Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Paramount Health And Rehabilitation during CMS and state inspections, most recent first.
A resident who required 1:1 supervision while smoking was left unattended in the smoking area by a PRN PT who was unaware of the supervision requirement. The resident's clothing caught fire, leading to significant burn injuries and hospitalization. Another resident sustained burns to his hand while attempting to help. The DON confirmed that staff were unaware of the unsupervised situation and that supervision was not provided as required.
The facility failed to implement its pre-employment screening policies, allowing a nursing assistant to work for three months with an invalid Social Security Number and without submitting required fingerprints. The facility's policy requires electronic submission of fingerprints within 15 working days, but this was not enforced, leading to the assistant's eventual termination.
A resident with limited mobility and multiple diagnoses, including hemiplegia and cerebral palsy, did not receive appropriate range of motion care for his right hand. Despite a care plan for contracture management, the facility failed to provide necessary services and devices, leading to further contracture. Observations showed the resident's hand clenched in a fist with long nails, and staff interviews revealed inconsistencies in care implementation.
The facility failed to maintain a safe environment, resulting in significant injuries to several residents. A resident suffered a partially amputated finger due to a wheelchair hinge, while another experienced multiple falls, including a hip fracture. Two residents fell during transport due to improper securing, and another sustained a burn while smoking unsupervised. These incidents reflect inadequate supervision and safety measures.
Two residents in an LTC facility experienced inadequate tube feeding administration, leading to unstable nutritional status. One resident's feeding schedule was inconsistent, with discrepancies in timing and duration, while the other resident's feeding was interrupted by personal care activities and outings. The facility failed to document feeding volumes and ensure proper positioning during feedings, contributing to the residents' risk of malnutrition.
The facility failed to serve breakfast within 14 hours of the evening meal, as breakfast was served later than the posted time, causing delays. Observations showed breakfast service started after 8:00 AM, despite a posted time of 7:20 AM. Residents expressed concerns about waiting for meals, and the Dietary Manager acknowledged the confusion caused by the posted schedule.
The facility failed to report incidents of abuse, neglect, or mistreatment to the SSA within the required timeframe for three residents. One resident sustained a severe finger injury, another was not secured in a transport van, and a third did not receive regular wound care. The Administrator did not initially report these incidents, leading to delays in notifying the SSA.
The facility failed to investigate and report incidents involving four residents, including a finger injury, alleged abuse by a CNA, and improper transport leading to injury. Investigations were incomplete, lacked documentation, and were not reported timely to the State Survey Agency.
A medication refrigerator in the facility was found to be at an improper temperature, affecting the storage of medications for three residents. The fridge was observed at 48 degrees Fahrenheit, outside the required range, compromising the storage of medications like Pipercillin/Tazobactam, Ceftriaxone, and Cefazolin. Interviews with staff confirmed awareness of the temperature requirements for medication storage.
The facility was found to have deficiencies in food storage and kitchen maintenance, with food items left open to air, undated containers, and structural issues like rusty vents and cracked tiles. The Dietary Manager acknowledged these issues, noting that the vent was not functioning and had not been reported, and that staff had not been sealing food boxes. Monthly audits were conducted, but there was no tracking of improvements.
The facility failed to implement effective QAPI processes, leading to multiple resident safety incidents, including a partial finger amputation, falls resulting in injuries, and inadequate care for skin breakdown. The QAPI team identified issues but did not follow up on corrective actions.
A resident with multiple health issues, including Alzheimer's and heart failure, did not receive proper wound care as per physician's orders. The resident's foot bandage was not changed as required, and a sore on the shin was not documented or assessed. Staff interviews revealed a lack of awareness and documentation regarding the resident's skin conditions, and interventions to prevent skin impairment were not consistently implemented.
The facility did not ensure a nurse aide, employed full-time for six months, was competent and had completed a state-approved training and competency evaluation program. HR could not find documentation of the aide's enrollment in a CNA course, despite the requirement to do so within 120 days of hire.
The facility failed to maintain a safe and homelike environment, with issues including protruding drywall with unknown substances, persistent odors, and torn fall mats. Staff were unaware or did not address these deficiencies, leading to unsafe conditions for residents.
