Rocky Mountain Care - Cottage On Vine
Inspection history, citations, penalties and survey trends for this long-term care facility in Murray, Utah.
- Location
- 835 East Vine Street, Murray, Utah 84107
- CMS Provider Number
- 465125
- Inspections on file
- 21
- Latest survey
- November 5, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Rocky Mountain Care - Cottage On Vine during CMS and state inspections, most recent first.
A resident with a history of neurological and kidney conditions, who was cognitively intact, left the facility without signing out or notifying staff and remained unaccounted for over 18 hours. Multiple shifts, including agency CNAs and nurses unfamiliar with the resident, failed to notice or escalate his absence, and a nurse was found to have falsified documentation of resident checks. The facility's LOA protocol was not followed, leading to a significant lapse in supervision until the resident was eventually located and returned.
Surveyors found that kitchen staff failed to properly label and date multiple opened food items in both the refrigerator and freezer, did not consistently wear required hairnets, and did not maintain correct sanitizer levels in dish machines and cleaning buckets. These actions did not meet professional standards for food safety and sanitation.
Three residents experienced significant medication errors, including a dialysis patient not receiving phosphate binders with meals as ordered, a resident with chronic wounds missing scheduled IV antibiotics, and a resident with epilepsy not having seizure medication held as directed by the provider. These errors were linked to late or missed doses, lack of alignment with meal times, and inconsistent communication among staff and providers.
The facility did not ensure that laboratory reports were filed in the medical records for four residents who underwent diagnostic testing and received treatment for infections and other conditions. Despite orders and administration of antibiotics and other interventions, the required lab documentation was missing from the residents' records, as confirmed by staff interviews and record review.
Staff failed to provide correct portion sizes during meal service, as food was plated using tongs and incorrect scoops rather than the standardized utensils specified in the menu plan. The cook in training did not measure items as required, resulting in residents not receiving the appropriate portions needed to meet their nutritional requirements.
A resident with multiple medical conditions was found with a bottle of B-complex supplements in her closet, which she self-administered after her daughter brought them in. Although the resident had an intact BIMS score, staff interviews and documentation indicated she experienced confusion and memory deficits, and no assessment supported her ability to safely self-administer medications. Facility policy required staff to report and remove medications found in resident rooms, but this was not followed in this case.
The facility did not notify the physician when a resident's suprapubic catheter was changed to a different size due to supply issues, nor when two residents received intravenous antibiotics later than the ordered times. Staff interviews and record reviews confirmed that physician notification did not occur in these instances, despite facility policy requiring it when treatment orders could not be followed as prescribed.
A resident who was admitted with multiple medical conditions and later discharged home was not given a Notice of Medicare Non-coverage (NOMNC) when Medicare Part A services ended. Review of the medical record and interview with the ADM confirmed the absence of the required notice.
A resident's shower was repeatedly observed to have a bad odor, black substance on grout, white buildup on tiles, and red rings on the floor, despite daily cleaning and staff awareness. Interviews with LPN, housekeeping, and maintenance staff confirmed the ongoing presence of these issues, with explanations given for the stains but no resolution achieved after cleaning.
A resident with multiple medical and psychiatric conditions reported that a nurse used profane language in response to a care request. The resident informed the CNAC, who failed to report the allegation to the ADM or appropriate authorities as required. The incident was not investigated or reported to the SSA or APS within the mandated timeframe.
The facility did not provide evidence of thorough investigations or timely reporting to the SSA for two residents who alleged abuse or neglect by staff. In both cases, required investigation reports were missing, and there was no documentation that findings were submitted as mandated.
Two residents did not receive appropriate care: one was not placed on a scheduled toileting program despite being assessed as a candidate, and another with a suprapubic catheter did not receive the correct catheter size per physician orders, with the physician not notified of the change. Staff interviews confirmed lapses in toileting assistance and supply management, resulting in care that did not follow regulatory or clinical guidelines.
A resident with neuropathic pain and multiple comorbidities did not receive five consecutive doses of prescribed pregabalin because the medication was not available and pending delivery. Nursing staff documented the unavailability and described inconsistent backup procedures, with facility guidelines outlining steps that were not fully effective in ensuring timely medication administration.
