Prevention Measures
Penalty
Summary
The facility failed to ensure a safe environment for residents who smoke, as evidenced by inadequate assessments and supervision. Several residents, including those with cognitive impairments and physical limitations, were observed smoking without necessary safety measures, such as smoking aprons or supervision. For instance, one resident with involuntary hand movements was seen smoking independently, resulting in burn holes in clothing, while another resident shared cigarettes with a peer, despite a history of noncompliance with smoking policies. Additionally, the facility did not conduct timely smoking assessments for new admissions, leading to a lack of appropriate interventions for residents who smoke. One resident was not assessed for smoking safety until 21 days after admission, and another resident's smoking status was not documented in their medical record. This lack of documentation and assessment contributed to residents keeping smoking materials in their rooms, contrary to facility policy, and smoking without supervision. The facility also failed to update care plans and implement interventions following falls. One resident, with a history of falls, was found without a call light within reach and no updated interventions in their care plan after multiple falls. This oversight in monitoring and updating care plans for fall prevention further highlights the facility's deficiencies in maintaining a safe environment for its residents.
Resident's Right to Dignity and Self-Determination Not Honored
Penalty
Summary
The facility failed to honor a resident's right to a dignified existence and self-determination by not allowing him to access his room and placing him under a call light panel that was intermittently beeping. The resident, who had severe cognitive impairment and was a fall risk, was observed multiple times attempting to go to his room but was repeatedly redirected to the nurses' station. Staff members, including CNAs and LPNs, were observed telling the resident he could not go into his room, citing safety concerns due to his fall risk. The resident expressed a need to use the bathroom and was only assisted after several minutes of waiting and asking for help. The resident's family member corroborated that the resident was not allowed in his room alone and was often placed at the nurses' station for supervision. The family member also noted that the resident was unhappy with the situation and felt terrible about being locked out of his room. The family member mentioned that the facility seemed understaffed, which might have contributed to the situation. Interviews with staff revealed that the resident was placed at the nurses' station to ensure supervision due to his fall risk. However, the call light system's beeping was not addressed, and staff assumed the resident could not hear it due to his hearing impairment. The DON confirmed that increased supervision was a fall intervention, but there was no specific reason for placing the resident under the call light system. The staff's actions and inactions led to the resident feeling undignified and restricted in his movements within the facility.
Deficiencies in UTI Management and Toileting Programs
Penalty
Summary
The facility failed to provide appropriate treatment and services for residents who were incontinent of bladder, leading to delays in treatment for urinary tract infections (UTIs) and lack of implementation of bowel and bladder training programs. For Resident 35, there was a significant delay in receiving appropriate antibiotic treatment for a UTI. Despite initial symptoms reported on October 24, 2024, and a positive urinalysis result on October 28, 2024, the correct antibiotic was not administered until November 6, 2024, after the urine culture results were finally reviewed. This delay was due to the facility's failure to follow up promptly with the laboratory for culture results, resulting in prolonged symptoms for the resident. Resident 6 experienced a similar delay in receiving treatment for a UTI. Although a urinalysis was ordered on December 19, 2024, the results indicating the presence of Escherichia coli were not acted upon until December 27, 2024, when a second urinalysis was ordered due to the initial results not being received. The delay in obtaining and acting on the laboratory results led to a delay in starting the appropriate antibiotic treatment, which was not initiated until December 27, 2024. Additionally, the facility failed to implement a bowel and bladder training program for Residents 25 and 31, despite assessments indicating they were candidates for such a program. Resident 25 was observed to have a strong urine odor and was not placed on a scheduled toileting program, which could have helped manage incontinence. Similarly, Resident 31, who was aware of the need to void and required assistance, was not placed on a toileting program, despite being identified as a candidate. The lack of a structured toileting program contributed to the residents' continued incontinence and reliance on briefs, which was not in line with their assessed needs and potential for maintaining or restoring continence.