A resident in a long-term care facility reported abuse by a CNA who allegedly placed a gait belt around her own neck, mimicked hanging herself, and pinned a sheet over the resident's head. The resident, who was cognitively intact, felt trapped and frightened. The CNA was suspended and later terminated for gross misconduct. The facility's investigation was inconclusive, and the incident was reported to the State Survey Agency and police.
The facility failed to implement comprehensive care plans for three residents, leading to unmet medical and psychosocial needs. A resident at risk for pressure ulcers was not provided with necessary interventions, another had a call light out of reach despite fall risks, and a third resident's request for a side rail was not evaluated or documented. These deficiencies highlight lapses in care planning and execution.
A resident with multiple medical conditions, including dysphagia and a history of traumatic brain injury, was not provided with the necessary feeding assistance and supervision, leading to a deficiency in maintaining their ability to perform activities of daily living. Observations showed the resident's meal tray was left untouched without staff intervention, despite care plan requirements for supervision. Staff interviews revealed inconsistencies in the assistance provided, with some unaware of the need to ensure the resident ate in the dining room.
A resident with severe cognitive impairment and physical disabilities was observed with long fingernails, indicating a failure in maintaining grooming needs. Despite having a padded device to prevent self-scratching, the resident's nails were not regularly trimmed, as confirmed by observations and interviews. Medical records and CNA tasks showed inconsistent documentation and attention to nail care, leading to this deficiency.
A resident with severe cognitive impairment and multiple health issues was not properly positioned during continuous tube feeding, as required by her care plan and physician orders. Staff acknowledged the difficulty in maintaining the required head elevation, and the facility failed to document the total volume of feeding infused, leading to a deficiency in care.
A resident with multiple diagnoses had a half side rail installed without an evaluation of risks versus benefits. The resident requested an additional rail for repositioning, but no evaluation was documented. Facility staff, including the Maintenance Director, Director of Therapy, and LPN, were unaware of the existing rail and the need for a care plan or consent. The DON confirmed the lack of documentation and evaluation.
A resident with multiple diagnoses, including functional quadriplegia and traumatic brain injury, was involved in an incident that led to a physician's order for a bilateral hip x-ray. The facility failed to document the x-ray results in the resident's medical record, and the DON confirmed the report could not be located despite requesting it from the x-ray company.
A facility failed to maintain an effective infection control program when an LPN touched an unknown red/orange substance on protruding drywall in a resident's room without gloves. The resident had multiple health issues, including Alzheimer's and heart failure. The LPN admitted to not following proper protocols, highlighting a lapse in infection control practices.
A resident with a complex medical history, including traumatic brain injury and seizures, was found to have their call light out of reach, tied around a light fixture. Staff interviews confirmed the resident's confusion and forgetfulness, and the importance of having the call light accessible was acknowledged by the LPN, CNA, and DON. Despite prior education on this issue, the deficiency was observed.
Failure to Supervise Smoking Resident Results in Fire and Injuries
Penalty
Summary
The facility failed to provide adequate supervision to prevent accidents for two of seven sampled residents. One resident, who had a physician's order and care plan requiring one-to-one supervision while smoking due to a seizure disorder and potential for injury, was left unattended in the designated smoking area by a PRN physical therapist. The therapist, who was not aware of the supervision requirement, left the resident with cigarettes and a lighter and returned inside the facility. There were no other staff present in the smoking area at the time. While unsupervised, the resident's shirt caught on fire. Another resident attempted to extinguish the flames with his hand but was unsuccessful, resulting in burn injuries to his own hand. A third resident alerted staff by shouting for help. Staff responded by bringing a smoking blanket and a fire extinguisher, and the nurse used the blanket to put out the flames. The fire department arrived within 5-10 minutes, and the resident who caught fire was transported to the hospital with significant burn injuries. The second resident sustained burns to his fingers while trying to help. The facility's investigation confirmed that the resident who required supervision was left alone due to a lack of communication and understanding of the care plan by the PRN therapist, who primarily worked at another facility. The Director of Nursing acknowledged that the staff were unaware of the resident being left unsupervised and that the required supervision was not provided, resulting in injuries to both residents involved.