A resident with a history of neurogenic bladder and frequent UTIs was prescribed Levaquin for suspected UTI symptoms without a urinalysis or urine culture, despite prior evidence of resistance to this antibiotic. Facility staff interviews revealed inconsistent adherence to protocols for obtaining necessary lab tests before prescribing antibiotics, and communication issues with lab reports further contributed to the failure to properly monitor antibiotic use as part of the facility's antibiotic stewardship program.
Two residents with complex medical histories did not have complete documentation regarding their pneumococcal vaccinations. One resident's consent form lacked details on administration, such as date, location, and lot number, while another's form did not indicate whether the vaccine was accepted or declined. Interviews with the DON and Corporate Nurse confirmed that required documentation was missing, contrary to facility policy.
A resident with psychological needs and a history of falls did not have a comprehensive care plan addressing mental health or fall prevention. Despite self-injurious behavior and multiple falls, no protocols were established, and the care plan was outdated. The DON acknowledged the absence of specific care plans and the lack of centralized information for staff.
A resident with severe cognitive impairment and a history of behavioral issues, including inappropriate sexual behavior and alleged drug use, did not have their care plan updated by the interdisciplinary team. Despite interventions such as one-on-one observation and medication evaluation, these were not documented in the care plan, highlighting a deficiency in the facility's care planning process.
A resident with a complex medical history experienced multiple falls in a facility, but required neurological assessments were not documented in the medical record. Despite staff initiating neuro checks after falls, interviews revealed that these were not consistently recorded, leading to a deficiency in supervision and care.
A resident with multiple psychological diagnoses, including suicidal ideations, did not receive necessary behavioral health care services in a LTC facility. Despite self-harming incidents and expressed suicidal thoughts, the facility failed to implement appropriate monitoring or mental health interventions. The care plan was not updated, and staff were unaware of the resident's mental health needs, compromising her well-being.
A facility failed to maintain complete and timely medical records for a resident with complex diagnoses. Numerous late entries were made by the ADON, who documented information from floor nurses instead of the staff directly involved in the resident's care. Interviews revealed a lack of awareness and improper documentation practices, with the DON unaware of the ADON's actions and the ADON acknowledging the ethical concerns of her documentation approach.
Resident Unaccounted for Due to Inadequate Supervision and Communication Failures
Penalty
Summary
A deficiency occurred when a resident left the facility and was unaccounted for approximately 18 hours before management was alerted. The resident, who had a history of cerebral infection sequelae, left kidney injury, and right-sided hemiplegia and hemiparesis, was cognitively intact as indicated by a BIMS score of 15. The resident did not sign out or inform staff of his departure, and his absence went unnoticed by multiple shifts, including agency CNAs and nurses who were unfamiliar with the resident. The resident's television was left on and his dinner untouched, but these signs were not acted upon in a timely manner. Communication breakdowns occurred during shift changes, with staff assuming the resident was with family or that his absence was normal. Documentation in the medical record indicated the resident was not present, but this information was not escalated promptly. The night shift nurse was later found to have falsified documentation, indicating checks on the resident that did not occur. Agency staff, unfamiliar with the residents, contributed to the lack of awareness regarding the resident's whereabouts. The facility's procedures required residents to sign out in a Leave of Absence (LOA) book when leaving, but this protocol was not followed or enforced in this instance. The resident was eventually located after a pharmacy contacted the facility, and he was returned without injury. The incident revealed lapses in supervision, communication, and adherence to established protocols for monitoring resident whereabouts, particularly when agency staff were involved.
