Provo Rehabilitation And Nursing
Inspection history, citations, penalties and survey trends for this long-term care facility in Provo, Utah.
- Location
- 1001 North 500 West, Provo, Utah 84604
- CMS Provider Number
- 465119
- Inspections on file
- 24
- Latest survey
- March 16, 2026
- Citations (last 12 mo.)
- 8 (1 serious)
Citation history
Health deficiencies cited at Provo Rehabilitation And Nursing during CMS and state inspections, most recent first.
Facility staff failed to provide safe tracheostomy and respiratory care for multiple residents, including not entering or following updated ENT recommendations for extended trach-change intervals, attempting trach changes without active orders, and proceeding with trach changes on a vented resident with known tracheal stenosis despite an "ENT only" limitation communicated outside the chart. In one case, an RT attempted to change a trach after a complaint of tightness, encountered resistance with two different tube sizes, and the resident developed acute respiratory distress and cardiac arrest, leading to death. In another case, an RT found a trach tube broken at the flange and dislodged, changed the trach, and repeated suctioning produced large amounts of blood while SpO2 remained low, culminating in a code and death. Staff interviews described awareness of broken trach flanges, concerns about ventilator alarms and inadequate pulse oximetry equipment, and additional events where a resident with a displaced BiPAP was found unresponsive and could not be resuscitated.
Two residents with chronic respiratory failure and tracheostomy status experienced neglect related to trach management and access to ENT care. For one resident, ENT had previously changed the trach and recommended three‑month changes, but this was never entered as an order, prior routine trach‑change orders had expired, and an ENT referral was not completed after the ENT office declined to schedule due to insurance concerns that were not escalated to the BOM. Despite verbal communication that the trach should be changed only by ENT, an RT attempted a trach change after the resident complained of tightness, encountered resistance with both the original and a smaller tube, and the resident developed acute respiratory distress, required a code blue, and died. For another comatose resident, an RT found a broken trach flange with the tube dislodged and not midline, changed the trach, and suctioned large amounts of frank blood while the resident’s O2 saturation remained low; the resident was found pulseless, CPR was initiated, and the resident could not be revived. The DON and RT staff interviews showed inconsistent documentation and communication of trach‑change orders and equipment issues, and both events resulted in resident death.
The facility failed to immediately report an alleged violation involving an injury of unknown source to the SSA and APS after a resident with a trach and respiratory failure was found with a broken trach flange and a dislodged trach tube. An RT discovered the broken trach during rounds, performed an urgent trach change with assistance, and noted significant bleeding, declining SpO2, and eventual loss of pulse, leading to a code blue, EMS involvement, and the resident’s death. Documentation confirmed the event and the resident’s unstable condition during the trach change, but SSA records showed no report was made. In interviews, the DON stated that she and the Administrator decided not to report the incident because they believed respiratory staff followed policy and there was no concern for negligence, and the DON was unsure how the trach broke or whether the RT director investigated the event.
A resident who was comatose, ventilator‑dependent, and had a tracheostomy with multiple respiratory diagnoses was found by respiratory staff with a broken trach flange and a dislodged trach tube that was shifted from midline. Respiratory staff notified nursing, called in another RT, and attempted a trach change and suctioning, during which they noted significant bleeding and continued blood accumulation. The resident’s O2 saturation dropped, manual ventilation was initiated without improvement, and nursing staff found no pulse, started CPR, and involved EMS, but the resident could not be revived. In a later interview, the DON acknowledged that while staff responded to the event, she had not investigated how the trach broke and was unsure if the RT director had done so, resulting in no evidence of a thorough investigation into the alleged violation.
A resident with chronic respiratory failure and tracheostomy status had prior orders for routine trach changes that were discontinued, and an ENT later recommended trach changes every three months, but this recommendation was never entered as an active order in the medical record. The RT Director reported receiving a VO that only ENT should change the trach unless emergent, but this VO was not documented in the chart and was only communicated verbally and on a whiteboard. Believing a trach change was appropriate, RT staff attempted what they considered a scheduled trach change when the resident complained the trach felt too tight, encountered resistance with reinsertion attempts, and the resident developed acute respiratory distress, leading to a Code Blue and subsequent death. Interviews showed RT staff were unaware that trach changes were restricted to ENT and that there was no active order for a trach change at the time, demonstrating a failure to ensure services met professional standards of quality.
A resident with chronic respiratory failure, tracheostomy status, pneumonia, anoxic brain damage, and documented subglottic/proximal tracheal stenosis had a provider order for an ENT referral and a subsequent NP note calling for ENT f/u. The Transportation Driver sent the referral to an ENT office, which refused to schedule due to the resident’s lack of active insurance and self-pay status, and the driver documented unsuccessful attempts to reach the family to confirm payment. The Business Office Manager later stated the resident was Medicaid pending and that the facility would have been responsible for payment if an outside provider would not accept that status, but she was never informed that the ENT would not see the resident for this reason. Consequently, the ordered ENT evaluation for the resident’s tracheostomy and tracheal stenosis was not obtained.