Failure to Implement Pre-Employment Screening Policies
Penalty
Summary
The facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents, as well as the misappropriation of resident property. A nursing assistant was employed at the facility for approximately three months despite providing an invalid Social Security Number and failing to submit fingerprints as required. The facility's Pre-Employment Investigations Policy mandates that employees submit fingerprints electronically to the Department of Health within 15 working days of engagement. However, the nursing assistant's fitness determination was still in process, and the facility was aware that the fingerprints had not been submitted. The nursing assistant was eventually terminated after the discovery of the invalid Social Security Number.
Failure to Provide Appropriate ROM Care for Resident
Penalty
Summary
The facility failed to provide appropriate care for a resident with limited mobility, specifically in maintaining or improving the range of motion in the resident's right hand. The resident, who was admitted with multiple diagnoses including hemiplegia, intellectual disabilities, and cerebral palsy, was observed with a padded device on his right wrist, which was not effectively preventing further contracture of his hand. Observations revealed that the resident's right hand was clenched in a fist with long fingernails, indicating a lack of proper range of motion exercises or devices to prevent contractures. The resident's care plan included interventions for contracture management, such as the use of hand rolls and therapy evaluations, but there were no specific orders for devices or treatments related to the right hand. Despite the presence of a care plan, the facility did not ensure the consistent application of these interventions. Observations and interviews with staff indicated that the resident was not receiving the necessary range of motion services, and there was a lack of documentation regarding nail trimming, which is essential for preventing further complications. Interviews with various staff members, including the ADON, PT, and OT, revealed inconsistencies in the understanding and implementation of the resident's care plan. The staff acknowledged the use of a padded device, referred to as a 'mit', for protection against self-injury, but there was no clear protocol for its use in preventing contractures. The facility's failure to provide consistent and appropriate care for the resident's right hand, as outlined in the care plan, contributed to the deficiency identified by the surveyors.
Inadequate Supervision and Safety Measures Lead to Resident Injuries
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for several residents, leading to significant injuries. One resident, diagnosed with Alzheimer's Disease and other conditions, suffered a partially amputated finger after it became caught in a tilting wheelchair hinge. The incident occurred while the resident was being wheeled to her room, and the injury was severe enough to require hospital treatment, including the removal of the fingernail and stitches. The facility's investigation into the incident was inconclusive, with conflicting accounts from staff about how the injury occurred. Another resident, with a history of falls and multiple medical conditions including dementia and Alzheimer's disease, experienced several falls, one of which resulted in a hip fracture. Despite being identified as high risk for falls, the resident's care plan did not include effective interventions to prevent further incidents. The resident was found on multiple occasions on the floor, sometimes with injuries, and the facility's response was limited to re-educating staff without implementing new preventive measures. Additionally, two residents were not properly secured during transportation in the facility vehicle, resulting in falls. Another resident sustained a burn while smoking unsupervised. These incidents highlight a pattern of inadequate supervision and failure to implement necessary safety measures, contributing to the residents' injuries and compromising their safety.
Inadequate Tube Feeding Administration for Two Residents
Penalty
Summary
The facility failed to ensure that two residents maintained acceptable nutritional status due to improper administration of tube feedings. Resident 26, who had a history of severe protein-calorie malnutrition and dysphagia, was not receiving tube feedings as ordered. The resident's tube feeding schedule was inconsistent, with discrepancies in the timing and duration of feedings. The medical records lacked documentation of the exact times and amounts of formula administered, leading to potential nutritional deficiencies. Interviews with nursing staff revealed confusion about the correct tube feeding orders, and the resident's weight was not consistently monitored or maintained within a stable range. Resident 39, who relied entirely on enteral feeding due to severe cognitive impairment and dysphagia, also experienced issues with tube feeding administration. Observations showed that the resident's feeding pump was turned off, and the head of the bed was not consistently elevated as required during feedings. The facility did not document the total volume of formula infused, and the resident's feeding schedule was interrupted by personal care activities and outings with family. The Registered Dietitian was unaware of the actual volume of formula administered, and the facility did not ensure the resident's nutritional needs were met consistently. Both residents were at risk of malnutrition due to the facility's failure to adhere to prescribed tube feeding protocols. The lack of proper documentation and monitoring of feeding schedules and volumes contributed to the residents' unstable nutritional status. The facility's inability to maintain consistent feeding practices and ensure proper positioning during feedings highlighted deficiencies in the care provided to these residents.
