Rocky Mountain Care - Maple Dell
Inspection history, citations, penalties and survey trends for this long-term care facility in Payson, Utah.
- Location
- 55 South Professional Way, Payson, Utah 84651
- CMS Provider Number
- 465129
- Inspections on file
- 17
- Latest survey
- August 28, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Rocky Mountain Care - Maple Dell during CMS and state inspections, most recent first.
The facility was found to have deficiencies in food storage, preparation, and sanitation. Observations revealed unlabeled and unsealed food items, improper dish machine temperatures, and staff handling food with bare hands. The kitchen was also noted to be unclean, with personal items in the food preparation area.
A resident with multiple health conditions did not receive their prescribed fentanyl patch for several days due to a pharmacy error and lack of follow-up by the nursing staff. The resident's dosage was changed from a single 37.5 mcg patch to two patches totaling 37 mcg, but the medication was not delivered, and the staff failed to verify its receipt.
The facility failed to meet the nutritional needs of residents, as observed in small portion sizes and resident complaints. During lunch service, residents received inadequate portions, such as chicken pieces the size of a silver dollar. One resident reported poor meal quality the previous day. The Registered Dietitian was unsure about test tray records, and the Dietary Manager noted a cook needed more training. Observations showed inconsistencies in portion sizes, indicating non-compliance with nutritional guidelines.
The facility failed to provide palatable and properly heated meals, leading to resident complaints about cold, flavorless food and inadequate portions. A test tray confirmed the food was below recommended temperatures and lacked seasoning. The new Dietary Manager acknowledged the issues, noting a need for better training for staff.
A registered nurse in an LTC facility failed to perform hand hygiene and used bare hands to handle medications during a medication pass. This breach in infection control protocol was observed during the administration of medications to two residents. Interviews with staff confirmed that hand hygiene was required and that medications should not be touched with bare hands.
The facility failed to maintain an effective pest control program, resulting in a significant presence of flies affecting multiple residents. Observations revealed flies on residents and in common areas, with staff acknowledging the issue and attributing it to frequently opened doors. Despite some measures, such as installing a fly light and residents purchasing their own fly swatters, the problem persisted, causing discomfort and dissatisfaction.
The facility failed to investigate allegations of neglect and abuse for five residents, leading to deficiencies in care. One resident experienced a fall resulting in a hip fracture, another sustained a laceration with unclear origins, and a third alleged neglect by a CNA. Two other residents had incidents involving falls and neglect allegations, but investigations were incomplete or inconclusive, highlighting systemic issues in the facility's response to such allegations.
The facility failed to implement effective policies for monitoring and addressing deficiencies, including abuse reporting, pain management, medication availability, and infection control. Recurring issues were noted in food quality and safety, with inadequate labeling and handling of medications. Despite regular QAPI meetings, the facility did not effectively address these ongoing issues.
A resident with chronic pain did not receive prescribed Fentanyl patches for several days due to a change in prescription and miscommunication with the pharmacy. Despite the resident's complaints of pain, the facility staff failed to ensure the availability of the medication, resulting in a deficiency in pain management.
The facility was found to have deficiencies in medication handling and storage, including leaving medication carts unlocked and unattended, using insulin pens past expiration, and improperly repackaging narcotics. Observations revealed that medication carts were left open with resident information visible, and insulin pens were used beyond the recommended 28-day period. Additionally, narcotics were taped back into medication cards, contrary to facility protocol, indicating a lack of staff understanding and adherence to proper procedures.
The facility did not employ a full-time Registered Dietitian (RD) or a clinically qualified nutrition professional as the director of nutrition services. The Dietary Manager (DM) lacked the required certification and was still in training. The RD visited weekly and was available for consultation, but the DM had only recently started and was not yet certified.
The facility failed to report alleged violations involving abuse, neglect, or mistreatment to the State Survey Agency within the required timeframe for two residents. A resident with multiple medical conditions experienced a fall while using a mechanical lift, which was not reported. Another resident had an unwitnessed fall resulting in a hip fracture, and the incident was not reported within the required two-hour window. The facility's reporting process was found to be deficient.