Deficient Food Storage, Sanitation, and Staff Practices in Kitchen
Penalty
Summary
Surveyors observed multiple failures in food storage, preparation, and sanitation practices within the facility's kitchen. Several food items in both the refrigerator and freezer, including mayonnaise, green peppers, whipped topping, sausage links, lettuce, churros, donuts, pork egg rolls, ice cream, and rolls, were found opened and undated. The Dietary Manager (DM) was observed working in the kitchen without a hairnet. During the inspection, the chemical dish machine was tested twice and failed to show the presence of sanitizer, as indicated by the test strips not changing color. Additionally, sanitizer buckets used for cleaning were found to have insufficient sanitizer levels, as confirmed by the DM using test strips. On a follow-up visit, some food items remained undated, and the dish machine, after being serviced, was found to have sanitizer levels below the required standard. The sanitizer buckets were also found to have excessively high sanitizer concentrations, which the DM acknowledged could result in chemical residue remaining on dishes. Interviews with the DM, Registered Dietitian (RD), and Director of Nursing (DON) confirmed that all food should be labeled and dated, proper head coverings are required, and sanitizer levels must be maintained within safe limits. These observations and interviews demonstrate that the facility did not consistently adhere to professional standards for food safety and sanitation.
Significant Medication Administration Errors Affect Multiple Residents
Penalty
Summary
Three residents experienced significant medication errors due to failures in medication administration practices. One resident with end stage renal disease and dependent on dialysis did not consistently receive his phosphate binder medication, Auryxia, with meals as ordered. The medication was often administered late or not at all, and administration times did not align with scheduled meal times. The resident reported the issue to the DON, who attempted to prioritize the medication in the electronic medical record, but the problem persisted, particularly when agency nurses were on duty. Documentation showed multiple missed or late doses, and the resident frequently had to remind staff to administer his medication. Another resident with chronic wounds, osteomyelitis, and a history of amputation did not receive scheduled intravenous antibiotics (Daptomycin and Micafungin) at the prescribed times. The MAR documented several instances where these antibiotics were administered hours late. Staff interviews confirmed that the antibiotics should be given within a 30-minute window of the scheduled time, and that delays should be reported to the physician. However, there was no evidence that the physician was notified of these delays, and the errors were not consistently documented as medication errors. A third resident with epilepsy and a history of seizures did not have her seizure medication, Lacosamide, held for the full duration ordered by the provider after a high serum level was reported. The provider ordered the medication to be held for two doses, but the MAR showed it was only held for one dose. Communication between nursing staff and providers was inconsistent, and the medication was resumed before the full hold period was completed. These events demonstrate failures in following physician orders and ensuring timely and accurate medication administration for multiple residents.
Failure to File Laboratory Reports in Resident Medical Records
Penalty
Summary
The facility failed to ensure that complete, dated laboratory records, including the name and address of the testing laboratory, were filed in the clinical records of four residents. For these residents, laboratory results such as urinalysis, urine culture and sensitivity, and other diagnostic tests were not documented in their medical records despite orders and treatments being administered based on these tests. In several cases, nursing notes and infection control logs referenced laboratory testing and subsequent medication administration for conditions such as urinary tract infections, but the corresponding laboratory reports were missing from the residents' records. Specifically, one resident with paraplegia and a neurogenic bladder received antibiotics for a urinary tract infection, but the urinalysis and culture results were not present in the record. Another resident with quadriplegia and bladder dysfunction was treated for a UTI, yet no urinalysis or culture report was found in the medical record. A third resident with diabetes and acute kidney failure was administered antibiotics for a UTI, but the relevant laboratory documentation was absent. The fourth resident, with osteomyelitis and MRSA infection, had multiple lab tests ordered and referenced in nursing notes, but none of the results were filed in the medical record.
Failure to Provide Correct Portion Sizes During Meal Service
Penalty
Summary
The facility failed to follow menus that met the nutritional needs of residents in accordance with established national guidelines, specifically by not providing correct portion sizes during meal service. During a lunch observation, the cook in training was seen plating food items such as meat, potatoes, and Brussels sprouts using tongs and an ice cream scoop, rather than the required measurement scoops. The gravy was served with a ladle that did not match the specified portion size. The cook in training admitted to attempting to give even amounts of food to fill the plate, rather than following the prescribed portion sizes listed on the menu spreadsheet. A review of the menu spreadsheet showed specific portion sizes for each food item, which were not adhered to during service. The Dietary Manager confirmed that the cook in training used incorrect serving utensils and did not measure the pot roast due to its crumbly texture. The Registered Dietitian stated that the menus were designed to meet residents' nutritional requirements and should be followed using standardized utensils. The Director of Nursing also expected kitchen staff to follow the menus correctly. These actions resulted in residents not receiving the appropriate portion sizes as outlined in the facility's menu plan.