Delayed Breakfast Service Exceeds 14-Hour Meal Interval
Penalty
Summary
The facility failed to provide meals with no more than 14 hours between the substantial evening meal and the breakfast meal the following day. Observations and interviews revealed that breakfast meals were being served more than 30 minutes beyond the posted time, causing more than 14 hours to elapse between the evening meal and the breakfast meal. The posted meal schedule indicated breakfast at 7:20 AM, but the actual serving of breakfast started much later, with the first tray being served at 8:03 AM and the last at 8:16 AM. This delay was confirmed by multiple observations and resident interviews, where residents expressed that they had to wait a long time for their meals. The Dietary Manager (DM) acknowledged that the posted 7:20 AM mealtime was when the kitchen staff began plating the food, and the actual serving of breakfast started between 7:45 AM and 8:00 AM. The DM also mentioned that hallway trays were served first, and residents could request drinks while waiting for their meals. However, the DM admitted that the posted meal time could be confusing to residents. Despite attending resident council meetings, the DM stated that residents had not mentioned any issues about waiting for meals. The deficiency affected several residents, including those identified as 7, 9, 30, 31, 49, 51, and 106.
Failure to Timely Report Incidents of Abuse and Neglect
Penalty
Summary
The facility failed to report incidents of abuse, neglect, or mistreatment to the State Survey Agency (SSA) within the required timeframe for three residents. Resident 21 sustained a severe finger injury while being pushed in her wheelchair, which was not reported to the SSA until several days after the incident. The Administrator, who was also the abuse coordinator, initially did not believe the incident required reporting based on the information provided by a Certified Nursing Assistant. The report was eventually submitted, but the dates were inconsistent, indicating a delay in the reporting process. Resident 20 experienced an incident during transportation in a facility van where he was not secured with a seatbelt, resulting in him being thrown from his wheelchair. Despite the resident reporting the incident upon returning to the facility, it was not reported to the SSA. The Administrator admitted to not having detailed knowledge of the incident and acknowledged that it should have been reported. Resident 256's case involved allegations of neglect due to the failure to provide regular wound care dressing changes, as reported by the resident's podiatrist. The facility was notified of the neglect, but the report to the SSA was delayed by five days. The Administrator and Director of Nursing were uncertain about the exact timing of when they were informed of the incident. The facility's policy on abuse and neglect required timely reporting, which was not adhered to in these cases.
Failure to Investigate and Report Incidents
Penalty
Summary
The facility failed to thoroughly investigate and report the results of all investigations to the State Survey Agency within the required timeframe for four residents. One resident suffered a finger injury when it became impinged in a wheelchair hinge, but the investigation was delayed, and the incident was not reported promptly. The resident, who was non-verbal and had Alzheimer's Disease, was dependent on staff for transfers and mobility. The investigation concluded that the injury was not due to abuse, but the facility did not provide additional staff educational materials following the incident. Another resident reported physical and mental abuse by a CNA, who allegedly placed a sheet and towel over the resident's head and neck, causing distress. The facility's investigation was deemed inconclusive, and the CNA was terminated. However, the facility did not document interviews with other staff or residents, and the investigation lacked thoroughness. The resident, who had a history of type 2 diabetes and hypertension, was assessed and found to have no physical injuries but was emotionally shaken. A third resident was not secured in a transport van and sustained injuries when the van stopped abruptly. The resident, who had functional quadriplegia and a traumatic brain injury, reported the incident, but the facility did not document an investigation or provide education to the transportation staff. The transportation driver admitted to not securing the resident properly and did not notify anyone of the incident. The facility administrator did not verify the details of the incident and relied on the driver's account without further investigation.