Failure to Provide Appropriate Care for Resident with PTSD
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident diagnosed with mental disorders and PTSD, leading to undue stress and anxiety. The resident, who had a history of trauma and sensory processing disorder, reported feeling harassed and threatened by staff regarding room changes. The resident experienced significant distress when informed by the Administrator and DON about the possibility of moving rooms or having a roommate, which exacerbated their mental health symptoms. The resident's medical history included anxiety disorder, major depressive disorder, PTSD, and somatization disorder. Despite the resident's need for a private room due to their conditions, the facility administration attempted to move the resident or assign a roommate, causing the resident to experience heightened anxiety and depressive symptoms. The resident's family member corroborated these claims, stating that the facility's actions seemed to intentionally upset the resident. Additionally, the resident required female CNAs due to PTSD, but male CNAs were assigned, further contributing to the resident's distress. Observations revealed multiple signs on the resident's door indicating specific care preferences, which were not consistently respected by the staff. The resident also had to self-administer medications due to delays in nursing care, and the facility failed to provide the specific type of Tylenol the resident could swallow. Interviews with staff confirmed the resident's distress over male caregivers and the facility's inability to accommodate the resident's specific needs, highlighting a lack of understanding and support for the resident's mental health conditions.
Delayed Grievance Resolution and Documentation Issues
Penalty
Summary
The facility failed to promptly address and resolve grievances for several residents, as evidenced by interviews and record reviews. Resident 27 reported a grievance regarding missing Nike shoes, which was not documented or addressed in a timely manner. The Administrator was not informed of the issue until a month later, and no grievance form was filled out because the resident did not want to file a formal grievance. This lack of documentation and delayed response highlights a failure in the facility's grievance handling process. Resident 29 experienced delays in grievance resolution, with a grievance about missing laundry items taking over a month to be addressed. The resident also filed a grievance about a nurse not administering medication on time, but there was no follow-up on whether other residents were affected. The Social Services Director, who was responsible for grievances, had left the facility, and the new Administrator was not fully prepared to handle the grievance process, leading to further delays. Additional grievances were filed by other residents, including issues with staff attitudes and delayed assistance. These grievances were not resolved promptly, with some taking over a month to address. The facility's grievance policy states that grievances should be resolved within seven business days, but this was not adhered to, resulting in unresolved issues and dissatisfaction among residents.
Failure to Notify Residents and Ombudsman of Transfers
Penalty
Summary
The facility failed to provide timely notification to residents and their representatives regarding transfers or discharges, as well as failing to notify the State Long-Term Care Ombudsman. For Resident 32, who had multiple diagnoses including end-stage renal disease and osteomyelitis, the facility did not provide written notification of the reasons for his transfer to the hospital. The resident was found lethargic after choosing to sleep outside, and despite staff attempts to encourage him to come inside, he was eventually transferred to the hospital for evaluation. The Director of Nursing confirmed that the resident was not informed about the reason for the hospital transfer. Similarly, Resident 8, who had conditions such as multiple sclerosis and type 2 diabetes, was transferred to the hospital due to respiratory distress without proper notification to the Ombudsman. The resident's daughter was informed, and a collective decision was made to send him to the hospital. However, the facility did not notify the Ombudsman about this transfer, as confirmed by the Administrator, who was unaware of the requirement to report hospital discharges. The State Long-Term Care Ombudsman confirmed that they had not received any notifications of transfers or discharges from the facility. The facility's failure to notify the Ombudsman and provide written reasons for transfers or discharges in a language and manner understood by the residents and their representatives constitutes a deficiency in compliance with regulatory requirements.
Deficiencies in Care Planning and Safety Measures
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for five residents, leading to deficiencies in addressing their medical, nursing, and psychosocial needs. Resident 12, who had a history of smoking, was observed smoking unsafely due to involuntary hand movements, yet his care plan allowed unsupervised smoking. Despite observations of burn holes in his clothing and tremors, the facility did not update his care plan to ensure his safety until after these issues were noted by staff. Resident 32 and Resident 34 both required oxygen therapy, but their care plans did not include this critical intervention. Resident 32's care plan lacked orders for oxygen use despite a history of nocturnal hypoxemia, and staff interviews revealed inconsistent use of oxygen. Similarly, Resident 34's care plan did not address oxygen use, even though he was observed without his oxygen and had a history of obstructive sleep apnea requiring oxygen therapy. Resident 18 experienced multiple falls without appropriate updates to her care plan to prevent future incidents. Despite several falls resulting in injuries, including a fracture, the facility failed to implement effective interventions. Additionally, Resident 293, a smoker, did not have a smoking evaluation or care plan addressing his smoking habits, indicating a lack of comprehensive assessment and planning for his needs.
