Pine Creek Rehabilitation And Nursing
Inspection history, citations, penalties and survey trends for this long-term care facility in Salt Lake City, Utah.
- Location
- 876 West 700 South, Salt Lake City, Utah 84104
- CMS Provider Number
- 46A064
- Inspections on file
- 18
- Latest survey
- October 9, 2025
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Pine Creek Rehabilitation And Nursing during CMS and state inspections, most recent first.
A resident with multiple medical and psychological diagnoses gave a NA $100 after learning of her financial difficulties. The NA accepted the money after the resident insisted, but did not return the funds when the resident later requested them back. The resident reported the issue to staff and became increasingly distressed, while the NA admitted to accepting the money and not knowing it was prohibited. Staff interviews confirmed the resident's upset state, and there was no evidence of specific training addressing this type of incident.
A resident with multiple medical conditions gave $100 to a NA, later requesting its return when needed for personal expenses. The NA did not respond, and the resident reported the issue to staff. The facility verified the misappropriation but failed to report the incident to APS within the required timeframe and did not notify law enforcement, as required by regulations.
Two residents experienced significant health complications after falls due to the facility's failure to provide timely care and monitoring. One resident, with a history of falls and heart disease, was not given neurological assessments after an unwitnessed fall, leading to hospitalization for sinus arrest. Another resident, with a history of brain injury, experienced a fall and subsequent deterioration in condition, resulting in hospitalization for a subdural hematoma. The facility's inaction and delayed response to these acute changes in condition were identified as deficiencies at the Immediate Jeopardy level.
A resident with a complex medical history was not properly secured in a facility vehicle during transport, leading to a fall and serious injuries, including a Thoracic (T)11-T12 fracture. The transportation driver, also the Therapeutic Recreation Specialist, failed to secure the resident with a seatbelt, relying instead on wheelchair straps, which resulted in the resident falling forward and sustaining injuries.
A resident with a history of suicidal ideations did not receive necessary behavioral health services for over two months after a hospitalization for a suicide attempt. Despite a care plan indicating the need for counseling, there was a significant delay in implementing mental health therapy. Interviews revealed staff were unaware of when services began, and no psychosocial assessment was conducted after re-admission. The resident's room contained items that could be used for self-harm, highlighting a lack of environmental safety measures.
The facility failed to ensure a dignified dining experience for residents, as staff were observed standing while assisting with meals, using labels instead of names, and not serving meals simultaneously. A resident with multiple diagnoses struggled during a meal without adequate assistance, and flies were observed landing on them. The DON confirmed that aides should be seated and provide proper assistance.
Two residents experienced incidents that were not reported in a timely manner. A resident with severe cognitive impairment was found with a new bruise, but the facility did not report it to the SSA or APS. Another resident experienced verbal abuse from a CNA, and while the SSA was notified, APS was not. The facility's policies require immediate reporting, but these procedures were not followed, leading to a deficiency in regulatory compliance.
The facility failed to prevent further potential abuse during investigations involving a resident with dementia and bipolar disorder. In two separate incidents, the resident was involved in physical and alleged sexual abuse cases with other residents. Despite implementing 15-minute checks as a corrective measure, the facility did not consistently document these checks, contributing to the deficiency.
The facility failed to document and communicate necessary information during the transfer of four residents to the hospital. This included missing documentation of transfer paperwork and lack of communication of essential details such as the POLST form, care instructions, and comprehensive care plans. Interviews with staff revealed inconsistent practices in ensuring that all required information accompanied residents during transfers.
The facility failed to properly store and label medications, including insulin pens and vaccines, in accordance with professional standards. Insulin pens lacked open dates and resident names, and some medications were expired yet available for use. Staff interviews revealed a lack of adherence to labeling protocols.
The facility failed to obtain necessary lab tests for two residents, leading to deficiencies in care. One resident did not receive INR tests for two months despite physician orders, and another resident's BMP was missed entirely. The DON acknowledged lapses in the lab process, including reliance on a single staff member for accessing lab results and lack of documentation by nurses.
The facility failed to secure resident-identifiable information on two occasions when nurses left computer screens open on medication carts. Additionally, the facility did not maintain complete medical records for a resident with multiple medical conditions, as documentation of a hospital visit following a suicidal incident was initially missing. The DON confirmed the expectation to lock computer screens to protect HIPAA information and later obtained the necessary hospital documentation.
The facility failed to document COVID-19 vaccine education and administration for several residents, as required by its policy. The medical records of four residents with various health conditions lacked evidence of vaccine education, administration, or declination. The DON was unable to locate the necessary documentation, indicating non-compliance with the facility's vaccination policy.
The facility failed to protect residents from abuse, including inappropriate communication by a CNA, verbal abuse by another CNA, and physical abuse between residents. A resident was asked for nude photos by a CNA, another was mocked during a meal service, and a resident was stabbed with a pen by another resident during a manic episode.
The facility failed to notify physicians of significant changes in two residents' conditions. A resident with multiple diagnoses was found with an unexplained bruise, and another resident refused blood tests without proper documentation or physician notification. Interviews revealed inconsistencies in documentation and communication practices.