Improper Medication Storage Temperature
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored and labeled in accordance with accepted professional principles, specifically regarding temperature control. During an observation, a medication refrigerator in the medication room was found to have a temperature of 48 degrees Fahrenheit, which is outside the required range for medication storage. This deficiency affected three residents, as medications such as Pipercillin/Tazobactam, Ceftriaxone, and Cefazolin were stored in this refrigerator. Interviews with the Medication Technician and the Director of Nursing confirmed that the refrigerator's temperature was not within the acceptable range. The Director of Nursing observed the temperature at 50 degrees Fahrenheit and acknowledged that it was not within the required range. The staff was aware that medications need to be stored at specific temperatures to maintain their effectiveness, and the Director of Nursing indicated that the pharmacy should be contacted if the temperature is not within range.
Deficiencies in Food Storage and Kitchen Maintenance
Penalty
Summary
The facility was found to have several deficiencies in food storage, preparation, and safety standards. During an initial tour of the kitchen, it was observed that food items in the walk-in freezer and refrigerator were left open to air, and a container of sliced cheese was not dated. In the dry storage room, boxes of lasagna and spaghetti noodles were also open to air, and the vent was rusty with an unknown dried substance. Additionally, there was black residue on the wall from a previous water leak, and tiles in the dish room were cracked and chipped. A follow-up tour revealed similar issues, with additional food items left open to air and the same structural and cleanliness problems persisting. The Dietary Manager (DM) acknowledged these issues during an interview, stating that the kitchen was cleaned daily and that each staff member had specific responsibilities. However, the DM admitted that the vent in the dry storage room was not functioning and had not been reported to maintenance. The DM also noted that the pasta did not arrive in sealed bags and that staff had not been sealing the boxes with tape. The DM mentioned that the Registered Dietitian (RD) conducted monthly kitchen audits, but there was no tracking of items requiring improvement from month to month. Despite recent tile repairs, the DM had not informed maintenance about the additional tiles needing repair in the dish room, and the black residue was from a previously repaired roof leak.
Deficiencies in QAPI Implementation and Resident Safety
Penalty
Summary
The facility failed to establish and implement written policies and procedures for feedback, data collection systems, and monitoring, including adverse event monitoring. This deficiency was identified during a recertification survey where multiple areas of harm were noted but not addressed through the Quality Assurance and Performance Improvement (QAPI) process. Specific incidents included a resident's finger being partially amputated due to a wheelchair hinge, multiple falls resulting in injuries such as a hip fracture and head lacerations, and residents not being properly secured in a facility vehicle, leading to falls. Additionally, a resident sustained a burn while smoking unsupervised. The facility did not ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. One resident experienced skin breakdown, and the dressing was not changed according to orders. This resident was also observed to bump another area on the wheelchair, indicating a lack of adequate supervision and care. The Administrator acknowledged that the QAPI team met quarterly and identified issues such as the van incident but failed to follow up on corrective actions. The QAPI process included asking the 5 Why's, but there was no follow-up on falls or ulcers. The facility's policy and procedure for QAPI, updated in 2022, outlined the establishment of a Quality Assessment and Assurance Committee and the development of a QAPI plan, but these were not effectively implemented to prevent the identified deficiencies.
Inadequate Wound Care and Monitoring for Resident
Penalty
Summary
The facility failed to provide appropriate treatment and care according to orders, resident preferences, and goals for one of the sampled residents, identified as Resident 8. The resident, who was admitted with multiple diagnoses including Alzheimer's and chronic systolic heart failure, had a skin breakdown on the left inner foot that was not treated according to the physician's orders. Observations revealed that the bandage on the resident's foot had not been changed since 5/3/24, despite orders for daily dressing changes until 5/8/24, and then three times a week thereafter. Additionally, Resident 8 was observed to have a black sore on the right shin, which was repeatedly bumped against a protruding brake handle on the wheelchair. This sore was not documented in the resident's medical records, and there was no evidence of a pressure assessment being completed for this area. Interviews with staff, including a Licensed Practical Nurse (LPN) and the Wound Nurse (WN), indicated a lack of awareness and documentation regarding the sore on the right shin, and the WN admitted to needing to educate nurses on proper wound care. The facility's care plan for Resident 8 included interventions to prevent skin impairment, such as ensuring good nutrition, keeping skin clean and dry, and using pressure-relieving devices. However, these interventions were not consistently implemented, as evidenced by the lack of heel floats while the resident was in bed and the failure to reposition the resident in the wheelchair. The Director of Nursing (DON) and other staff members were aware of the resident's tendency to scratch and pick at the skin, but there was insufficient monitoring and documentation of new wounds, leading to inadequate care and treatment of the resident's skin conditions.