Deficiencies in Food Safety and Sanitation Practices
Penalty
Summary
The facility was found to have several deficiencies in its food storage, preparation, and sanitation processes. During an initial walk-through of the kitchen, it was observed that food items in the walk-in freezer and refrigerator were not properly labeled or sealed, leaving them open to air. This included packages of a green substance, beef patties, cookie dough, and other items. Additionally, personal items belonging to kitchen staff were found in the food preparation area, which is against professional standards for food service safety. The dish machine used for cleaning dishware was not operating at the required temperatures necessary for proper sanitation. Multiple observations showed that the wash and rinse temperatures were consistently below the required levels, with the wash temperature often below 160 degrees Fahrenheit and the rinse temperature below 180 degrees Fahrenheit. The temperature logs for the month of August revealed numerous instances where the temperatures did not meet the necessary standards, and there were even days when no temperatures were documented at all. This failure to maintain proper sanitation temperatures poses a risk of foodborne bacteria. Furthermore, kitchen staff were observed handling food with bare hands, which is a violation of food safety protocols. One staff member was seen pulling apart dinner rolls and filling cups with brown sugar using her bare hands. The kitchen was also noted to be unclean, with food splatter on the stove, crumbs on the griddle, and greasy surfaces. Interviews with dietary aides and the dietary manager revealed a lack of awareness and adherence to the required temperature standards for the dish machine, as well as inadequate monitoring and maintenance of the equipment.
Medication Unavailability for Resident
Penalty
Summary
The facility failed to provide routine and emergency pharmaceutical services to a resident, identified as Resident 16, who was not administered medications as ordered by the physician due to unavailability from the pharmacy. Resident 16, who had multiple diagnoses including type II diabetes mellitus, vascular dementia, and chronic pain, was observed questioning the RN about the absence of his fentanyl patch, which had been unavailable for a week. The RN confirmed the change in dosage from a single 37.5 mcg patch to two patches totaling 37 mcg, but was unsure of the reason for the change. The resident's medical records indicated that the fentanyl patch was not administered from 8/21/24 to 8/26/24 due to the drug being unavailable or waiting for the correct dosage patches. Interviews with the RN and the Director of Nursing (DON) revealed a communication error with the pharmacy, which led to the resident not receiving his medication. The pharmacy could no longer provide the 37.5 mcg dose and instead offered a combination of two patches to equal 37 mcg. However, the pharmacy did not send the medication, and the nurses continued to order it without verifying its receipt. The DON acknowledged that the resident should not have gone without his pain medication and recognized the need for clarification and follow-through in the medication ordering process to prevent such occurrences.
Deficiency in Nutritional Menu Compliance
Penalty
Summary
The facility failed to provide menus that met the nutritional needs of residents, as evidenced by observations and resident complaints about portion sizes. Specifically, four residents were affected by this deficiency. During a lunch service observation, residents were served portions that were smaller than expected, with pieces of chicken described as being the size of a silver dollar. Residents expressed dissatisfaction with the portion sizes, stating that the food was inadequate and not satisfactory. Additionally, one resident reported that meals served the previous day were of poor quality, with insufficient meat in the beef stroganoff and watery gravy. The facility's dietary practices were further scrutinized through interviews and record reviews. The Registered Dietitian admitted to conducting weekly food quality audits but was unsure if records of test trays were maintained. The Dietary Manager acknowledged that one of the cooks required additional training, particularly in food presentation and adherence to menus and spreadsheets. Observations of the tray line revealed inconsistencies in portion sizes, with the meat portions not appearing to meet the specified 3 oz size. These findings indicate a failure to adhere to established nutritional guidelines and menu specifications, resulting in resident dissatisfaction and complaints.
Deficiency in Food Quality and Temperature
Penalty
Summary
The facility failed to provide food that was palatable, attractive, and served at an appetizing temperature, as evidenced by multiple resident complaints and a test tray evaluation. Residents reported that the food was often cold, lacked flavor, and did not match the menu. Specific instances included residents receiving cold meals, meals that were not as described, and portions that were inadequate. A test tray evaluation revealed that the food was served at temperatures below the recommended levels, lacked seasoning, and some menu items were missing. Interviews with residents and family members highlighted dissatisfaction with the food quality, which had reportedly declined after a change in dietary management. The new Dietary Manager acknowledged the issues and noted that one of the cooks required additional training. The Registered Dietitian also identified palatability issues during her audits but did not maintain records of these audits. The facility's failure to maintain food quality and temperature standards led to widespread resident dissatisfaction and complaints.