A facility failed to report an allegation of verbal abuse by a CNA towards a resident to Adult Protective Services (APS). The incident involved the CNA mocking the resident while passing breakfast trays. Although the State Survey Agency (SSA) was notified, there was no documentation of APS notification, contrary to the facility's abuse reporting policy.
A facility failed to implement PASRR Level II recommendations for a resident with mental illness, leading to a deficiency. The resident, with a history of major depressive disorder and suicide attempts, did not receive timely counseling services as recommended. Despite experiencing suicidal ideations and being hospitalized, there was no psychosocial assessment conducted, and the initiation of behavioral health services was unclear. Interviews with the DON and an RN highlighted gaps in the facility's response to the resident's mental health needs.
A resident with schizoaffective disorder did not receive their prescribed psychotropic medications due to unavailability from the pharmacy, leading to increased irritability and an aggressive incident. The facility's process for reordering medications was followed, but delays in delivery and lack of availability in the Nexsys system contributed to the deficiency.
Two residents experienced deficiencies in medication management, including inadequate monitoring of blood glucose for a diabetic resident and failure to administer thyroid medication and address pain for another. The facility lacked proper documentation and follow-up on medication effectiveness, highlighting issues in ensuring necessary and effective drug regimens.
A resident with a complex medical history, including schizoaffective disorder and generalized anxiety disorder, was prescribed multiple psychotropic medications without adequate monitoring for adverse side effects or behavioral episodes. The facility failed to document non-pharmacological interventions prior to medication administration, as expected by the DON.
A facility was found to have a medication error rate of 7.41%, exceeding the acceptable 5% threshold. Two residents received incorrect medication dosages due to errors by an RN. One resident was nearly given an incorrect dose of Haloperidol, while another received only half the prescribed dose of Loperamide. The RN admitted to not realizing the errors and lacked knowledge of potential side effects. The DON acknowledged that incident reports were not always completed as required.
A resident's lab results were not communicated to the physician despite being outside clinical reference ranges, and tests were conducted without a physician's order. The DON was responsible for lab orders and follow-ups, but the process lacked proper documentation and verification.
A facility failed to maintain complete laboratory records for a resident, as lab results for lithium level checks were not uploaded into the electronic medical record. The resident, with multiple health conditions including bipolar disorder, had physician orders for lithium monitoring, but the results were missing from the record. The DON confirmed the oversight.
A facility failed to include signed and dated EKG reports in a resident's medical records. The resident, with a complex medical history, was ordered a 12 lead EKG for monitoring, but the reports were not filed. The DON confirmed the report was sent to the provider but not to the facility.
The facility failed to provide food that was palatable, attractive, and at a safe temperature, as evidenced by resident complaints and a test tray evaluation. Two residents reported issues with cold and bland food, and a test tray revealed soggy, bland, and overly salty items. The Corporate Dietitian noted that grievances could be filed for food complaints.
The facility's QAA committee did not include the Medical Director as a participating member, violating regulatory requirements. The committee met quarterly, but the Medical Director's attendance was inconsistent, with the Administrator confirming that the Medical Director did not attend the June 2024 meeting and was unsure about the March 2024 meeting. This deficiency highlights a failure to meet the mandated composition and function of the QAA committee.
A registered nurse in an LTC facility failed to maintain proper infection control practices during medication administration for two residents. The nurse did not perform hand hygiene before preparing medications and was observed dropping medications onto the cart and floor. Despite disposing of dropped medications, the nurse continued without sanitizing hands, contrary to facility expectations.
A resident with multiple diagnoses, including Alzheimer's and diabetes, returned from the hospital with a urinary tract infection and received a Rocephin shot. The facility failed to follow up on culture and sensitivity results from the hospital, leading to inadequate monitoring of antibiotic use. The DON attempted to obtain the necessary records but was unsuccessful, resulting in a deficiency in the facility's infection prevention and control program.
A staff member who was not a CNA, Licensed Nurse, or paid feeding assistant improperly assisted a resident with feeding, contrary to facility policy. The resident, who had multiple health issues including dementia and malnutrition, required varying levels of assistance during meals. The facility lacked paid feeding assistants, and the unqualified staff member intervened when the resident had not received dining assistance.
The facility failed to maintain a clean and homelike environment, as restrooms in resident rooms were found with stains and strong urine odors. Despite the housekeeper's efforts, odors returned shortly after cleaning, attributed to residents urinating outside the toilet bowl. Reduced staffing hours further hindered housekeeping duties, such as washing curtains, which had not been done for over a month. The DON was unaware of the cleaning frequency, indicating a lack of oversight.
Failure to Prevent Misappropriation of Resident Property
Penalty
Summary
A resident with chronic obstructive pulmonary disease, generalized anxiety disorder, and adjustment disorder offered a Nursing Assistant (NA) $100 after learning about the NA's financial struggles. Despite initial refusal, the NA ultimately accepted the money after the resident insisted and placed the funds in the NA's pocket. When the resident later requested the money back to cover personal expenses, the NA did not respond to her messages. The resident reported the issue to two different staff members, expressing increasing distress over not having her funds returned. Multiple staff interviews confirmed the resident's upset state and her repeated attempts to recover the money. The NA admitted to accepting the funds and stated she was unaware that this was not allowed. The incident was reported to facility leadership, but there was no documentation of specific training or guidance provided to staff regarding this type of situation at the time of the incident. The facility's abuse training was conducted twice a year, but there was no evidence of additional or incident-specific training related to this event.