Nurse Aide Training and Competency Deficiency
Penalty
Summary
The facility failed to ensure that a nurse aide, who had been employed full-time for approximately six months, was competent to provide nursing and nursing-related services and had completed a training and competency evaluation program approved by the State. The deficiency was identified during an interview and record review conducted on 5/14/24. The facility's Human Resources (HR) department stated that newly hired nurse aides were required to sign a contract to enroll in a Certified Nurses Assistant (CNA) course within 120 days of hire. However, HR could not locate documentation confirming that the nurse aide in question had enrolled in or completed the required CNA course, despite being employed beyond the four-month threshold for training completion.
Deficiencies in Resident Environment and Maintenance
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for its residents, as evidenced by several observations and interviews. A resident's room was found to have a protruding piece of drywall with screws sticking out, and an unknown red and orange substance on it. The Licensed Practical Nurse (LPN) and the Maintenance Director were unaware of the drywall issue until it was pointed out during the survey. The Maintenance Director acknowledged that the drywall should have been flush with the wall. Additionally, the facility was noted to have persistent odors, including strong urine and bowel movement smells in the west hallway and dining room. Housekeeping staff and some nursing staff were aware of the odors, but there was a lack of consistent action to address the source of the smells. Interviews revealed that garbage and soiled linens were not always removed promptly, contributing to the odors. The facility also had issues with fall mats next to residents' beds, which were found to be torn, exposing the foam padding. This was observed in multiple rooms, and staff interviews indicated a lack of awareness and action to replace the damaged mats. The Director of Nursing (DON) and other staff acknowledged that the torn mats could pose a risk and should be replaced, but this had not been done at the time of the survey.
Resident Abuse Incident Involving CNA
Penalty
Summary
The facility failed to protect a resident from abuse, as evidenced by an incident involving a Certified Nurse Assistant (CNA) who allegedly engaged in abusive behavior towards a resident. The resident, who was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 14, reported that the CNA placed a looped gait belt around her own neck and mimicked hanging herself. The CNA then allegedly pinned a sheet over the resident's head and placed a towel against the resident's neck, causing the resident to feel trapped and frightened. The incident was reported to the facility's Administrator and Abuse Coordinator, and the resident was assessed for physical and emotional harm. Although no physical injuries were observed, the resident expressed feeling shaken and anxious. The CNA involved in the incident was suspended pending investigation and subsequently terminated for gross misconduct. The facility's investigation into the incident was deemed inconclusive, and the matter was reported to the State Survey Agency and the police for further investigation. Interviews with facility staff, including the Director of Nursing, Registered Nurse, CNA Coordinator, and Resident Advocate, corroborated the resident's account of the incident. The staff noted that the resident was alert, oriented, and had not made similar allegations in the past. The resident expressed fear of retaliation from the CNA and requested a room change for safety. The facility's policy on abuse prevention and prohibition was reviewed, highlighting the facility's responsibility to ensure residents are free from abuse and neglect.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for three residents, leading to deficiencies in addressing their medical, nursing, and psychosocial needs. Resident 8, who was at risk for developing pressure ulcers, was observed with a black sore on the right shin, which was repeatedly banged against a broken part of the wheelchair. Despite being identified as at risk for pressure ulcers, the care plan did not include specific interventions to address this risk, and observations revealed that the resident's heels were not floated as required. Resident 36, who had a history of seizures and cognitive issues, was found with the call light out of reach, contrary to the care plan's intervention to ensure the call light was accessible. This oversight was significant given the resident's risk for falls and communication difficulties. Interviews with staff confirmed that the call light should have been within reach, but it was not, indicating a failure to implement the care plan effectively. Resident 17 expressed a need for an additional half side rail to assist with repositioning in bed, but there was no documentation of an evaluation or consent for this request in the medical record. The care plan did not address the resident's request for the side rail, and staff interviews revealed a lack of communication and follow-up regarding the resident's needs. This deficiency highlights the facility's failure to assess and document the resident's needs adequately, resulting in unmet care requirements.