The facility failed to use its QAPI process to identify, investigate, and analyze three respiratory‑related deaths and did not document corrective actions. Two residents on ventilators experienced critical tracheostomy events—an inappropriate trach change by respiratory staff and a broken trach flange causing dislodgement—leading to cardiac arrest and death. Two residents did not receive access to outside provider appointments for trach care, and verbal orders for trach changes were not followed. For one comatose resident in a vegetative state whose trach flange broke and who later died, the SSA and APS were not notified within the required timeframe. The ADM reported that only two of the deaths were reviewed in QAPI, was not informed of one death and its circumstances until the next morning, and stated that a contracted respiratory company, which had not reported equipment issues, was responsible for respiratory equipment.
A ventilator-dependent resident with a tracheostomy and respiratory failure experienced a broken trach flange and significant tube displacement, yet the ventilator and continuous pulse oximeter did not alarm despite low O2 saturation and visible cyanosis. During suctioning, staff noted substantial bleeding and the resident’s oxygen level continued to drop, leading to manual ventilation, a pulseless state, CPR, EMS involvement, and the resident’s death. A RT later reported prior concerns about broken ventilator alarm cables that could prevent alarms from reaching the call system and non-functioning pulse oximeters, while the Administrator stated that a contracted respiratory company supplied the equipment and had not reported any equipment issues.
The facility failed to protect residents from abuse and neglect, particularly in cases involving consensual relationships where residents lacked the capacity to consent. Residents with cognitive impairments were involved in inappropriate interactions, which were not properly assessed or reported. The facility relied on family consent without consulting medical professionals, leading to multiple incidents of potential abuse and exploitation.
The facility failed to maintain cleanliness and proper maintenance in the kitchen, with observations of a soiled steam table, dusty hood vents, a soiled wall behind the dish machine, missing grout, and a dusty fan. The Dietary Manager acknowledged these issues, noting that the vents were cleaned quarterly and the fan was a personal item. The steam table shelf was cleaned daily but was stained, and a work order was to be sent for the wall behind the dish machine.
Two residents with cognitive impairments were found in compromising situations, but the facility failed to report these incidents to the SSA and APS, citing them as consensual relationships. Despite the lack of documented capacity to consent, the facility relied on family input and staff observations, leading to a deficiency in compliance with reporting requirements.
A resident with COPD and other health issues did not have an active physician's order for oxygen therapy upon returning from the hospital, despite requiring it. Nursing staff acknowledged the need for such orders, but none were documented, leading to a deficiency in providing appropriate respiratory care.
A resident with multiple diagnoses, including anoxic brain damage and mental health disorders, experienced chronic mouth pain for ten months without adequate pain management. Despite a care plan and various prescribed medications, the resident's pain was not effectively addressed, leading to ongoing distress. Delays in dental care and specialist referrals further contributed to the deficiency in pain management.
A resident with multiple diagnoses, including depression and anxiety, did not receive prescribed medications like Zoloft, busPIRone, traMADol, TEGretol-XR, and Depakote due to unavailability. Despite refill requests, the facility's emergency medication system and pharmacy coordination failed, leading to unmanaged pain and agitation for the resident. Interviews revealed ongoing issues with medication supply and a recent pharmacy change.
A resident with a history of diabetes, hypertension, and atrial fibrillation self-administered medications brought by a family member, which were not documented by the nursing staff. The MAR indicated the medications were administered, but interviews revealed inconsistencies in the administration process. The DON was not informed until the next day, highlighting procedural lapses in medication management.
Two residents with cognitive impairments eloped from a memory care unit due to inadequate supervision. One resident, initially assessed as low risk, was allowed to leave unsupervised and was found outside after a fall. Another resident, assessed as high risk, was moved off the secured unit and later eloped, being found by emergency services. These incidents highlight failures in risk assessment and supervision processes.