Failure to Ensure Safe Self-Administration of Medications
Penalty
Summary
A resident with diagnoses including osteomyelitis of the vertebra, MRSA infection, paraplegia, and encephalopathy was found to have a large bottle of B-complex supplement in her closet. The resident reported that her doctor approved her taking supplements and that her daughter brought them in to save money. Review of the resident's medical record showed that she had previously indicated she did not wish to self-administer medications, and her care plan did not address self-administration. The resident's BIMS score indicated intact cognition, but nursing notes and staff interviews revealed concerns about her memory and ability to safely self-administer medications. Staff interviews confirmed that medications or supplements found in resident rooms should be reported to nursing staff, and that residents were not allowed to have medications at the bedside. A nurse stated that the resident had episodes of confusion, needed reminders, and was not safe to self-administer medications due to short-term memory deficits and a tendency to forget if she had already taken her medication. The DON acknowledged the resident's cognitive score but noted that the self-administration assessment did not support allowing the resident to keep medications at the bedside.
Failure to Notify Physician of Changes in Treatment and Delays in Medication Administration
Penalty
Summary
The facility failed to notify and consult with the physician when there was a need to alter the treatment for two residents. For one resident with quadriplegia and a history of neuromuscular bladder dysfunction, the physician's order specified the use of a 24 French suprapubic catheter. However, due to the unavailability of the correct catheter size in stock, a 22 French catheter was inserted without notifying the physician or obtaining a new order. Interviews with staff confirmed that the physician was not informed of the change, and documentation did not reflect any physician notification or updated order for the different catheter size. For another resident with multiple diagnoses including polyneuropathy, diabetes, osteomyelitis, and chronic ulcers, intravenous antibiotics were ordered to be administered at specific times. The medication administration records showed that both Daptomycin and Micafungin were given late on several occasions, outside the 30-minute window allowed by facility policy. There was no documentation indicating that the physician was notified of these late administrations, despite staff acknowledging that such notification was required when medications were not given as scheduled. These deficiencies were identified through interviews with the residents, nursing staff, and the Director of Nursing, as well as a review of medical records and treatment administration logs. The lack of timely physician notification and consultation occurred in both cases when treatment orders could not be followed as prescribed, either due to supply issues or delays in medication administration.
Failure to Provide Notice of Medicare Non-Coverage
Penalty
Summary
The facility failed to inform a resident of the termination of Medicare Part A services by not providing a Notice of Medicare Non-coverage (NOMNC) as required. Specifically, a resident admitted with diagnoses including pneumonia, septicemia, renal insufficiency, and diabetes mellitus was discharged home, but a review of the medical record did not find a signed NOMNC form. Upon request, the Administrator was unable to locate the NOMNC for this resident, confirming that the required notice was not issued during the resident's stay.
Persistent Unsanitary Conditions in Resident Shower
Penalty
Summary
A deficiency was identified when a resident's shower was observed to have a persistent bad odor, black substance along the grout lines, white buildup on tile surfaces, and circular red rings on the shower floor. These conditions were first noted during an observation and remained unchanged during subsequent inspections, even after daily cleaning was reportedly completed. The resident involved had multiple medical diagnoses, including atherosclerosis, malnutrition, rhabdomyolysis, and osteoarthritis. Staff interviews confirmed that the resident's bathroom was supposed to be cleaned daily, with specific cleaning products and procedures described, but the visible issues in the shower persisted after cleaning. Further interviews with housekeeping and maintenance staff revealed that the black substance might be dirt, the red rings were identified as rust marks from shower chair feet, and the white buildup was not specifically addressed. The maintenance director stated that visual inspections of resident rooms and bathrooms were conducted weekly, and maintenance needs were to be reported in a binder at the nursing station. Despite these protocols, the unsanitary conditions in the resident's shower were not resolved, as confirmed by multiple staff members and direct observation.
