Monument Healthcare Stonecreek
Inspection history, citations, penalties and survey trends for this long-term care facility in Bountiful, Utah.
- Location
- 523 North Main Street, Bountiful, Utah 84010
- CMS Provider Number
- 465156
- Inspections on file
- 18
- Latest survey
- January 5, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Monument Healthcare Stonecreek during CMS and state inspections, most recent first.
A resident with a left foot wound and a history of orthopedic aftercare, toe amputation, and type 2 DM did not receive wound vac treatment as ordered due to delayed provision of wound vac supplies. After returning from wound clinic visits, notes documented that a wound vac was to be ordered and used on a specific schedule, with a physician order to start the wound vac ASAP to the left foot. A subsequent order specified that the wound vac must be in place and functioning with changes three times weekly and PRN. However, the wound vac could not be placed because supplies were not available. In interviews, an LPN and the DON reported that wound vacs and supplies from the contracted vendor typically arrived the same day, within hours, and not longer than a week, yet the DON was unable to explain why it took so long for this resident to receive the necessary supplies, resulting in failure to provide timely ordered wound care.
Two residents did not receive multiple ordered medications because drugs were out of stock or not delivered from the pharmacy. One resident with T2DM, orthopedic aftercare needs, and an amputation had repeated missed doses of glimepiride, Eucerin cream, and amitriptyline documented on the MAR, with notes stating medications were out of supply, on order, or not in stock, even after the resident questioned whether her antidepressant should still be given. Another resident admitted for post‑operative rehab with acute osteomyelitis and cellulitis had IV Piperacillin‑Tazobactam and Vancomycin ordered for infection but missed two scheduled Piperacillin‑Tazobactam doses and received a Vancomycin dose several hours late due to prescriptions not being faxed on arrival, fax transmission problems, and lack of delivered medication or emergency stock. Staff interviews described expectations to reorder medications several days before running out and to notify providers when medications are unavailable, but the documented missed doses and unavailability show these processes were not effectively carried out for these residents.
A resident admitted after hospitalization for osteomyelitis and sepsis with a left great toe amputation had hospital discharge orders for IV Cefazolin 2 g q8h for an extended course of therapy. At admission, staff misread the hospital order and entered the IV antibiotic in the system as a once-daily (q24h) dose, resulting in the resident not receiving any additional dose on the day of admission and only a single 2 g dose the following day, instead of the ordered q8h regimen. The resident reported to nursing staff multiple times that the antibiotic should be given q8h, and the DON later confirmed that the admitting nurse had misread the hospital order.
The facility failed to label an insulin pen and a vial of Lidocaine with open dates and improperly repackaged narcotics into medication cards. RNs acknowledged the medications were in use and should have been labeled, and the DON confirmed the proper procedures for labeling and wasting narcotics.
A resident who required maximum assistance for bed mobility and toilet use fell out of bed during a brief change performed by one CNA, resulting in contusions and emotional distress. The resident had requested a second staff member, but the CNA proceeded alone, leading to the fall. Interviews revealed that the resident was generally considered a two-person assist, highlighting a failure in communication and adherence to the care plan.
A resident with chronic pain and multiple medical conditions did not receive timely pain medication due to the facility running out of the prescribed narcotics and a non-functional emergency kit. The resident had to wait almost two hours for pain relief, causing significant distress and discomfort.
A resident with a history of major depressive disorder did not receive the necessary behavioral health services despite a physician's order and a referral for therapy. The resident expressed feelings of depression and a desire to see a therapist, but no action was taken to provide these services, and there was no documentation indicating that the resident had been seen by behavioral health services.
Delay in Wound Vac Supplies Resulting in Missed Ordered Treatment
Penalty
Summary
A resident with diagnoses including orthopedic aftercare, acquired absence of the left great toe, and type 2 diabetes was not provided wound vac supplies in a timely manner, resulting in a failure to implement ordered wound care according to professional standards and the resident’s care plan. On 6/5/25, a progress note documented that the resident had returned from a wound clinic appointment with instructions to order a wound vac, send it with the resident to the next appointment, and consider hyperbaric oxygen therapy. The note indicated that the DON and ADON were aware of these requests and orders. On 6/13/25, another progress note documented that the resident returned from an appointment with instructions that the wound vac was to be used on Monday, Wednesday, and Friday, with dressing changes every two days. The physician’s note/orders at that time stated to start the wound vac as soon as possible to the left foot, but also documented that they were unable to place the wound vac due to lack of supplies. On 6/16/25, a formal order was documented for a wound vac to the left foot, specifying that the wound vac should be in place and functioning, with changes on Monday, Wednesday, Friday, and as needed for wound healing. Despite these orders and the facility’s established process for obtaining wound vacs and supplies, the resident did not receive the necessary supplies in a timely manner. During interviews, an LPN stated that wound vacs were supplied by a contracted company and were brought the same day they were ordered, with all needed supplies. The DON stated that wound vacs arrived within two hours on the day they were ordered and that it would not take more than a week for a wound vac and supplies to be delivered, but she was unsure why it took so long for this resident to receive wound vac supplies. This discrepancy between the facility’s stated process and the actual delay in obtaining supplies led to the resident not receiving ordered wound vac treatment as prescribed.