Failure to Timely Report Misappropriation of Resident Property
Penalty
Summary
The facility failed to ensure that an allegation of misappropriation of resident property was reported immediately, as required, to Adult Protective Services (APS) and local law enforcement. A resident with multiple diagnoses, including chronic obstructive pulmonary disease and anxiety disorders, reported giving $100 to a nursing assistant (NA) after learning of the NA's financial struggles. The resident later requested the money be returned, but the NA did not respond, prompting the resident to report the issue to two staff members. The NA admitted to accepting the money after repeated offers from the resident and stated she was unaware it was not allowed. The facility verified the allegation and terminated the NA's employment. Despite the verification of misappropriation, the facility did not report the incident to APS until 17 days after the allegation was made, and there was no report made to local law enforcement. Interviews with the Resident Advocate and Administrator revealed that the incident was communicated internally, but proper external reporting protocols were not followed. Staff training on abuse recognition and reporting was provided biannually, but there was no documentation of training specific to this incident.
Failure to Provide Timely Care After Falls
Penalty
Summary
The facility failed to provide appropriate treatment and care for two residents following falls, leading to significant health complications. Resident 9, who had a history of repeated falls and various medical conditions including epidural hemorrhage and heart disease, experienced a fall in the bathroom. Despite the fall being unwitnessed, no neurological assessments were conducted, and the physician was notified five hours later. The resident later exhibited symptoms of hypotension and bradycardia, leading to hospitalization for sinus arrest. The lack of timely intervention and monitoring after the fall contributed to the resident's acute change in condition. Resident 87, with a history of traumatic brain injury and use of anticoagulants, fell from a wheelchair and sustained a scalp laceration. Although neuro checks were initiated, the resident's condition deteriorated with symptoms of hypertension, tachycardia, and respiratory distress. Despite attempts to contact medical providers, there was a delay in emergency intervention. The resident was eventually sent to the hospital with a subdural hematoma and brain compression, requiring emergent intubation. The delay in recognizing and responding to the resident's declining condition after the fall was a critical factor in the deficiency. Both cases highlight the facility's failure to adhere to professional standards of practice and the comprehensive person-centered care plan. The lack of prompt identification, monitoring, and intervention for acute changes in condition following falls resulted in severe health outcomes for the residents. The deficiencies were identified at the Immediate Jeopardy level, indicating a serious threat to the health and safety of the residents involved.
Resident Unsecured During Transport Results in Injury
Penalty
Summary
The facility failed to ensure adequate supervision and safety measures for a resident during transportation, resulting in a serious accident. A resident, who was cognitively intact and required extensive assistance for mobility, was not properly secured in a facility vehicle during transport. The resident fell out of her wheelchair, sustaining a Thoracic (T)11-T12 fracture and a contusion of the abdominal wall. The incident occurred because the seatbelt was not secured, and the resident was unrestrained in the back of the van. The transportation driver, who was also the Therapeutic Recreation Specialist (TRS), did not secure the resident with a seatbelt, relying instead on the straps that secured the wheelchair to the floor of the van. The TRS admitted that he did not see the lap belt at the time of the accident and attempted to use an old shoulder strap that did not function properly. The TRS had been under the impression that the wheelchair straps were sufficient for securing the resident, which led to the resident falling forward and hitting the driver's seat before falling to the floor. The resident involved had a complex medical history, including a stable burst fracture of the Thoracic (T)11-T12 vertebra, type II diabetes mellitus, chronic obstructive pulmonary disease, and other conditions. At the time of the incident, the resident was returning from a hospital appointment and was not properly restrained, leading to the fall and subsequent injuries. The facility's failure to ensure the resident's safety during transport was a significant oversight, resulting in harm to the resident.
Failure to Provide Timely Behavioral Health Services
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to a resident with a history of suicidal ideations, leading to a deficiency in ensuring the resident's highest practicable physical, mental, and psychosocial well-being. The resident, who had a complex medical history including major depressive disorder and a previous suicide attempt, was hospitalized for suicidal ideations but did not receive behavioral health services for over two months following the hospitalization. This gap in care occurred despite the resident's comprehensive assessment and care plan indicating the need for such services. The resident's medical records showed multiple diagnoses, including major depressive disorder, and a history of suicidal ideations. Physician orders included medications for depression, but there was a significant delay in implementing mental health therapy after the resident's hospitalization for a suicide attempt. The resident's care plan and PASRR Level II evaluation recommended counseling services to help cope with psychiatric symptoms, yet these services were not provided in a timely manner. Interviews with facility staff revealed a lack of awareness and follow-through regarding the resident's behavioral health needs. The Director of Nursing and other staff members were unable to confirm when behavioral health services began, and there was no psychosocial assessment conducted after the resident's re-admission. Additionally, the resident's room contained items that could be used for self-harm, indicating a lack of environmental safety measures. These oversights contributed to the facility's failure to meet the resident's behavioral health care needs, as outlined in their care plan.
