Monument Healthcare South Salt Lake
Inspection history, citations, penalties and survey trends for this long-term care facility in Salt Lake City, Utah.
- Location
- 2472 South 300 East, Salt Lake City, Utah 84115
- CMS Provider Number
- 465146
- Inspections on file
- 19
- Latest survey
- June 19, 2025
- Citations (last 12 mo.)
- 22 (2 serious)
Citation history
Health deficiencies cited at Monument Healthcare South Salt Lake during CMS and state inspections, most recent first.
Surveyors found that the facility failed to prevent accident hazards and provide adequate supervision, including allowing excessively hot water in resident rooms, unsupervised smoking by residents who required supervision, and incidents of residents with cognitive impairment eloping from the facility undetected. Staff interviews revealed confusion about supervision policies, and additional hazards such as a non-working front doorbell and unsafe storage in resident areas were observed.
A resident with a mental disorder, psychosocial adjustment difficulty, or a history of trauma and/or PTSD did not receive the necessary treatment and services to address their mental health and psychosocial needs.
The facility did not consistently calibrate glucometers according to manufacturer instructions, with calibration logs showing irregular entries and some logs missing. Interviews with nursing staff revealed confusion about calibration procedures and documentation, and not all staff were authorized or trained to perform blood sugar checks. This resulted in laboratory services not meeting resident needs.
Residents were served beverages in Styrofoam cups and prepackaged juice containers during meal service, with some food items also provided in disposable containers. Staff used these items due to a shortage of regular cups, as explained by the Dietary Manager. These actions did not support the maintenance or enhancement of residents' dignity and quality of life.
Three residents experienced incidents involving elopement and alleged abuse that were not reported to the State Survey Agency or Adult Protective Services within the required timeframe. In one case, a resident with dementia eloped and was returned by a CNA, but APS was not notified. Another resident with cognitive impairment left with a friend and did not return, with no evidence of required notifications. A third resident alleged inappropriate touching by a CNA, but the allegation was not promptly reported or investigated.
Surveyors found that expired eye drops and insulin, as well as multiple opened eye drop bottles without open dates, were present in medication carts and administered to residents. Staff, including RNs and LPNs, acknowledged that medications should be labeled with open dates and discarded after 28 days, but this was not consistently done, resulting in expired or improperly labeled drugs being used.
Surveyors identified multiple deficiencies in food storage, preparation, and sanitation, including soiled kitchen surfaces and equipment, improper sanitizer solution levels, open spices, and a broken steamer. A Registered Dietitian was also observed in the food prep area without a hairnet, and cleaning routines were found inadequate to maintain professional standards.
The facility did not ensure effective policies were in place to correct identified deficiencies, resulting in unsafe hot water temperatures in resident rooms, unsupervised smoking by residents who required supervision, and incidents of resident elopement. Despite previous QAPI plans, the facility failed to maintain updated supervision lists, assess residents for smoking safety, or consistently implement interventions for elopement risks. Repeat deficiencies from a prior survey were also cited again.
The facility did not ensure that two residents or their representatives were informed and able to participate in care decisions, including starting an antidepressant and placing a wanderguard device, as both interventions were initiated before obtaining proper consent.
Two residents were discharged or left the facility without receiving written notification of discharge and the reasons for transfer in a language and manner they understood, and the Office of the State LTC Ombudsman was not notified as required. Staff interviews revealed inconsistent practices regarding notification and documentation for residents discharged to hospitals or who left against medical advice.
A resident with a documented history of depression and ongoing treatment with escitalopram did not have this diagnosis reflected in their medical record or MDS assessment. Multiple staff members were unaware of the depression diagnosis, and the DON confirmed it was not updated in the chart, leading to an inaccurate assessment.
A resident lost the ability to perform ADLs without a documented medical reason. The facility did not ensure that the decline in the resident's functional abilities was clinically unavoidable, as required by regulations.
A resident did not receive care and treatment in accordance with physician orders and their stated preferences and goals, as observed and documented by surveyors.