Deficiency in Feeding Assistance and Supervision
Penalty
Summary
The facility failed to provide appropriate feeding assistance and supervision to a resident, leading to a deficiency in maintaining or improving the resident's ability to perform activities of daily living. The resident, who was admitted with multiple diagnoses including encephalopathy, seizures, and dysphagia, was observed on one occasion to have a meal tray left untouched while in bed, without any staff assistance or supervision. This lack of assistance was contrary to the resident's care plan, which indicated the need for supervision and setup assistance during meals. Interviews with staff revealed inconsistencies in the level of assistance provided to the resident. While some staff members acknowledged the resident's need for supervision and assistance with eating, others were unaware of the requirement to ensure the resident was taken to the dining room for meals. The Director of Nursing confirmed that the resident required setup assistance and supervision to ensure adequate nutrition, especially when the resident was sleepy. The failure to consistently provide the necessary assistance and supervision resulted in the resident not receiving adequate nutrition during the observed period.
Failure to Maintain Resident's Grooming Needs
Penalty
Summary
The facility failed to ensure that a resident with contractures in his hands received the necessary services to maintain good grooming, specifically in relation to nail care. Resident 30, who has severe cognitive impairment and multiple physical disabilities, was observed on several occasions with long fingernails on both hands. Despite having a padded device on his right hand to prevent self-scratching, the nails on this hand were noted to extend beyond the fingertips, indicating a lack of regular trimming. Observations and interviews revealed that the resident's right hand was often clenched in a fist, with the thumb nail extending beyond the thumb. The Assistant Director of Nursing confirmed that the padded device was removed every four hours for skin checks, yet the nails remained untrimmed. The resident's left hand, which he could move, also had long nails initially, but they were trimmed by the following day. Despite the resident's ability to communicate using a board, there was no consistent documentation or action taken to address the nail length. A review of the resident's medical records and CNA tasks showed a lack of documentation regarding nail trimming. Shower sheets from March to May indicated inconsistent attention to nail care, with many entries either blank or marked as 'no' for nail clipping. Interviews with CNAs confirmed that nail trimming should occur during showers, which were scheduled every other day or upon family request. However, the records did not reflect consistent adherence to this practice, leading to the deficiency in maintaining the resident's grooming needs.
Failure to Maintain Proper Positioning During Tube Feeding
Penalty
Summary
The facility failed to ensure that a resident receiving enteral feeding was properly positioned to prevent complications. Resident 39, who was admitted with multiple diagnoses including anoxic brain damage, severe protein calorie malnutrition, and dysphagia, was observed lying flat in bed while receiving continuous tube feeding. Despite the care plan and physician orders requiring the head of the bed to be elevated between 30 to 45 degrees during and after feeding, staff did not maintain this position. RN 1 acknowledged the issue, stating that the resident often slid down in bed, and there was no effective method to keep her elevated, despite attempts to use pillows. Further observations revealed that the staff did not document the total volume of feeding infused, and the Director of Nursing confirmed that the resident was not receiving continuous feedings due to interruptions for care and outings with family. The lack of consistent monitoring and adherence to physician orders and care plans contributed to the deficiency, as the facility did not ensure the resident's head and torso were elevated during tube feeding, potentially compromising her care.