Failure to Ensure Dignified Dining Experience for Residents
Penalty
Summary
The facility failed to treat residents with respect and dignity during meal times, as observed in several instances. Staff were seen standing while assisting residents with eating, which is contrary to the facility's protocol of sitting next to residents to promote dignity. Additionally, staff used labels instead of residents' names when addressing them, which further undermines the residents' dignity. During meal service, residents were not served meals simultaneously, and some residents did not receive the necessary assistance, as evidenced by Resident 11 receiving his meal significantly later than others. Resident 18, who has multiple diagnoses including dementia and major depressive disorder, was observed struggling during a meal service. Despite requiring supervision and setup help for dining, Resident 18 was seen attempting to eat with an empty fork, and the assisting staff did not fully assist in feeding. Furthermore, flies were observed landing on Resident 18 during the meal, indicating a lack of attention to the resident's environment. The Director of Nursing confirmed that aides should be seated with residents and provide appropriate assistance during meals, which was not adhered to in these instances.
Failure to Report Abuse and Injuries in a Timely Manner
Penalty
Summary
The facility failed to report alleged violations involving abuse or injuries of unknown source within the required timeframe for two residents. Resident 18, who has severe cognitive impairment, was found with a new bruise on the upper thigh, but the incident was not reported to the State Survey Agency (SSA) or Adult Protective Services (APS). The facility's Director of Nursing (DON) acknowledged that the bruise's location could be suspicious and should have been reported, but the nurse's documentation lacked sufficient detail to determine the bruise's exact location or characteristics. Resident 22 experienced verbal abuse from a Certified Nurse Assistant (CNA), who was observed yelling in a mocking tone. Although the incident was reported to the SSA, there was no documentation that APS was notified. The facility's Administrator stated that he would ensure resident safety and gather information before reporting to the necessary authorities, but the report to APS was not completed as required. The facility's policies on abuse and reporting require immediate action and notification to appropriate authorities, but these procedures were not followed in these cases. The policies were last revised in 2024, indicating that the facility should have been aware of the requirements. The failure to report these incidents in a timely manner represents a deficiency in the facility's adherence to regulatory requirements for reporting suspected abuse or injuries of unknown origin.
Failure to Prevent Further Potential Abuse During Investigation
Penalty
Summary
The facility failed to prevent further potential abuse while investigations were in progress for three residents. Resident 86, who had a history of multiple medical conditions including dementia and bipolar disorder, was involved in two separate incidents. In the first incident, Resident 86 and Resident 14, who also had a complex medical history including dementia and substance abuse, were found on the floor after an argument over a radio. Both residents sustained minor injuries, but the facility did not document the completion of 15-minute safety checks that were supposed to be implemented as a corrective measure. In a second incident, Resident 86 was involved in an alleged sexual abuse case with Resident 85, who had Alzheimer's disease and significant cognitive deficits. An LPN witnessed Resident 86 engaging in inappropriate behavior with Resident 85. Although the residents were separated, the facility again failed to consistently document the 15-minute checks that were intended to monitor Resident 86's behavior following the incident. Interviews with the Director of Nursing (DON) and the Administrator (ADM) revealed that the facility struggled to maintain the 15-minute checks due to staffing challenges and the demographic of the residents. The DON acknowledged that the checks were not a typical intervention and were difficult to maintain, while the ADM noted that the checks were essentially a 1:1 staffing situation and were not effectively implemented. The lack of consistent documentation and monitoring contributed to the facility's failure to prevent further potential abuse during the investigation period.
Deficiency in Resident Transfer Documentation and Communication
Penalty
Summary
The facility failed to ensure proper documentation and communication during the transfer or discharge of residents to the hospital, affecting four out of 28 sampled residents. The deficiency was identified through interviews and record reviews, revealing that the necessary information was not documented in the residents' medical records nor communicated to the receiving providers. This information should have included the contact details of the practitioner responsible for the resident's care, resident representative information, advanced directives, special instructions or precautions for ongoing care, comprehensive care plan goals, and other necessary information to ensure a safe and effective transition of care. Resident 9 was transferred to the hospital due to hypotension, lethargy, and bradycardia, but there was no documentation of the transfer paperwork or what information was sent to the receiving provider. Interviews with the nursing staff and the Director of Nursing (DON) revealed that while some information, such as the medication list and face sheet, was given to the paramedics, the Physician Order for Life Sustaining Treatment (POLST) form was not included. The DON confirmed that the POLST form should accompany the resident to the hospital, but it was not documented in the progress notes. Similarly, Resident 14 was transferred to the hospital after attempting self-harm, yet there was no documentation of the transfer paperwork or information sent to the receiving provider. Resident 8 experienced multiple hospital transfers due to various medical conditions, including low oxygen saturation and falls, but again, there was no documentation of the transfer paperwork or information sent to the hospital. Resident 19 was also transferred to the hospital without proper documentation or communication of necessary information. Interviews with the nursing staff and the DON highlighted the lack of consistent documentation practices, such as using the e-interact system, to ensure that all necessary information was communicated during resident transfers.
