Rocky Mountain Care- Clearfield
Inspection history, citations, penalties and survey trends for this long-term care facility in Clearfield, Utah.
- Location
- 1481 East 1450 South, Clearfield, Utah 84015
- CMS Provider Number
- 465067
- Inspections on file
- 17
- Latest survey
- March 27, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Rocky Mountain Care- Clearfield during CMS and state inspections, most recent first.
A resident who recently returned from a hospital stay for pneumonia suffered a fall resulting in a femur fracture and required transfer to the ED. Staff attempted to contact the primary emergency contact multiple times without success and did not notify additional emergency contacts as required. The family was not informed of the injury or hospitalization until two days later, learning of the situation from the hospital.
A resident with severe cognitive impairment and multiple medical conditions, including diabetes, experienced a delay in receiving appropriate foot care, resulting in toe necrosis. Despite documentation of toe pain, the issue was not addressed by a physician for several weeks, leading to urgent medical intervention. Interviews revealed confusion among staff regarding responsibility for podiatry referrals, contributing to the delay in care.
The facility failed to maintain a safe environment and provide adequate supervision, resulting in injuries to several residents. A resident with a history of falls was unable to call for help due to a broken call light, leading to a hip fracture. Another resident was injured during a transfer attempt by a family member due to delayed staff response. Additionally, a resident was at risk from a damaged bedside table, and another fell due to a bed with a broken locking mechanism.
The facility failed to maintain resident dignity and provide timely care, affecting four residents. A resident was denied a shower for two weeks, and another struggled with eating due to inadequate assistance, leading to a lack of a dignified dining experience. Additionally, two residents experienced significant delays in call light responses, waiting over 30 minutes for assistance.
The facility failed to provide a safe, clean, and homelike environment for residents. A resident reported an unkempt smoking area, while another was observed with a damaged bedside table posing a risk. A third resident fell due to a malfunctioning bed lock, which was not routinely checked. Additionally, several rooms were found unclean, with trash and debris on the floors.
The facility failed to thoroughly investigate abuse allegations for three residents, leading to deficiencies in addressing potential abuse and neglect. A resident reported feeling unsafe and experiencing inappropriate touch, but follow-up actions were not documented. Another resident was allegedly mishandled during care, with inconsistencies in witness statements and missing interviews with supervisory staff. A third resident suffered a fall resulting in a fracture, but the investigation lacked interviews with staff present before the fall, leaving the allegation unverified.
Three residents in the facility did not receive adequate assistance with activities of daily living, specifically in maintaining a regular schedule for showers and bed baths. One resident, dependent on staff for showering, reported receiving showers only once a week, contrary to the scheduled three times per week. Another resident expressed dissatisfaction with the frequency of bed baths, indicating a week-long gap without one. A third resident experienced irregular shower schedules, with significant gaps between showers. The care plans lacked specific references to the residents' needs for assistance with bathing, and there were procedural lapses in documenting refusals and ensuring follow-through on scheduled showers.
The facility failed to provide regular bathing assistance to residents who were unable to perform activities of daily living. Several residents, including those with significant medical conditions, did not receive showers as scheduled, and there were lapses in documentation and understanding of shower refusals among staff. This deficiency affected residents who were dependent on staff for personal hygiene, leading to significant gaps between bathing activities.
The facility failed to ensure timely physician visits for six residents, who were instead seen by NPs, not meeting regulatory requirements. Residents with complex medical conditions, such as Alzheimer's and chronic pain, were not seen by a physician within the required timeframes. The issue was exacerbated by a turnover in the Medical Director position, leading to missed visits.
The facility was found to have insufficient nursing staff, leading to unmet resident needs and safety concerns. Residents reported long wait times for call lights, missed showers, and delayed medications, particularly during night shifts. Staff interviews confirmed understaffing issues, with CNAs unable to complete necessary tasks. Management acknowledged staffing challenges but believed the facility was adequately staffed based on census.
