Red Cliffs Health And Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in St George, Utah.
- Location
- 1745 East 280 North, St George, Utah 84790
- CMS Provider Number
- 465137
- Inspections on file
- 21
- Latest survey
- March 25, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Red Cliffs Health And Rehab during CMS and state inspections, most recent first.
Two residents with ADL deficits did not receive scheduled bathing assistance, with documentation showing multiple missed showers and some showers provided by a family member instead of staff. Staff interviews confirmed that showers were often missed and not documented, and the facility could not provide records showing that showers were offered or completed as scheduled.
A resident with paralysis and aphasia requiring maximal assistance did not receive scheduled showers or twice-daily oral care as required. Documentation showed multiple missed showers and frequent lapses in oral hygiene, with facility staff confirming that care not documented was likely not completed.
A facility failed to ensure a safe environment, resulting in falls and elopement. A resident with severe cognitive impairment fell multiple times, sustaining fractures, due to inadequate supervision and missing fall mats. Another resident, also with severe cognitive impairment, eloped multiple times due to incomplete safety checks and a propped open door, highlighting the facility's failure to provide adequate supervision and safety measures.
The facility failed to notify physicians of significant changes in two residents' conditions. One resident, with a knee surgery, experienced bladder spasms and confusion, but the facility delayed contacting the surgeon. Another resident with diabetes had multiple high blood sugar readings, yet the physician was not informed. The facility's policy on notifying physicians was not followed, leading to deficiencies.
The facility failed to protect residents from abuse and neglect, including a staff member recording a video of a cognitively impaired resident in the shower and sharing it on social media, and a resident with dementia kissing another resident without consent. Additionally, a resident was involved in a sexual relationship without proper assessment of their capacity to consent.
The facility failed to provide timely and appropriate care for three residents, leading to deficiencies in their treatment. One resident experienced a significant change in condition that was not addressed promptly, resulting in hospitalization. Another resident underwent a dental procedure but was not monitored for post-operative complications, and a third resident developed Moisture Associated Skin Damage due to inadequate incontinence care. The facility's lack of timely intervention and communication contributed to these deficiencies.
Two residents in the facility developed UTIs due to inadequate management of urinary devices and delayed antibiotic treatment. One resident, using a PureWick system, did not receive proper device management due to lack of staff training, leading to a UTI. Another resident experienced a delay in receiving Macrobid treatment for a UTI, attributed to communication issues with the provider and delayed follow-up on lab results. Interviews with staff revealed systemic issues in training, documentation, and communication, contributing to these deficiencies.
A resident with chronic pain and multiple diagnoses did not receive Oxycodone as scheduled, leading to uncontrolled pain. The medication was often delayed, particularly the 4:00 AM dose, despite a care plan requiring timely pain relief. Staff interviews confirmed the resident should have received six doses daily, but discrepancies in administration times were noted.
Three residents in the facility experienced significant medication errors. A resident received Linezolid for 23 days instead of 14, leading to hospitalization. Another resident was given Lorazepam more frequently than prescribed due to incorrect order entry. A third resident's Oxycodone was administered at irregular intervals, risking overdose. These errors were confirmed by staff interviews and record reviews.
A resident with a complex medical history had 28 teeth extracted but did not receive timely follow-up care for dentures. Despite the resident's inquiries, facility staff were unaware of any scheduled follow-up appointments or plans for dentures. Interviews revealed a lack of communication and documentation regarding the resident's dental care, resulting in the resident not receiving necessary follow-up treatment.
The facility failed to accommodate the needs and preferences of three residents. One resident was denied transportation for personal errands due to restrictive policies, despite having a motorized wheelchair and the ability to use public transport. Another resident, who was cognitively intact, was unable to access an ATM for cash due to similar transportation restrictions. A third resident, with sensitive skin, was not provided with preferred incontinence briefs, leading to discomfort and a rash. The facility's policies and inconsistent communication among staff contributed to these deficiencies.
The facility failed to address ongoing grievances from the resident council regarding call light response times. Residents repeatedly expressed frustration over CNAs turning off call lights and not responding promptly, especially during night and early morning hours. Despite these complaints, the facility's responses were insufficient, with no significant improvement in response times and a lack of documented departmental responses for some meetings.
The facility failed to report alleged violations and incidents involving abuse, neglect, or mistreatment to the State Survey Agency (SSA) within the required timeframe. For example, a resident experienced a fall resulting in a cervical fracture, but the incident was reported the next day. Another resident suffered a femur fracture, and the incident was also reported late. Additionally, a resident eloped multiple times without documentation of reporting to the SSA or APS. The facility's administrator acknowledged these reporting failures.
The facility failed to investigate and report incidents involving missing fentanyl patches, medication mismanagement, and an allegation of sexual abuse. Residents with severe cognitive impairments were affected, with no documented investigations into missing fentanyl patches. An incident involving a resident being kissed by another resident was not thoroughly assessed for consent capacity. Staff interviews revealed procedural lapses and lack of documentation, highlighting deficiencies in the facility's response to these incidents.
A facility failed to initiate a baseline care plan within 48 hours for a resident with complex medical conditions, including COPD and bipolar disorder. The care plan, which should have addressed immediate needs based on admission and physician orders, was delayed by four days. The MDS Coordinator acknowledged the responsibility for timely care planning, but the required actions were not completed within the regulatory timeframe.
The facility was found to have insufficient nursing staff, leading to delayed response times to call lights and unmet care needs. Residents reported long waits for assistance, with some experiencing delays in receiving pain medication and missed showers. Interviews with CNAs confirmed staffing challenges, and the facility's assessment tool indicated a need for more staff than were present. The administrator acknowledged the issues but could not provide specific corrective actions.
The facility failed to implement effective policies and procedures, leading to deficiencies in abuse prevention, timely medical intervention, accident prevention, and medication management. Incidents included inappropriate interactions among residents, delayed medical responses, accidents resulting in injuries, and significant medication errors. These issues were noted in multiple surveys, indicating ongoing non-compliance.
A resident with multiple health conditions was found with lactulose all over her body after an unwitnessed fall, indicating an attempt to self-administer medication without proper assessment. Facility staff confirmed there was no documentation of an assessment or physician's order for self-administration, highlighting a failure in ensuring the resident's ability to safely manage her medications.
The facility failed to honor the shower preferences of two residents, leading to a deficiency in supporting resident choice. One resident, who is cognitively intact, desired more frequent showers but was not asked about their preferences. Another resident experienced a reduction in shower frequency without prior discussion. Interviews with staff revealed a lack of awareness and communication regarding shower scheduling, contributing to the deficiency.
A resident with multiple health conditions reported a recurring issue with their bathroom toilet not being securely fixed, despite multiple repair attempts. The toilet base was observed to be unsecured, and the seat moved side to side. The maintenance log showed no repair requests, and the Director of Maintenance admitted to making undocumented repairs and highlighted the need for staff to report maintenance issues.