Failure to Provide Safe Tracheostomy and Respiratory Care Resulting in Resident Deaths
Penalty
Summary
The deficiency involves the facility’s failure to provide safe and appropriate respiratory and tracheostomy care in accordance with physician orders, professional standards, and resident-specific limitations. For one ventilator-dependent resident with chronic respiratory failure, tracheostomy status, pneumonia, anoxic brain damage, and documented subglottic and proximal tracheal stenosis, hospital records indicated that ENT had changed the trach in the OR and recommended trach changes every three months instead of monthly, and advised against trialing a Passy Muir Valve. A nurse practitioner note directed continued trach care per RT protocol with ENT follow-up for the stenosis. The DON reported seeing a provider note indicating the trach should be changed every three months, but this order was never entered into the medical record. The prior standing order to change the trach every 45 days had been converted to every 30 days by the contracted respiratory company, and then the trach change order dropped off the MAR in January, leaving no active order for trach changes at the time of the resident’s death. On the day of the event, RT documentation earlier in the day described the resident as alert and oriented, on a ventilator with an XLT cuffed, non-fenestrated size 7 trach, with the trach midline, secure, and patent, and no signs of respiratory distress. Later, an RT note documented that the RT performed a trach change because the resident reported the trach was too tight that morning. The RT pre-oxygenated the resident and recorded stable SpO2 and HR before the attempt. During removal and reinsertion of the trach tube, resistance was encountered and insertion was unsuccessful; a smaller trach was then attempted and also could not be inserted. The resident developed acute respiratory distress with pallor and cyanosis, oxygen saturation dropped, and a code blue was initiated. Nursing documentation corroborated that during the attempted trach change, resistance was met twice, the resident became cyanotic with decreasing oxygen saturation, and CPR was initiated after the resident was found unresponsive, apneic, and pulseless. EMS continued resuscitative efforts, and the resident was pronounced dead. Interviews revealed that RT 1 believed the resident’s complaint of tightness meant the trach needed to be changed immediately, pushed a partially dislodged trach back in earlier that morning, and then proceeded with a trach change despite the resident not being in distress and the trach being described as secure, patent, and midline. RT 2 stated he was unaware the trach was not supposed to be changed and had never changed a vented patient’s trach before. RT 3 stated there were instructions that the resident’s trach was not to be changed until seen by ENT, and that he had seen the resident’s name on a whiteboard with an “ENT only” notation. The RT Director stated she had received a verbal order that the trach should be changed only by ENT unless emergent, but this was not entered into the chart and was only communicated verbally and on a whiteboard. A second resident with anoxic brain damage, acute and chronic respiratory failure, tracheostomy status, and pneumonia due to pseudomonas experienced a fatal event related to a broken trach flange and trach displacement. A late-entry RT note documented that during first rounds at night, the RT found the trach tube broken and dislodged from the flange, with the tube about 1.5 inches out of position and deviated from midline. The RT called a nurse and another RT to assist, removed the old tube, and inserted a new Shiley XLT 6 that had been tested and lubricated. During suctioning, a significant amount of blood was observed, and repeated suction passes continued to remove blood. The SpO2 alarm indicated low oxygen saturation, the resident was disconnected from the ventilator for manual bagging, and SpO2 did not improve. A pulse check revealed no pulse, the resident was transferred to the floor, a smaller XLT 5 trach was placed without resistance, and manual ventilation and chest compressions continued until EMS arrived, but the resident could not be revived. A nursing late entry confirmed that the RT showed the nurse the broken trach, that vital signs were stable before the change, and that copious bleeding occurred during the trach change, followed by code blue and unsuccessful resuscitation. RT 4 reported that the trach was broken at the flange and deviated at a 45-degree angle, that the ventilator was not alarming despite the deviation, that the resident’s lips appeared cyanotic with SpO2 below 90%, and that he changed the trach to restore a patent airway. He described large amounts of frank blood and mucus on suctioning and believed the airway was filled with blood. RT 4 also reported concerns about ventilator alarms, pulse oximeters, alarm cables, and lack of needed supplies prior to the current RT Director’s tenure, and stated he had asked repeatedly for alarms, pulse oximeters, and cables. A third resident with quadriplegia, anoxic brain damage, and chronic respiratory failure with hypoxia and hypercapnia had orders related to BiPAP/ventilator use, including checking body positioning, nasal cannula placement, and BiPAP vent settings with humidity. The overall deficiency cited that staff did not follow physician orders for changing tracheostomies, did not obtain needed consultations with outside providers, did not accurately document resident condition prior to trach changes, and did not initiate hospital transfer when there were concerns about trach integrity. Staff interviews revealed knowledge of faulty trach equipment, including broken flanges that caused trach dislodgement, and that one resident with a broken flange and dislodged trach went into cardiac arrest and died. Additionally, another resident with displaced BiPAP was found unresponsive, CPR was initiated, and the resident could not be resuscitated and died. These failures in respiratory and tracheostomy care for multiple residents resulted in findings of immediate jeopardy for two of the residents.