A facility failed to properly label and store medications, leading to deficiencies. A resident with diabetes had insulin pens at the bedside without proper storage, despite facility policy requiring storage in a medication cart. Another resident had a medication pill left at the bedside without an assessment for self-administration. Additionally, expired insulin vials were found, and the medication fridge was at an unsafe temperature, risking medication integrity.
The facility failed to store, prepare, and serve food according to professional standards, with undated food items found in storage areas and unhygienic practices observed among kitchen staff. A dusty vent and peeling paint posed contamination risks, and a lack of proper sanitation for thermometers was noted.
The facility failed to maintain complete and accurate medical records for three residents, leading to deficiencies. A resident's psychiatric evaluation was missing, another had inconsistencies in wound documentation despite significant toe issues, and a third had discrepancies between progress notes and skin assessments. Interviews revealed inconsistent documentation practices among nursing staff.
The facility failed to implement written policies for feedback and monitoring, leading to unaddressed medical issues and unsafe conditions. A resident's toe issue was neglected for 27 days, resulting in necrosis and surgery. Additionally, several residents experienced accidents due to inadequate supervision, including falls and injuries. Previous deficiencies were also cited again.
The facility failed to document education and consent for influenza and pneumococcal vaccines for three residents. Despite having a process to check vaccination status and update records, the facility did not consistently include consent forms in medical records. Interviews with the ADON and DON revealed gaps in ensuring residents were offered vaccines and in maintaining accurate documentation.
The facility was found to have inadequate ventilation, resulting in persistent odors of bowel movements, urine, and garbage throughout various hallways and areas. Despite using odor fresheners and cleaning agents, the odors remained, indicating insufficient ventilation measures.
The facility failed to provide written notice to two residents before room changes, violating their rights. One resident with multiple medical conditions and another with chronic illnesses were moved without written notification. Staff interviews revealed that only verbal notifications were given, and the facility was in the process of addressing this issue.
A resident's mail was opened by facility staff without consent, compromising their privacy. The mail contained important legal documents related to the resident's divorce and 401K. The Business Office Manager Assistant opened the mail, assuming it was related to Medicaid paperwork, and failed to deliver it promptly. The facility lacked a clear process for handling resident mail, leading to this privacy breach.
Two residents in the facility had discrepancies between their electronic medical records and their POLST forms regarding code status. One resident's EMR showed DNR while the POLST indicated full treatment, and another resident's face sheet showed DNR while the POLST indicated full code. These inconsistencies were confirmed by staff and posed a risk of incorrect medical response.
Failure to Notify Resident Representatives After Serious Injury
Penalty
Summary
Staff failed to immediately notify a resident's representatives following a significant accident that resulted in injury and required physician intervention. The resident, who had recently returned from a hospital stay for pneumonia, experienced a fall that led to a displaced femur fracture. Staff assessed the resident, contacted the provider, and obtained an X-ray confirming the fracture. The provider instructed staff to contact the family to determine their wishes for treatment. Multiple attempts were made to reach the primary emergency contact (POA) by phone, but staff were unable to make contact and only possibly left a voicemail. Despite being unable to reach the primary contact, staff did not attempt to notify any additional emergency contacts as required by facility expectations. The resident was transferred to the emergency department for further care. The family was not informed of the hospitalization and injury until two days later, having first learned of the hospital admission from the hospital itself. Interviews confirmed that staff did not consider the incident critical enough to warrant contacting other emergency contacts, contrary to facility policy.