A long-term care facility failed to prevent the misappropriation of fentanyl patches for three cognitively impaired residents. Despite physician orders for regular application and checks, the patches were frequently missing, with staff interviews revealing inconsistencies in documentation and verification processes. The facility's failure to monitor and secure the patches led to inadequate pain management for the residents.
The facility failed to coordinate PASARR assessments for two residents with serious mental illness (SMI). One resident with anxiety and bipolar disorder was not referred for a Level II evaluation despite new medication prescriptions. Another resident with a psychotic disorder was not screened for Level II due to communication lapses. The oversight was acknowledged by the facility's social service staff.
A resident developed a urinary tract infection due to the facility's failure to implement a comprehensive care plan for the proper use and monitoring of a PureWick urinary system device. Staff interviews revealed a lack of awareness and documentation regarding the device's maintenance, with the resident having to instruct staff on its care. The MDS Coordinator confirmed the absence of specific orders or documentation procedures for the device.
A resident expressed a desire to transfer to a facility closer to family, but the LTC facility failed to develop a discharge plan or follow up with the resident or family. The Resident Advocate did not document follow-ups or contact the family to facilitate the transfer, leaving the resident without a clear plan for discharge.
A resident in an LTC facility did not receive scheduled bathing assistance due to staffing shortages, leading to a seven-day gap between showers. Despite being cognitively intact and requiring limited assistance, the resident had to insist on receiving a shower. Interviews and records revealed inconsistencies in the documentation and provision of showers, resulting in a deficiency.
A resident with complex medical needs was not provided showers for weeks due to staffing shortages at the facility. The resident, dependent on staff for daily living activities, reported missed showers and inconvenient timing. Staff interviews confirmed the issue, citing insufficient staffing and the resident's need for two CNAs for assistance.
Two residents with limited range of motion did not receive necessary restorative nursing services to prevent further decline. One resident, with multiple diagnoses including cervical disc disorder, had to perform exercises independently due to lack of support. Another resident, with conditions like fibromyalgia, expressed a need for therapy but did not receive it, leading to decreased function. Facility staff acknowledged systemic issues with the restorative nursing program, which was not functioning effectively.
The facility failed to provide adequate respiratory care for two residents, leading to deficiencies. One resident did not receive a water trap for their nasal cannula, causing discomfort and potential choking hazards, while another resident's oxygen tubing was not changed weekly as required. Staff interviews revealed a lack of clarity and responsibility regarding equipment maintenance, contributing to the deficiencies.
A resident with complex medical conditions was hospitalized after receiving 17 extra doses of Linezolid due to the facility's failure to monitor the medication as required. The resident experienced symptoms of fatigue, confusion, and dark stools, and was later found to have critically low blood cell counts, necessitating blood transfusions. Facility staff failed to ensure proper monitoring and communication regarding the medication regimen.
Two residents in an LTC facility were prescribed psychotropic medications without attempts at gradual dose reduction (GDR) or documented clinical contraindications. Resident 36, with bipolar disorder, was on Lithium and Seroquel, but the facility failed to document GDR attempts or contraindications. Resident 47, with bipolar disorder and depression, was on Risperidone and Escitalopram, and the facility struggled to obtain necessary physician documentation for GDR. The physician was overwhelmed by paperwork, leading to delays in compliance.
The facility failed to properly manage fentanyl patches and medication administration, involving residents with severe cognitive impairments. Fentanyl patches were frequently not found on residents, with no documentation of recovery or proper disposal. Additionally, a resident was administered discontinued eye drops due to a lack of verification with current orders. Staff interviews revealed inconsistencies in following protocols for medication management.
The facility failed to provide necessary lab services for two residents as per physician orders. One resident, with multiple diagnoses, was missing serum creatinine results despite a blood draw. Another resident, with chronic conditions, reported UTI symptoms but lacked documentation for ordered urinalysis and CBC. Interviews revealed lapses in obtaining and documenting lab results, confirmed by the Regional Nurse Consultant.
A facility failed to notify a physician of critical lab results for a resident with a complex medical history, including bipolar disorder and opioid dependence. Despite having a process for handling lab results, there was no documentation that the physician was informed of the resident's lithium levels and urinalysis results, which were outside clinical ranges.
A facility failed to maintain complete laboratory records for a resident with multiple diagnoses, including chronic obstructive pulmonary disease and bipolar disorder. Laboratory results for tests ordered on several occasions were not found in the electronic medical records. Staff interviews revealed that the process for handling lab results was not consistently followed, leading to the deficiency.
A resident with significant mobility issues and multiple diagnoses did not receive required physical and occupational therapy due to perceived insurance reimbursement issues. Despite orders from the facility doctor, the necessary rehabilitative services were not provided, leaving the resident to perform inadequate self-exercises.
The facility failed to maintain confidentiality and accuracy in resident medical records. A resident's name was improperly included in another's medical record, and hospital records for another resident's ER visit were missing. Staff acknowledged these practices violated HIPAA regulations, and the missing records were only provided upon request.
The facility failed to maintain an effective infection control program, lacking measures for Legionella testing. Additionally, two residents were observed improperly handling food, with one resident using bare hands to assist another during a meal. Staff interviews confirmed these actions violated facility protocols.
Failure to Provide Scheduled Bathing Assistance to Residents
Penalty
Summary
Surveyors determined that two residents were not provided with the necessary assistance to maintain their ability to perform activities of daily living, specifically bathing and showering. One resident, who had a care plan indicating a self-care performance deficit and required substantial to maximal assistance with bathing, was scheduled to receive showers twice a week. Documentation showed that in one month, the resident received only two showers, both provided by her husband, and missed six out of eight scheduled showers. In the following month, the resident was offered or received four showers, missing three out of eight scheduled, with one again provided by her husband. Interviews with facility administrators confirmed that staff were responsible for offering and documenting showers, and that lack of documentation indicated the care was not completed. Another resident's records revealed that only two showers were documented over the course of a month. Interviews with staff members confirmed that resident showers were often missed, and the facility was unable to provide documentation that showers were offered or completed on the missing dates for both residents. These findings indicate that the facility did not ensure residents received the appropriate treatment and services to maintain or improve their ability to carry out activities of daily living as required.
Failure to Provide Scheduled Showers and Oral Care for Dependent Resident
Penalty
Summary
A deficiency was identified for failing to provide necessary services to maintain good nutrition, grooming, and personal and oral hygiene for a resident who was unable to perform activities of daily living independently. The resident had a history of left-sided paralysis and aphasia following a cerebrovascular accident (CVA), resulting in a need for substantial to maximal assistance with bathing, showering, and complete dependence on staff for personal hygiene. Despite being scheduled for showers twice a week, documentation showed that the resident missed 6 out of 8 scheduled showers in one month and 4 out of 7 in the following month, with one missed due to a lack of soap. Additionally, the resident required oral care twice daily, but records indicated that this care was missed on 22 out of 25 days reviewed. Interviews with facility administrators confirmed that the resident required assistance with all personal care and that showers and oral care should be documented when completed. The administrators acknowledged that if care was not documented, it was likely not provided. No documentation could be found to show that showers and oral care were offered or completed on the missing dates, confirming the deficiency in providing necessary care for the resident.