Failure to Coordinate Tracheostomy Care and Specialty Access Resulting in Harm and Death
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from neglect related to tracheostomy management and access to necessary outside specialty care, resulting in harm to two residents. One resident with chronic respiratory failure, tracheostomy status, pneumonia, and anoxic brain damage had physician orders for routine tracheostomy changes that were later discontinued, with no active order for trach changes at the time of death. An ENT referral was ordered due to subglottic and proximal tracheal stenosis, and the hospital H&P documented that ENT had changed the trach in the OR and recommended trach changes every three months instead of monthly, and against use of a Passy Muir Valve. A nurse practitioner note referenced continued trach care per RT protocol and follow-up with ENT, but the ENT appointment was never obtained. The transportation driver later documented that the ENT office would not schedule because the resident had no insurance and would be self-pay, and that repeated attempts to reach the family were unsuccessful; however, the business office manager stated that the resident was Medicaid pending and that, if an outside provider would not accept that status, the facility would be responsible for payment, and she was not informed of any barrier to the ENT visit. On the day of the first resident’s death, RT documentation earlier in the day showed the trach as midline, secure, and patent, with stable vital signs and no respiratory distress. Later, RT 1 documented attempting a scheduled trach change after the resident complained the trach was too tight, pre-oxygenating the resident, and then encountering resistance when removing and reinserting the trach tube; a smaller size trach was also unsuccessfully attempted. The resident developed acute respiratory distress with pallor and cyanosis, and a code blue was initiated. Nursing documentation described that during the attempted trach change, resistance was met twice, the resident exhibited respiratory distress with decreasing oxygen saturation and cyanosis, and manual ventilation and CPR were initiated, but the resident was ultimately pronounced dead by EMS. RT 1 reported that the resident had complained of tightness, that the trach appeared dislodged about 1.5 inches from the stoma earlier, and that she pushed it back in; she stated that complaints of tightness could indicate the trach was dirty and needed immediate change, and that she attempted the change with RT 2 assisting, met resistance with both the original and a smaller trach, and then the resident’s oxygen saturation dropped significantly before cardiac arrest. RT 2 stated he did not know the trach was not supposed to be changed and had never changed a vented patient’s trach before; he also noted that he learned only after the death that the physician was supposed to change the trach and that prior monthly trach-change orders had expired. Additional interviews revealed conflicting and incomplete communication about trach-change orders and ENT-only status. RT 3 stated that due to tracheal stenosis, the resident’s trach was not to be changed until seen by ENT, that he had seen the resident’s name on a whiteboard with a note stating “ENT only,” and that he would not change an ENT-only trach if it was patent, midline, and secure. The RT Director reported receiving a verbal order from the provider in early February that the resident’s trach should be changed only by ENT unless in an emergent situation, but acknowledged this order was never entered into the resident’s chart; she said it was communicated verbally to staff and written on a whiteboard as “trach change on hold until otherwise notified.” The DON stated she had seen a provider note indicating the trach should be changed every three months, but that this order was never placed in the medical record, and that the prior 45-day trach-change order had been changed to every 30 days by the contracted respiratory company and then dropped off the MAR in January, leaving no active trach-change order. The facility’s trach-change policy required changes per doctor’s orders or every 30 days, including emergency changes for damaged or non-patent tubes, and outlined steps for managing inadequate airflow and failed reinsertion, including manual ventilation and calling emergency services. The second resident involved in the deficiency had anoxic brain damage, acute and chronic respiratory failure, tracheostomy status, and pneumonia due to pseudomonas, and was comatose and in a vegetative state. Respiratory staff entered the resident’s room in the evening and found the trach flange broken, with the trach tube dislodged about 1.5 inches out of position, shifted to the right, and not midline. RT 4 stated that trachs should be centered and midline to avoid airway obstruction or bleeding, and that the ventilator was not alarming despite every breath being pressurized. The resident’s lips appeared cyanotic, and when the oxygen sensor was repositioned, the saturation was below 90%. RT 4 called for another RT and a nurse, determined the trach needed to be changed to ensure a patent airway, and changed the trach and suctioned the airway. On the first suction pass, a large amount of frank blood and mucus was removed, and two additional passes continued to yield large amounts of blood. The resident’s oxygen remained low, a nurse checked for a pulse and found none, the resident was lowered to the floor, and CPR was initiated while RT 4 continued suctioning large amounts of blood, stating he believed the airway was filled with blood. EMS arrived, but the resident could not be revived and died. The DON confirmed that respiratory staff had identified a broken trach and decided to change it, that there was increased bleeding, and that the resident went into cardiac arrest and passed away, and stated she did not know how the flange broke and was unaware of other residents with broken trach flanges.
Failure to Report Tracheostomy-Related Injury and Death to SSA and APS
Penalty
Summary
The facility failed to ensure that an alleged violation involving an injury of unknown source was reported immediately, but no later than 2 hours after the allegation was made, to the administrator, State Survey Agency (SSA), and Adult Protective Services (APS). For one resident with anoxic brain damage, acute and chronic respiratory failure, tracheostomy status, and pneumonia due to pseudomonas, the tracheostomy flange was found broken and the tracheostomy tube dislodged. A respiratory therapist documented that around 9:00 PM, during first rounds, the tracheostomy tube was observed broken and approximately 1.5 inches out of position, requiring immediate replacement. During the trach change, significant bleeding was noted, multiple suction passes were performed, the resident’s SpO2 alarmed low, and manual bagging was initiated. Despite these interventions, the resident’s SpO2 did not improve, no pulse was detected, chest compressions were started, and EMS later took over. A nursing late entry note documented that the RT called the nurse into the room, showed that the trach was broken and needed replacement, and that another RT was called to assist. At that time, the resident’s oxygen and other vital signs were stable. The RTs then alerted the nurse to copious bleeding during the trach change, after which the resident became unstable, a code blue was initiated, additional staff arrived, 911 was called, and the resident could not be revived, with time of death pronounced. Review of SSA records showed the incident was not reported. In interviews, the DON stated that night shift respiratory staff identified the broken trach and changed it, that there was increased bleeding and the resident went into cardiac arrest, and that the incident was not reported to the SSA because it was believed staff followed policy and there was no concern for negligence. The DON also stated she was unsure how the trach broke and was unsure if the respiratory director investigated the incident, and that she and the Administrator decided not to report the event because they believed respiratory staff followed policy when changing the broken trach.