Failure to Provide Timely Foot Care Leads to Resident's Toe Necrosis
Penalty
Summary
The facility failed to provide appropriate foot care for a resident, leading to a serious health issue. The resident, who had severe cognitive impairment and multiple medical conditions including type 2 diabetes mellitus, experienced pain in the right first and second toes, which was documented by staff on January 23, 2024. Despite this documentation, the issue was not addressed by a physician until February 19, 2024, when the toes were found to be red and sore, with the second toe showing signs of necrosis. This delay in addressing the resident's foot condition resulted in the need for urgent medical intervention, including a podiatry referral and vascular studies. The resident's care plan included interventions for diabetes management and skin integrity, but these were not effectively implemented to prevent the complication. The resident's medical records indicated that a podiatry referral was pending for several weeks, and the necessary care was not provided in a timely manner. The facility's staff, including the Physician Assistant, failed to act on the initial reports of toe pain, and the resident's condition worsened significantly over the following weeks. Interviews with facility staff revealed a lack of clarity and responsibility regarding the process for making podiatry referrals. The Director of Nursing and Resident Advocate both indicated that the responsibility for referrals had shifted, and there was confusion about who was accountable for ensuring the resident received timely care. This lack of coordination and communication contributed to the delay in addressing the resident's foot condition, ultimately leading to the need for surgical intervention.
Failure to Ensure Safe Environment and Adequate Supervision
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents for several residents. Resident 166, who had a history of falls and multiple medical conditions, experienced multiple falls due to a non-functioning call light, which was not promptly repaired. This resulted in a hip fracture. Despite being alert and oriented, the resident was unable to call for help due to the broken call light, leading to a fall that was not immediately addressed by staff. Resident 60, who required assistance for transfers, was injured when her husband attempted to help her transfer from her wheelchair to her bed. The husband slipped, resulting in the resident dislocating her shoulder and fracturing ribs. The incident occurred because staff did not respond to the call light in a timely manner, leaving the resident and her husband to wait for over an hour without assistance. Resident 20 was observed pulling on a damaged bedside table with sharp edges, posing a risk of injury. Additionally, Resident 80 fell and injured his finger when his bed, which had a broken locking mechanism, rolled during a transfer. The facility did not conduct routine checks on the beds to ensure their safety, and the broken lock was only discovered after the resident's fall. These incidents highlight the facility's failure to ensure a safe environment and adequate supervision for its residents.
Failure to Maintain Resident Dignity and Timely Care
Penalty
Summary
The facility failed to treat four residents with respect and dignity, impacting their quality of life. Resident 259, who was cognitively intact and required assistance for bathing, reported not having a shower for two weeks. When the resident expressed this concern to the Unit Manager (UM 1), the response was dismissive and condescending, failing to address the resident's needs appropriately. The resident's care plan emphasized the importance of dignity and respect, which was not upheld in this interaction. Resident 20, who required substantial assistance with eating due to various medical conditions, was observed struggling during a meal. The staff did not provide adequate support, leaving the resident to attempt eating and drinking independently, resulting in spills and a lack of a dignified dining experience. The resident was left in wet clothing for an extended period, and staff interactions were not supportive or respectful, as evidenced by laughter at the resident's expense. Residents 12 and 50 experienced significant delays in response to their call lights, waiting 33 and 39 minutes, respectively. Resident 12 needed assistance finding personal items, while Resident 50 was hungry and requested food. The prolonged wait times for assistance indicate a failure to provide timely care and respect for the residents' needs, further contributing to the deficiency in maintaining a dignified environment.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by several observations and interviews. Resident 259 reported that the smoking area was unkempt, with overflowing cigarette ashtrays and trash cans, and a piece of metal rain gutter was found in the courtyard. Housekeeping staff were unclear about their responsibilities regarding the courtyard's cleanliness, and the Assistant Director of Maintenance admitted that maintenance was responsible but had not cleaned due to winter weather. Resident 20 was observed sitting in a wheelchair with a damaged bedside table that had sharp, jagged edges, posing a potential risk. Despite the observation, the broken table remained in use for several days. Another damaged table was also found in the hallway, indicating a lack of attention to maintaining safe and functional equipment for residents. Resident 80 experienced a fall due to a malfunctioning bed lock, which was not identified until after the incident. The Director of Nursing acknowledged that staff should check bed brakes before transfers, but there were no routine checks by maintenance to ensure bed safety. Additionally, several rooms were observed to be unclean, with puddles, trash, and debris on the floors, further highlighting the facility's failure to provide a clean and safe environment.