Inadequate Supervision and Safety Measures Lead to Resident Falls and Elopement
Penalty
Summary
The facility failed to ensure a safe environment for residents, resulting in multiple incidents of falls and elopement. Resident 5, who had severe cognitive impairment and was at high risk for falls, experienced several falls, including one that resulted in a fractured femur and tibia. Despite interventions such as a fall mat and bed in the lowest position, the resident was found on the floor after being left unattended briefly by a CNA who went to seek assistance. The fall mat was not in place at the time of the fall, contributing to the resident's injury. Another resident, identified as Resident 374, who had severe cognitive impairment and was at high risk for wandering, eloped from the facility multiple times. The resident's care plan included interventions such as frequent checks and monitoring, but documentation of these checks was incomplete or missing for several days. The resident was able to exit the facility due to a door being propped open, and staff failed to adequately monitor and prevent the resident from leaving the premises. The facility's failure to maintain a safe environment and provide adequate supervision and assistance devices led to these incidents. The lack of consistent monitoring and incomplete documentation of safety checks contributed to the residents' ability to fall or elope, resulting in harm and potential risk to their safety.
Failure to Notify Physicians of Significant Changes in Residents' Conditions
Penalty
Summary
The facility failed to immediately consult with the physicians of two residents when there was a significant need to alter treatment. Resident 365, who was admitted with a spontaneous right patellar tendon rupture and other conditions, showed symptoms of a change in condition. The facility physician instructed the nurses to contact the orthopedic surgeon, but there was no evidence that this was done. The resident experienced bladder spasms and confusion, and despite the physician's note to contact the surgeon as soon as possible, the facility staff delayed reaching out, resulting in harm to the resident. Resident 53, diagnosed with type 2 diabetes mellitus and other conditions, had multiple instances of elevated blood glucose levels that exceeded the threshold for physician notification. Despite the facility's policy requiring notification of blood sugars over 400, there was no documentation that the physician was informed of these critical levels. The resident's medical record showed numerous instances of blood sugar levels exceeding 400, yet the facility staff failed to notify the physician, which could have led to serious health complications. The facility's policy on notifying physicians of significant changes in a resident's condition was not followed in these cases. The Regional Nurse Consultant acknowledged that the facility nurses should have acted promptly to contact the necessary medical professionals. The lack of timely communication and documentation regarding the residents' conditions and the failure to adhere to the facility's policy contributed to the deficiencies identified in the report.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to protect residents from abuse and neglect, as evidenced by several incidents involving inappropriate actions by staff and resident-to-resident interactions. In one case, a staff member recorded a video in the shower room while a resident with severe cognitive impairment was naked in the bathtub. The video was shared on social media without the resident's consent, violating their privacy and dignity. The resident was unable to recall the incident due to their cognitive condition, and the facility did not report the incident to law enforcement. Another incident involved a cognitively impaired resident kissing another resident with severe dementia in the activity room. The staff witnessed the incident and separated the residents, but the facility did not report the incident to law enforcement. The investigation revealed that the resident who initiated the kiss had a history of similar behaviors and was on medication that could increase libido. Despite the cognitive impairments of both residents, the facility did not provide counseling or other interventions to address the incident. Additionally, a resident with moderate cognitive impairment was involved in a sexual relationship with another resident. The facility did not adequately assess the resident's capacity to consent to the relationship, as evidenced by the lack of documentation regarding their cognitive evaluations. The facility's administrator and regional nurse consultant acknowledged that the physician's evaluation was necessary to determine consent capacity, but it had not been completed. The facility's failure to ensure proper assessment and documentation of consent capacity put the resident at risk of exploitation.
Deficiencies in Resident Care and Monitoring
Penalty
Summary
The facility failed to provide timely and appropriate care for three residents, leading to deficiencies in their treatment. Resident 365, who was admitted with a right patellar tendon rupture and other conditions, experienced a significant change in condition that was not addressed promptly. Despite complaints of bladder spasms and potential infection, the facility did not contact the orthopedic surgeon as instructed, nor did they perform a urinalysis to investigate the symptoms. This lack of timely intervention resulted in the resident being admitted to the hospital's intensive care unit. Resident 7 underwent a dental procedure involving tooth extraction but was not monitored for post-operative complications such as pain, bleeding, or infection. The facility failed to document any follow-up care or schedule a necessary appointment for dentures, leaving the resident without proper dental care. Interviews with staff revealed a lack of awareness and communication regarding the resident's dental needs and follow-up care. Resident 5, who had severe cognitive impairment and was at risk for skin issues, developed Moisture Associated Skin Damage (MASD) due to inadequate incontinence care. The facility's records showed multiple missed treatments for the resident's skin condition, and the resident's skin integrity deteriorated over time, leading to pressure sores. The facility's failure to provide consistent and adequate skin care contributed to the resident's worsening condition.
Inadequate Management of Urinary Devices and Delayed Treatment Leads to UTIs
Penalty
Summary
The facility failed to provide appropriate care for two residents, leading to urinary tract infections (UTIs) due to inadequate management of urinary devices and delayed antibiotic treatment. Resident 54, who was admitted with multiple diagnoses including type 2 diabetes and morbid obesity, used a PureWick urinary system for incontinence. The care plan required monitoring and changing of the PureWick device, but staff were not trained or instructed on its proper use. Interviews revealed that the resident herself instructed staff on changing the device, and there was no documentation or directive order for its management. This lack of training and documentation contributed to the resident developing a UTI. Resident 36, with a history of frequent UTIs and multiple health conditions, experienced a delay in receiving appropriate antibiotic treatment. Despite a urinalysis indicating the presence of Klebsiella pneumoniae, there was a delay in starting the prescribed Macrobid treatment. The resident's medical records showed that the urinalysis was ordered on January 9, but the results were not acted upon until January 15, when the Macrobid was finally ordered. The delay in treatment was attributed to communication issues with the provider and the facility's failure to follow up promptly on lab results. Interviews with facility staff, including LPNs and the Regional Nurse Consultant, highlighted systemic issues in managing lab orders and communicating results. Staff reported that lab results could take 1-2 days to return, and there was a lack of immediate follow-up with providers. The Regional Nurse Consultant acknowledged the inappropriate timeframe for treating Resident 36's UTI and noted difficulties in obtaining timely responses from the provider. These deficiencies in training, documentation, and communication contributed to the inadequate care provided to the residents, resulting in preventable UTIs.
