Orem Rehabilitation And Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Orem, Utah.
- Location
- 575 East 1400 South, Orem, Utah 84097
- CMS Provider Number
- 465104
- Inspections on file
- 24
- Latest survey
- May 1, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Orem Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
Two high fall risk residents with significant cognitive and physical impairments experienced multiple falls without the facility implementing new or adequate interventions after each incident. Despite repeated falls and clear documentation of high risk, staff did not update care plans or provide increased supervision, relying instead on repeated education and minor environmental changes. Interviews confirmed that interventions were not sufficiently revised to address the ongoing risk, resulting in a failure to maintain a safe environment and prevent accidents.
Several nurse aides were employed for more than four months without completing the required state-approved training and competency evaluation program. Despite the 120-day limit for certification, these aides continued to work until it was discovered and they were removed from the schedule.
Several residents reported that their meals were often cold, bland, or unappetizing, with food fortification practices involving the addition of cold milk or butter to already plated food. Observations confirmed that food was served at improper temperatures and was not consistently palatable, and the dietary manager was unaware of resident dissatisfaction prior to the survey.
Surveyors identified multiple breaches in food safety standards, including unlabeled and undated food items, improper storage of meat above produce, food and cleaning supplies stored together, and staff personal items in food prep areas. Additionally, a staff member was observed handling food and plates with dirty gloves after touching various surfaces, and water was seen dripping onto the plate warmer.
A resident with chronic pain and intact cognition reported receiving the wrong medication from a nurse when requesting prescribed oxycodone. The resident and his daughter noticed discrepancies, including being given a different colored pill and experiencing symptoms consistent with medication errors. Facility investigation, including video review, confirmed that the nurse diverted the resident's narcotic medication and instead administered other medications, leading to substantiated misappropriation.
A resident with hemiplegia, diabetes, and reduced mobility experienced significant delays in receiving timely specialist appointments for hand contractures and foot drop, despite repeated requests and multiple physician orders. The facility's process required several steps and handoffs before appointments could be scheduled, resulting in the resident having to ask multiple times before an appointment was finally arranged.
A resident receiving oxygen therapy for acute respiratory failure was found to have undated nasal cannulas in use, and there was no physician's order in the medical record for changing oxygen supplies. Staff interviews confirmed that nurses were responsible for changing and dating the cannulas, but the absence of an order led to inconsistent practice and lack of documentation.
Nurse staffing information was not posted daily as required, with outdated postings observed and no updates made on weekends. The receptionist responsible for posting the data was absent on certain days, and no other staff took over the task. The weekend receptionist was not trained to post the information, resulting in missing postings that were later completed retroactively.
A resident with multiple chronic conditions had physician orders for several CBC tests, but the corresponding laboratory results were not found in the clinical record. The facility used two EHR systems, and the lab uploaded results to both; however, Medical Records staff only had access to one system, leading to the omission of required lab reports in the resident's record.
Two residents receiving prophylactic antibiotics for UTI were not consistently monitored under an antibiotic stewardship program. The IP tracked antibiotic use only during the month of initiation and did not maintain ongoing monitoring for long-term use, and the DON did not participate in infection control monitoring.
A resident with a history of trauma was denied the right to exit a room by the ADON, triggering distress. The ADON stood in front of the door during a conversation about the resident's inquiries into staff disciplinary actions, preventing her from leaving. The resident felt trapped, recalling past trauma, and the facility's investigation found the ADON's actions inappropriate, though not malicious.
A facility failed to report an abuse allegation involving a resident and the ADON within the required 2-hour timeframe. The incident, which caused the resident distress, was reported to the SSA 27.5 hours later and to APS eight days later. The resident had multiple health conditions, and the Administrator misunderstood the reporting requirements.