Inadequate Respiratory Care and Documentation
Penalty
Summary
The facility failed to provide adequate respiratory care for five residents, as evidenced by the lack of proper oxygen orders and failure to follow established protocols for labeling and dating oxygen equipment. Resident 29, who was admitted with chronic respiratory failure and other conditions, reported that her oxygen tubing and water were not changed regularly, and observations confirmed the absence of dates on the equipment. Despite physician orders requiring weekly changes, documentation showed inconsistencies in the execution of these orders. Resident 32, diagnosed with sleep-related hypoventilation and congestive heart failure, used oxygen at night but had no documented oxygen orders in his medical records. Interviews with staff revealed that the resident used oxygen during dialysis and at night, yet there was no formal care plan or physician orders to support this practice. Similarly, Resident 34, with a history of obstructive sleep apnea, was observed without oxygen during an interview, and his medical records lacked any oxygen orders or care plan, despite his reported need for continuous oxygen use. Residents 11 and 14 also experienced deficiencies in their respiratory care. Resident 11, with a history of coronary artery disease and respiratory failure, was observed with unlabeled oxygen tubing, and records indicated missed equipment changes. Resident 14, who required continuous oxygen due to chronic obstructive pulmonary disease, believed her tubing was changed every three months, contrary to the weekly schedule outlined in her physician orders. These findings highlight the facility's failure to adhere to professional standards and ensure proper respiratory care for its residents.
Deficiency in Food Temperature and Quality
Penalty
Summary
The facility failed to provide food that was palatable, attractive, and at an appetizing temperature for five of the 33 sampled residents. Multiple residents reported dissatisfaction with the quality and temperature of the food, particularly during dinner and on weekends. Observations confirmed that plate warmers were not consistently used, leading to cold meals being served. Residents expressed concerns about the repetitive nature of meals, such as sandwiches and hamburgers, and the poor quality of certain dishes, including overcooked meats and undercooked vegetables. Interviews with residents revealed specific complaints about the food service. One resident noted that scrambled eggs were unappetizing, while another mentioned that meals were often cold due to the lack of plate warmers. A resident also reported that the kitchen staff indicated it would take too long to use the warmers for each meal. Observations during meal service confirmed that not all plates were placed on warmers, and some meals were left on a kitchen rack without being kept warm before being served. The Dietary Manager acknowledged the issue, stating that plate warmers were supposed to be used for all meals unless they were cold meals. However, it was noted that the weekend cook was not using the warmers consistently. The Dietary Manager also mentioned that complaints about cold food were more frequent on weekends and that they had been monitoring the situation. Resident council meeting records from August 2024 to January 2025 documented ongoing grievances about cold food, indicating a persistent issue with meal temperature and quality.
Deficiencies in Food Storage and Sanitation Practices
Penalty
Summary
The facility was found to have multiple deficiencies in food storage, preparation, and sanitation practices. During an initial kitchen walk-through, it was observed that the floors under the stove and oven had crumbs and food particles, the microwave had a brown substance inside, and the dish machine had crumbs on top. Food splatter was noted on the wall behind a food preparation table, and a mop head was found on the floor under the steam table. Additionally, the garbage was overflowing near the Dietary Manager's (DM) desk, and there were no paper towels in the dispenser by the sink. In the food storage areas, several items in the reach-in refrigerator and freezer were open to air, not labeled, or past their use-by dates. The reach-in refrigerator and freezer lacked thermometers to confirm the internal temperatures. The DM was observed attempting to check the sanitation bucket with test strips meant for the dish machine, which yielded no results. The DM stated that the correct strips were not available due to budgetary constraints and restrictions on ordering supplies. Further observations revealed that food storage shelves had open boxes of food items, and the walk-in freezer and refrigerator contained items open to air and past their use-by dates. Temperature logs for storage areas were completed for future dates, and several days on the dish machine temperature log were incomplete. The DM admitted to being restricted in ordering supplies and had not received new thermometers for the reach-in refrigerator. Interviews with the DM revealed that he conducted his own audits of the kitchen and had taken disciplinary action against kitchen staff for not meeting expectations. The DM acknowledged that the lack of proper sanitation strips could lead to foodborne illness and cross-contamination. He also noted that food left open to air in storage areas would not last as long and would have reduced quality. The DM mentioned that the Regional Dietitian had not conducted audits since November 2024, and the consultant RD had only recently started audits. The DM attributed some of the issues to staff's lack of knowledge and laziness, and stated that standard kitchen attire was not consistently worn by staff members.