Inadequate Pain Management for Resident
Penalty
Summary
The facility failed to provide appropriate pain management for a resident, identified as Resident 50, who required such services. The resident was admitted with multiple diagnoses, including palliative care, chronic pain, and osteoarthritis, and had a physician's order for Oxycodone 10 mg to be administered every 4 hours. However, the medication was not consistently administered according to the prescribed schedule, leading to instances of uncontrolled pain as reported by the resident. The resident expressed that when the medication was given on time, the pain was managed, but there were delays, particularly with the 4:00 AM dose, which was sometimes administered as late as 6:00 AM or 7:00 AM. A review of the resident's Medication Administration Record (MAR) for May 2024 showed discrepancies in the administration times of Oxycodone, with several instances where the medication was not given at the scheduled times. The resident's pain scores varied, with some scores indicating moderate to severe pain, suggesting that the pain was not adequately controlled. The care plan for the resident included anticipating the need for pain relief and responding immediately to complaints of pain, but this was not consistently followed. Interviews with facility staff, including an LPN and the Regional Nurse Consultant, revealed that the resident should have received six doses of Oxycodone daily, and the importance of adhering to the scheduled times to prevent complications such as overdose was emphasized. The facility's policy on administering pain medications required that they be given as ordered, and any adverse effects should be monitored. However, the failure to administer the medication as scheduled and the resulting uncontrolled pain indicate a deficiency in the facility's pain management practices.
Significant Medication Errors in Resident Care
Penalty
Summary
The facility failed to ensure that three residents were free from significant medication errors. Resident 41 was administered Linezolid for 23 days instead of the 14 days as ordered by the hospital upon discharge. This error resulted in the resident receiving 17 extra doses, which led to symptoms of fatigue, confusion, and dark stools, eventually causing acute blood loss and hospitalization. The Regional Nurse Consultant acknowledged that the order entry lacked an end date, leading to the prolonged administration of the medication. Resident 372 experienced medication errors related to the administration of Lorazepam. Despite the absence of initial orders for Lorazepam, the medication was scheduled and administered more frequently than prescribed. The hospice nurse provided verbal orders, which were incorrectly entered into the electronic medical record, leading to the medication being scheduled every four hours instead of three times a day. This discrepancy was confirmed by the Regional Nurse Consultant, who noted that the orders were entered incorrectly. Resident 50's medication administration was not in accordance with the physician's orders for Oxycodone. The medication was supposed to be administered every four hours, but records showed it was given at irregular intervals, sometimes early, which could potentially lead to overdose. The facility's policy on administering pain medications was not followed, as the medication was not administered at the prescribed intervals. Interviews with the LPN and the Regional Nurse Consultant confirmed the deviation from the prescribed schedule and highlighted the risk of overdose due to early administration.
Failure to Provide Follow-Up Dental Care
Penalty
Summary
The facility failed to provide adequate follow-up care for a resident who had undergone a dental procedure involving the extraction of 28 teeth. The resident, who had a medical history including paroxysmal atrial fibrillation, fibromyalgia, type 2 diabetes mellitus, obesity, and major depressive disorder, expressed concern about not having a follow-up appointment for dentures after the extractions. Despite the resident's inquiries, staff members, including the Resident Advocate, Assistant Director of Nursing, and Licensed Practical Nurse, were unaware of any scheduled follow-up appointments or plans for dentures. The lack of communication and coordination among the facility staff resulted in the resident not receiving timely dental care and follow-up. Interviews with various staff members revealed a breakdown in communication and documentation regarding the resident's dental care. The Assistant Director of Nursing acknowledged the absence of monitoring and documentation following the dental procedure, and the Regional Nurse Consultant confirmed that there was no follow-up or monitoring for potential complications such as bleeding or infection. Additionally, the Transport Driver, responsible for scheduling appointments, did not have a follow-up dental appointment scheduled for the resident. An email from an outside dental service indicated that impressions for dentures were planned but had not yet occurred, despite the 10-week period since the extractions.
Failure to Accommodate Resident Needs and Preferences
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of three residents, leading to deficiencies in their care. Resident 15, who was admitted with multiple diagnoses including acute respiratory failure and diabetes, expressed a desire to be transported to the bank and park to see his children. However, the facility's transportation policy restricted the use of the van to medical appointments only, and the resident was advised to rely on family or friends for personal errands. This policy was inconsistently communicated among staff, as the Regional Nurse Consultant indicated that the van could be used for personal errands if staff were not busy with medical appointments. Resident 114, who was cognitively intact, also faced transportation issues. Despite repeatedly requesting to be taken to an ATM to withdraw cash, the resident was denied transportation services due to the facility's policy. The Business Office Manager mentioned that residents could be taken to the bank or post office, but this was not consistently applied, as the Transport Driver stated that such requests required administrative approval and were rarely granted. Resident 7, who had a history of incontinence and sensitive skin, was not provided with the specific type of incontinence briefs that she preferred and that were more comfortable for her. The facility provided briefs that were part of a contracted medical supply formulary, which did not include the brand preferred by the resident. Despite the resident developing a rash from the facility-provided briefs, the Administrator cited cost issues and did not authorize the purchase of the preferred briefs. The lack of documentation and follow-up on the resident's grievances further highlighted the facility's failure to accommodate her needs.
Failure to Address Resident Council Grievances on Call Light Response
Penalty
Summary
The facility failed to adequately address and resolve grievances and recommendations from the resident council regarding issues of resident care, specifically concerning call light response times. Over several months, residents consistently expressed frustration about CNAs turning off call lights and not responding promptly, particularly during night and early morning hours. Despite these ongoing complaints, the facility's responses were insufficient, as evidenced by the lack of significant improvement in call light response times and the absence of a documented department response for some of the meetings. The facility's administrator acknowledged the recurring nature of the call light issue but could not provide concrete steps taken to rectify the situation. Although there were mentions of staff education and potential staffing adjustments, these measures were either delayed or not effectively implemented, as residents continued to report the same problems. The facility's failure to act promptly and effectively on the resident council's concerns demonstrates a deficiency in honoring the residents' rights to have their grievances addressed and resolved in a timely manner.
Failure to Timely Report Alleged Violations and Incidents
Penalty
Summary
The facility failed to report alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, to the State Survey Agency (SSA) within the required timeframe. Specifically, for four residents, the facility did not submit reports of neglect and abuse allegations in a timely manner. For instance, Resident 367 experienced a fall resulting in a cervical fracture, but the incident was reported to the SSA the following day, beyond the two-hour requirement. Resident 370 suffered a left femur fracture after a fall, and the incident was reported to the SSA the next day, not within the mandated two-hour window. Additionally, Resident 374 eloped from the facility multiple times, but there was no documentation to show that these incidents were reported to the SSA or Adult Protective Services (APS). The facility's administrator acknowledged that elopements should be reported to the SSA, but this was not done. Resident 364 sustained a hip fracture after a fall, but the incident was not reported to the SSA until several days later. The administrator admitted that the incident should have been reported within two hours, as it was a significant injury. The delay in reporting was attributed to a failure by the previous Director of Nursing (DON) to meet the reporting requirements.