Inadequate Investigation of Abuse Allegations
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse for three residents, leading to a deficiency in addressing potential abuse and neglect. Resident 79, who was admitted with acute respiratory failure and anxiety disorder, reported feeling ignored and unsafe, and mentioned inappropriate touch. Despite these serious allegations, the facility's internal investigation did not document follow-up actions or interviews with all relevant staff members. The Director of Nursing and Administrator acknowledged the resident's communication challenges but did not substantiate the claims, leaving the allegations unresolved. Resident 82, with a history of chronic respiratory failure and traumatic brain injury, was involved in an incident where a CNA allegedly hit the resident's knees against the wall during care. The facility's investigation noted inconsistencies in witness statements and failed to document interviews with supervisory staff, leaving the allegation unverified. The Administrator admitted to not typing up interviews with key staff, which contributed to the incomplete investigation. Resident 86, who had multiple complex medical conditions, experienced a fall resulting in a clavicular fracture. The facility's investigation did not include interviews with staff who might have been present before the fall, and the Administrator could not confirm the resident's activities or care prior to the incident. The lack of thorough investigation into the circumstances surrounding the fall, including potential neglect, resulted in an unverified allegation, highlighting deficiencies in the facility's response to such incidents.
Inadequate Assistance with Activities of Daily Living
Penalty
Summary
The facility failed to ensure that three residents received appropriate assistance with activities of daily living, specifically in maintaining a regular schedule for showers and bed baths. Resident 46, who was dependent on staff for showering due to impairments, reported receiving showers only once a week, contrary to the scheduled three times per week. The medical records corroborated this inconsistency, showing missed showers without documented refusals, and the care plan lacked specific references to the resident's need for assistance with bathing. Resident 3, also dependent on staff for bathing, expressed dissatisfaction with the frequency of bed baths, indicating a week-long gap without one. The medical records showed infrequent bed baths, with no documented refusals, and the care plan did not address the resident's bathing needs. Interviews with staff revealed a lack of communication and documentation regarding the completion of bed baths, with reliance on external hospice services without proper coordination. Resident 60, requiring partial assistance for bathing, experienced irregular shower schedules, with significant gaps between showers. Despite having a care plan that highlighted the need for assistance, the records showed numerous missed showers without adequate documentation of refusals. Interviews with CNAs and the DON highlighted procedural lapses in documenting refusals and ensuring follow-through on scheduled showers, contributing to the deficiency in care provided to the residents.
Failure to Provide Regular Bathing Assistance to Dependent Residents
Penalty
Summary
The facility failed to ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain good personal and oral hygiene. Specifically, residents requiring assistance with bathing were not provided regular showers or bed baths. This deficiency was identified for four residents, each with varying medical conditions that necessitated assistance with bathing. Resident 2, who was dependent on staff for bathing due to multiple medical conditions including hemiplegia and dysphagia, did not receive regular showers as per the physician's orders. The care plan did not reference the need for assistance with bathing, and there were significant lapses between documented bathing activities. Similarly, Resident 259, who required substantial assistance, reported not having a shower for two weeks, and there were documented gaps in the provision of showers following her readmission from the hospital. Resident 82, who was completely dependent on staff for all activities, had multiple instances where bathing activities did not occur, and there were significant gaps between documented showers. The care plan did not address the need for assistance with bathing. Resident 34, who was also completely dependent on staff, experienced numerous missed showers according to the schedule, with no documented refusals or reasons for the missed showers. Interviews with staff revealed inconsistencies in the documentation and understanding of shower refusals, contributing to the deficiency.