Two residents were not provided with the therapeutic diets ordered for their medical conditions. One resident with diabetes received high-carbohydrate meals instead of a carbohydrate-controlled diet, while another with end stage renal disease was served high-potassium foods despite a renal diet order. Dietary staff and the RD were unaware of the residents' specific needs and preferences, and the meal planning system did not consistently ensure compliance with diet orders.
A resident with complex psychiatric and medical conditions did not receive scheduled Invega IM injections on multiple occasions because the medication was not available at the facility, with missed doses attributed to delivery delays and insurance coverage issues. Documentation confirmed the missed administrations, and in one instance, no reason was documented for the omission.
Two residents did not receive timely outside professional services as required. One resident, needing dental care for decay causing injury, had no documented appointment or refusal for outside dental treatment. Another resident with uncontrolled diabetes had multiple referrals for endocrinology, but there were delays and unclear follow-through in scheduling the specialist appointment. Staff interviews revealed confusion and lack of documentation regarding responsibility and process for arranging these services.
Two residents' medical records were found to be incomplete and not systematically organized. One resident's record lacked an updated PASRR reflecting a new depression diagnosis, despite documentation of depression and related treatment in progress notes. Another resident's record did not contain any documentation of a reported elopement event, contrary to facility policy requiring such incidents to be recorded.
Staff did not consistently use Enhanced Barrier Precautions, such as wearing gowns, when providing care to a resident with chronic wounds and a feeding tube. The resident's tube feed was also left uncapped when disconnected, contrary to facility protocols. Interviews indicated staff were unclear about EBP requirements, and observations confirmed lapses in infection control practices.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
Multiple Failures in Accident Prevention, Supervision, and Elopement Safeguards
Penalty
Summary
Surveyors identified multiple deficiencies related to accident hazards and inadequate supervision throughout the facility. Hot water temperatures in resident rooms were found to be excessively high, ranging from 121.7 to 145.5 degrees Fahrenheit, well above the safe range of 105-115 degrees as stated by the Maintenance Director. Residents with varying degrees of cognitive impairment and physical limitations were exposed to these hazardous water temperatures, with some residents reporting the water was hot enough to make noodles. The facility's water temperature logs over the previous six months did not reflect these high temperatures, instead showing much lower readings, and discrepancies were noted between the surveyors' thermometers and the facility's infrared thermometer during testing. In addition to the water temperature issue, the facility failed to provide adequate supervision for residents who required it while smoking. Several residents who were assessed as needing supervision were observed smoking unsupervised in various locations, including outside the facility and near the sidewalk. Some residents kept their own smoking materials despite care plans and evaluations indicating that these should be stored by staff and only used under supervision. There were inconsistencies in the facility's smoking policy implementation, with staff interviews revealing confusion about which residents required supervision and how smoking materials were managed. One resident was not properly evaluated for smoking, and the list of supervised smokers was outdated. The facility also failed to prevent elopement for residents assessed as being at risk. Two residents with significant cognitive impairment and histories of wandering were able to leave the facility without staff knowledge. In one case, a resident was found walking two blocks away and returned by a CNA, while another resident was found by police after leaving the facility and becoming combative. The facility's elopement prevention measures, such as wander guards, were not effective in preventing these incidents, and staff were unsure how a resident was able to exit the building while wearing a wander guard. Additional hazards were noted, such as a non-functioning front doorbell that left residents locked outside and unable to alert staff, and the storage of metal bed frames and boxes in a dayroom occupied by residents.
Failure to Provide Appropriate Mental Health and Psychosocial Services
Penalty
Summary
A resident who displayed or was diagnosed with a mental disorder, psychosocial adjustment difficulty, or had a history of trauma and/or post-traumatic stress disorder did not receive the appropriate treatment and services as required. The facility failed to ensure that the necessary care and interventions were provided to address the resident's mental health and psychosocial needs, as observed and documented by surveyors.