Deficiencies in Investigation and Reporting of Incidents
Penalty
Summary
The facility failed to thoroughly investigate and report the results of all investigations to the State Survey Agency within 5 days of the incident for 7 of 53 sampled residents. The incidents included missing fentanyl patches for multiple residents, medication left in a resident's room without evaluation for safe self-administration, hot coffee thrown on a resident resulting in skin redness, an allegation of sexual abuse involving a resident being kissed, and a resident eloping from the facility. The report highlights the lack of documentation and investigation into these incidents, particularly concerning the missing fentanyl patches for residents with severe cognitive impairments. Resident 5, who had severe cognitive impairment, was observed without a fentanyl patch on their back, despite physician orders requiring regular checks and replacements. Multiple administration notes documented the absence of the patch over several months, yet there was no documentation of an investigation into the missing patches. Interviews with staff revealed a lack of proper disposal and monitoring of the patches, with some staff unaware of the procedures for handling narcotics. Similar issues were noted for residents 42 and 43, who also had severe cognitive impairments and missing fentanyl patches, with no investigations documented. In another incident, resident 12, with severe cognitive impairment, was allegedly kissed by another resident, 374, who also had dementia. The facility's investigation concluded that the evidence did not verify abuse, but there was no documentation of an evaluation of the residents' capacity to consent to sexual activity. Interviews with staff and the resident's POA revealed inconsistencies in the investigation process, including a lack of documentation and assessment by a physician to determine the capacity to consent. The facility's failure to conduct thorough investigations and document findings for these incidents highlights significant deficiencies in their response to allegations of abuse, neglect, and mistreatment.
Failure to Initiate Baseline Care Plan Within 48 Hours
Penalty
Summary
The facility failed to develop and implement a baseline care plan for a resident within 48 hours of admission, as required. The resident, who was admitted and later readmitted with multiple complex diagnoses including chronic obstructive pulmonary disease, malignant neoplasm of the ovary, and bipolar disorder, did not have a baseline care plan initiated until four days after readmission. This delay in care planning did not meet the regulatory requirement to address the resident's immediate needs based on admission orders, physician orders, dietary orders, therapy services, social services, and any pre-admission screening and resident review (PASARR) recommendations. The Minimum Data Set (MDS) Coordinator stated that the baseline care plan was typically completed on the day of admission or within the first 48 hours, and she was responsible for this task. However, in this case, the baseline care plan was not initiated in a timely manner. The comprehensive care plan for the resident included several care areas such as fall risk, psychotropic medication use, and nutritional problems, but these were not initiated within the required 48-hour timeframe following the resident's initial admission.
Staffing Deficiencies Lead to Delayed Resident Care
Penalty
Summary
The facility was found to have insufficient nursing staff to meet the needs of its residents, as evidenced by multiple complaints and observations regarding delayed response times to call lights and unmet care needs. Residents expressed frustration with long wait times for assistance, with some reporting waits of 20 to 40 minutes or more. The issue was repeatedly raised in resident council meetings, and residents reported that call lights were often turned off without their needs being addressed. Interviews with residents revealed that the facility struggled to maintain adequate staffing levels, with new hires often leaving shortly after being employed. Specific residents were affected by the staffing deficiencies, including those with complex medical needs. For instance, one resident with multiple diagnoses, including chronic obstructive pulmonary disease and anxiety disorder, reported delays in receiving pain medication, which affected their pain management. Another resident, who required assistance with showers, noted that their scheduled showers were often missed due to staffing shortages, requiring them to insist on receiving care. Additionally, a resident with a history of falls and other medical conditions expressed concerns about the time it took for staff to respond to their call light, which could exceed 20 minutes. Interviews with CNAs confirmed the staffing challenges, with staff acknowledging that they were unable to complete all required tasks, such as showers, due to insufficient personnel. The facility's assessment tool indicated the need for a specific number of licensed nurses and nurse aides, but the actual staffing levels did not meet these requirements. The facility's administrator acknowledged the ongoing issues with call light response times but could not provide specific steps taken to address the problem. Overall, the deficiency was characterized by a lack of adequate staffing to ensure timely and effective care for residents, impacting their safety and well-being.
Deficiencies in Policy Implementation and Resident Care
Penalty
Summary
The facility failed to establish and implement written policies and procedures for feedback, data collection systems, and monitoring, including adverse event monitoring. This deficiency was evident in several areas, including abuse prevention, timely medical intervention, accident prevention, and medication management. Specifically, a staff member recorded a video of a resident in a vulnerable state, and there were incidents of inappropriate interactions among cognitively impaired residents. Additionally, the facility did not act promptly to address changes in residents' conditions, leading to harm in some cases. The facility also failed to maintain a safe environment, resulting in multiple accidents. Residents experienced falls, one of which resulted in a fracture, and another resident was injured during transport due to improper securing. There were also incidents of resident-on-resident aggression, including a case where hot coffee was thrown on a resident. Furthermore, the facility did not provide adequate treatment for residents with incontinence, leading to urinary tract infections and delayed antibiotic therapy. Medication management was another area of concern, with residents receiving unnecessary drugs or experiencing significant medication errors. One resident was hospitalized due to inadequate monitoring of their medication regimen, while others received medications outside of prescribed parameters. These deficiencies were noted during both annual recertification and complaint surveys, with several issues being re-cited in subsequent surveys, indicating ongoing non-compliance with professional standards of practice.
Failure to Assess Resident's Ability to Self-Administer Medication
Penalty
Summary
The facility failed to ensure that the interdisciplinary team determined a resident's ability to self-administer medications was clinically appropriate. Specifically, a resident with a history of palliative care, cirrhosis of the liver, hepatic failure, type 2 diabetes with chronic kidney disease, altered mental status, depression, insomnia, and hypothyroidism was not assessed for the ability to self-administer medications. The resident was found with liquid medication, lactulose, all over her body after an unwitnessed fall, indicating that she may have attempted to self-administer the medication without proper assessment or authorization. Interviews with facility staff revealed that there was no documentation of an assessment or physician's order allowing the resident to self-administer medications. The Regional Nurse Consultant stated that residents could self-administer medications only after an appropriate assessment by nursing staff. The MDS Coordinator confirmed that there was no order or assessment for the resident to self-administer lactulose. The Administrator acknowledged that the investigation focused on the fall and potential neglect but did not address the issue of medication being left in the resident's room.