Failure to Evaluate Risks of Bed Rail Installation
Penalty
Summary
The facility failed to evaluate the risks versus benefits of an installed side rail for a resident, identified as Resident 17. This resident was admitted with multiple diagnoses, including cerebrovascular disease and diabetes mellitus, and had a half side rail on the left side of her bed without any documented evaluation. During an interview, Resident 17 expressed a desire for an additional half side rail on the right side of her bed to assist with repositioning, but was informed that an evaluation by the nurse and doctor was necessary. However, there was no information in the resident's medical record regarding an evaluation for the existing half side rail. Interviews with facility staff revealed a lack of communication and documentation regarding the side rail. The Maintenance Director was unaware of the resident's request for an additional side rail and stated that he referred such requests to the clinical department. The Director of Therapy was also unaware of the existing side rail and stated that positioning devices should be care planned. The Licensed Practical Nurse mentioned that a half side rail would be considered a restraint and would require a signed release, but no evaluation was completed. The Director of Nursing confirmed that there was no care plan or consent for Resident 17's half side rail and acknowledged the need for evaluations to be completed.
Missing X-ray Report in Resident's Medical Record
Penalty
Summary
The facility failed to file the signed and dated reports of radiological and other diagnostic services in the resident's clinical record for one of the sampled residents. Resident 20, who has a medical history including functional quadriplegia, delusional disorder, bipolar disorder, traumatic brain injury, and cervical disc disorder, was involved in an incident on 5/2/23 where he was thrown from his wheelchair in a van, leading to a physician's order for a bilateral hip x-ray. However, the x-ray results were not documented in the resident's medical record. The Director of Nursing confirmed that the x-ray report could not be located despite having requested it from the local mobile x-ray company.
Infection Control Lapse Involving Unknown Substance
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by an incident involving a staff member and a resident. A staff member, identified as LPN 1, was observed touching an unknown red/orange substance on a piece of protruding drywall in a resident's room without wearing gloves. This action was contrary to infection control protocols, especially since the substance could potentially be blood. The resident involved, identified as Resident 8, had multiple diagnoses, including joint derangements, Alzheimer's, and chronic systolic heart failure, and was in a vulnerable state due to these conditions. The deficiency was further highlighted by the physical state of the resident's room, where a piece of drywall was protruding from the wall, secured with screws, and had an unknown substance on it. LPN 1 admitted to not knowing about the drywall issue and initially did not recognize the potential risk of the substance being blood. Despite acknowledging the need for gloves when dealing with potential blood, LPN 1 failed to adhere to this protocol, demonstrating a lapse in infection control practices. This incident underscores the facility's failure to maintain a safe and sanitary environment for its residents.
Resident's Call Light Out of Reach
Penalty
Summary
The facility failed to ensure that a reliable and easily accessible call system was available for a resident, identified as Resident 36. During an observation, it was noted that the call light was placed around a light fixture by the resident's bed, making it out of reach. Resident 36 had a complex medical history, including encephalopathy, seizures, hyperglycemia, diabetes mellitus, protein calorie malnutrition, dysphagia, and a personal history of traumatic brain injury. The care plans for Resident 36 emphasized the importance of having the call light within reach to anticipate and meet needs, ensure a safe environment, and minimize the risk of falls. Interviews with staff, including an LPN and a CNA, revealed that Resident 36 was sometimes confused and forgetful, which affected his ability to use the call light. Both staff members acknowledged that the call light should be within reach at all times. The Director of Nursing also confirmed that education had been provided to staff regarding the importance of keeping call lights within reach, following complaints from the resident council about long wait times for call lights. Despite these measures, the deficiency was observed, indicating a lapse in ensuring the call light was accessible to Resident 36.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 187 citations issued within 25 miles in the last 12 months — including the 8 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Salt Lake City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Monument Healthcare Murray Creek | 0.6 mi | ★★★★★ | 2 | 0 |
| Monument Healthcare Millcreek | 1.3 mi | ★★★★★ | 10 | 0 |
| Little Cottonwood Rehabilitation And Nursing | 1.4 mi | ★★★★★ | 5 | 0 |
| Aspen Ridge West Transitional Rehab | 2 mi | ★★★★★ | 11 | 0 |
| Meadow Brook Rehabilitation And Nursing | 2 mi | ★★★★★ | 14 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.