San Rafael Health And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Ferron, Utah.
- Location
- 455 West Mill Road, Ferron, Utah 84523
- CMS Provider Number
- 465085
- Inspections on file
- 15
- Latest survey
- November 15, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at San Rafael Health And Rehabilitation during CMS and state inspections, most recent first.
A resident with cognitive impairment and physical limitations was subjected to verbal and physical abuse by an RN, who aggressively handled and transferred the resident without consent. The incidents were witnessed by CNAs who delayed reporting, allowing the RN continued access to the resident, violating the facility's abuse policy.
The facility failed to ensure immediate reporting of abuse allegations involving multiple residents. CNAs witnessed a RN aggressively transferring a resident and delayed reporting, allowing further incidents. Another case involved delayed reporting of potential resident-to-resident sexual abuse, and a separate verbal abuse allegation was not reported promptly. These delays indicate systemic issues in handling abuse allegations, compromising resident safety.
The facility failed to properly investigate abuse allegations involving a resident and an RN, and another incident of resident-to-resident aggression. The RN was reported to have forcibly transferred a resident against their will, and the facility's investigation was inadequate, lacking interviews with other residents and skin assessments. In a separate incident, a resident displayed aggressive behavior towards another resident, and the facility's investigation was incomplete, missing a sheriff's report and a nurse's statement.
The facility failed to implement interventions to prevent falls for two residents, resulting in multiple injuries. Additionally, a resident with COPD and asthma had medications left at their bedside without a documented self-administration assessment. Furthermore, a resident with severe cognitive impairment eloped from the facility, and there was no evidence of a wandering risk assessment. The facility's investigation into the elopement was incomplete.
The facility failed to maintain a clean and sanitary kitchen, affecting all residents receiving meals. Observations revealed dirty appliances and inadequate cleaning documentation. The Dietary Manager cited staffing shortages as a reason for the lack of monitoring and deep cleaning. The DON and Administrator expected daily cleaning, but the kitchen was not thoroughly inspected.
A facility failed to provide required training on abuse prevention and reporting, leading to a deficiency. An RN allegedly abused a resident, and the incident was reported late. Interviews revealed that a CNA and the RN did not receive necessary training, and documentation was lacking. The administration acknowledged deficiencies in tracking and documenting training.
The facility failed to develop individualized care plans for four residents, omitting critical elements such as oxygen use, catheter care, and respiratory issues. These deficiencies were identified during a survey through observation, interviews, and record reviews, with staff acknowledging the oversights.
A facility failed to implement infection control policies, specifically Enhanced Barrier Precautions (EBP) during catheter care, and did not conduct annual TB risk screenings for residents. Staff were observed providing catheter care without gowns, and interviews revealed a lack of awareness and training on EBP. Additionally, TB testing was not conducted annually, and no risk assessments were documented. The DON and Administrator were unaware of these lapses, attributing them to changes in infection prevention staff.
The facility failed to address and follow up on concerns raised by the Resident Council, such as hot water issues, room changes, and food quality. Despite the facility's policy requiring grievances to be logged and investigated, no RC grievances were recorded, and unresolved issues persisted. Interviews revealed ongoing problems like unmade beds and disturbances from loud televisions, with the Resident Advocate admitting to not managing these concerns as formal grievances. The DON and Administrator were unaware of some issues and did not ensure proper follow-up, leading to a deficiency in honoring residents' rights.
The facility failed to ensure physician's orders included specified dosages for medications prescribed to two residents. One resident with a history of diabetes and osteoporosis had orders for vitamin C and D3 without dosages, while another with heart disease had an incomplete order for vitamin D3. Interviews confirmed that orders should include dosages, highlighting a lapse in policy adherence.
A resident with severe cognitive impairment and a history of chronic heart failure had an unsecured indwelling urinary catheter, contrary to facility policy and state guidelines. The catheter was not anchored due to an allergic reaction to the adhesive on the stabilization device, and no alternative securing methods were attempted. The resident's care plan did not address catheter use, and there was no physician's order for the catheter, although catheter care was ordered.
A facility failed to address pharmacy recommendations for a resident with schizophrenia and paranoid personality disorder, who was receiving multiple medications including lorazepam without an end date. Despite a pharmacy report recommending a 14-90 day auto-stop date, the medication was administered multiple times without reassessment. The DON acknowledged missing the recommendation, and the Consultant Pharmacist confirmed the facility's non-compliance.