Infection Control Breach During Medication Pass
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the actions of a registered nurse (RN) during a medication pass. On the morning of August 27, 2024, RN 2 was observed administering medications to residents without performing hand hygiene before or after the medication pass. Specifically, RN 2 was seen pushing medications through a medication pack into the palm of his hand and then placing them into a medication cup using bare fingers. This occurred multiple times, including when administering medications to resident 14 and another resident. Interviews conducted with RN 2, RN 3, and the Director of Nursing (DON) confirmed that the facility's protocol requires hand hygiene to be performed before and after each medication pass, and that medications should not be touched with bare hands. RN 2 acknowledged that hand hygiene should have been performed and that touching medications with bare hands was not appropriate. RN 3 and the DON reiterated the importance of hand hygiene and the expectation that gloves should be used if necessary, ensuring they are clean and used for one patient at a time.
Ineffective Pest Control Leads to Fly Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in a significant presence of flies within the premises. Multiple residents, including those identified as 2, 5, 6, 24, 37, and 40, reported and were observed to have flies around and on them. Resident 24, for instance, was seen with flies in her room and on her knee, expressing frustration over the persistent issue. Similarly, resident 2 had flies on her feet and face during an interview, indicating a need for pest control measures. Resident 37 corroborated these observations by mentioning that she could hear her roommate, resident 2, yelling at the flies. Resident 6 also had a fly swatter within reach and complained about the pervasive presence of flies. The problem extended to common areas, as observed in the dining area near the 400 hall, where flies were seen landing on dining tables. Staff members, including a CNA and the Maintenance Director, acknowledged the issue, attributing the increase in flies to the frequent opening of doors by smokers. The CNA mentioned that fly swatters were even given as bingo prizes, and efforts were made to keep doors and windows closed. The Maintenance Director noted that residents had resorted to purchasing their own fly swatters and lights, and a fly light was installed over the fridge in the long-term care area. Despite these efforts, the fly problem persisted, causing discomfort and dissatisfaction among residents.
Failure to Investigate Allegations of Neglect and Abuse
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse, neglect, exploitation, or mistreatment for five residents, leading to deficiencies in care. Resident 156 experienced an unwitnessed fall resulting in a right hip fracture and subsequent surgical intervention. Despite the severity of the incident, the Director of Nursing acknowledged that the fall should have been investigated for possible neglect, but no comprehensive investigation documentation was provided. Resident 158 sustained a laceration to the shin from an unknown origin, which led to hospitalization. The initial report indicated uncertainty about the injury's source, and while some staff interviews were conducted, the investigation was incomplete, lacking detailed documentation and timely submission. Similarly, Resident 15 alleged neglect by a CNA, but no investigation or documentation was found in the facility's records, and the current administrator was unable to locate any investigation related to the incident. Resident 53 experienced a fall resulting in injury, but the investigation was deemed inconclusive, with insufficient documentation to verify the cause. Resident 161 was reported to Adult Protective Services by a local hospital for neglect, but the facility's investigation lacked comprehensive documentation. The administrator admitted to discussing the incidents with staff but failed to provide adequate investigative notes, indicating a systemic issue in the facility's response to allegations of neglect and abuse.
Facility Fails to Address Recurring Deficiencies in Care and 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 noted during the recertification survey, where several deficiencies cited in the previous survey were found again. These included issues related to abuse reporting, pain management, medication availability, drug labeling, food quality, food safety, and infection control. Specifically, the facility did not report alleged violations involving abuse or neglect to the State Survey Agency within the required timeframe, and pain management was not provided to a resident who required it. The facility also failed to provide routine and emergency drugs as ordered by the physician due to unavailability from the pharmacy. Medications were not labeled according to professional standards, with medication carts left unlocked and insulin pens used past their expiration date. Additionally, the quality of food served was found lacking in flavor and appearance, and food safety standards were not adhered to, with issues such as unlabeled food items and improper handling by kitchen staff. Infection control measures were inadequate, as evidenced by a staff member touching resident medications with bare hands. The facility's Quality Assessment and Performance Improvement (QAPI) meetings were held regularly, but the documentation and follow-up actions were insufficient to address these ongoing issues. The facility's failure to address these deficiencies indicates a lack of effective monitoring and corrective action implementation.