Failure to Honor Resident Shower Preferences
Penalty
Summary
The facility failed to honor the residents' right to self-determination by not offering showers according to their preferences. Resident 27, who is cognitively intact with a BIMS score of 14, expressed a desire for showers every other day but was only scheduled for showers on Mondays and Thursdays. Despite being able to shower independently, Resident 27 was not asked about their shower preferences, and the care plan indicated a need for dependent assistance as needed. The CNA documentation showed that Resident 27 received showers on specific dates, but there was no documentation of their preferences being considered. Resident 15, who has a history of acute respiratory failure, diabetes, and other conditions, reported a reduction in the frequency of showers from three times a week to two, without prior discussion in the resident council. The care plan indicated a need for substantial or maximal assistance with bathing, and records confirmed that Resident 15 received only two showers per week. The facility's Guardian Angel Rounds document claimed showers were given per resident preference, but did not document the actual preferences of the residents. Interviews with facility staff, including the DON, CNA Coordinator, and Administrator, revealed a lack of awareness and communication regarding the scheduling of showers. The CNA Coordinator admitted to not asking Resident 27 about their shower preferences and stated that residents needed to request additional showers. The Administrator was unaware of the shower scheduling process and did not know if residents were asked about their preferences. This lack of communication and documentation led to the deficiency in supporting resident choice regarding shower frequency.
Deficiency in Bathroom Maintenance for Resident
Penalty
Summary
A deficiency was identified in the facility's maintenance of a resident's bathroom, specifically concerning the safety and security of the toilet. The resident, who has multiple health conditions including chronic obstructive pulmonary disease, polyosteoarthritis, and morbid obesity, reported that the toilet seat was not secure and had been repaired multiple times but continued to break. An observation confirmed that the toilet base was not secured to the ground, and the seat moved from side to side, posing a safety risk. Interviews with facility staff revealed that there was a maintenance log at the nurse's station for reporting issues, but no requests for repair of the resident's toilet seat were found in the log from January to May 2024. The Director of Maintenance acknowledged that the toilet had been removed and reinstalled when the bathroom flooring was replaced two months prior and admitted to tightening the toilet seat and base several times without documenting these repairs. The Director also noted that the toilet needed further repair, specifically the replacement of the metal ring, and emphasized the importance of staff reporting maintenance needs either verbally or in the maintenance binder.
Misappropriation of Fentanyl Patches in LTC Facility
Penalty
Summary
The facility failed to prevent the misappropriation of fentanyl patches for three residents, all of whom were cognitively impaired. Resident 5, who had severe cognitive impairment, was observed without a fentanyl patch on their back, despite having physician orders for its application every 72 hours. Multiple administration notes documented the absence of the patch on various dates, and a CNA admitted to discarding a patch after it came off during cleaning. The Regional Nurse Consultant was unaware of the discarded patch, indicating a lack of communication and proper disposal procedures. Resident 42, also with severe cognitive impairment, had similar issues with missing fentanyl patches. Despite orders to check the patch placement every shift, several notes indicated the patch was not found on the resident. The resident was known to remove their patches, leading to inconsistent pain management. The facility's failure to monitor and secure the patches resulted in the discontinuation of the patches for this resident, as documented by a Nurse Practitioner. Resident 43, with severe cognitive impairment, experienced repeated instances of missing fentanyl patches. Despite orders for regular checks and removal procedures, the patches were frequently not found on the resident. Interviews with nursing staff revealed inconsistencies in the documentation and verification process for the patches. The Assistant Director of Nursing acknowledged the inadequacy of the current procedures, emphasizing the need for immediate notification and investigation when patches were missing.
Failure to Coordinate PASARR Assessments for Residents with SMI
Penalty
Summary
The facility failed to coordinate assessments with the Pre-Admission Screening and Resident Review (PASARR) program for two residents with serious mental illness (SMI). Resident 36, who was diagnosed with anxiety disorder and bipolar disorder, was initially screened out for a Level II PASARR evaluation despite being prescribed medications for SMI. A new Level II referral was not made when the resident was prescribed additional medication for bipolar disorder, indicating a significant change in status. The Corporate Social Service Worker (CSSW) acknowledged that a new Level II PASARR referral should have been made under these circumstances. Resident 44 was admitted with a diagnosis of psychotic disorder with delusions, which was not included in the initial PASARR Level I screening. The Social Service Worker (SSW) stated that the resident should have been referred for a Level II evaluation upon diagnosis of SMI, but this did not occur due to a lack of communication from the nursing staff and absence of information in the provider orders or medication records. The CSSW confirmed that the resident was overlooked and would be referred for a Level II evaluation.
Failure to Implement Comprehensive Care Plan for Urinary Device
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which resulted in a deficiency. The care plan did not include specific tasks related to the proper changing and monitoring of the resident's PureWick urinary system device. This oversight led to the resident developing a urinary tract infection while using the device. The resident, who had a BIMS score indicating intact cognition, was admitted with multiple diagnoses including cervical disc disorder, type 2 diabetes with neuropathy, and morbid obesity, among others. Interviews with facility staff revealed a lack of awareness and documentation regarding the frequency and responsibility for changing the PureWick device. The resident reported that she had to train the staff on the device's care and that it was only being changed once daily. Staff members, including an LPN, RN, and CNA, were either unaware of the directives for the device or unsure of their responsibilities concerning its maintenance. The MDS Coordinator confirmed that there were no specific orders or documentation procedures in place for the PureWick device, contributing to the deficiency.
Failure to Develop and Implement Discharge Plan for Resident
Penalty
Summary
The facility failed to ensure that the discharge needs of a resident were identified and resulted in the development of a discharge plan. The resident, who was cognitively intact and had expressed a desire to transfer to another long-term care facility closer to family, did not have an active discharge plan in place. Despite the resident's request to move near her son and daughter, the facility did not follow up with the resident or her family to facilitate the transfer. The resident's medical record lacked a discharge care plan, and there was no documentation of regular re-evaluation or referrals to local agencies to assist with the transition. The Resident Advocate (RA) acknowledged that when a resident desired to discharge, staff would notify her, and she would typically contact the family and resident to discuss the transfer. However, in this case, the RA did not ask the resident if she could contact her family to determine the preferred facility for transfer. The RA admitted to not documenting follow-ups with the resident and planned to follow up in the coming weeks. The resident was waiting to call her son to decide on the transfer location, and the RA had not taken proactive steps to assist in this process.
Failure to Provide Timely Bathing Assistance
Penalty
Summary
The facility failed to ensure that a resident was provided with the appropriate treatment and services to maintain or improve their ability to carry out activities of daily living, specifically in relation to bathing assistance. The resident, who was cognitively intact and required limited assistance with supervision for personal care, was scheduled to receive showers twice a week on Tuesdays and Fridays. However, the resident reported that due to staffing shortages, she did not receive her showers as scheduled and had to insist on receiving a shower on one occasion. The facility's records confirmed that there was a seven-day gap between showers, from May 24 to June 1, which was not in accordance with the resident's shower schedule. Interviews with CNAs and the Director of Nursing revealed inconsistencies in the documentation and provision of showers. While the CNAs acknowledged the resident's need for limited assistance and confirmed the shower schedule, the records showed discrepancies in the actual provision of showers. The Director of Nursing stated that showers should be provided according to the schedule unless the resident refused, but the documentation did not support consistent adherence to this schedule. This failure to provide timely bathing assistance as per the resident's needs and preferences led to the identified deficiency.