Failure to Consistently Calibrate Glucometers per Manufacturer Guidelines
Penalty
Summary
The facility failed to provide or obtain laboratory services to meet the needs of its residents, specifically regarding the calibration and quality control of glucometers. Review of calibration logs for various hallways revealed inconsistent and infrequent calibration dates, with some logs missing or not readily available on medication carts. Interviews with nursing staff, including LPNs, RNs, and CMAs, indicated a lack of consistent understanding and adherence to the manufacturer's instructions for glucometer calibration. Some staff believed calibration was performed weekly by the night shift, while others were unsure of the frequency or location of calibration logs. The Director of Nursing confirmed that not all staff were authorized to perform blood sugar checks, as some had not been properly trained or passed off. Further interviews with the Regional Nurse Consultant and review of the glucometer manual confirmed that calibration and control solution testing should be performed weekly and under specific circumstances, such as when using a new bottle of test strips or if the accuracy of the meter was in question. However, the facility was not consistently following these requirements, as evidenced by the irregular calibration dates and staff uncertainty. This failure to adhere to manufacturer guidelines for glucometer calibration resulted in the facility not meeting the laboratory service needs of its residents.
Use of Disposable Cups and Containers During Meal Service
Penalty
Summary
Surveyors observed that residents dining in the facility's dining room were served beverages in Styrofoam cups and prepackaged juice cups, rather than in standard dining ware. During multiple meal services, staff distributed milk and water in Styrofoam cups, while juices were provided in small cartons or foil-covered cups. Coffee and tea were served in coffee cups, and some food items, such as strawberries, were served in disposable containers. One resident was observed with multiple beverage containers, including cartons and Styrofoam cups, at their dining table. The Dietary Manager explained that the use of Styrofoam cups was due to a shortage of regular cups, as several had gone missing and replacements had not yet arrived. The facility had some regular cups available, but not enough for all residents. These practices did not promote an environment that maintained or enhanced residents' quality of life or recognized their individuality, as required by regulations regarding dignity and respect in resident care.
Failure to Timely Report Alleged Abuse, Neglect, and Elopement
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, or elopement 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) for three residents. In the first case, a resident with a history of traumatic brain injury and dementia eloped from the facility and was found by a community member. The CNA who located the resident notified the Director of Nursing (DON) of the elopement, but there was no documentation that APS was notified as required. In the second case, a resident with paranoid schizophrenia, major depressive disorder, and moderate cognitive impairment left the facility with a friend and did not return as expected. The facility made attempts to contact the resident but did not notify law enforcement, APS, or the Ombudsman about the resident's absence. The resident eventually returned to collect belongings and stated he would not be returning, but there was no evidence that the required notifications were made regarding his prolonged absence or potential elopement. In the third case, a resident with Parkinson's disease, schizoaffective disorder, dementia, and other chronic conditions alleged that a CNA had inserted her fingers into the resident's private parts during care. The resident reported the incident to the CNA Coordinator, who did not recall the name of the CNA involved and did not initiate an investigation or report the allegation to the DON or administrator in a timely manner. The CNA Coordinator stated she discussed the situation with the DON, but there was no documentation that the incident was reported to the SSA or APS within the required timeframe. The administrator later acknowledged that the incident was not recognized as an abuse allegation until much later, resulting in a failure to report as required.
Expired and Unlabeled Medications Found in Use
Penalty
Summary
Surveyors identified that the facility failed to ensure drugs and biologicals were labeled and stored according to professional standards for four residents. Specifically, expired medications were found in use, including Ketotifen Fumarate eye drops administered to a resident after the labeled open date had passed, and an insulin pen that was past its expiration date. Additionally, several eye drop bottles, both prescription and over-the-counter, were found without open dates, making it impossible to determine if they were still safe for use. Staff interviews confirmed that medications such as eye drops and insulin are expected to be discarded after a set period post-opening, but this protocol was not consistently followed. The observations included a nurse administering expired eye drops, multiple medication carts containing opened eye drops and insulin pens without proper labeling, and staff acknowledging the lack of required open dates or the presence of expired medications. Medication administration records confirmed that these medications were actively being given to residents. The Director of Nursing and other staff stated that all opened eye drops and insulin should be discarded after 28 days, but this was not adhered to, resulting in the use and storage of expired or improperly labeled medications.