Failure to Timely Report Alleged Verbal Abuse
Penalty
Summary
A resident with multiple diagnoses, including chronic kidney disease, morbid obesity, type 2 diabetes mellitus, borderline personality disorder, PTSD, bipolar disorder, anxiety disorder, and hypertension, reported an incident of verbal abuse by a male nurse. The resident, who was assessed as cognitively intact, stated that when she requested her blood sugar be checked early, the nurse responded with profanity. The resident reported this incident to the Certified Nursing Assistant Coordinator (CNAC) during incontinence care. Despite being informed of the incident, the CNAC did not report the allegation to nursing management or the facility Administrator (ADM) as required. The CNAC acknowledged knowing that all allegations of abuse should be reported immediately to the ADM but failed to do so, stating uncertainty about whether the incident constituted abuse. The ADM only became aware of the incident days later and confirmed that no abuse investigation had been initiated or reported to the State Survey Agency (SSA) or Adult Protective Services (APS) within the required timeframe.
Failure to Investigate and Report Alleged Abuse and Neglect
Penalty
Summary
The facility failed to provide evidence that all alleged violations of abuse, neglect, exploitation, or mistreatment were thoroughly investigated and failed to report the results of all investigations to the State Survey Agency (SSA) within 5 working days of the incident. For two sampled residents, allegations of abuse or neglect by staff members were not fully investigated, and required documentation was missing. In the first case, a resident with multiple diagnoses including atrial fibrillation, chronic kidney disease, bipolar disorder, type 2 diabetes, and morbid obesity alleged that a CNA told her to go to the bathroom in her pants and pulled up her shirt without permission. While the CNA was placed on administrative leave and APS was notified, the investigation report could not be found, and the information provided was limited to an email summary from a previous administrator. There was no evidence of a thorough investigation or submission of findings to the SSA. In the second case, an anonymous report alleged that another resident was left soiled due to lack of care or neglect. The facility notified APS and the SSA, but the investigation report was missing from the abuse binder and no additional documentation was provided. The DON described the facility's general process for handling such allegations, but there was no evidence that a complete investigation was conducted or that findings were reported as required. Both cases lacked documentation of thorough investigations and timely reporting to the SSA.
Failure to Maintain Continence Services and Provide Proper Catheter Care
Penalty
Summary
The facility failed to ensure that residents who were continent of bladder received services and assistance to maintain continence, and did not provide appropriate catheter care in accordance with physician orders. For one resident, who had a history of urinary tract infections (UTIs), anxiety, and mobility limitations, the care plan identified the need for assistance with toileting and scheduled toileting interventions. Despite being assessed as a candidate for scheduled toileting, the resident was not placed on a toileting program. The resident reported that staff did not respond promptly to requests for toileting assistance and was told to use incontinence briefs instead, which she believed contributed to her UTIs. Staff interviews confirmed that the resident should have been on a toileting program and that some staff, particularly agency staff, encouraged residents to use briefs rather than assist with toileting. Another resident with quadriplegia and a suprapubic catheter did not receive catheter care in accordance with physician orders. The resident required a specific size (24 French) suprapubic catheter, but the facility ran out of this size and inserted a smaller (22 French) catheter without notifying the physician or obtaining a new order. The care plan for this resident was not updated to reflect the current physician orders for catheter size. The resident also reported concerns about the cleanliness of the catheter change procedure, stating that the nurse did not change gloves or use antiseptic during the last catheter change. Staff interviews revealed that supply management issues led to the unavailability of the correct catheter size, and the Director of Nursing confirmed that the physician was not notified of the change in catheter size. These deficiencies demonstrate that the facility did not provide services to maintain continence for a resident who was a candidate for scheduled toileting, and did not ensure that catheter care was provided according to physician orders for another resident. The lack of timely toileting assistance and failure to maintain appropriate catheter supplies and procedures resulted in care that did not meet regulatory requirements for these residents.