A facility failed to specify the duration of use for a PRN psychotropic medication for a resident with schizophrenia and paranoid personality disorder. The resident's order for lorazepam lacked an end date, contrary to the facility's policy requiring a 14-day stop date. Interviews with staff and the Consultant Pharmacist revealed the facility's ongoing issue with placing stop dates on orders, leading to this deficiency.
A resident's medical records at an LTC facility contained inaccurate admission dates, with records indicating an admission on one day, while staff interviews confirmed the resident arrived the following day. The discrepancy arose from initial plans and communications with the hospital, which were not updated in the electronic health record system.
Failure to Protect Resident from Abuse by RN
Penalty
Summary
The facility failed to protect a resident from verbal and physical abuse by a registered nurse (RN). On two separate occasions, the RN was reported to have aggressively handled the resident, including yelling in the resident's face, shaking them, and transferring them to bed without consent. The incidents were witnessed by certified nurse aides (CNAs) who did not immediately report the abuse, allowing the RN to continue working with access to the resident. The resident involved had a medical history of hemiplegia, hemiparesis, muscle wasting, difficulty walking, and anxiety disorder. The resident was admitted to the facility with moderate cognitive impairment and required assistance with daily activities. The resident was known to have behavioral symptoms that interfered with care and had a history of rejecting care. The facility's policy prohibits any form of abuse, yet the RN's actions were in direct violation of this policy. The CNAs who witnessed the incidents were unsure of how to respond and delayed reporting the abuse. The facility's failure to immediately address the situation and protect the resident from further abuse resulted in a deficiency related to the resident's right to be free from abuse, neglect, and exploitation.
Failure to Report Abuse Allegations Promptly
Penalty
Summary
The facility failed to ensure that staff immediately reported allegations of abuse involving several residents. On one occasion, certified nurse aides (CNAs) witnessed a registered nurse (RN) aggressively transferring a resident against their will, but did not report the incident immediately. This allowed the RN to continue working with access to the resident, leading to a second incident where the RN shook the resident to convince them to allow a transfer. The CNAs delayed reporting these incidents to facility management, which resulted in a failure to protect the resident from potential harm. In another case, a CNA reported an incident involving potential resident-to-resident sexual abuse, but the RN on duty failed to notify management immediately. This delay resulted in the facility not submitting an initial report to the State Survey Agency (SSA) within the required timeframe. The resident involved had a history of dementia and anxiety disorder, and the incident involved another resident with similar cognitive impairments. Additionally, there was a failure to report an allegation of verbal abuse involving another resident. Staff members who were aware of the allegation did not report it to management immediately, and once management was informed, the facility failed to report the allegation to the SSA within the required two-hour window. This pattern of delayed reporting indicates a systemic issue in the facility's handling of abuse allegations, potentially compromising resident safety.
Inadequate Investigation of Abuse Allegations
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse involving two residents. On one occasion, a registered nurse (RN) was reported to have yelled at a resident, shook them, and forcibly transferred them to bed against their will. This incident was witnessed by several certified nurse aides (CNAs) who did not immediately report the abuse to the administration, resulting in a delay in initiating an investigation and implementing protective measures. Consequently, the RN continued to work and was involved in another incident of abuse with the same resident. The facility's investigation was inadequate as it did not include interviews with other residents or skin assessments to check for potential injuries. In another incident, the facility reported an allegation of resident-to-resident abuse. A resident was reported to have blocked a CNA from taking another resident for a shower, displaying aggressive behavior. The resident later reported that the aggressor had attempted to force them into sexual activity. The facility's investigation into this incident was incomplete, lacking a copy of the sheriff's office report and a witness statement from the nurse involved at the time of the incident. The facility's non-compliance with the requirements of participation was determined to have caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) situation began when the RN forcibly transferred a resident against their will, and the facility's subsequent investigation was insufficient, failing to document interviews or conduct a thorough inquiry into the incidents.