Deficient Food Storage, Preparation, and Sanitation Practices Identified
Penalty
Summary
Surveyors observed multiple deficiencies in food storage, preparation, and sanitation practices within the facility's kitchen. During initial and follow-up tours, areas behind and under kitchen equipment such as the steamer, storage shelves, and carts were found to be soiled with substances including white splatter, debris, grease, and a black substance. The table supporting the steamer was rusty and also had visible splatter. The floor under preparation sinks and storage areas was similarly soiled, and tape was found on the ceiling above a preparation sink. Large bins containing powdered milk, sugar, flour, and oatmeal were soiled around the tops, and spices were left open to air. Plastic drawers containing serving utensils were also found to be soiled. Sanitizer solution used in the kitchen did not meet professional standards, as test strips failed to register the required parts per million (PPM) for quaternary ammonium sanitizer, with the color on the strip not matching the required range. The Dietary Manager confirmed the sanitizer was recently changed but was unable to verify the correct concentration. Additionally, a Registered Dietitian was observed in the food preparation area without a hairnet. The facility's steamer, used for cooking vegetables, pork ribs, and mashed potatoes, had been broken for about a year, requiring staff to boil foods instead, which was reported to be less effective. Cleaning routines for various kitchen areas and equipment were described by the Dietary Manager, but observations indicated that these routines were not sufficient to maintain required sanitation standards.
Failure to Correct Hazards and Supervision Deficiencies Through QAPI
Penalty
Summary
The facility failed to establish and implement effective policies to correct identified deficiencies, as evidenced by repeated areas of non-compliance and failure to detect or address immediate jeopardy situations through the QAPI process. Specifically, for 12 out of 61 sampled residents, the environment was not maintained free of accident hazards, and residents did not consistently receive adequate supervision or assistive devices to prevent accidents. Hot water temperatures in resident rooms were observed to range from 121.7 to 145.5 degrees Fahrenheit, significantly exceeding safe limits. However, facility water temperature logs for the same period recorded much lower temperatures, indicating a lack of accurate monitoring or reporting. Additionally, residents assessed as requiring supervision while smoking were observed smoking unsupervised, and some residents were not evaluated for smoking safety at all. There were also incidents of residents with a history of wandering eloping from the facility without staff awareness. Despite previous QAPI plans addressing supervised smoking and elopement risks, the facility did not maintain updated lists of residents requiring supervision, failed to assess residents for smoking safety, and did not ensure interventions for elopement risks were consistently in place. Repeat deficiencies from a prior survey were cited again, including those related to accident hazards, resident rights, medication management, and infection control. The Administrator confirmed that QAPI meetings were held monthly and that action plans had been created for some issues, but hot water concerns had not been identified or addressed through the QAPI process.
Failure to Inform and Obtain Consent for Medication and Wanderguard Placement
Penalty
Summary
The facility failed to ensure that two residents or their representatives were fully informed and able to participate in decisions regarding their care and treatment. For one resident with severe vascular dementia and significant cognitive impairment, the facility initiated an antidepressant medication (Escitalopram) without notifying or obtaining consent from the resident's representative prior to starting the medication. Record review and interviews confirmed that no documentation of consent or notification was found before the medication was administered. In another case, a resident who had recently eloped from the facility was fitted with a wanderguard device upon return. Documentation showed that the wanderguard was placed before obtaining informed consent from the resident or her guardian. The consent form and related progress note were completed two days after the device was applied, and staff interviews confirmed that consent should have been obtained prior to placement. These actions demonstrate a failure to inform and involve residents or their representatives in advance of significant care interventions.