Facility Fails to Address Multiple Quality Deficiencies
Penalty
Summary
The facility failed to establish and implement policies to correct identified quality deficiencies, resulting in several instances of noncompliance. One significant issue was the lack of assessment for smoking safety, which led to a resident having a burn hole in his pants, indicating an immediate jeopardy level of noncompliance. Additionally, residents experienced falls without updated interventions, resulting in injuries, and a resident was subjected to an alarming call light system and restricted from entering his room, both of which were identified as harm-level noncompliance. Further deficiencies included the failure to provide person-centered care for a resident with mental disorders, causing unnecessary psychological harm, and the lack of treatment for a resident with a urinary tract infection. The facility also did not have a bowel and bladder retraining program in place. The Administrator acknowledged that QAPI meetings were held monthly, but certain critical issues such as smoking safety, bowel and bladder care, and behavioral health were not discussed. The Administrator admitted to not having enough experience to identify trends and relied on the Regional Nurse Consultant for developing performance improvement plans.
Inadequate Infection Control and EBP Implementation
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the lack of Enhanced Barrier Precautions (EBP) for several residents. Resident 5, who had multiple chronic wounds and indwelling devices, initially had no Personal Protective Equipment (PPE) or EBP signage in place. Similarly, Resident 3, with a dialysis catheter and a history of Methicillin-resistant Staphylococcus aureus, did not have EBP implemented despite having physician orders to monitor for infection. Resident 6, with vascular wounds, also lacked EBP, highlighting a systemic issue in the facility's infection control practices. The report further reveals that the facility's infection prevention and control program was not reviewed annually, as required. Interviews with staff, including the Unit Manager/Infection Preventionist and the Director of Nursing, indicated that EBP was only recently introduced, and staff had not been adequately trained. This lack of training led to confusion among staff, as evidenced by interviews with a Registered Nurse and a Certified Nursing Assistant, who were unsure about the implementation of EBP and the necessary precautions for residents with indwelling devices or wounds. Additional deficiencies were observed in medication administration and dining services. A Licensed Practical Nurse was seen handling medications with bare hands, compromising infection control standards. During meal service, a Lead CNA failed to perform hand hygiene while handling utensils, cups, and feeding residents, further increasing the risk of infection transmission. The facility also lacked documentation for Legionella testing, as the Director of Maintenance could not provide records of water testing results, indicating a gap in the facility's water management practices.
Failure to Ensure Proper Evaluation for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure a resident's right to self-administer medications was properly evaluated and documented by the interdisciplinary team (IDT) before allowing the practice. A resident was observed with a fluticasone propionate inhaler on her bedside table and reported having an emergency inhaler in her purse. The resident stated that the nurse would leave her morning medications on her bedside table while she slept, and she preferred taking them at her own pace. However, there was no documentation of an IDT evaluation or physician orders permitting self-administration prior to January 28, 2025. The resident, who had an intact cognition as indicated by a BIMS score of 13, was admitted with multiple diagnoses including a wedge compression fracture, spinal stenosis, radiculopathy, aortocoronary bypass graft, type 2 diabetes mellitus, and hypertension. Although a nursing note and self-administration evaluation were completed on January 28, 2025, indicating the resident was capable of self-administering medications, the care plan and physician orders were not initiated until after the observation of the inhaler at the bedside. This lack of prior evaluation and documentation led to the deficiency noted in the report.
Delay in Wheelchair Evaluation for Resident
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of a resident who had a physician's order for a tilt wheelchair evaluation that was not addressed for five months. The resident, who was admitted with conditions including non-traumatic intracerebral hemorrhage, hemiplegia, and hemiparesis following a cerebral infarction, was dependent on mobility and had a care plan indicating the need for a tilt in space wheelchair. Despite the physician's order dated 8/29/24 for a physical and occupational therapy evaluation for a custom wheelchair, the evaluation was not conducted until 1/30/25. During this period, the resident was not observed out of bed or in a wheelchair, and the resident reported falling from bed and injuring his shoulder. The resident's medical records indicated a need for a tilt in space wheelchair to improve mobility, independence, and quality of life, as well as to prevent complications related to immobility. The delay in addressing the physician's order for the wheelchair evaluation resulted in the resident not receiving the necessary equipment to accommodate his needs and preferences, as outlined in his care plan.