Improper Storage and Labeling of Medications
Penalty
Summary
The facility failed to ensure the safe and secure storage of drugs and biologicals in accordance with accepted professional principles. During an inspection of the medication refrigerator, it was observed that a multi-dose vial of Tuberculin was open and lacked an open date. Additionally, a Prevnar 13 vaccine was found to be expired and still available for use. Several insulin pens, including Tresiba, Lantus, and aspart insulin flex pens, were either missing open dates or resident names, and one Lantus insulin pen was noted to be expired. Interviews with staff revealed a lack of adherence to proper labeling protocols. RN 1 acknowledged that insulin pens should be discarded if the name or date is unreadable, yet some pens lacked this information. The Director of Nursing confirmed that all medications should be labeled with the resident's name and that insulin should be marked with an open date and stored properly. The DON also stated that insulin is viable for 30 days once opened, and only medications should be stored in the refrigerator.
Failure to Obtain Required Lab Tests for Residents
Penalty
Summary
The facility failed to provide necessary laboratory services for two residents, leading to deficiencies in care. Resident 31, who had multiple complex medical conditions including chronic embolism and thrombosis, had physician orders for INR labs to be drawn every four weeks. However, the facility did not obtain INR results for May and June 2024, despite the importance of monitoring INR levels for residents on warfarin treatment. The Director of Nursing (DON) acknowledged that the phlebotomist contracted by the facility likely did not obtain the labs for those months, which was confirmed by pharmacy consultant reviews noting the absence of routine monitoring. Similarly, Resident 9, who had a range of serious health issues including type 2 diabetes and hypertensive heart disease, had a physician order for a Basic Metabolic Panel (BMP) on August 13, 2024. The BMP was not obtained, and the DON confirmed that the order was missed. The facility's process involved placing lab orders in a computer system and notifying the DON through a portal when results were ready. However, the lack of a carbon copy for facility records and the reliance on a single staff member to access the portal contributed to the oversight. The DON also noted that nurses were expected to document lab completion in progress notes, which did not occur in this instance.
Confidentiality and Record-Keeping Deficiencies
Penalty
Summary
The facility failed to maintain the confidentiality and completeness of medical records for one resident. On two separate occasions, registered nurses left a computer screen open on a medication cart, displaying resident-identifiable information, while unattended and in the presence of other residents. This action was contrary to the facility's policy, as confirmed by interviews with the nurses and the Director of Nursing (DON), who stated that the expectation was to lock the computer screen to protect Health Insurance Portability and Accountability Act (HIPAA) protected information. Additionally, the facility did not maintain complete medical records for a resident who had a history of multiple medical conditions, including cerebral infarction and major depressive disorder. The resident was taken to the hospital following a suicidal incident, but there was no documentation of the hospital visit in the electronic medical records. The DON later discovered that the hospital had no record of the resident's admission, although the ambulance service confirmed the transport. Eventually, the facility obtained the hospital history and physical documentation, revealing a lapse in the systematic organization and accessibility of the resident's medical records.
Failure to Document COVID-19 Vaccine Education and Administration
Penalty
Summary
The facility failed to ensure that residents or their representatives were given the opportunity to accept or refuse a COVID-19 vaccine, and that their medical records included documentation of education regarding the vaccine's benefits and risks, as well as records of vaccine administration or declination. Specifically, for four out of five sampled residents, there was no evidence in their medical records that they were provided education about the COVID-19 vaccine, received the vaccine, or declined it. The residents involved had various medical conditions, including chronic obstructive pulmonary disease, dementia, hypertension, and Alzheimer's disease. The facility's policy required that residents be given the opportunity to accept or refuse the vaccine, be educated about its benefits and risks, and sign a consent form before vaccination. Additionally, the policy mandated that documentation of vaccine administration or declination be included in the resident's record. However, the Director of Nursing was unable to locate the documentation for the residents' COVID-19 immunization records, indicating a failure to adhere to the facility's vaccination policy.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from various forms of abuse, including sexual, verbal, and physical abuse. In one incident, a Certified Nurse Assistant (CNA) engaged in inappropriate communication with a resident, asking for nude photos and expressing a desire for a romantic relationship, which made the resident uncomfortable. The resident, who was cognitively intact, reported the incident to the facility staff, leading to the CNA's termination. However, the facility's initial response did not prevent the CNA from continuing to contact the resident, causing further distress. In another incident, a resident with a history of neurocognitive disorder and impulse control issues was verbally abused by a CNA who mocked her in a loud and aggressive manner. This behavior was witnessed by other staff members, and the resident, who had a BIMS score of 0, was unable to fully articulate her feelings about the incident. The verbal abuse occurred during a meal service when the resident was seeking food, a behavior consistent with her medical history. Additionally, the facility failed to prevent physical abuse between residents. A resident with a history of psychiatric disorders and aggressive behavior stabbed another resident with a pen during a manic episode. The facility's investigation confirmed the physical abuse, but there was a lack of immediate intervention to prevent such incidents, as evidenced by the absence of a skin assessment for the victim immediately following the altercation.
Failure to Notify Physician of Resident Condition Changes
Penalty
Summary
The facility failed to immediately consult with the resident's physician and notify them of significant changes in the resident's condition for two residents. Resident 18, who had multiple diagnoses including asthma, dementia, and chronic pain, was found with a bruise of unknown origin on their upper thigh. Despite the discovery, there was no documentation of an assessment of the bruise, and the physician was not notified. The care plan for Resident 18 did not include interventions related to monitoring, reporting, or treating altered skin conditions. Interviews with the RN and DON revealed inconsistencies in documentation and notification practices. Resident 14, with a complex medical history including cerebral infarction and chronic obstructive pulmonary disease, had physician orders for blood tests that were not completed due to the resident's refusal. However, there was no documentation of the refusal or notification to the physician. The DON confirmed that the refusal should have been documented in a progress note and communicated to the physician, but this was not done, indicating a lapse in the facility's communication and documentation processes.