Failure to Provide Adequate Hygiene Care Due to Staffing Issues
Penalty
Summary
The facility failed to provide necessary services to maintain good nutrition, grooming, and personal and oral hygiene for a resident who was unable to carry out activities of daily living. Specifically, Resident 41, who was admitted with multiple complex medical conditions including chronic respiratory failure, functional quadriplegia, and protein-calorie malnutrition, was not provided showers for weeks at a time. The resident reported that showers were frequently missed and sometimes offered at inconvenient times, such as 2:00 AM or 3:00 AM, which she declined. The resident believed the missed showers were due to low staffing levels at the facility. Interviews with facility staff, including CNAs and an RN, confirmed that Resident 41's showers were often missed due to insufficient staffing and the resident's need for two CNAs to assist with bathing. The facility's documentation revealed that the resident received only one shower over a 30-day period. Staff members acknowledged the challenges in completing all required showers and suggested that additional aides would be beneficial. The RN confirmed that Resident 41 was completely dependent on staff for showers and other daily tasks.
Failure to Provide Restorative Nursing Services for Residents with Limited Range of Motion
Penalty
Summary
The facility failed to ensure that residents with limited range of motion received appropriate treatment and services to prevent further decline. Specifically, two residents were identified as not receiving restorative nursing services necessary to maintain or improve their range of motion. Resident 54, who had multiple diagnoses including cervical disc disorder and osteoarthritis, was observed to have contractures in her lower extremities and reported a decrease in range of motion in her upper extremities. Despite her condition, she was not provided with restorative nursing services and had to perform exercises on her own. Resident 7, who had conditions such as paroxysmal atrial fibrillation and fibromyalgia, expressed a desire for therapy to maintain her level of functioning. She reported performing her own therapy in bed due to the lack of provided services. After a hospital stay, she received 30 days of therapy, but her functional level decreased after being discharged from therapy. Her medical records indicated a need for daily range of motion exercises, but there was no documentation of these exercises being completed in the previous 30 days. Interviews with facility staff revealed systemic issues with the restorative nursing program. The Regional Nurse Consultant and other staff members acknowledged that the program was not functioning as a traditional restorative nursing program, and there was no straightforward RNA program in place. Staff shortages led to the RNA staff being pulled to provide CNA care, further impacting the delivery of restorative services. Both residents would have benefited from RNA services, but due to the facility's inadequate program, they did not receive the necessary care to prevent further decline in their range of motion.
Deficiencies in Respiratory Care for Two Residents
Penalty
Summary
The facility failed to provide necessary respiratory care for two residents, leading to deficiencies in their treatment. Resident 41, who had multiple complex medical conditions including chronic respiratory failure and dependence on supplemental oxygen, was not provided with a water trap for her nasal cannula. This resulted in water dripping from the tubing, causing discomfort and potential choking hazards. Despite the family providing the necessary equipment, the facility misplaced the water traps, and the issue was not addressed until it was brought to the attention of the staff during the survey. Resident 36, who had a history of chronic obstructive pulmonary disease and required oxygen therapy, did not have their oxygen tubing changed weekly as per the facility's policy. The tubing was labeled with a date indicating it had not been changed for several weeks, contrary to the requirement for weekly changes. The resident's medical records showed that the oxygen order was discontinued, and there was no active order for oxygen therapy, leading to inconsistencies in the care provided. Interviews with staff revealed a lack of clarity and responsibility regarding the maintenance of respiratory equipment. Certified Nurse Assistants (CNAs) were unsure about the documentation and specific responsibilities for changing oxygen tubing, indicating a breakdown in communication and adherence to the facility's infection prevention policy. This lack of proper respiratory care and equipment management contributed to the deficiencies observed during the survey.
Failure to Monitor Medication Leads to Resident Hospitalization
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs, leading to the resident's hospitalization. The resident, who had multiple complex medical conditions including chronic respiratory failure, heart failure, and major depressive disorder, was discharged from the hospital with an order to take Linezolid for 14 days. However, the facility administered the medication for 23 days, resulting in 17 extra doses being given. Additionally, the facility did not conduct the necessary blood work to monitor for potential side effects of Linezolid, such as myelosuppression, which is a known risk associated with the medication. The resident's family member reported that the facility failed to perform blood work to monitor for acute blood loss while the resident was on Linezolid, which led to the resident being re-hospitalized. The resident experienced symptoms of fatigue, confusion, and dark stools prior to hospitalization. Hospital records indicated that the resident was admitted with sepsis secondary to a urinary tract infection and had critically low blood cell counts, necessitating blood transfusions. The hospital suspected myelosuppression from Linezolid as the cause of the resident's condition. Interviews with facility staff revealed a lack of communication and oversight regarding the monitoring of the resident's medication. The Director of Nursing stated that monitoring orders should have been included in the hospital discharge orders, while the Regional Nurse Consultant believed monitoring was not mandatory. The Assistant Director of Nursing acknowledged that the physician did not provide specific orders for blood work, and the nursing staff did not perform lab tests without such orders. This oversight resulted in the resident receiving excessive doses of Linezolid without appropriate monitoring, contributing to the resident's adverse health outcomes.
Failure to Implement Gradual Dose Reductions for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents who used psychotropic drugs received a gradual dose reduction (GDR) unless clinically contraindicated. Specifically, two residents, identified as Resident 36 and Resident 47, were prescribed psychotropic medications without attempts at GDR or documented clinical contraindications with physician rationale. This deficiency was identified through interviews and record reviews conducted by surveyors. Resident 36, who had multiple diagnoses including bipolar disorder, was prescribed Lithium and Seroquel at various dosages over time. Despite the facility's documentation indicating that a GDR was due, there was no evidence of an attempt to reduce the dosage or a documented rationale for clinical contraindication. The Regional Nurse Consultant confirmed that the GDR for Lithium was not completed and lacked a rationale for contraindication and duplicate therapy. Resident 47, with diagnoses including bipolar disorder and major depressive disorder, was prescribed Risperidone and Escitalopram. The facility's records showed no attempts at GDR or documentation of clinical contraindication. Despite requests for physician review and signatures on GDR forms, the physician did not provide timely responses, and the facility struggled to obtain the necessary documentation. The Assistant Director of Nursing noted that the physician was overwhelmed by the paperwork and had requested the facility to stop sending signature requests.