Misappropriation of Resident's Fentanyl Patches
Penalty
Summary
The facility failed to prevent the misappropriation of a resident's medications, specifically fentanyl patches, for a cognitively impaired resident with severe chronic pain. The resident, who had a BIMS score indicating severe cognitive impairment, was prescribed fentanyl patches for pain management. However, the patches frequently went missing, and the facility did not consistently replace them, leading to unmanaged pain and increased agitation in the resident. The medical records and interviews with staff revealed multiple instances where the fentanyl patches were not found on the resident's body or in their room. Despite orders to check the patch placement every two hours, the patches were often missing, and the facility's documentation was inconsistent. The narcotic log and MAR showed discrepancies in the administration and documentation times, and there were instances where only one nurse's initials were recorded for the removal of a patch, contrary to the requirement for two signatures. Interviews with nursing staff and the DON indicated a lack of education and clear procedures for handling and disposing of fentanyl patches. The staff attempted to secure the patches with Tegaderm, but they continued to disappear. The DON acknowledged the issue but did not provide evidence of a comprehensive investigation or resolution. The facility's failure to ensure the proper management and security of the resident's fentanyl patches resulted in a deficiency in protecting the resident's belongings and managing their pain effectively.
Failure to Review and Revise Resident Care Plan
Penalty
Summary
The facility failed to review and revise the comprehensive care plan for one resident, identified as resident 31, for a period of seven months. The resident was admitted with multiple diagnoses, including malignant neoplasm of the cerebellum, mood disorder, bladder disorders, major depressive disorder, anxiety disorder, neuralgia and neuritis, systemic lupus erythematosus, and hypertension. Despite having an intact cognitive status as indicated by a BIMS score of 14, the resident and her family were not involved in any care plan meetings after the initial admission meeting. The resident and her family confirmed that they were not invited to any subsequent care plan meetings. Interviews with facility staff revealed a lack of documentation and follow-up regarding the interdisciplinary team (IDT) meetings. The MDS Coordinator admitted that no IDT meetings were documented in the resident's medical record after the admission meeting. The Social Services Director/Resident Advocate acknowledged that the scheduling of quarterly IDT meetings was inconsistent and that the electronic medical record system failed to notify staff when these meetings were due. Consequently, there was no evidence of ongoing review or revision of the resident's care plan, highlighting a significant oversight in the facility's care planning process.
Failure to Provide Scheduled Showers for Residents
Penalty
Summary
The facility failed to ensure that two residents, identified as Resident 6 and Resident 293, received appropriate treatment and services to maintain or improve their ability to carry out activities of daily living, specifically in relation to bathing and showering. Resident 6, who was admitted with diagnoses including type 2 diabetes mellitus, muscle weakness, and major depressive disorder, reported that staff did not wake him up for scheduled showers and that when he did receive showers, they were rushed, making him feel uncomfortable. Despite being cognitively intact, as indicated by a BIMS score of 15, Resident 6's medical record showed inconsistencies in shower documentation, with no records of refusals being documented as required. Resident 293, admitted with conditions such as a displaced intertrochanteric fracture of the left femur and major depressive disorder, reported not receiving a shower since his arrival and resorted to washing himself with bottled water. His medical record indicated he was scheduled for showers twice a week, but there was a lack of documentation to confirm these showers were provided. Interviews with staff revealed inconsistencies in the documentation process, with shower sheets not being properly completed or filed in the residents' medical records. The facility's staff, including CNAs and the Director of Nursing, acknowledged the process for documenting showers and refusals, but there were clear lapses in execution. The lack of proper documentation and adherence to scheduled shower days contributed to the deficiency, as residents were not consistently receiving the care necessary to maintain their personal hygiene and dignity.