Failure to Ensure Timely Physician Visits for Residents
Penalty
Summary
The facility failed to ensure that six residents were seen by a physician at the required intervals after admission. Specifically, these residents were seen by a Nurse Practitioner (NP) instead of a physician, which did not meet the regulatory requirements for physician visits. The residents involved had various medical conditions, including Alzheimer's disease, type 2 diabetes mellitus, schizoaffective disorder, and acute respiratory failure, among others. Resident 46, for example, was admitted with multiple diagnoses such as morbid obesity and chronic pain but had not been seen by a physician since admission nearly three months prior. Similarly, Resident 19 went nine months without a physician visit, despite having complex medical issues like Alzheimer's disease and chronic obstructive pulmonary disease. Resident 62 was seen by a physician 69 days after admission, which was beyond the required timeframe. The facility's process for scheduling physician visits involved the Medical Records Staff (MRS) entering residents into the electronic medical record system and scheduling their visits. However, due to a turnover and vacancy in the Medical Director position, there were missed visits in March 2024, contributing to the deficiency. The MRS acknowledged that the previous Medical Director missed several scheduled visits, affecting the compliance with required physician visits for the residents.
Insufficient Staffing Leads to Resident Care Deficiencies
Penalty
Summary
The facility was found to have insufficient nursing staff with the necessary competencies and skills to ensure resident safety and maintain their highest practicable physical, mental, and psychosocial well-being. Multiple residents and staff expressed concerns about the staffing levels, noting that showers were not provided as scheduled, call lights were not answered in a timely manner, and the environment was observed to be soiled. Specific incidents included a resident slipping on ice and breaking a hip, and another resident developing a sore that went unnoticed due to low staffing levels. Interviews with residents revealed that many experienced long wait times for call lights to be answered, with some waiting up to 45 minutes or more. Residents also reported that there were significant differences in staffing levels between day and night shifts, with night shifts being particularly understaffed. This lack of staffing led to delays in receiving medications and assistance, with some residents having to sit in soiled briefs for extended periods, potentially leading to health issues such as urinary tract infections. Staff interviews corroborated the residents' concerns, with several CNAs stating that the facility was consistently understaffed, leading to an inability to complete necessary tasks such as changing briefs and repositioning residents. Some staff members reported leaving the facility due to the poor working conditions and lack of support from management. The Director of Nursing and the Certified Nursing Assistant Coordinator acknowledged the staffing challenges but believed that the facility was adequately staffed based on census and that management would assist when staffing was at maximum ratios.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled and stored according to professional principles, leading to several deficiencies. Resident 21, who has type 2 diabetes mellitus, was observed with insulin pens on his bedside table without proper storage to prevent access by other residents. Although there was a physician's order allowing self-administration, the facility's documentation indicated that medications should be stored in the nursing medication cart. Interviews with nursing staff revealed inconsistencies in the process of self-administration, with some nurses leaving insulin pens at the bedside contrary to the Director of Nursing's (DON) expectations. Resident 92, diagnosed with multiple conditions including schizoaffective disorder and anxiety, was found with a medication pill left at her bedside despite not being assessed for self-administration. Her medical records indicated that she did not want to self-administer medications, and there was no documentation of an assessment for safe self-administration. Similarly, Resident 15, who was severely cognitively impaired, had medications left at the bedside without a physician's order for self-administration, and no assessment was documented to ensure safety. Additionally, the facility failed to manage medication storage properly. Insulin vials were found expired and still available for use, and the medication fridge was at an unsafe temperature, risking the integrity of stored medications. The DON confirmed that medications should not be left at the bedside without a completed assessment and that the fridge's temperature issue was addressed by removing and destroying affected medications.
Food Safety and Hygiene Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food safety, as evidenced by multiple observations of improperly stored and undated food items in various storage areas, including the walk-in fridge, freezer, and dry storage. Numerous food items, such as ice cream, buns, pie crusts, cookie dough, whipped topping, frozen pies, and fruits, were found undated in the freezer. Similarly, undated beverages and food items were observed in the walk-in refrigerator, including juices, milk, deli ham, cookies, and vegetables. The dry storage area contained open and undated bags of breakfast cereal and rice. Additionally, the kitchen environment presented physical contamination hazards, with a dusty ceiling vent and peeling paint above a food preparation area. The kitchen staff did not maintain hygienic practices during food preparation and service. One staff member was observed scratching her hair, touching her face, and allowing her soiled sweatshirt to come into contact with food and plates. Another staff member failed to properly sanitize a food thermometer after it was dropped on the ground, merely rinsing it under running water without using a sanitizing solution. An interview with the Dietary Manager revealed that the facility's procedures for checking and labeling food items were not consistently followed, and there was a lack of sanitizing wipes for thermometers, leading to inadequate sanitation practices.