Failure to Report Verbal Abuse Allegation to APS
Penalty
Summary
The facility failed to implement its written policies and procedures to ensure the reporting of all alleged violations to the appropriate authorities. Specifically, an allegation of verbal abuse by a Certified Nurse Assistant (CNA) towards a resident, identified as Resident 22, was not reported to Adult Protective Services (APS). The incident involved the CNA yelling 'Goodbye' in an aggravating and mocking tone to the resident while passing breakfast trays. Although the facility notified the State Survey Agency (SSA) using form 358, there was no documentation indicating that APS was informed of the incident. Resident 22, who was admitted to the facility with multiple diagnoses including frontotemporal neurocognitive disorder, mood disorder, and anxiety disorder, was the subject of the verbal abuse allegation. During an interview, the Administrator (ADM) described the process followed upon receiving an abuse allegation, which included ensuring resident safety, gathering information, interviewing witnesses, and reporting the incident to the SSA, APS, and the ombudsman within two hours. However, the facility's investigation documentation lacked evidence of APS notification, indicating a failure to adhere to the facility's abuse reporting policy.
Failure to Implement PASRR Recommendations for Mental Health Services
Penalty
Summary
The facility failed to implement the recommendations from the Pre-Admission Screening and Resident Review (PASRR) Level II evaluation for a resident with a history of mental illness. The resident, who had multiple diagnoses including major depressive disorder and a history of suicide attempts, was admitted and readmitted to the facility. Despite the PASRR Level II evaluation recommending counseling services to help the resident cope with psychiatric symptoms, these services were not initiated in a timely manner. The resident experienced suicidal ideations and was hospitalized after an incident involving self-harm behavior, yet there was no psychosocial assessment conducted post-incident, and it was unclear when behavioral health services began. Interviews with the Director of Nursing (DON) and a Registered Nurse (RN) revealed gaps in the facility's response to the resident's mental health needs. The DON acknowledged that the resident did not receive a psychosocial assessment after expressing suicidal ideations and that the resident was not evaluated by a Social Service Worker (SSW) following the incident. The RN confirmed that the resident did not have therapy services prior to the hospitalization for suicidal ideations and was uncertain about the details of any therapy received afterward. This lack of adherence to the PASRR recommendations and inadequate follow-up on the resident's mental health needs contributed to the deficiency identified by the surveyors.
Medication Unavailability Leads to Resident Aggression
Penalty
Summary
The facility failed to provide routine and emergency drugs and biologicals to a resident, identified as Resident 9, due to unavailability from the pharmacy. Resident 9, who was admitted with multiple diagnoses including schizoaffective disorder, bipolar type, and generalized anxiety disorder, did not receive their prescribed psychotropic medications for several days. Specifically, Lurasidone, Haloperidol, and Escitalopram were not administered on multiple occasions as they were not available from the pharmacy. The medical records and progress notes for Resident 9 indicated that the medications were on order but not available from the pharmacy on several dates. The resident's Medication Administration Record (MAR) documented that these medications were not administered due to unavailability. This lack of medication led to an incident where Resident 9 exhibited aggressive behavior, reportedly stabbing another resident with a pen due to increased irritability and manic symptoms from being off their medication. Interviews with the facility's RN and DON revealed that the process for reordering medications involved pulling a sticker from the blister pack and placing it on a reorder sheet. However, there were delays in medication delivery from the pharmacy, and the facility's Nexsys system did not have the medication available. The DON acknowledged the issue and contacted the pharmacy, but the explanation provided was insufficient, as there was no dose change ordered at the time the medication was unavailable.
Medication Management Deficiencies in Resident Care
Penalty
Summary
The facility failed to ensure that the drug regimens for two residents were free from unnecessary drugs, as evidenced by inadequate monitoring and administration of medications. Resident 32, who had multiple diagnoses including type 2 diabetes mellitus, was prescribed insulin and required regular blood glucose monitoring. However, there were several instances where blood glucose levels were not recorded, and the facility did not provide documentation of any orders to cease finger sticks, despite the resident's expressed discomfort with the procedure. Interviews with nursing staff revealed a lack of clarity regarding the necessity of blood glucose monitoring and the documentation of such orders. Resident 9, with a complex medical history including hypothyroidism and chronic pain, did not receive their prescribed thyroid medication on one occasion, and there was no documentation to confirm its administration. Additionally, the resident's pain management was inadequate, as the prescribed oxycodone was documented as ineffective, yet there was no follow-up or documentation of alternative pain management strategies. Interviews with nursing staff indicated that there should have been communication with the provider and documentation of any additional interventions, but this was not evident in the resident's records. The deficiencies highlight a failure in the facility's medication management processes, particularly in monitoring and documenting the administration and effectiveness of medications. The lack of adequate monitoring and documentation for these residents' drug regimens suggests systemic issues in ensuring that residents receive necessary and effective medication management, as required by their medical conditions and physician orders.