Failure to Implement Fall Prevention and Medication Safety Measures
Penalty
Summary
The facility failed to implement interventions to prevent future falls for two residents who were reviewed for falls. One resident, who had a history of dementia, seizures, bipolar disorder, and anxiety disorder, experienced multiple falls resulting in injuries such as a head laceration, a right clavicle fracture, and abrasions. Despite these incidents, there was no evidence that the facility initiated any interventions to prevent future falls. The Director of Nursing (DON) acknowledged the lack of documented interventions and stated that the nurses were responsible for investigating the root cause of falls and implementing new interventions. The facility also failed to ensure resident safety regarding medication administration. A resident with a history of chronic obstructive pulmonary disease (COPD) and asthma was observed with medications left at their bedside, including a rescue inhaler and nasal spray. The facility's policy required an assessment to determine if self-administration of medications was safe, but there was no documentation of such an assessment for this resident. Interviews with nursing staff revealed inconsistencies in understanding and implementing the policy, with some staff unaware of the requirement for a self-administration assessment. Additionally, the facility did not adequately assess or address the risk of elopement for a resident with severe cognitive impairment and a history of wandering. The resident eloped from the facility shortly after admission, and there was no evidence of a wandering or elopement risk assessment being completed. The facility's investigation into the elopement was incomplete, lacking documentation of interviews, corrective actions, and a root cause analysis. The Administrator admitted to not maintaining documentation of the incident, and the DON acknowledged that a wandering assessment should have been conducted but was missed.
Failure to Maintain Sanitary Kitchen Conditions
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen, which had the potential to affect all 39 residents receiving meals from the dietary department. Observations during the initial tour of the kitchen revealed that various appliances, including the commercial oven, convection oven, grill, and steamer, were dirty with grease and splatters. Further observations showed that the top of the microwave had a layer of fuzz and dirt, and crumbs covered the counter behind the toaster and microwave. Additional inspections revealed thick layers of dirt and food splatters on the grill, steamer, and conventional stove top/oven combination, as well as dust and grease on the convection oven. The facility's cleaning schedules and chore lists indicated that required cleaning tasks were not consistently completed or documented. The AM Cook's Daily Cleaning Schedule showed that tasks were not signed off on certain days, and the PM Cook's Daily Cleaning Schedule also lacked documentation for required cleaning. The facility's September and October Chore Lists revealed that tasks were either not signed off or had lines through them, indicating they were not completed. Interviews with staff, including the Dietary Manager (DM), revealed that the kitchen was short-staffed, and the DM had been working shifts in the kitchen, which affected her ability to monitor and ensure cleaning tasks were completed. The DM acknowledged that the appliances were dirty and stated that she usually performed deep cleaning three to four times a year but had not been able to do so recently. The Director of Nursing (DON) and the Administrator both expressed expectations that the kitchen should be cleaned daily and before every meal. The Administrator noted that the kitchen had always been in top shape during previous inspections but admitted to not thoroughly inspecting the kitchen during his visits.
Deficiency in Staff Training on Abuse Prevention and Reporting
Penalty
Summary
The facility failed to provide annual and periodic training in accordance with its policy to educate staff on activities that constitute abuse and procedures for reporting incidents of abuse. This deficiency was identified through interviews, document reviews, and facility policy reviews. The facility's policy, dated February 2017, required that all employees receive training during orientation and ongoing in-services on issues related to the prohibition of abuse, including appropriate behavioral interventions, reporting procedures, and signs of burnout that may lead to abuse. However, it was found that two staff members, a CNA and an RN, did not receive the required training. An incident was reported where an RN allegedly physically and verbally abused a resident. The incident was reported to the state agency four days after it occurred, indicating a delay in reporting. The RN was accused of yelling at the resident, grabbing their arms and wrist, and moving them to the bed against their will. Despite the serious nature of the allegations, the facility unsubstantiated the abuse claims and did not provide immediate retraining for the involved staff members. Interviews with staff revealed that the CNA did not recall receiving any training on abuse prohibition or reporting, and the RN did not receive retraining after the incident. The facility's documentation was lacking, with no sign-in sheets for a March 2024 training session and no evidence of individual training for staff who missed sessions. The facility's administration acknowledged the deficiencies in tracking and documenting training, which contributed to the failure to ensure staff were adequately trained on abuse prevention and reporting.
Failure to Develop Individualized Care Plans
Penalty
Summary
The facility failed to develop individualized, resident-centered care plans with measurable objectives for four residents. Specifically, the care plans did not address oxygen use for two residents, an indwelling urinary catheter for another resident, and respiratory care for a resident with COPD and asthma. These omissions were identified during a survey through observation, interviews, and record reviews. Resident #1, who had a medical history of unspecified heart failure, was receiving oxygen therapy as per an order dated February 2023. However, the resident's care plan, last revised in August 2024, did not include any interventions addressing oxygen use. Similarly, Resident #3, with a history of morbid obesity, was also receiving oxygen therapy, but their care plan, last revised in September 2024, lacked any mention of oxygen use. Both the MDS Coordinator and the Director of Nursing acknowledged these oversights during interviews. Resident #24, who had severe cognitive impairment and an indwelling urinary catheter, did not have their catheter care included in their care plan. Additionally, Resident #4, with a history of COPD and asthma, had orders for multiple respiratory medications, but their care plan did not address respiratory issues or the need for these medications. The Director of Nursing and the MDS Coordinator confirmed that these elements should have been included in the care plans to ensure proper care and communication among staff.