Failure to Investigate Broken Tracheostomy Incident Leading to Resident Death
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate an alleged violation related to a serious incident involving a ventilator‑dependent, comatose resident with a tracheostomy. The resident had diagnoses including anoxic brain damage, acute and chronic respiratory failure, tracheostomy status, and pneumonia due to pseudomonas. On the evening in question at 9:00 PM, respiratory staff entered the resident’s room and found the tracheostomy flange broken, with the tracheostomy tube dislodged and approximately 1.5 inches out of position, shifted to the right and not midline. Respiratory therapy staff notified nursing and called a second respiratory therapist to assist with a tracheostomy tube change. During suctioning, respiratory staff observed a significant amount of blood and performed additional suction passes due to continued accumulation of blood. As the event progressed, the resident’s oxygen saturation dropped, and respiratory staff initiated manual ventilation, but oxygen levels did not improve. Nursing staff performed a pulse check, found no pulse, and the resident was lowered to the floor where CPR was initiated. EMS arrived, but the resident could not be revived and died. In a subsequent interview, the DON stated that staff had identified the broken tracheostomy and decided to change it, that increased bleeding occurred, and that the resident went into cardiac arrest, leading to CPR and EMS involvement. The DON further stated she had not investigated how the tracheostomy broke and was unsure whether the respiratory therapy director at the time had conducted any investigation, demonstrating that the facility did not have evidence that the alleged violation was thoroughly investigated.
Failure to Enter and Follow Tracheostomy Orders Leading to Improper Trach Change
Penalty
Summary
The deficiency involves the facility’s failure to ensure that respiratory services met professional standards of practice for a resident with chronic respiratory failure, tracheostomy status, pneumonia, and anoxic brain damage. The resident had prior physician orders for tracheostomy tube changes every 45 days and then every 30 days, but these orders were discontinued and no new order to change the tracheostomy tube was entered after a certain date. A hospital H&P documented that the resident’s tracheostomy had been exchanged by ENT due to hemoptysis, that the resident had experienced a dislodged trach with respiratory arrest and PEA, and that ENT recommended against PMV trials and advised trach changes every three months instead of monthly. Despite this, the ENT recommendation was not converted into an active physician order in the resident’s medical record. On the day of the incident, an RT note documented that the RT performed a trach change because the resident reported that the trach felt too tight. During removal and attempted reinsertion of the trach tube, resistance was encountered and insertion was unsuccessful, even with a smaller size trach. The resident then developed acute respiratory distress with pallor and cyanosis, leading to a Code Blue. A nursing note corroborated that the RTs initiated what they described as a scheduled trach tube change, encountered resistance with two insertion attempts, and that the resident became cyanotic with decreasing oxygen saturation, prompting immediate resuscitative efforts including manual ventilation, CPR, AED application, and EMS involvement, after which the resident was pronounced dead. Interviews revealed that RT staff and leadership were operating under inconsistent and undocumented directives. RT 1 stated that trach changes were done if the trach was dislodged or if the resident complained, and otherwise the MD changed the trach. RT 3 stated that, due to tracheal stenosis, the resident’s trach was not to be changed until seen by ENT and recalled seeing the resident’s name on a whiteboard labeled “ENT only.” RT 2 stated he was not informed that the trach was not supposed to be changed and believed there were monthly trach change orders, not realizing those orders had expired. The RT Director reported receiving a VO from the provider that the resident’s trach should be changed only by ENT unless emergent, but this VO was never entered into the resident’s chart; instead, it was only communicated verbally and noted on a whiteboard. The DON confirmed that the ENT recommendation for trach changes every three months was never entered as an order and that the prior standing trach change order had dropped off the MAR, leaving the resident without an active trach change order at the time of the event.