Failure to Implement Effective Fall Prevention Interventions for High-Risk Residents
Penalty
Summary
The facility failed to ensure that the environment was as free from accident hazards as possible and did not provide adequate supervision or implement new interventions to prevent accidents for two high fall risk residents. One resident with multiple diagnoses including dementia, muscle weakness, morbid obesity, and unsteadiness on feet was documented as a high fall risk and experienced several falls within a short period. Despite being a full assist and having a history of falls, no new fall prevention interventions were documented in the medical record after each incident. Staff interviews confirmed that no additional interventions were implemented, and the resident was not on continuous observation, even though the resident had fallen multiple times in a short timeframe and was ultimately sent to the hospital after a change in condition. Another resident with epilepsy, brain deformity, unsteadiness, and muscle weakness was also identified as a high fall risk and experienced multiple falls over several months. After each fall, the interventions implemented were often repeated or limited to education and minor environmental changes, such as providing a non-slip mat or instructing on proper footwear. Despite the resident's cognitive delays, impulsivity, and difficulty following instructions, the interventions did not change significantly after repeated falls, and the care plan was not sufficiently updated to address the ongoing risk. Interviews with nursing staff and consultants revealed that both residents required frequent prompting and supervision due to their cognitive and physical limitations. However, the facility did not implement new or different interventions after repeated falls, and the care plans were not adequately revised to prevent further incidents. The lack of timely and appropriate updates to interventions and care plans contributed to the deficiency in maintaining a safe environment and providing adequate supervision for these high-risk residents.
Nurse Aides Worked Beyond 120 Days Without Required Certification
Penalty
Summary
The facility failed to ensure that nurse aides who had been employed for more than four months were trained, competent, and had completed a state-approved training and competency evaluation program. Specifically, three nurse aides were found to have worked at the facility for over four months without obtaining certification as nursing assistants. Employee records showed that these nurse aides continued to work beyond the 120-day period allowed for certification. Interviews with the Administrator and the CNA Coordinator confirmed that the aides had exceeded the permitted timeframe for certification and had only recently been removed from the schedule due to this deficiency.
Failure to Provide Palatable and Appropriately Tempered Food
Penalty
Summary
The facility failed to provide food that was palatable, attractive, and at a safe and appetizing temperature for several residents. Multiple residents on specialized and regular diets reported that their food was often cold, bland, or unappetizing. Observations and interviews revealed that food fortification practices involved adding cold milk or drizzling butter onto already prepared and plated food, rather than incorporating these items during the cooking process. The dietary manager (DM) confirmed that fortification was done by adding unmeasured amounts of butter or cold milk directly to the plated food due to space constraints, and that the exact caloric content provided to residents was not tracked. During tray line service, staff were observed squirting cold milk and drizzling butter onto plated meals, resulting in food that was oily, bland, and not at the appropriate temperature. A test tray showed that the pureed chicken was cold and oily, the couscous was bland, and the broccoli was cool to the taste. Residents consistently reported dissatisfaction with the temperature and palatability of their meals, and the DM was unaware of these complaints prior to the survey. These findings were based on direct observation, interviews with residents and staff, and review of food service practices.
Food Storage and Service Safety Deficiencies
Penalty
Summary
Surveyors observed multiple failures in food storage, preparation, and service within the facility's kitchen. Unlabeled and undated food items, including a large container of liquid and carafes of juice, were found in the walk-in refrigerator. An opened box of bacon was stored above open produce, and a can of beets was found on the floor in dry storage. Large bins of rice and cereal were not labeled or dated. Staff personal items, such as cellphones and drink cups without lids, were stored on food preparation tables. Cleaning supplies were stored in the same room as fresh produce. Water was observed dripping from a ceiling vent onto the plate warmer. During meal service, a staff member was seen handling plates and food with dirty gloves after touching other surfaces, including plate covers, meal tickets, the faces of plates, a shelf, and an electrical cord. The Dietary Manager confirmed that these practices were not in accordance with facility policy or professional standards, stating that food should not be stored on the floor, meat should be stored below produce, bins should be labeled and dated, and staff should not have personal items in food preparation areas or touch other surfaces before handling food or plates.