Infection Control and TB Screening Deficiencies
Penalty
Summary
The facility failed to implement infection control and prevention policies, specifically regarding the use of Enhanced Barrier Precautions (EBP) during indwelling urinary catheter care for a resident. The facility's policy required the use of gowns and gloves during high-contact resident care activities, including catheter care. However, during an observation, a registered nurse and a nurse aide provided catheter care to a resident without donning gowns, only wearing gloves. Interviews with staff revealed a lack of awareness and training on EBP, with some staff members not having heard of the term or being instructed to use gowns during such care. The facility also failed to conduct annual tuberculosis (TB) risk screenings for several residents. The facility's policy required annual risk assessments to determine TB risk classification and subsequent testing based on the classification. However, reviews of immunization records for multiple residents showed that TB testing had not been conducted annually, and there was no documentation of annual risk assessments. Interviews with the Infection Preventionist and the Director of Nursing confirmed that annual TB risk assessments had not been completed for residents, attributing the oversight to changes in infection prevention staff. The Director of Nursing and the Administrator were both unaware of the lapses in EBP implementation and TB risk assessments. The Director of Nursing admitted to not having a good reason for not initiating EBP for residents with catheters and wounds, while the Administrator expected EBP to be followed and was unaware that annual TB risk assessments for residents had not been completed. The lack of proper training and oversight contributed to the deficiencies in infection control practices at the facility.
Failure to Address Resident Council Concerns
Penalty
Summary
The facility failed to consistently follow up on concerns presented by the Resident Council (RC) and did not provide a verbal or written response regarding actions taken to address these concerns. The facility's policy required all grievances and complaints to be investigated and recorded in a grievance log, but no RC grievances were logged from January to October 2024. The RC minutes from several months indicated various concerns, such as hot water issues, room changes, and food quality, but lacked documentation of planned actions or follow-up discussions to resolve these issues. Interviews with residents revealed ongoing unresolved issues, such as sheets not being changed regularly, beds not being made, and disturbances from loud televisions at night. The Resident Advocate (RA) admitted to documenting concerns during RC meetings and verbally communicating them to department managers but did not manage these concerns as formal grievances with written plans or summaries of actions taken. The RA acknowledged that unresolved issues appearing multiple times in RC meetings indicated they had not been addressed. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) were unaware of some concerns, such as beds not being made, and had not followed up on others, like the loud television issue. The Administrator expected the RA to communicate all RC concerns to department managers and anticipated immediate changes with follow-up within a week, but this did not occur. The lack of documentation and follow-up on RC concerns led to ongoing unresolved issues, indicating a deficiency in honoring residents' rights to organize and participate in facility groups effectively.
Incomplete Physician's Orders for Medication Dosages
Penalty
Summary
The facility failed to ensure that physician's orders included all necessary components, specifically the specified dosages for medications prescribed to residents. This deficiency was identified during a review of the medication administration task for two residents. Resident #13, who was admitted on January 3, 2024, had a medical history including type two diabetes mellitus, chronic kidney disease, hypertension, intervertebral disc degeneration, and osteoporosis. The resident's Order Summary Report showed active orders for vitamin C and vitamin D3, but the physician's orders did not specify the dosages for these medications. Similarly, Resident #20, admitted on January 11, 2023, with a medical history of hypertensive heart disease with heart failure, tremor, atherosclerotic heart disease, and atrial fibrillation, had an order for a vitamin D3 tablet without a specified dosage. Interviews with the Director of Nursing and the Administrator confirmed that physician's orders should include the intended dosages, indicating a lapse in adherence to the facility's policy on medication orders. This oversight in documenting complete medication orders was noted as a deficiency by the surveyors.