Failure to Secure ENT Evaluation for Resident With Tracheostomy and Tracheal Stenosis
Penalty
Summary
The facility failed to obtain outside professional ENT services for a resident when it did not employ a qualified professional to provide the required service. The resident was admitted with chronic respiratory failure, tracheostomy status, pneumonia, and anoxic brain damage. Hospital records documented that the resident previously had a tracheostomy exchange by ENT due to hemoptysis, experienced a respiratory arrest with a dislodged trach, and had significant subglottic and proximal tracheal stenosis. ENT had recommended against trialing a Passy Muir Valve and advised changing the trach every three months. A physician order for an ENT referral related to stenosis and tracheostomy status was initiated, and a later nurse practitioner note documented the need for follow-up with ENT for subglottic and tracheal stenosis. The Transportation Driver documented that an order for the ENT visit was received and sent to the ENT office, but the office reported the resident did not have insurance and would require self-pay, and therefore would not schedule the appointment without confirmation from the family. The Transportation Driver reported multiple unsuccessful attempts to contact the family and did not secure an appointment. The Business Office Manager stated the resident was Medicaid pending, that she had been in contact with Medicaid since admission, and that if an outside provider would not accept a Medicaid pending resident, the facility would be responsible for payment. The Business Office Manager also stated she was not informed that the ENT provider would not see the resident due to Medicaid pending status and that, had she known, she would have discussed payment with the Administrator so the resident could be seen by ENT. As a result, the resident did not receive the ordered ENT evaluation for tracheostomy and tracheal stenosis.
Failure to Integrate Respiratory-Related Deaths and Tracheostomy Incidents into QAPI and Required Reporting
Penalty
Summary
The deficiency involves the facility’s failure to use its QAPI and QAA processes to identify, report, investigate, analyze, and prevent adverse events related to three respiratory‑related resident deaths, and to document corrective actions. Surveyors found that the facility did not include all three deaths, particularly one resident’s death, in its QAPI review despite the events involving serious clinical issues with ventilators and tracheostomies. Two residents on ventilators experienced critical tracheostomy events: in one case, respiratory staff changed a tracheostomy when they were not supposed to, and in another, a tracheostomy flange broke, causing the tracheostomy to become dislodged. Both residents went into cardiac arrest and died. The facility also failed to ensure residents had access to outside provider appointments for tracheostomy care and did not follow verbal orders for tracheostomy changes. The report further notes that the facility did not ensure residents were free from neglect and did not meet reporting requirements for incidents involving serious bodily injury. For two residents, the facility did not provide access to outside tracheostomy care as ordered, and verbal orders for tracheostomy changes were not followed. One comatose resident in a vegetative state experienced a broken tracheostomy flange, resulting in a dislodged tracheostomy, cardiac arrest, and death. For this same resident, the State Survey Agency and Adult Protective Services were not notified when the tracheostomy flange broke and the resident died, despite the requirement to report such events within two hours. During interview, the Administrator stated that deaths were reviewed in QAPI with a focus on staff adherence to procedure and reported that residents associated with the immediate jeopardy events had been addressed in QAPI, but one resident’s death had not been reviewed. The Administrator also stated he was not informed of one resident’s death and the broken flange until the following morning and indicated that the contracted respiratory company was responsible for respiratory equipment and had not reported any equipment issues.
Ventilator and Monitoring Equipment Alarms Failed During Tracheostomy Dislodgement
Penalty
Summary
Failure to maintain mechanical, electrical, and patient care equipment in safe operating condition resulted in a ventilator not alarming when a resident’s tracheostomy tube flange broke and the tube became dislodged. The resident had diagnoses including anoxic brain damage, acute and chronic respiratory failure, tracheostomy status, and pneumonia due to pseudomonas, and was ventilator-dependent. On the evening in question, a respiratory therapist (RT 4) entered the resident’s room and found the tracheostomy flange broken, the tracheostomy tube deviated approximately 45 degrees to the right, partially out of the stoma, and about 1.5 inches out of position, with the resident’s lips noted to be blue. Despite this significant displacement, the ventilator was not alarming, and the continuous pulse oximeter alarm was also not sounding even though the resident’s oxygen saturation was below 90%, requiring RT 4 to move the sensor to a different location. During subsequent suctioning, respiratory staff observed a significant amount of blood and performed additional suction passes due to continued blood accumulation. The resident’s oxygen saturation dropped further, prompting initiation of manual ventilation, but oxygen levels did not improve. Nursing staff checked for a pulse, found none, and the resident was lowered to the floor where CPR was performed until EMS arrived; the resident could not be revived and died. RT 4 later reported that he checked all ventilators after the event because the ventilator had not alarmed, and he had previously expressed concerns to the interim respiratory supervisor that some ventilator alarm cables were breaking, which could prevent alarms from signaling to the call system, and that some pulse oximeters were not working, leaving him at times without needed monitoring equipment. The Administrator stated that the contracted respiratory company was responsible for supplying all respiratory equipment and that no equipment issues had been reported to him.