Failure to Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary psychotropic drugs. Specifically, the resident's psychotropic medications were not adequately monitored for behavioral episodes, non-pharmacological interventions, and adverse side effects. The resident, who had a complex medical history including schizoaffective disorder, generalized anxiety disorder, and a history of suicidal behavior, was prescribed multiple psychotropic medications, including Escitalopram, Lurasidone, Clonazepam, and Haloperidol. However, there was no documentation indicating that the facility monitored the resident for adverse side effects or episodes of anxiety, nor was there evidence of non-pharmacological interventions being attempted prior to medication administration. During an interview, the Director of Nursing (DON) acknowledged that licensed nurses should monitor for adverse side effects, medication effectiveness, and behavioral episodes. Despite this expectation, the report found no evidence of such monitoring in the resident's records. The lack of documentation and monitoring suggests a failure in the facility's processes to ensure the safe and appropriate use of psychotropic medications for this resident.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility was found to have a medication error rate of 7.41%, exceeding the acceptable threshold of 5%. This was observed during a survey on 9/24/24, involving two residents. For Resident 12, a registered nurse (RN 1) was observed to have spilled a medication cup and subsequently replaced the medications incorrectly, resulting in an incorrect dosage of Haloperidol being prepared. The nurse was about to administer the wrong dosage when stopped by a surveyor. The nurse admitted to not realizing the error and expressed a lack of knowledge regarding the potential side effects or overdose symptoms of Haloperidol. According to the physician's orders, Resident 12 was supposed to receive two tablets of Haloperidol 1 mg, but three tablets were prepared. For Resident 31, RN 1 administered only one tablet of Loperamide 2 mg instead of the prescribed two tablets. The nurse claimed to always double-check medications before administration, but this was not reflected in the observed actions. The Director of Nursing (DON) later explained the protocol for handling medication errors, which includes contacting the provider and completing an incident report, although it was noted that this was not always done. The errors were classified as wrong dose errors, and the facility's failure to adhere to proper medication administration protocols led to these deficiencies.
Failure to Notify Physician of Abnormal Lab Results and Conduct Tests Without Orders
Penalty
Summary
The facility failed to promptly notify the ordering physician of laboratory results that were outside of clinical reference ranges for one resident. Specifically, the resident's Basic Metabolic Panel (BMP) and lipid panel results showed abnormal values, but there was no documentation indicating that the physician was informed of these results. Additionally, the laboratory tests were conducted without a physician's order, which is a breach of protocol. The resident involved had a complex medical history, including conditions such as cerebral infarction, hemiplegia, cognitive communication deficit, and several other chronic conditions. The Director of Nursing (DON) was responsible for placing lab orders and following up with providers. However, the process lacked proper documentation and verification, as evidenced by the absence of a physician's order for the labs conducted on January 30, 2024. The DON stated that the lab results were automatically uploaded to a portal and faxed to the facility, but there was no evidence that the results were reviewed or signed by a provider. This oversight in communication and documentation led to the deficiency identified by the surveyors.
Failure to Maintain Complete Laboratory Records
Penalty
Summary
The facility failed to maintain complete and dated laboratory records in the clinical record of a resident, identified as Resident 31. This deficiency was identified during a review of the resident's medical records, which revealed that laboratory reports for lithium level checks were not filed or uploaded in the resident's electronic medical record. Specifically, there were two instances where physician orders for lithium level monitoring were placed, but the corresponding lab results were not documented in the electronic medical record. The facility was able to provide copies of the lab results upon request, indicating that the lithium levels were within normal limits. Resident 31 was admitted with multiple diagnoses, including bipolar disorder, chronic obstructive pulmonary disease, asthma, and other significant health conditions. The deficiency was confirmed during an interview with the Director of Nursing, who acknowledged that the lithium lab results should have been uploaded into the resident's medical record. The absence of these records in the electronic medical record constitutes a failure to comply with the requirement to keep complete and dated laboratory records in the resident's clinical record.
Missing EKG Reports in Resident's Medical Records
Penalty
Summary
The facility failed to maintain complete medical records for one resident, identified as Resident 14, by not including signed and dated reports of diagnostic services. Resident 14, who had a complex medical history including cerebral infarction, hemiplegia, cognitive communication deficit, and other conditions, was ordered a 12 lead EKG for monitoring over two days. However, the EKG reports were not found in the resident's medical records. During an interview, the Director of Nursing (DON) acknowledged that the EKG report was obtained but was sent to the provider instead of being filed in the facility's records.
Deficiency in Food Quality and Temperature
Penalty
Summary
The facility failed to ensure that food and drink provided to residents were palatable, attractive, and served at a safe and appetizing temperature. This deficiency was identified through observations, interviews, and record reviews involving two residents. Resident 17 complained during a lunchtime meal observation that the food was too cold and would be better if served warm. Additionally, a resident council note from earlier in the month documented a complaint about undercooked and tough pork, while another note from July mentioned burnt eggs being served frequently at breakfast. Further investigation included a test lunch tray on September 25, which revealed several issues with the meal's quality. The collard greens were soggy and bland, the potatoes had a chunky texture, and the cornbread was overly salty and not sweet. The soup was also overly salty, and the apple pie mousse dessert tasted like plain sour yogurt. Resident 30 expressed dissatisfaction with the food, describing it as bland. The Corporate Dietitian mentioned that residents could fill out grievance forms for food complaints, and the dietary manager would follow up individually with those who filed grievances.