Failure to Provide Prescribed Medication Due to Unavailability
Penalty
Summary
The facility failed to provide routine and emergency pharmaceutical services to meet the needs of a resident who was prescribed pregabalin for neuropathic pain. The resident, who had multiple diagnoses including neuropathy, osteomyelitis, diabetes mellitus, and amputations, did not receive five consecutive doses of pregabalin as prescribed. Documentation in the Medication Administration Record (MAR) indicated that the medication was not available during the scheduled administration times, and nursing notes confirmed the medication was either unable to be located or pending delivery. Interviews with nursing staff revealed inconsistent practices regarding the management of out-of-stock medications. One RN stated that there was no backup supply of prescription medications in the facility, while another indicated that some prescription medications were available in the emergency medication system. The facility's guidelines required staff to take specific steps when medications were unavailable, such as contacting the pharmacy, checking the emergency kit, and notifying the provider, but the documentation showed that the medication remained unavailable for multiple doses, resulting in missed administrations for the resident.
Failure to Monitor Antibiotic Use and Obtain Required Testing
Penalty
Summary
The facility failed to implement an infection prevention and control program that included a system to monitor antibiotic use as part of its antibiotic stewardship program. Specifically, for one resident with a history of paraplegia, neurogenic bladder, and neuromuscular dysfunction of the bladder, a urinalysis and urine culture and sensitivity were not completed prior to prescribing antibiotics for suspected urinary tract infection (UTI) symptoms. The resident reported symptoms consistent with a UTI, and the physician prescribed Levaquin based on the resident's history and preference, without obtaining a urinalysis or culture. Nursing documentation confirmed the new order for Levaquin, and the responsible party was notified. However, a previous urinalysis and culture had shown resistance to Levaquin in this resident. Interviews with facility staff, including the DON, NP, and Infection Preventionist, revealed that while there were protocols in place for nurses to notify medical staff of suspected infections and for typically obtaining urinalysis and cultures, these were not consistently followed. The NP acknowledged prescribing antibiotics without obtaining a urinalysis or culture in at least one instance. The Infection Preventionist also noted challenges with lab report communication and recognized the need for more vigilant monitoring of antibiotic use and lab results. The lack of a consistent system to monitor antibiotic use and ensure appropriate testing contributed to the deficiency identified during the survey.
Deficient Documentation of Flu and Pneumonia Vaccinations
Penalty
Summary
The facility failed to ensure that each resident was properly offered and documented for influenza and pneumococcal immunizations, as required by policy. For two out of five sampled residents, there were deficiencies in the documentation process. One resident, with a history of quadriplegia, type 2 diabetes mellitus, dysphagia, anemia, antiphospholipid syndrome, pressure ulcer, and hypertension, had signed a consent form for the pneumococcal vaccine, but the form lacked documentation regarding whether the vaccine was administered, the location of administration, the lot number, or the date of administration. Another resident, with diagnoses including osteomyelitis, type 2 diabetes mellitus, polyneuropathy, anemia, hypothyroidism, and pain, had a signed consent form for the pneumococcal vaccine, but the form did not indicate whether the resident consented or declined the vaccination, nor did it contain any additional information. Interviews with the Director of Nursing and the Corporate Nurse confirmed that the expected documentation for immunization administration should include the date, medication, time, manufacturer, lot number, and location of administration. However, in these cases, such documentation was missing. The facility's policy required that residents be offered the vaccines annually, be provided education on the benefits and potential side effects, have the opportunity to refuse, and that documentation reflect education and immunization status, but these requirements were not met for the two residents in question.
Failure to Develop Comprehensive Care Plan for Resident with Psychological Needs and Falls
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with significant psychological needs and a history of multiple falls. The resident, who had been admitted and readmitted with various diagnoses including suicide attempt, dissociative identity disorder, and bipolar disorder, did not have a care plan addressing mental health or fall prevention. Despite a complaint indicating self-injurious behavior and a subsequent incident where the resident inflicted a wound on herself, no protocol for self-harm or suicidal ideation was established. The care plan had not been updated since its initial entry, and a psychotropic care plan was marked as completed but was not found in the medical record. Additionally, the resident experienced multiple falls over a period of time, yet no fall care plan was documented in the medical record. The Director of Nursing acknowledged the absence of specific care plans for the resident's behaviors and falls, noting that while staff had a checklist for post-fall procedures, there was no centralized location for information on previous interventions. The DON also recognized that the resident's behaviors were not being managed, despite medication management being in place. Staff were expected to use various resources to understand resident care needs, but the lack of a comprehensive care plan hindered effective management of the resident's conditions.