Failure to Protect Residents from Abuse and Inadequate Consent Assessment
Penalty
Summary
The facility failed to ensure that residents were protected from abuse, neglect, and exploitation, particularly in cases involving consensual relationships where residents lacked the capacity to consent. For instance, Resident 70, who had moderate cognitive impairment, was involved in a relationship with Resident 208, who was unable to complete a mental status interview. Despite family consent, the facility did not assess the residents' capacity to consent, leading to inappropriate interactions that were not reported as abuse. The Director of Nursing (DON) and staff considered the relationship consensual based on family input, without consulting medical professionals to evaluate the residents' cognitive abilities. Another incident involved Resident 409, who had severe cognitive impairment, and Resident 209, who had a history of violent behavior and moderate cognitive impairment. Resident 209 was found inappropriately touching Resident 409, an act that was later confirmed as non-consensual. Despite Resident 209's known history of aggression and inappropriate behavior, the facility failed to prevent the incident, which was only addressed after it occurred. The facility's documentation revealed that Resident 409 expressed sadness and discomfort following the incident, indicating a failure to protect him from abuse. The facility's approach to managing resident interactions, particularly those with potential sexual implications, was inadequate. The staff relied heavily on family consent and did not consistently involve medical professionals to assess residents' capacity to consent. This lack of proper assessment and intervention led to multiple incidents where residents were exposed to potential abuse and exploitation, highlighting significant deficiencies in the facility's safeguarding practices.
Deficiencies in Kitchen Cleanliness and Maintenance
Penalty
Summary
The facility failed to maintain food service areas in accordance with professional standards for food safety. During an initial tour of the kitchen, several deficiencies were observed, including a soiled steam table, dusty hood vents, a soiled wall behind the dish machine, missing grout in the tile, and a fan with dust buildup. The steam table was noted to be soiled under the shelf above the food, and the hood vents, which were due for cleaning, were dusty. The wall behind the dish machine was soiled with a yellow/brown substance and had a hole, while the tile in the dish machine room was missing grout. A follow-up tour revealed that the hood vents remained dusty, and the fan, which was pointed toward the food preparation area, had dust buildup. The wall behind the dish machine was still soiled, and the grout was still missing in the dish machine room. The Dietary Manager acknowledged these issues, stating that the vents were cleaned quarterly by an external company and that the fan was a personal item from an employee. The manager also noted that the steam table shelf was cleaned daily but was stained, not soiled, and had not noticed the missing grout. A work order was to be sent to the Maintenance department for the wall behind the dish machine.
Failure to Report Alleged Abuse and Assess Consent Capacity
Penalty
Summary
The facility failed to report alleged violations involving abuse, neglect, exploitation, or mistreatment to the State Survey Agency (SSA) and Adult Protective Services (APS) within the required timeframe. Specifically, the facility did not report an incident involving two residents with cognitive impairments who were found in a compromising situation. Resident 70, who had a BIMS score indicating moderate cognitive impairment, was found disrobed in his room with Resident 208, who was unable to complete a BIMS interview due to severe cognitive impairment. Despite the potential for non-consensual interaction, the facility did not report the incident, citing it as a consensual relationship. Resident 70 was admitted with multiple diagnoses, including dementia and cognitive communication deficit, and was found on multiple occasions in situations that suggested inappropriate or potentially non-consensual interactions with Resident 208. Nursing progress notes documented these interactions, and the facility's response was to separate the residents and monitor their interactions. However, the facility did not consult the Medical Director or other professionals to assess the capacity to consent, nor did they report the incidents to the appropriate authorities. Resident 208, diagnosed with Alzheimer's disease and unable to complete a BIMS interview, was involved in similar incidents with Resident 70. Despite the lack of documented capacity to consent, the facility relied on family input and staff observations to determine the interactions as consensual. The Director of Nursing stated that the interactions were considered companionship, and thus, the incidents were not reported as abuse. This oversight in reporting and assessing the capacity to consent led to a deficiency in the facility's compliance with reporting requirements.
Deficiency in Respiratory Care Due to Lack of Physician's Orders
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident who required oxygen therapy, as there were no active physician's orders specifying the type of oxygen delivery system, when to administer the oxygen, and the equipment settings for the prescribed flow rates. The resident, who had a history of chronic obstructive pulmonary disease (COPD) and other serious health conditions, was observed using oxygen without a current order upon returning from the hospital. Despite previous orders for oxygen therapy, these were discontinued after hospital discharges, and no new orders were documented upon the resident's return to the facility. Observations and interviews revealed that nursing staff, including a Registered Nurse (RN) and the Director of Nursing (DON), acknowledged the necessity of having an active order for oxygen therapy. The RN mentioned using nursing judgment to adjust oxygen levels based on the resident's condition, but confirmed that an active order should be in place. The DON also stated that oxygen therapy should be documented in the resident's medical record, even if standing orders were present. This lack of documentation and adherence to professional standards of practice led to the deficiency in providing safe and appropriate respiratory care for the resident.