Failure to Notify Ombudsman and Provide Written Discharge Notices
Penalty
Summary
The facility failed to provide required written notification of discharge and the reasons for transfer in a language and manner understandable to the resident, and did not send a copy of the discharge notice to the Office of the State Long-Term Care Ombudsman for two residents. For one resident with diagnoses including type 1 diabetes mellitus and end-stage renal disease, multiple hospital transfers were documented in the medical record. However, the Admissions Marketing Director (AMD) stated that the Ombudsman was only notified monthly of residents discharged against medical advice (AMA) or to the community, and not when residents were transferred to a hospital. The Regional Nurse Consultant (RNC) confirmed that the Ombudsman should be notified of all discharges, including hospital transfers, but this was not done for this resident. Another resident with a history of paranoid schizophrenia, major depressive disorder, and other medical conditions left the facility with a friend and did not return. The resident later came back to collect belongings and stated he would not return. The Administrator acknowledged that no AMA form or discharge instructions were provided because the resident was in a rush, and the Ombudsman was not notified of the resident's departure. The AMD considered the situation as leaving AMA, but did not follow the required notification procedures. Interviews with facility staff, including the Administrator, AMD, RNC, and Director of Nursing (DON), revealed inconsistent practices regarding notification of the Ombudsman and provision of discharge documentation. Staff described procedures for contacting residents or families and involving law enforcement if a resident did not return from a leave of absence, but did not consistently notify the Ombudsman or provide written discharge notices as required.
Failure to Accurately Document Depression Diagnosis in Resident Assessment
Penalty
Summary
A deficiency was identified when the facility failed to ensure that a resident's assessment accurately reflected their current medical status. The resident in question had a documented history of severe vascular dementia, hypertension, attention and concentration deficit following cerebral infarction, depression, and cognitive communication deficit. Multiple psychiatric and nursing notes, as well as physician orders, indicated that the resident was being treated for depression with escitalopram (Lexapro), and the diagnosis of depression was referenced in several clinical documents. Despite this, the resident's medical diagnoses list and the Quarterly Minimum Data Set (MDS) did not include depression as a diagnosis. Interviews with facility staff revealed a lack of awareness and documentation regarding the resident's depression diagnosis. Registered nurses and the social service worker were either unsure or unaware of the depression diagnosis, and the face sheet did not reflect it. The Director of Nursing confirmed that the resident had been diagnosed with depression, but this information was not updated in the medical chart or the MDS, resulting in an inaccurate assessment of the resident's condition.
Failure to Prevent Unnecessary Decline in ADL Abilities
Penalty
Summary
Residents experienced a loss in their ability to perform activities of daily living (ADLs) without a documented medical reason. The facility failed to ensure that residents maintained their highest practicable level of functioning in ADLs, as required, unless a decline was clinically unavoidable due to a medical condition. This deficiency was identified through surveyor observation and review of resident records, which did not provide evidence of a medical justification for the decline in ADL performance.
Failure to Follow Treatment Orders and Resident Preferences
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, as well as the resident's preferences and goals. This deficiency was identified through surveyor observation and review of records, which showed that care provided did not align with the documented orders or the expressed wishes and care goals of the resident involved.
Failure to Provide Ordered Therapeutic Diets to Residents
Penalty
Summary
Two residents were not provided with the therapeutic diets ordered for their medical conditions. One resident with type 1 diabetes, who was on a carbohydrate-controlled diet, consistently received high-carbohydrate meals and was not offered low-carbohydrate options as requested by the resident and family. The resident experienced high blood glucose readings, and the family expressed concern that insulin was administered without regard to the carbohydrate content of meals. Observations confirmed that the resident was served meals inconsistent with the prescribed diet, such as being given bread pudding instead of fruit, and the dietary manager was unable to specify the carbohydrate content of meals provided. Another resident, with end stage renal disease, diabetes, and gastroparesis, reported not receiving a renal diet as ordered by the physician. The resident stated that meals included high-potassium foods such as beans and bananas, which are not appropriate for a renal diet. The resident had communicated these concerns to dietary staff without resolution. Review of dietary records and interviews with the dietary manager and registered dietitian revealed a lack of awareness and oversight regarding the specific dietary needs and preferences of these residents, and the computer system used for meal planning did not consistently ensure compliance with therapeutic diet orders.