Failure to Update Care Plan for Resident with Behavioral Issues
Penalty
Summary
The facility failed to ensure that the care plan for a resident with severe cognitive impairment was revised by the interdisciplinary team to address repeated behaviors. The resident, who had a history of substance use disorder, schizoaffective disorder, anxiety, and traumatic brain injury, exhibited behaviors such as engaging in sexual activity with another cognitively impaired resident, entering other residents' rooms, and alleged drug use. Despite these incidents, the resident's behavior care plan, dated several months prior, was not updated to include interventions to prevent and address these behaviors. The facility's Director of Nursing (DON) confirmed that the care plan should have been updated following these incidents. The DON mentioned that the resident had been placed on one-on-one and line of sight observation, and the facility had been purchasing cigarettes for the resident, suspecting the behaviors might be transactional. Additionally, the resident's medications were evaluated. However, these interventions were not documented in the care plan, indicating a deficiency in the facility's care planning process.
Inadequate Supervision and Documentation of Falls
Penalty
Summary
The report identifies a deficiency in the supervision and care provided to a resident who experienced multiple falls without adequate neurological assessments being completed. The resident, who has a complex medical history including conditions such as morbid obesity, obstructive sleep apnea, and bipolar disorder, was admitted and readmitted to the facility with a history of falls. Despite several incidents where the resident fell, including unwitnessed falls and instances where the resident hit their head, the facility failed to document the required neurological assessments in the medical record. Interviews with facility staff, including a CNA, RN, and the DON, revealed that while neuro checks were initiated following falls, they were not consistently documented in the resident's medical record. The staff indicated that neuro checks were supposed to be completed and then scanned into the medical record, but this process was not followed, leading to a lack of documentation. This oversight in documentation and supervision contributed to the deficiency noted in the report.
Failure to Provide Behavioral Health Care Services
Penalty
Summary
The facility failed to provide necessary behavioral health care services to a resident, identified as Resident 10, who was admitted with multiple psychological diagnoses, including suicidal ideations and a history of self-harm. Despite these significant mental health concerns, the facility did not implement a protocol for self-harm or suicidal ideation after the resident inflicted a wound on herself. The only action taken was the application of bacitracin to the wound, without any further mental health interventions or monitoring. Interviews and record reviews revealed that Resident 10 had expressed suicidal thoughts and self-harming behaviors on multiple occasions. The resident had a history of cutting and had used a plastic spoon to harm herself. Despite these incidents, there was no documentation of 15-minute checks or 1:1 observation in the medical record. The care plan for Resident 10 was not updated to reflect her specific behaviors and needs, and there was no evidence of mental health services being arranged for her. Staff interviews indicated a lack of awareness and communication regarding Resident 10's mental health needs. The Director of Nursing acknowledged that the resident's behaviors were not being managed appropriately, and there was no centralized location in the medical record for staff to access information about the resident's mental health status. The facility's failure to provide adequate behavioral health care services compromised Resident 10's quality of life and well-being.
Incomplete and Late Documentation in Resident's Medical Records
Penalty
Summary
The facility failed to maintain complete, accurately documented, and readily accessible medical records for one of the sampled residents. The deficiency was identified through a review of the medical records of a resident who had been admitted and readmitted with multiple complex diagnoses, including suicide attempt, morbid obesity, and bipolar disorder. The review revealed numerous instances of late entries in the resident's progress notes, with delays ranging from several days to over a month. These late entries were not documented by the staff directly involved in the resident's care, but rather by the Assistant Director of Nursing (ADON), who recorded information obtained from floor nurses. Interviews with the Director of Nursing (DON) and the ADON highlighted a lack of awareness and improper documentation practices. The DON was unaware that the ADON was entering late notes into the medical records, and acknowledged that late charting could lead to inaccuracies. The ADON admitted to documenting information based on recollections from floor nurses, regardless of the time elapsed since the events occurred. The ADON also recognized that it would be more ethical for the floor nurses, who were directly involved with the residents, to document the information themselves.
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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