Misappropriation of Resident's Pain Medication by Nursing Staff
Penalty
Summary
A resident with diagnoses including cerebral infarction, respiratory failure, and chronic pain syndrome, and who was cognitively intact, reported concerns about receiving incorrect medications from a specific nurse. The resident stated that on multiple occasions, when requesting his prescribed oxycodone for pain, he was given a different colored pill, which he identified as not being his usual pain medication. The resident's daughter also witnessed the administration of a white pill instead of the expected medication and later raised the issue with facility staff. The resident experienced symptoms such as an upset stomach and noted that his pain medication supply depleted faster than expected, while his heart medication was being administered in excess, as confirmed by his physician. The facility's investigation included interviews, review of medication administration records, and examination of video footage. The footage showed the nurse in question accessing the narcotic drawer, removing medication, and placing it in her pocket rather than administering it to the resident. The nurse was also observed preparing pill packs and explaining the process to the resident's daughter, who expressed confusion about the medication packaging. The nurse denied any wrongdoing but could not account for the discrepancies in medication administration. The facility verified that the resident was not administered his prescribed narcotic as ordered and that the nurse had diverted the medication. The nurse was found to have violated the facility's code of conduct regarding drug diversion. The incident was reported to the appropriate authorities, and the nurse was subsequently terminated. The resident was considered a vulnerable adult with full capacity at the time of the incident, and the misappropriation of his medications was substantiated by both facility and external investigations.
Delay in Specialist Referrals for Contractures and Foot Drop
Penalty
Summary
A deficiency was identified when a resident with hemiplegia, hemiparesis, type 2 diabetes mellitus, reduced mobility, and major depressive disorder was not provided timely appointments with referred specialists for hand contractures and foot drop. The resident, who had intact cognition as indicated by a BIMS score of 15, repeatedly requested to see an orthopedic hand surgeon and a podiatrist for worsening contractures and drop foot. Despite multiple encounter notes and physician orders documenting the need for these referrals, there were significant delays in scheduling the appointments. The process for scheduling specialist appointments involved several steps: the in-house physician would order the referral, the floor nurse would enter and print the order for the physician's signature, and the signed order would then be routed to the Director of Transportation (DT) for scheduling. Interviews with staff revealed that the DT could only schedule appointments after receiving the signed order, and that delays could occur due to the need for provider acceptance, insurance verification, and document transmission. The DT, nurses, and DON described a workflow that required multiple handoffs and physical movement of paperwork, which contributed to the delay. Documentation showed that the resident's requests and the need for specialist evaluation were repeatedly noted from early February through late March, with orders for referrals being placed and re-affirmed multiple times. However, the actual appointment for the orthopedic hand surgeon was not scheduled until late April, with the appointment set for early May. The resident reported having to ask multiple times before the appointment was finally arranged, indicating that the facility did not reasonably accommodate her needs and preferences in a timely manner.
Failure to Ensure Proper Orders and Documentation for Oxygen Supply Changes
Penalty
Summary
A deficiency was identified when a resident with acute respiratory failure with hypoxia, epilepsy, and subarachnoid hemorrhage was observed using oxygen therapy without proper documentation or adherence to professional standards for respiratory care. The resident was seen with undated nasal cannulas attached to both an oxygen concentrator and a portable oxygen tank. Multiple staff interviews confirmed that nurses were responsible for changing and dating the nasal cannulas, and that such changes were expected to occur weekly. However, there was no physician's order in the medical record for changing the oxygen supplies, and the cannulas in use were not dated as required. Further review and staff interviews revealed that the process for changing and documenting oxygen supplies was not being followed due to the absence of a physician's order in the resident's medical record. The lack of an order resulted in the failure to consistently change and date the nasal cannulas as per facility protocol and professional standards. This lapse was confirmed by nursing staff and the regional nurse consultant, who acknowledged that the required order was missing and that the changes had not been occurring as expected.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post daily nurse staffing information as required, with observations showing that the posted information was outdated and not updated on weekends. During an initial tour, the nurse staffing posting was found to be several days old. Interviews revealed that the receptionist, who was responsible for posting the staffing data, was absent on certain days and no one else assumed the responsibility in her absence. Additionally, the daily nurse staffing information was not posted on weekends because the weekend receptionist was not trained to do so. For days when the information was not posted, the receptionist later completed the records retroactively and stored them in a binder.