Failure to Provide Scheduled Invega Injections Due to Medication Unavailability
Penalty
Summary
A deficiency occurred when a resident with multiple psychiatric and medical diagnoses, including severe dementia with agitation, paranoid schizophrenia, and schizoaffective disorder, did not receive scheduled doses of Invega intramuscular injections as ordered. On several occasions, the medication was not available at the facility when it was due to be administered. Specifically, on one occasion, the injection was not given because it had not arrived at the facility, and on another, the medication was unavailable due to issues with insurance coverage. Documentation in the Medication Administration Record (MAR) and nurse notes confirmed these missed doses, with one instance lacking a documented reason for non-administration. The resident's medication orders for Invega were adjusted multiple times, including changes in dosage and administration schedule, in an effort to accommodate insurance requirements. Despite these adjustments, there were repeated failures to provide the medication as scheduled, resulting in missed doses. The facility's process for ordering and ensuring the timely availability of the medication was insufficient, as evidenced by the need to call the pharmacy to reorder the medication and the subsequent delay in administration.
Failure to Arrange Timely Outside Professional Services
Penalty
Summary
The facility failed to arrange for timely outside professional services for two residents who required them. One resident, with multiple diagnoses including Parkinson's disease, schizoaffective disorder, and dementia, was identified as needing dental care after an in-room dental exam revealed decay causing injury to her lip and a need for fillings. Despite a care plan intervention to coordinate dental care and transportation, there was no documentation that an outside dental appointment was scheduled or that the resident refused or canceled such appointments. Interviews with nursing staff and the former unit manager revealed confusion about who was responsible for scheduling and documenting these appointments, and a lack of clarity regarding insurance coverage and the current process for arranging outside services. Another resident, with diagnoses including hemiplegia, chronic respiratory failure, morbid obesity, major depressive disorder, type 1 diabetes, and epilepsy, was referred multiple times to an endocrinologist due to poorly controlled diabetes, as evidenced by elevated Hemoglobin A1c levels. Although the need for an endocrinology referral was documented in several provider notes and discussed in an interdisciplinary team meeting, there was a significant delay in arranging the appointment. The resident's family specifically requested a preferred endocrinologist, and while a referral was eventually made and an assessment conducted, staff interviews indicated uncertainty about when or if previous referrals were acted upon, and the responsible unit manager was unavailable for clarification. In both cases, the facility did not ensure that required outside professional services were arranged in a timely manner, as evidenced by the lack of documentation and follow-through on referrals and appointments. The deficiencies were identified through interviews with residents, staff, and review of medical records, which showed gaps in the process for coordinating and documenting outside care.
Incomplete and Disorganized Medical Records for Two Residents
Penalty
Summary
The facility failed to maintain complete, accurate, and systematically organized medical records for two residents. For one resident with severe vascular dementia, hypertension, and depression, the medical record did not contain an updated Pre-admission Screening/Resident Review (PASRR) reflecting a new diagnosis of depression, despite multiple psychiatric and nursing notes indicating the presence of depression and the initiation of antidepressant therapy. Interviews with staff confirmed that the PASRR was not updated in the medical chart when the new diagnosis was made, and the updated PASRR was not initially available in the resident's record. For another resident with a history of atherosclerotic heart disease, hypertension, diabetes, bipolar disorder, and muscle weakness, there was no documentation in the medical record regarding an elopement event that had been reported by the facility. The Regional Nurse Consultant confirmed that any change of condition, such as an elopement, should be documented in the progress notes, but no such documentation was found in the resident's file.
Failure to Implement Enhanced Barrier Precautions and Maintain Tube Feed Sanitation
Penalty
Summary
Staff failed to implement Enhanced Barrier Precautions (EBP) for a resident with chronic wounds and a feeding tube. Multiple observations showed that staff, including registered nurses and certified nursing assistants, did not wear gowns while providing direct care such as changing bed linens and briefs, or when reconnecting the resident's tube feed. The resident reported that staff wore gloves but not gowns during care. Staff interviews revealed inconsistent knowledge about the requirement to use gowns as part of EBP for residents with tube feeds and chronic wounds. Additionally, the resident's tube feed was observed to be disconnected and left uncapped, exposing the end of the tube to air. Both nursing staff and the regional nurse consultant confirmed that the tube should be capped when not in use to prevent contamination. The facility had a system in place to identify residents requiring EBP and provided gowns and masks outside the resident's room, but these precautions were not consistently followed by staff during care activities.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the actions, inactions, or events leading to the deficiency, nor information about the residents involved or their medical conditions at the time, are provided in the report.
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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