Failure to Ensure Availability and Timely Administration of Ordered Medications
Penalty
Summary
The deficiency involves the facility’s failure to provide routine and emergency medications as ordered for two residents, resulting in multiple missed doses due to medications being out of stock or not delivered. For one resident with type 2 diabetes, orthopedic aftercare needs, and an amputation of the left great toe, the medical record showed standing orders for glimepiride 4 mg at bedtime for diabetes, Eucerin Advanced Repair cream twice daily for dry, scaly skin on both lower extremities, and amitriptyline 25 mg at bedtime as an antidepressant. The MAR documented that glimepiride was not administered on multiple dates in September because the medication was not on hand, out of stock, or awaiting refill from the pharmacy. Progress notes repeatedly recorded that the glimepiride was unavailable, reordered, and awaiting delivery, and that staff were unable to give the medication because it was not in stock. For the same resident, the Eucerin cream was not administered on multiple dates in June and August. Progress notes documented that the cream was out of supply and on order. Additionally, amitriptyline was not administered on two consecutive dates in June. An eMAR note indicated there was “no med,” and a subsequent note documented that the medication was not available. A separate encounter note recorded that the resident sought verification that she was still supposed to receive her amitriptyline dose, and staff verified that the order was still active and that she should be receiving it nightly. Despite this, the MAR and notes show that the medication remained unavailable on at least one of those dates. The second resident was admitted for post‑operative rehabilitation with IV infusions and had diagnoses including orthopedic aftercare following an amputation, acute osteomyelitis of the right ankle and foot, cellulitis of the right lower limb, and type 2 diabetes mellitus. This resident had physician orders for Piperacillin‑Tazobactam 3.375 g IV every 6 hours and Vancomycin 1 g IV twice daily for infection. The MAR showed that the resident did not receive the ordered Piperacillin‑Tazobactam doses at two scheduled administration times and that the ordered Vancomycin evening dose was not given at the scheduled time but was instead administered several hours later. Nursing documentation stated that the resident was admitted after the scheduled dose time, that none of the prescriptions were faxed to the pharmacy on arrival, that faxes were not going through, and that the Piperacillin‑Tazobactam was not in the emergency kit and had not been delivered from the pharmacy. The resident later reported being very upset about not receiving antibiotics for several hours after they were due and expressed concern about his infection. Interviews with staff further described the facility’s processes and expectations for medication ordering and availability. An LPN stated that when a medication needed to be refilled, it was reordered in the electronic medical record to alert the pharmacy, and that residents should not go a week without a medication. The LPN also stated that nurses should notify the provider when a resident is out of medication and document those communications. An RN reported that medications should be reordered when there is about one week of supply left and that residents should never run out of medications, emphasizing that it is the nurse’s job to ensure medications are ordered and do not run out. The DON stated that medications should be reordered when there are five days left, that unavailable medications should be communicated to the provider for further direction, and that such issues should be documented and brought to nursing management. Despite these stated expectations, the records for both residents show repeated missed doses and documented unavailability of ordered medications.
Resident Did Not Receive IV Antibiotic at Ordered Frequency
Penalty
Summary
A resident admitted with orthopedic aftercare needs, an acquired absence of the left great toe, and type 2 diabetes had hospital discharge orders for IV Cefazolin 2 g every 8 hours for 50 days, with the last hospital dose given the morning of admission. Upon admission, facility staff entered the IV antibiotic order incorrectly into the system as 2 g IV every 24 hours/once daily instead of every 8 hours, and no additional dose was administered on the day of admission after the morning hospital dose. The Medication Administration Record showed the resident received only one 2 g dose on the day after admission, rather than the ordered every-8-hour regimen. Progress notes documented that a medication error occurred when the IV antibiotic was entered incorrectly and scheduled every 24 hours instead of every 8 hours, and that the resident reported not receiving the antibiotic the night of admission and told nursing staff multiple times that it was supposed to be given every 8 hours. The DON stated that the facility obtained medication orders from the hospital, that nursing managers were to review medications and orders within 72 hours of admission, and that nurses were instructed to have nursing management double-check all ordered medications. The DON reported that the admitting nurse misread the hospital order, leading to the incorrect frequency being entered and the resident not receiving the IV antibiotic as ordered every 8 hours.