Failure in Pain Management for Resident
Penalty
Summary
The facility failed to provide appropriate pain management for Resident 16, who was admitted with multiple diagnoses including chronic pain and opioid dependence. The resident's care plan indicated a need for pain management, including the use of Fentanyl patches. However, there was a disruption in the supply of these patches due to a change in the prescription from a 37.5 mcg patch to a combination of two patches totaling 37 mcg, reportedly due to insurance issues. This change led to a period where the resident did not receive the prescribed Fentanyl patches from 8/20/24 to 8/26/24, as they were unavailable. During this period, the resident expressed concerns about not receiving the Fentanyl patches and reported experiencing pain. The nursing staff, including RN 3 and the ADON, were aware of the issue but did not resolve it effectively. The pharmacy was supposed to deliver the medications multiple times a day, but there was a miscommunication, and the patches were not delivered. The facility's medication administration record (MAR) indicated that the patches were not administered due to being unavailable, and the staff did not verify the availability of the patches in the facility's supply. The Director of Nursing (DON) acknowledged the issue, stating that the pharmacy believed they had already sent the medication, leading to a failure in delivery. The DON also noted that the resident's pain did not increase significantly during this period due to adjustments in other medications. However, the facility did not take adequate steps to ensure the resident received the necessary pain management, highlighting a deficiency in the facility's process for managing medication supply and communication with the pharmacy.
Medication Handling and Storage Deficiencies
Penalty
Summary
The facility was found to have several deficiencies related to the handling and storage of medications. During observations, it was noted that medication carts were left unlocked and unattended, with computer screens displaying resident information in view of others. This occurred on multiple occasions with different registered nurses, compromising both the security of the medications and the privacy of resident information. Additionally, insulin pens were found to be used past their expiration date. Insulin pens labeled with open dates were observed in the medication carts, indicating they were available for use beyond the recommended 28-day period after opening. Interviews with nursing staff revealed a lack of knowledge regarding the proper duration for insulin use after opening, contributing to the improper handling of these medications. Furthermore, the facility was found to be improperly handling narcotics. Medications were observed to be repackaged and taped back into medication cards, which is against the facility's protocol. This practice was acknowledged by some staff as acceptable under certain conditions, while others recognized it as inappropriate. The Director of Nursing confirmed that narcotics should be wasted with another nurse and not retaped, highlighting a discrepancy in staff understanding and adherence to medication handling procedures.
Deficiency in Nutrition Services Staffing
Penalty
Summary
The facility was found to have a deficiency in employing a clinically qualified full-time dietitian or another clinically qualified nutrition professional to serve as the director of nutrition services. The Dietary Manager (DM) did not meet the necessary certification requirements for the position. During an interview, the DM admitted to not having completed the required certification and mentioned that the Registered Dietitian (RD) visited the facility once a week and was available for consultation by phone. The RD confirmed that the DM was still undergoing training and had only recently started in the position, and that efforts were being made to provide the DM with information on approved training programs.
Failure to Timely Report Suspected Abuse and Neglect
Penalty
Summary
The facility failed to report alleged violations involving abuse, neglect, exploitation, or mistreatment to the State Survey Agency within the required timeframe for two residents. Resident 28, who had multiple medical conditions including a wedge compression fracture and type II diabetes, experienced a fall while using a mechanical lift. The incident was not reported to the State Survey Agency, and the facility's Administrator was unaware of the fall. Interviews revealed that the CNA assisting Resident 28 did not report the incident due to uncertainty about the reporting process, and the Director of Nursing was unaware of the frequency of such falls. Resident 156, with diagnoses including a fracture of the right femur neck and major depressive disorder, had an unwitnessed fall resulting in a right hip fracture. The fall was not reported to the State Survey Agency within the required two-hour window. The Director of Nursing acknowledged that unwitnessed falls should be investigated for possible neglect and admitted that the facility could have reported the incident more promptly. The delay in reporting these incidents indicates a deficiency in the facility's process for handling and reporting suspected abuse or neglect.
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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