Deficiencies in Medical Record Documentation
Penalty
Summary
The facility failed to ensure complete and accurate documentation of medical records for three residents, leading to deficiencies in maintaining resident-identifiable information. For Resident 46, a psychiatric evaluation conducted on 2/25/24 was missing from the medical record, as confirmed by the Director of Nursing (DON) during an interview. This omission indicates a lapse in maintaining comprehensive medical records for the resident, who had multiple diagnoses including schizoaffective disorder and depression. Resident 19's medical records showed inconsistencies in documenting skin integrity and wound care. Despite multiple observations indicating no wounds, progress notes revealed significant issues with the resident's toes, including redness, soreness, and necrosis, which required urgent vascular studies. The records also indicated a delay in addressing the resident's condition, as a podiatry referral was pending for several weeks, and there was difficulty in coordinating care with a vascular specialist. For Resident 3, there was a discrepancy between the nursing progress notes and the weekly skin assessments. A wound on the sacrum was reported and treated, yet the skin assessments documented no wound present. Interviews with nursing staff revealed inconsistencies in how wounds were documented, with some relying on progress notes or the Task Administration Record (TAR) rather than the skin assessment forms. This inconsistency in documentation practices contributed to the deficiency in maintaining accurate medical records.
Deficiencies in Policy Implementation and Resident Safety
Penalty
Summary
The facility failed to establish and implement written policies and procedures for feedback, data collection systems, and monitoring, including adverse event monitoring. This deficiency was evident in the lack of appropriate plans of action to correct identified quality deficiencies. Specifically, for one resident, a staff member documented a problem with the resident's toe, which was not addressed by a doctor for 27 days, leading to necrosis and the need for surgery. Additionally, the facility did not ensure that residents received proper treatment and care to maintain mobility and good foot health, as required by professional standards of practice. The facility also failed to maintain a safe environment free of accident hazards and did not provide adequate supervision and assistance to prevent accidents. This was observed in several incidents involving residents, including a resident left unsupervised with a damaged bedside table, a resident falling outside while smoking, a bed not locked in place resulting in a fall, a resident falling during a transfer by a family member, and residents experiencing unwitnessed falls and remaining on the floor for extended periods. These incidents resulted in harm to three residents. Furthermore, during the previous recertification survey, the facility was cited for multiple deficiencies, which were cited again in the current survey.
Deficiency in Immunization Documentation
Penalty
Summary
The facility failed to ensure that each resident's medical record included documentation of education regarding the benefits and potential side effects of influenza and pneumococcal immunizations, as well as documentation of consent or refusal for these vaccines. This deficiency was identified for three residents. Resident 3, who had multiple diagnoses including polyneuropathy and type 2 diabetes, received a pneumococcal vaccine outside the facility, but there was no documentation of consent or education in their medical record. Similarly, Resident 15, with conditions such as schizophrenia and chronic kidney disease, was due for a pneumococcal vaccine, but their medical record lacked documentation of consent or education. Resident 19, diagnosed with Alzheimer's and COPD, received a pneumococcal vaccine at the facility, yet their record also did not contain the necessary documentation. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) revealed that the facility had a process for checking vaccination status through the Utah Statewide Immunization Information System and updating records when vaccines were administered. However, the ADON and DON acknowledged that consent forms, which should indicate acceptance or refusal of vaccines, were not consistently documented in the residents' medical records. The DON admitted that there were issues with ensuring residents were offered pneumococcal vaccines and that the facility was working on improving their system for managing immunization records.