Inadequate Pain Management for Resident with Chronic Mouth Pain
Penalty
Summary
The facility failed to provide timely and appropriate pain management for a resident who had been experiencing mouth pain for approximately ten months. The resident, who was admitted with multiple diagnoses including anoxic brain damage and various mental health disorders, consistently reported mouth and gum pain. Despite having a care plan in place that included interventions such as pain assessments every shift and the use of non-pharmacological interventions, the resident's pain was not adequately addressed. The resident's medical records indicate that various medications were prescribed for pain management, including acetaminophen, benzocaine gel, celecoxib, gabapentin, and lidocaine patches. However, the documentation shows that these interventions were often ineffective, and the resident continued to report significant pain. Nursing notes frequently documented the resident's complaints of pain and requests for additional pain relief, yet there were delays in adjusting the pain management plan or seeking further medical evaluation. The resident's condition was further complicated by the lack of timely dental care and the potential impact of smoking on their oral health. Despite multiple notes indicating the need for dental evaluation and potential concerns for conditions such as TMJ, there were significant delays in coordinating appropriate dental and specialist care. This lack of timely intervention and effective pain management resulted in ongoing distress and discomfort for the resident, highlighting a deficiency in the facility's pain management practices.
Medication Unavailability for Resident in Pain
Penalty
Summary
The facility failed to provide routine and emergency medications to a resident, identified as Resident 64, who was experiencing pain, agitation, and depression. The resident was admitted with multiple diagnoses, including anoxic brain damage, antisocial personality disorder, and major depressive disorder. The medical records revealed that the resident did not receive prescribed medications such as Zoloft, busPIRone, traMADol, TEGretol-XR, and Depakote on several occasions due to unavailability, despite refill requests being sent to the pharmacy. Interviews with the resident and staff highlighted the ongoing issues with medication availability. Resident 64 expressed experiencing severe mouth pain and dissatisfaction with the lack of timely dental care and oral pain relief. The resident reported that the staff frequently ran out of oral gel, which was used to alleviate gum pain. Interviews with LPN 4 and the Director of Nursing (DON) revealed that the facility had an emergency medication system, but it primarily contained narcotics and antibiotics. The staff had to reorder medications through the eMAR system, and there were delays in receiving refills from the pharmacy. The DON mentioned that the facility had changed pharmacies six to eight months prior, which may have contributed to the medication supply issues. Despite having a system in place to reorder medications, the facility failed to ensure that Resident 64 received their prescribed medications consistently. This deficiency in pharmaceutical services resulted in the resident experiencing unmanaged pain and agitation, highlighting a significant lapse in the facility's ability to meet the medication needs of its residents.
Resident Self-Administers Medications Brought by Family
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs, as evidenced by an incident involving Resident 160. The resident, who had a medical history including diabetes mellitus, hypertension, and atrial fibrillation, was found to have self-administered medications brought in by a family member. These medications included Metformin, a blood pressure medication, and a blood thinner, which were not documented by the nursing staff. The resident reported having to chase down nurses to receive his medications, and his family member confirmed bringing the medications to him. The Medication Administration Record (MAR) indicated that the medications were administered at 8:25 AM, but there was no documentation of the resident self-administering the medications. Interviews with nursing staff revealed inconsistencies in the administration process. RN 1 mentioned a flex time for medication administration, while LPN 1 initially denied administering the medications but later acknowledged her initials on the MAR. LPN 1 admitted that the resident refused the medications she offered and that she failed to document the refusal properly. Further interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) highlighted procedural lapses. The ADON noted that the nurse did not document the family member's involvement, and the DON emphasized that medications should not be provided by family members. The DON was not informed of the incident until the following day, delaying communication with the physician. The Regional Nurse Consultant (RNC) suggested that an Interdisciplinary Team Meeting was necessary to address the issue, but this was not documented in the report.
Inadequate Supervision Leads to Resident Elopement
Penalty
Summary
The facility failed to ensure adequate supervision to prevent accidents for two residents with cognitive impairments, leading to their elopement from the memory care unit. Resident 70, who had a history of dementia and cognitive impairment, was initially assessed as a low risk for elopement. Despite this, the resident exhibited wandering behaviors and was eventually moved to a locked memory care unit. However, on one occasion, a CNA allowed Resident 70 to leave the unit unsupervised, resulting in the resident being found outside the facility by a bystander after falling. Resident 50, diagnosed with dementia and assessed as a high risk for elopement, was moved off the secured unit due to a perceived lack of exit-seeking behavior. This decision was made despite the resident's history of wandering. Subsequently, Resident 50 eloped from the facility and was found by emergency services after a fall. The resident was returned to the facility with only minor injuries. The incidents highlight a failure in the facility's risk assessment and supervision processes, as both residents were able to leave the secured areas unsupervised. The staff's actions, such as allowing a resident to exit without proper authorization and moving a high-risk resident off a secured unit, contributed to these deficiencies.
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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