Failure to File Laboratory Reports in Resident Record
Penalty
Summary
A deficiency was identified when it was found that laboratory reports for a resident were not filed in the resident's clinical record as required. The resident, who had multiple diagnoses including type 2 diabetes, congestive heart failure, essential hypertension, schizoaffective disorder, Bell's palsy, anxiety disorder, and depression, had physician orders for Complete Blood Count (CBC) tests on several occasions. However, no laboratory results for the CBCs ordered on three specific dates could be located in the resident's electronic medical record. During interviews, it was revealed that the facility used two electronic health record (EHR) applications, and the laboratory uploaded results to both. The Medical Records staff only had access to one of these applications and could only file results that were uploaded to the system they could access. The missing laboratory results were uploaded to the EHR application that Medical Records did not have access to, resulting in the reports not being filed in the resident's clinical record.
Failure to Monitor Long-Term Antibiotic Use
Penalty
Summary
The facility failed to maintain an effective antibiotic stewardship program that included protocols and a system to monitor all antibiotic use for residents. Specifically, two residents with orders for prophylactic antibiotics were not adequately monitored. One resident had a physician's order for Keflex 500 mg at bedtime for UTI prophylaxis, and another had a physician's order for Cephalexin 250 mg daily for chronic UTI prophylaxis related to long-term antibiotic use. Record reviews confirmed that these residents were on long-term antibiotic therapy. Interviews with facility staff revealed gaps in the monitoring process. The Infection Preventionist (IP) stated that antibiotic reviews were not consistently performed for residents on long-term prophylactic antibiotics, and tracking was only done for the month the antibiotic was initiated, without ongoing monitoring in subsequent months. The IP also confirmed there was no system in place to track residents on long-term antibiotic use. The Director of Nursing (DON) indicated that she did not participate in infection control monitoring, leaving all antibiotic stewardship responsibilities to the IP.
Resident Denied Right to Exit Room by ADON
Penalty
Summary
The deficiency involved a resident who was denied the right to exit a room by facility staff, specifically the Assistant Director of Nursing (ADON). The resident, who was cognitively intact with a BIMS score of 15, had a history of trauma and was triggered by the ADON's actions. The incident occurred when the ADON brought the resident into his office to address a concern about the resident asking staff about a disciplinary action involving another staff member. During the conversation, the resident attempted to leave, but the ADON stood in front of the door, preventing her from exiting, which caused the resident distress and triggered memories of past trauma. The facility's investigation revealed that the ADON's actions were inappropriate, although not malicious. The ADON admitted to standing in front of the door to stop the resident from leaving, which was confirmed by RN 1, who was present during the conversation. The ADON's demeanor and communication style were perceived as stern and could have been interpreted as intimidating by the resident. The resident reported feeling trapped and compared the situation to past experiences with her ex-husband, which exacerbated her distress. The facility's policy on abuse and involuntary seclusion was reviewed, which defines involuntary seclusion as the separation of a resident from others or confinement against their will. The ADON acknowledged that he should have allowed the resident to leave when she expressed a desire to do so. The incident highlighted a failure to respect the resident's right to freedom from involuntary seclusion, as the ADON's actions effectively confined the resident to the office against her will.
Delayed Reporting of Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident and the Assistant Director of Nursing (ADON) within the required timeframe. The incident occurred when the ADON brought a resident into his office to discuss a concern raised by a Certified Nurse Assistant (CNA) regarding inappropriate inquiries made by the resident. During the conversation, the resident attempted to leave the office, but the ADON stood in front of the door, insisting on continuing the discussion, which caused the resident distress. This incident was reported to the State Survey Agency (SSA) 27.5 hours after the allegation was made, exceeding the regulatory requirement of reporting within 2 hours if the event involved abuse. The resident involved had multiple diagnoses, including Parkinson's disease, congestive heart failure, and type II diabetes mellitus, among others, and was discharged from the facility on a later date. The facility also failed to notify Adult Protective Services (APS) of the incident until eight days after the allegation was made. The Administrator believed the report to the SSA was timely, misunderstanding the requirement, thinking he had 24 hours to report since the allegation did not result in serious bodily injury.
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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