Inconsistent Shower Scheduling and Documentation for Resident
Penalty
Summary
The facility failed to provide necessary services to maintain personal hygiene for a resident who was unable to carry out activities of daily living. Specifically, the resident, who had severe cognitive impairment and required extensive assistance for daily activities, was not offered showers regularly. The resident expressed a desire to have showers twice a week, but records indicated that showers were not consistently provided as per the resident's preference. The documentation showed inconsistencies in the recorded shower dates, and there were instances where the resident refused showers, but the follow-up procedures were not adequately documented. Interviews with CNAs and the Lead CNA revealed that there was a system in place for scheduling showers, and residents were generally assigned two showers per week. However, there was a lack of clarity and consistency in the documentation process, as the Shower Sheets were not always included in the resident's medical record. The CNAs mentioned that if a resident refused a shower, they would offer it the next day, but if the resident continued to refuse, they would not force them. The Director of Nursing confirmed the shower scheduling process and the use of Shower Sheets, but the documentation and follow-up on refusals were not effectively managed, leading to the deficiency in maintaining the resident's personal hygiene needs.
Failure to Provide Consistent Restorative Nursing Services
Penalty
Summary
The facility failed to provide appropriate restorative nursing services to two residents with limited range of motion, leading to deficiencies in maintaining or improving their mobility. Resident 6, who had diagnoses including type 2 diabetes mellitus, muscle weakness, and scoliosis, was not provided with a consistent restorative nursing program after being discharged from physical therapy. The Director of Rehab acknowledged that the resident needed a restorative nursing program, which was not available due to the retirement of the Restorative Nursing Assistant. Despite the resident's refusal to participate in the program at times, the lack of a structured program contributed to the resident's inability to achieve the goal of walking with less assistance. Resident 31, diagnosed with conditions such as malignant neoplasm of the cerebellum and systemic lupus erythematosus, also did not receive consistent restorative services. Although the resident expressed a desire to maintain her ability to ambulate, the walking program was only initiated three weeks prior to the survey. The Lead CNA, who was responsible for the program, stated that she walked with the resident when time permitted, and no other staff were involved on days she was not working. The Director of Rehab noted that RNA services were recommended months earlier, but the facility had not determined the frequency of these services. Both residents' care plans indicated a need for restorative programs to maintain or improve their mobility, but the facility's failure to implement these programs consistently resulted in deficiencies. The lack of a dedicated Restorative Nursing Assistant and the reliance on a Lead CNA to manage the program without adequate support or training contributed to the residents not receiving the necessary care to prevent further decline in their range of motion.
Failure to Ensure Timely Physician Orders for PICC Line Care
Penalty
Summary
The facility failed to ensure the safe and appropriate administration of intravenous (IV) fluids for a resident, identified as Resident 3, by not having physician orders for the care of a peripherally inserted central catheter (PICC) line for 10 days after its placement. Resident 3 was admitted with diagnoses including infection and inflammatory reaction due to cardiac and vascular devices, methicillin-resistant Staphylococcus aureus (MRSA), and end-stage renal disease requiring dialysis. The PICC line was placed on 12/28/24, but physician orders for its care were not documented until 1/7/25. Interviews with nursing staff revealed a lack of awareness and understanding regarding the necessary care for the PICC line. Registered Nurse (RN) 2 admitted to not knowing the status of Resident 3's PICC line flushes, dressing changes, and cap changes, while Licensed Practical Nurse (LPN) 2 emphasized the need for physician orders to flush the line and change the dressing. RN 1 confirmed that the PICC line required regular flushing to prevent blockage and that the site needed to be assessed for signs of infection. However, there were no physician orders for these procedures until 10 days after the line was placed. The Director of Nursing (DON) and Regional Nurse Consultant (RNC) 1 acknowledged the absence of physician orders for the PICC line care during the initial 10-day period. The facility's policy and procedure for the administration of parenteral fluids emphasized the need for care consistent with professional standards and physician orders, yet this was not adhered to in the case of Resident 3. The lack of timely physician orders and subsequent care for the PICC line represents a deficiency in the facility's adherence to its own policies and professional standards of practice.