Improper Management of Fentanyl Patches and Medication Administration
Penalty
Summary
The facility failed to ensure proper labeling, storage, and disposal of drugs and biologicals, specifically fentanyl patches, as per professional principles. Multiple residents, including those with severe cognitive impairments, were involved in incidents where fentanyl patches were not found on their bodies as per the scheduled checks. For instance, Resident 5, who had severe cognitive impairment, had multiple instances documented where the fentanyl patch was not located on their body, and there was no documentation indicating the missing patches were recovered or disposed of properly. Interviews with staff revealed that the patches were sometimes discarded improperly, such as being thrown in the trash, and there was a lack of consistent documentation and follow-up on missing patches. Resident 42, also with severe cognitive impairment, had similar issues with fentanyl patches not being found on their body during scheduled checks. The progress notes indicated that the resident might have been experiencing pain due to the absence of the patch, and there was no documentation of the missing patches being recovered or disposed of. Interviews with staff highlighted that the resident was known to remove their patches, leading to discontinuation of the patch use. However, there was no evidence of a systematic approach to address the missing patches or ensure their proper disposal. Additionally, Resident 41 was administered discontinued eye drops that were still available in their room, contrary to the facility's policy of removing discontinued medications from the medication cart. The LPN involved admitted to not verifying the medication with the current orders, leading to the administration of the wrong eye drops. Interviews with nursing staff and management revealed a lack of adherence to protocols for medication storage and verification, contributing to the deficiency in medication management.
Failure to Obtain and Document Lab Results for Residents
Penalty
Summary
The facility failed to ensure that laboratory services were provided to meet the needs of two residents, as required by physician orders. Resident 42, who had multiple diagnoses including dementia and diabetes, was supposed to have a serum creatinine level drawn every six months as per a physician order dated December 2, 2022. However, despite a nursing progress note indicating that blood was drawn on June 4, 2024, no lab results were found in the resident's medical record, and the Regional Nurse Consultant was unable to provide the missing documentation. Similarly, Resident 36, who had a history of chronic conditions such as COPD and anxiety disorder, reported symptoms suggestive of a urinary tract infection. Despite physician orders for a urinalysis on February 20, 2024, and a complete blood count on March 6, 2024, no documentation of these lab results was found. Interviews with LPNs revealed that lab results typically took 1-2 days to return and were supposed to be documented and communicated to the provider. The Regional Nurse Consultant confirmed that the lab orders were not obtained and explained that orders needed to be re-entered if samples were not obtained on the day they were ordered.
Failure to Notify Physician of Critical Lab Results
Penalty
Summary
The facility failed to promptly notify the ordering physician of laboratory results that fell outside of clinical ranges for one resident. This resident, who had a complex medical history including chronic obstructive pulmonary disease, bipolar disorder, and opioid dependence, had orders for lithium levels and urinalysis on multiple occasions. However, there was no documentation indicating that the physician was informed of these results, which is a critical step in managing the resident's care. Interviews with facility staff revealed that the process for handling lab results involved placing them in a medical records basket for scanning and notifying the provider via a communication app or telephone. However, there was no evidence that this process was followed for the resident in question. The Regional Nurse Consultant stated that nurses should follow up with labs for results and notify providers immediately if results are critical, but this protocol was not adhered to in this case.
Incomplete Laboratory Records for Resident
Penalty
Summary
The facility failed to maintain complete and dated laboratory records in the resident's clinical record for one of the sampled residents. Specifically, the laboratory results for a resident with multiple diagnoses, including chronic obstructive pulmonary disease, malignant neoplasm of the ovary, and bipolar disorder, were not found in the electronic medical records. The resident had physician orders for laboratory tests, including Lithium levels and urinalysis, on several occasions, but the results were not documented in the electronic medical records. Interviews with facility staff revealed that the process for handling laboratory results involved placing them in a medical records basket to be scanned into the resident's chart. However, the Regional Nurse Consultant noted that some results were obtained from a lab portal and not located in the facility's medical records. The results were supposed to be placed in a lab binder at each nurse's station and reviewed by the provider, who would then sign them before they were scanned into the electronic medical record. This process was not followed, leading to the deficiency in maintaining complete laboratory records.
Failure to Provide Required Rehabilitative Services
Penalty
Summary
The facility failed to provide specialized rehabilitative services, specifically physical therapy (PT) and occupational therapy (OT), to a resident as required by their comprehensive plan of care. The resident, who was admitted with multiple diagnoses including cervical disc disorder, osteoarthritis, and a history of falls, was noted to have significant mobility issues and required an electric wheelchair for mobility. Despite the medical doctor's orders for PT and OT upon admission, these services were not provided. The resident expressed difficulty in moving her lower extremities and had to perform exercises independently, which was inadequate given her condition. Interviews with facility staff revealed that the lack of therapy services was attributed to issues with the resident's insurance coverage, which the Director of Rehabilitation stated was difficult to get reimbursed for. However, the Administrator and other staff members indicated that there had been no recent issues with insurance payments. The Nurse Practitioner was unaware of why the therapy services were not initiated and confirmed that the facility doctor had ordered PT and OT, which were being reordered. This oversight resulted in the resident not receiving necessary rehabilitative care as outlined in her care plan.
Confidentiality and Record-Keeping Deficiencies
Penalty
Summary
The facility failed to maintain confidentiality and accuracy in resident medical records for three residents. For one resident, their name was improperly included in another resident's medical record, which was acknowledged by a Registered Nurse who admitted to using resident names in other residents' charts for identification purposes. This practice was not corrected by the facility, as the nurse stated she was not informed that it was prohibited. Both a Licensed Practical Nurse and the Regional Nurse Consultant confirmed that this was a violation of HIPAA regulations. Additionally, the facility did not maintain complete medical records for another resident, as hospital records from an emergency room visit were missing from the resident's electronic medical records. The resident had been sent to the emergency room after a fall, but the facility did not have a record of the hospital notes or a fall risk assessment completed at that time. The hospital records were only provided upon request, indicating a lapse in maintaining comprehensive and accessible medical records.
Inadequate Infection Control and Food Handling Practices
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the lack of assessment and control measures for Legionella and other opportunistic waterborne pathogens. During an interview, the Assistant Director of Nursing (ADON) 2, who was the designated infection preventionist, indicated that the Director of Maintenance (DOM) was responsible for water management. However, the DOM admitted to not testing for Legionella and was unaware of the necessity to do so, indicating a significant gap in the facility's infection control practices. Additionally, an incident was observed where a resident was assisting another resident during a meal, which involved direct contact with the food using bare hands. This was witnessed when one resident cut another's sandwich and handled the food without gloves, subsequently licking her fingers and continuing to touch the food. Interviews with staff, including a Registered Nurse (RN) and a Certified Nurse Assistant (CNA), confirmed that such practices were against the facility's protocols, which require staff to wash hands and use gloves or utensils when handling food. The staff acknowledged the need for better supervision in the dining area to prevent such occurrences.
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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