QAA Committee Lacks Required Medical Director Participation
Penalty
Summary
The facility failed to ensure that the Quality Assessment and Assurance (QAA) committee met the required composition and frequency as mandated by regulations. Specifically, the QAA committee did not include the Medical Director as a participating member, which is a requirement. The committee was composed of the Administrator, Director of Nursing (DON), Therapeutic Recreation Specialist (TRS), Resident Advocate (RA), Maintenance Director, Business Office Manager, and Dietary Manager. However, there was no evidence that the Medical Director participated in the quarterly Quality Assurance and Performance Improvement (QAPI) meetings, as required by the facility's 2024 QAPI Plan. During an interview, the Administrator confirmed that the QAA committee met quarterly and as needed, but the Medical Director's attendance was inconsistent. The Administrator stated that the Medical Director was invited to the meetings but often did not attend due to scheduling conflicts, and instead, the Medical Director was typically followed up with meeting notes. The Administrator was unsure if the Medical Director attended the March 2024 meeting and confirmed that he did not attend the June 2024 meeting. This lack of participation by the Medical Director in the QAPI meetings is a deficiency in meeting the regulatory requirements for the QAA committee's composition and function.
Inadequate Infection Control During Medication Administration
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of a registered nurse (RN) during medication administration. On the morning of September 24, 2024, RN 1 was observed preparing medications for two residents without performing proper hand hygiene. Specifically, RN 1 did not sanitize her hands before removing medications from their packs. During the medication pass for Resident 12, RN 1 dropped medications onto the medication cart and the floor, then proceeded to scoop up a medication that was partially on the cart and place it back into the medication cup before administering it to the resident. Additionally, RN 1 was observed dropping medication onto the cart and floor while preparing medications for Resident 25. She picked up the medication from the floor and disposed of it in the sharps container but continued with the medication preparation without performing hand hygiene. During an interview, RN 1 acknowledged that she sometimes gets distracted and may touch residents or other objects before returning to medication preparation. The Director of Nursing confirmed that the facility's expectation was for staff to perform hand hygiene before any resident care tasks, including medication preparation.
Failure to Monitor Antibiotic Use for Resident with UTI
Penalty
Summary
The facility failed to establish an effective infection prevention and control program, specifically lacking an antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use. This deficiency was identified in the case of a resident who was receiving an antibiotic for a urinary tract infection. The facility did not follow up with the hospital to obtain the culture and sensitivity results necessary to guide appropriate antibiotic use. The Director of Nursing (DON) acknowledged that the hospital discharge instructions indicated a culture and sensitivity test was to be performed, but the results were not verified or obtained by the facility. Resident 19, who was involved in this deficiency, was admitted and readmitted to the facility with multiple diagnoses, including Alzheimer's Disease, dementia, type 2 diabetes mellitus, and other conditions. Upon returning from the hospital, the resident was noted to have a urinary tract infection and was given a Rocephin shot. However, the facility did not ensure the continuation of appropriate antibiotic treatment due to the lack of follow-up on the culture and sensitivity results. Despite attempts by the DON to contact the hospital for these records, the necessary information was not obtained, leading to a gap in the resident's care management.
Unqualified Staff Member Assisted Resident with Feeding
Penalty
Summary
The facility failed to ensure that a staff member assisting with feeding was properly trained as a paid feeding assistant, as required by state regulations. Specifically, a staff member who was not a Certified Nursing Assistant (CNA), Licensed Nurse, or a paid feeding assistant provided feeding assistance to a resident. This occurred despite the facility's policy that only CNAs, Nurses, Speech Therapists, or paid feeding assistants should assist residents with feeding. The resident involved had multiple diagnoses, including aphasia following cerebrovascular disease, moderate protein-calorie malnutrition, and dementia with agitation. The resident's records indicated varying levels of assistance needed during meals, ranging from independent eating to total dependence on staff. On the day of the incident, the resident had not received any dining assistance with breakfast until the unqualified staff member intervened. Interviews with staff revealed that the facility had no paid feeding assistants and that the staff member who assisted was not qualified to do so.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for its residents, as evidenced by the condition of the restrooms. Observations revealed that restrooms in resident rooms had stains around the base of the toilets and strong odors of urine. Despite the housekeeper's efforts to clean the restrooms with disinfectant, the odors returned shortly after cleaning. The housekeeper attributed the persistent odor to residents urinating outside the toilet bowl and noted that her ability to complete all housekeeping duties was hindered by reduced staffing hours. The Director of Nursing (DON) was unaware of the frequency of room cleaning, indicating a lack of oversight in maintaining cleanliness standards. The housekeeper reported that the reduction in hours for the part-time housekeeper further limited her ability to perform tasks such as washing and cleaning curtains, which had not been done for over a month. This deficiency in maintaining a clean and homelike environment was observed after the housekeeper had completed her cleaning duties for the day, highlighting the inadequacy of the current housekeeping schedule and staffing levels.
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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