Failure to Implement Fluid Restrictions for Dialysis Residents
Penalty
Summary
The facility failed to ensure that two residents requiring dialysis received care consistent with professional standards of practice, specifically regarding fluid restrictions. Resident 3, who was admitted with multiple diagnoses including end-stage renal disease and Alzheimer's disease, had a care plan indicating a 1-liter fluid restriction. However, there was no physician's order for this restriction, and the facility lacked a system to track fluid intake. Interviews revealed that nurses were unaware of the fluid amounts provided to residents, and the resident was often non-compliant with the fluid restriction without clear interventions in place. Resident 32, also diagnosed with end-stage renal disease, did not have a physician's order for a fluid restriction despite dialysis communication reports consistently reinforcing the need for such a restriction. The Registered Dietitian (RD) acknowledged that Resident 32 sometimes monitored his fluid intake but was not on a formal fluid restriction due to the absence of a physician's order. The RD communicated with the dialysis RD but did not recall any specific mention of a fluid restriction, and the resident's fluid intake was documented in the CNA's Point of Care tasks. Interviews with the Director of Nursing (DON) and the Unit Manager (UM) revealed a lack of communication and documentation regarding fluid restrictions for dialysis patients. The DON stated that any new orders from the dialysis RD would be communicated via email, but the UM admitted to not reviewing all dialysis sheets. The facility's dialysis policy emphasized collaboration and communication with the dialysis center, but this was not effectively implemented, leading to the deficiency in providing appropriate dialysis care.
Medication Administration Error Due to Inadequate Monitoring
Penalty
Summary
The facility failed to adequately monitor a resident's drug regimen, resulting in the administration of a medication outside of the physician's prescribed parameters. A resident, who had been readmitted to the facility with multiple diagnoses including end-stage renal disease, Alzheimer's disease, and hypertension, was prescribed Metoprolol Succinate ER to manage blood pressure. The physician's order specified that the medication should be held if the systolic blood pressure was less than 105 or the heart rate was less than 55. On January 1, 2025, the resident's blood pressure was recorded at 100/59, which was below the specified threshold, yet the medication was administered. During an interview on February 6, 2025, the Director of Nursing confirmed that the medication should have been withheld under these circumstances.
Inappropriate Use of Psychotropic Medications
Penalty
Summary
The facility failed to ensure that psychotropic medications were administered appropriately for two residents. Resident 38 was prescribed quetiapine, an antipsychotic medication, without a supporting clinical diagnosis. Despite the facility's policy that antipsychotic medications should only be used for specific diagnoses such as Schizophrenia, Bipolar, and Huntington's Disease, Resident 38 was given quetiapine for mood without documented aggressive behaviors or a proper diagnosis. Interviews with nursing staff revealed that Resident 38 did not exhibit aggressive behaviors, and there was no documentation of such behaviors in the resident's medical records. Resident 35 was prescribed hydroxyzine, an anti-anxiety medication, on a PRN basis for anxiety. The facility's policy requires that PRN orders for psychotropic medications be limited to 14 days unless extended by a physician with documented rationale. However, Resident 35 received hydroxyzine PRN for several months without a 14-day limit or a scheduled review to assess the necessity of continued use. The DON acknowledged that the PRN order should have been limited to 14 days and reviewed for potential scheduling if needed beyond that period. The deficiencies highlight a lack of adherence to the facility's policies regarding the administration of psychotropic medications. There was a failure to document appropriate diagnoses and behaviors to justify the use of such medications, as well as a failure to limit PRN orders to the required 14-day period. These oversights indicate a need for improved monitoring and documentation practices to ensure compliance with regulatory standards.
Medication Administration Errors in Two Residents
Penalty
Summary
The facility failed to ensure that two residents were free from significant medication errors. For Resident 3, there were multiple instances where Vancomycin was not administered according to physician and pharmacy orders. The resident, who had a history of MRSA and end-stage renal disease requiring dialysis, had inconsistent Vancomycin dosing and trough level monitoring. There were discrepancies in the orders and actual administration, with some doses missed and trough levels not drawn as required. Interviews with nursing staff and the physician revealed confusion and lack of proper documentation regarding the Vancomycin administration and trough level monitoring. Resident 32, who had end-stage renal disease and other complex medical conditions, was prescribed Midodrine for low blood pressure during dialysis. However, there were instances where the administration of Midodrine was not documented in the Medication Administration Record (MAR). The nursing staff and dialysis nurse communicated about the resident's blood pressure and the need for Midodrine, but the documentation was inconsistent, leading to a lack of clarity on whether the medication was administered as needed. The deficiencies in medication administration and documentation for both residents highlight a failure in the facility's processes to ensure accurate and timely medication management. The lack of proper documentation and adherence to physician orders for medication administration and monitoring contributed to the significant medication errors identified during the survey.