Inadequate Ventilation and Persistent Odors
Penalty
Summary
The facility was found to have inadequate outside ventilation, as evidenced by persistent and strong odors throughout various hallways and areas. Observations made over several days revealed strong odors of bowel movements, urine, and garbage in multiple hallways, near rooms, and at nurse stations. These odors were noted at different times of the day, indicating a consistent issue with ventilation and odor management. Interviews with housekeeping staff revealed that they used natural odor fresheners, Pine Sol, and Febreze to manage odors. Despite these efforts, the odors persisted, suggesting that the measures taken were insufficient to address the underlying ventilation issues. The lack of adequate mechanical or window ventilation contributed to the inability to effectively remove these odors from the facility.
Failure to Provide Written Notification for Room Changes
Penalty
Summary
The facility failed to provide written notice to residents before making room changes, which is a violation of residents' rights. Specifically, two residents, identified as Resident 166 and Resident 259, did not receive written notification prior to their room changes. Resident 166, who had multiple medical conditions including a periprosthetic fracture and acute kidney failure, was moved from one room to another without any written notice documented in their medical record. Interviews with facility staff, including a CNA, Social Service Worker, Unit Manager, Resident Advocate, and the Administrator, revealed that the facility's practice was to provide only verbal notifications of room changes, with no written documentation provided to the residents. Similarly, Resident 259, who had a range of diagnoses including cellulitis, chronic respiratory failure, and heart failure, was moved to a different room without any written notification found in their medical record. An LPN interviewed was unaware of the reasons for Resident 259's room change. The facility's staff, including the Administrator, acknowledged that the current process involved only verbal notifications and that they were in the process of addressing this issue to comply with the requirement for written notifications.
Resident Mail Privacy Breach
Penalty
Summary
The facility failed to ensure that a resident had the right to privacy in their communications, specifically regarding mail. Resident 26, who was admitted with multiple medical conditions including cellulitis, orthopedic aftercare following surgical amputation, and type 1 diabetes mellitus, reported that their mail was opened by facility staff on two occasions. The resident stated that the mail contained important legal documents related to their divorce and 401K, and they had to request the same information again when the first letter was not received. The resident expressed that the staff member claimed it was an accident, but the resident disagreed, noting it happened twice. The grievance logs revealed that a concern was logged for Resident 26, indicating that the resident did not want their mail opened by staff and was missing important legal documents. The Administrator acknowledged the issue and stated that the Business Office Manager Assistant (BOMA) opened the mail, believing it was related to Medicaid paperwork due to the letter being addressed in care of the facility. The BOMA had been assisting the resident with Medicaid paperwork and assumed the letter was related to that, leading to the mail being opened and scanned into the resident's file without immediate delivery to the resident. Interviews with the Resident Advocate, Activities Director, and Administrator revealed that the facility's process for handling resident mail was not clearly defined, and there was confusion about when staff could open mail. The BOMA admitted to opening the mail without specific consent from the resident and acknowledged the error in not communicating with the resident first. The BOMA also confirmed that a second letter was opened and delivered to the resident only after they requested it. The lack of a clear process and communication led to the resident's privacy being compromised.
Discrepancies in Advance Directives Documentation
Penalty
Summary
The facility failed to ensure that the residents' right to formulate and have their advance directives accurately reflected in their medical records was upheld. For Resident 92, there was a discrepancy between the electronic medical record (EMR) and the Provider Order for Life-Sustaining Treatment (POLST) form. The EMR indicated a Do Not Resuscitate (DNR) status, while the POLST form documented full treatment, including life-sustaining measures. This inconsistency was confirmed during interviews with the Registered Nurse (RN) and the Director of Nursing (DON), who acknowledged the potential risk of delayed or absent chest compressions due to the incorrect code status displayed in the EMR. Similarly, for Resident 19, there was a conflict between the documented DNR status on the face sheet and the full code status on the POLST form. During an incident where Resident 19 exhibited severe symptoms, the RN was unable to contact the provider, family, or nursing leadership and called 911. The POLST form, which indicated full code, was not initially available in the medical records system, leading to confusion about the resident's code status. The RN later realized that the POLST form had not been submitted for scanning into the system, highlighting a lapse in ensuring accurate and accessible documentation of advance directives.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