Failure to Secure Indwelling Urinary Catheter
Penalty
Summary
The facility failed to ensure that an indwelling urinary catheter was properly secured for a resident, leading to potential risks of pulling or trauma to the urethral meatus. The facility's policy on catheter care, revised in August 2022, required that catheters be secured with a device to reduce friction and movement at the insertion site. However, during an observation, it was noted that the resident's catheter was not secured. The resident, who had severe cognitive impairment and a history of chronic diastolic heart failure, was admitted with frequent bladder incontinence and had a catheter placed due to fragile, sensitive skin. Despite the facility's policy and the State Operations Manual guidance, the catheter was not anchored, which could lead to urethral tears or dislodging. The resident's care plan did not address the use of an indwelling urinary catheter, and there was no physician's order for its use, although there was an order for catheter care. The RN and NA involved in the resident's care noted that the resident had a reaction to the adhesive on the stabilization device, which led to its removal. The Director of Nursing confirmed the resident's allergy to the adhesive and acknowledged that no alternative securing methods had been attempted. The Administrator expected that another type of stabilization device should have been tried if the resident was allergic to the adhesive, but this was not documented or actioned, leading to the deficiency.
Failure to Address Pharmacy Recommendations for PRN Medications
Penalty
Summary
The facility failed to address pharmacy recommendations for a resident who was reviewed for unnecessary medications. The resident, admitted on 04/03/2022, had a medical history of schizophrenia and paranoid personality disorder. During a significant change Minimum Data Set (MDS) assessment, it was noted that the resident had moderate cognitive impairment and received multiple medications, including antipsychotics and antianxiety drugs. The resident's medication orders included lorazepam without an end date, despite a pharmacy consulting report recommending a 14-90 day auto-stop date for PRN lorazepam. The medication was administered multiple times without reassessment. Interviews with facility staff revealed that the Director of Nursing (DON) was responsible for handling pharmacy recommendations, but the recommendation for a stop date on PRN psychotropic medications was missed. The Consultant Pharmacist confirmed that the facility did not follow the recommendations, and the DON acknowledged the oversight. The Administrator also stated that a 14-day stop date was necessary for reassessment, indicating a lapse in communication and implementation of pharmacy recommendations between the DON, Medical Director, and the Consultant Pharmacist.
Failure to Specify Duration for PRN Psychotropic Medication
Penalty
Summary
The facility failed to ensure that an as-needed (PRN) psychotropic medication order specified the duration of use for a resident with a history of schizophrenia and paranoid personality disorder. The resident was admitted to the facility with a medical history that included these diagnoses and was receiving multiple medications, including antipsychotics and antianxiety drugs. The resident's order summary report showed an active PRN order for lorazepam without an end date, which was against the facility's policy that required PRN psychotropic medications to have a 14-day stop date. Interviews with facility staff, including registered nurses and the Director of Nursing (DON), confirmed that the PRN lorazepam order lacked a stop date, which was necessary for reviewing the medication's effectiveness. The Consultant Pharmacist, who participated in psychotropic medication review meetings, also noted the facility's difficulty in placing stop dates on physician orders, despite recommendations. The facility's failure to follow its policy and the pharmacist's recommendations led to the deficiency, as the PRN lorazepam order for the resident did not comply with the required stop date protocol.
Inaccurate Admission Date Recorded for Resident
Penalty
Summary
The facility failed to maintain accurate medical records for a resident, identified as Resident #190, who was admitted to the facility. The discrepancy arose from conflicting admission dates recorded in the resident's medical records. The Admission Record, Admission Agreement, and the Minimum Data Set (MDS) indicated that the resident was admitted on August 4, 2023. However, interviews with staff, including the Director of Nursing (DON) and the Business Office Manager (BOM), revealed that the resident was actually brought to the facility by a family member on August 5, 2023. The confusion regarding the admission date was further compounded by the actions of the Registered Nurse (RN) #5, who documented the admission summary progress note on the day the resident was physically admitted, which was August 5, 2023. The DON and the Administrator acknowledged that the electronic health record system was updated with the admission date of August 4, 2023, based on initial plans and communications with the hospital, but the resident's actual arrival was delayed by a day. This discrepancy was not corrected in the electronic health record system, leading to inaccurate documentation. Interviews with the MDS Coordinator and the Administrator highlighted that the admission process was initiated on August 4, 2023, in anticipation of the resident's arrival. However, due to the family's decision to bring the resident a day later, the records were not updated to reflect the actual admission date. The facility's policy required accurate and timely documentation of admissions, which was not adhered to in this case, resulting in a deficiency in maintaining accurate medical records for the resident.
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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