Improper Labeling and Repackaging of Medications
Penalty
Summary
The facility did not label all drugs and biologicals in accordance with currently accepted professional principles. Specifically, an insulin pen and a vial of Lidocaine were found open and available for use without an open date, making it impossible to determine their expiration. Additionally, narcotics were improperly repackaged into narcotic cards. During observations, it was noted that a pre-filled pen of Lantus insulin and a vial of Lidocaine were not labeled with an open date. Registered Nurses (RNs) acknowledged that these medications were in use for residents and should have been labeled with an open date. The insulin pen was placed back into the medication cart for future use, and the Lidocaine vial was discarded by RN 2 after the observation. The Director of Nursing (DON) confirmed that medications should be labeled with an open date when taken out of the medication storage room, including insulin and Lidocaine. Furthermore, multiple instances of narcotics being repackaged into medication cards were observed. Medication cards containing Hydromorphone, Tramadol, Pregabalin, and Oxycodone were found with pockets taped, indicating that medications had been removed and possibly retaped back into the cards. RNs stated that the proper procedure was to waste narcotics with another nurse and not to retape them into the medication cards. The DON reiterated that nurses should waste narcotics with another nurse and not retape them into the medication cards, highlighting infection control issues and the inability to ensure the correct medication was retaped into the card.
Failure to Provide Adequate Supervision and Assistance Devices
Penalty
Summary
The facility failed to ensure that the resident environment remained as free of accident hazards as possible and that each resident received adequate supervision and assistance devices to prevent accidents. Specifically, Resident 41, who was dependent on staff and required maximum assistance for bed mobility and toilet use, had a brief change performed by one CNA, resulting in the resident rolling out of the bed, receiving contusions, and suffering emotional distress. The resident was admitted with multiple diagnoses, including fibromyalgia, hepatic encephalopathy, and muscle weakness, and was documented as requiring maximum assistance for bed mobility and other activities of daily living (ADLs). On the night of the incident, Resident 41 was being assisted by CNA 4, who raised the bed to waist level and attempted to change the resident's brief without additional help, despite the resident's request for a second staff member. The resident expressed fear of falling and requested to be moved back to the center of the bed, but CNA 4 proceeded to roll the resident further, resulting in the resident falling out of the bed and landing on the metal legs of a side table. The resident was transported to the hospital for evaluation and was found to have a chest contusion and shoulder bruise. Interviews with other CNAs and the DON revealed that Resident 41 was generally considered a two-person assist for all cares, including bed mobility and brief changes, due to her limited mobility and inability to grasp side rails. The DON and ADM initially stated that the resident was a one-person assist, but this was contradicted by other staff members who consistently reported that two people were needed to safely assist the resident. The incident highlighted a failure in communication and adherence to the resident's care plan, which specified the need for maximum assistance and the presence of two staff members during care activities.
Failure to Provide Timely Pain Management
Penalty
Summary
The facility failed to provide timely pain management for a resident who required such services. Resident 41, who had a history of chronic pain and multiple medical conditions, was observed in significant pain and tearful after being flipped out of bed by a CNA the previous night. Despite the resident's verbal expression of pain and the presence of a physician's order for pain medication, the resident did not receive pain medication in a timely manner due to the facility running out of the prescribed narcotics and the emergency kit being non-functional. The resident had to wait almost two hours before receiving pain medication, causing her significant distress and discomfort. The RN on duty acknowledged the issue, stating that the lack of medication was due to other staff members not reordering it when needed, a common occurrence at the facility. The RN attempted to use the emergency kit, but it was not functioning, and the pharmacy had not yet delivered the additional pain medication prescribed by the emergency room. The resident's care plan included interventions for pain management, such as applying hot or cold packs, educating the resident on pain management, and responding immediately to any complaint of pain, but these were not effectively implemented in this instance. Interviews with the DON and CNAs confirmed that the facility had a single emergency kit for all residents, and if it was not working, medication had to be brought from the pharmacy. The DON admitted that the staff were expected to reorder medications when they got low and use other pain management options if available. The resident expressed frustration and confusion about why she had to wait so long for her pain medication, and the CNAs noted that the resident was always in pain and required very gentle care to avoid exacerbating her discomfort.
Failure to Provide Necessary Behavioral Health Services
Penalty
Summary
The facility failed to ensure that Resident 29 received the necessary behavioral health care and services as per their comprehensive assessment and plan of care. Resident 29, who had a history of major depressive disorder, expressed feelings of depression and a desire to see a therapist. Despite being on antidepressants and having a physician's order for behavioral health evaluation and treatment, the resident did not receive the required behavioral health services. The resident had informed an unknown staff member about her need for therapy two to three months prior, but no action was taken to provide these services. The medical record review revealed that a referral for therapy was made on 2/2/24, but there was no documentation indicating that Resident 29 had been seen by behavioral health services. Interviews with the Social Services Director and the Director of Nursing confirmed that although a referral was made, there was no evidence that the resident received the necessary behavioral health care. The Director of Nursing mentioned that the nurse practitioner typically visits the facility the following Monday after an order is placed, but no notes from behavioral health services were received for Resident 29.
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.
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.
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.
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 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.
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.
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