Failure to Obtain Timely Lab Services for Vancomycin Monitoring
Penalty
Summary
The facility failed to provide timely laboratory services for a resident, specifically regarding the monitoring of vancomycin trough levels. The resident, who had been admitted with conditions including MRSA and end-stage renal disease requiring dialysis, had a physician's order dated 1/6/25 for a vancomycin trough level to be obtained before dialysis. However, the medical record showed no results for this test. A physician's note indicated that there was an issue with obtaining the vancomycin level, which was necessary for proper dosing. Consequently, a dose of vancomycin was administered without the trough level being available. Further investigation revealed that the laboratory sample was not picked up on the specified date, and the sample was left out too long to be tested, necessitating a redraw on the following day. Interviews with nursing staff confirmed that the vancomycin dosing and trough levels were not drawn according to the physician's orders. This lapse in obtaining timely lab results led to a delay in appropriate medication management for the resident.
Improper Preparation of Thickened Liquids for Residents with Dysphagia
Penalty
Summary
The facility failed to provide food prepared in a form designed to meet the individual needs of two residents diagnosed with dysphagia, among other conditions. Resident 4, with a physician's order for a regular diet with pureed food and nectar/mildly thick liquids, and Resident 2, with similar dietary requirements, were observed receiving beverages that were not thickened as per their dietary orders. The dietary staff prepared the thickened beverages the day before, but the liquids were not thickened to the required consistency, as the dietary aides did not follow the instructions on the thickener bottle. Specifically, the beverages were made slightly thick instead of mildly thick/nectar consistency, and the mixing time was insufficient. Interviews with the Dietary Manager and Speech Language Pathologist revealed that the dietary aides were trained to thicken liquids but did not adhere to the proper procedures, leading to the incorrect consistency of the beverages. The Dietary Manager acknowledged that improper thickening could pose a choking hazard or lead to aspiration pneumonia, although no such incidents were reported. The Speech Language Pathologist emphasized the importance of serving the correct consistency to prevent aspiration, highlighting that the facility staff should follow the instructions on the thickener container to ensure resident safety.
Incomplete and Inconsistent Medical Records for Residents
Penalty
Summary
The facility failed to maintain complete and accurate medical records for three residents, leading to discrepancies in wound care orders and missing documentation of showers. For Resident 6, there was a mismatch between the wound care orders documented by the Wound Physician Assistant, Certified (PA-C) and those recorded in the Treatment Administration Record (TAR). The PA-C's orders included specific instructions for wound care that were not reflected in the physician's orders on the TAR, indicating a lack of consistency in the resident's medical records. Resident 3's medical records were incomplete as the shower sheets documenting the resident's showers and refusals were not included in the medical record. The Lead Certified Nursing Assistant (CNA) confirmed that shower sheets were completed and provided to her or the medical records staff, but they were stored on a computer file rather than being added to the resident's medical record. This omission resulted in an incomplete record of the resident's care. Similarly, Resident 293's medical records lacked documentation of scheduled showers. Although the resident was scheduled for showers twice a week, there was no consistent documentation to confirm whether these showers were provided or refused. The Lead CNA acknowledged the absence of shower sheets for certain dates and stated that the sheets were scanned into a file rather than being included in the resident's medical record. This lack of documentation contributed to incomplete medical records for the resident.
Failure to Provide Behavioral Health Training to Staff
Penalty
Summary
The facility failed to provide behavioral health training to four staff members, as determined by the facility assessment. The Facility Assessment for Sandstone North Park, dated 5/20/24, outlined the resident population's needs, including psychiatric and mood disorders such as psychosis, depression, schizophrenia, PTSD, and anxiety. It specified that direct care personnel should complete a competency validation process, including training on care for residents with psychosocial, mental, and behavioral concerns, emphasizing effective communication, meaningful activities, person-centered care approaches, and non-pharmacological interventions. However, a review of the training records for an LPN, a Lead CNA, a CNA, and a Unit Manager revealed that they did not receive the required training. Interviews with the Administrator and the Director of Nursing (DON) highlighted a lack of clarity and oversight regarding the training process. The Administrator acknowledged the presence of residents with mental and behavioral health concerns and the necessity for staff training but was unsure if the training had been conducted. The DON stated that the Facility Assessment was completed by herself and the Administrator, and although there were no residents with aggressive behaviors, training should be based on the Facility Assessment. The DON also mentioned that corporate decided the training content, which did not align with the specific needs identified in the Facility Assessment.
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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