Sandy Health And Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Sandy, Utah.
- Location
- 50 East 9000 South, Sandy, Utah 84070
- CMS Provider Number
- 465111
- Inspections on file
- 26
- Latest survey
- April 16, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Sandy Health And Rehab during CMS and state inspections, most recent first.
Multiple residents and staff reported persistent foul odors and visible cleanliness issues in a shower room, including strong urine and sewage smells, soiled linens, and stained furniture. Observations confirmed broken tiles, mold, and a non-functioning toilet in other shower rooms. Staff interviews revealed inconsistent reporting and unclear responsibilities for maintenance and housekeeping, resulting in ongoing disrepair and an environment that was not safe, clean, or homelike.
Multiple residents reported that food was often cold, bland, unappetizing, and nutritionally inadequate, with observations confirming improper food temperatures and unattractive presentation. Resident council minutes and grievance forms documented ongoing dissatisfaction with food quality, and interviews with dietary staff and administration revealed a lack of awareness and oversight regarding these issues.
Dietary staff failed to follow sanitary food handling practices by touching multiple unclean surfaces and then handling plates and food with the same gloves, as well as chopping food on a cutting board that was not cleaned between uses. Both the cook and dietary manager acknowledged these lapses, confirming that food was prepared and served in a manner not consistent with professional standards.
Several residents with chronic medical conditions were not properly offered or administered influenza and COVID-19 vaccines, despite signed consents indicating acceptance. Documentation was missing for both the offer and administration of vaccines, as confirmed by facility leadership.
Two residents were unable to access their personal funds on weekends because only the Business Office Manager, who worked weekdays, could distribute money. Staff confirmed that no one was available to provide funds outside of business hours, and delays in obtaining cash from the corporate office further limited access.
A resident with multiple diagnoses returned from the hospital with sutures on the bridge of the nose and instructions for removal in 7 days. Facility staff failed to remove the sutures within the specified timeframe, and the resident was observed with the sutures still in place and tugging at them. Staff interviews revealed confusion about the correct removal period, and the DON confirmed the removal was overdue.
A resident with multiple chronic conditions did not have required serum phenytoin and phenobarbital lab results documented in the electronic medical record, despite pharmacy recommendations and physician approval for these labs. Staff interviews revealed that while diagnostic results were supposed to be scanned and uploaded promptly, the necessary laboratory reports were missing from the resident's chart.
A resident receiving antibiotics for pneumonia did not have a signed and dated chest x-ray report filed in their clinical record, despite staff confirming that such a report should have been present to support the diagnosis and treatment.
A resident with multiple documented food allergies, including peas, was served a meal containing peas despite clear indications on her meal ticket and care plan. The resident reported receiving foods she was allergic to on a recurring basis, and observation confirmed the presence of an allergen on her tray. The deficiency persisted even after previous complaints and staff education.
Several shower and bathing areas lacked working call lights or had missing cords, preventing residents from summoning staff assistance. Multiple residents and CNAs confirmed the call lights were non-functional or inaccessible, and maintenance staff noted cords should be floor-length but were absent. The administrator acknowledged the system's age and frequent failures, with staff compensating by checking on residents more often or remaining present during showers.
Two residents with cognitive impairments and a history of wandering eloped from a facility due to inadequate supervision and safety measures. One resident sustained severe burns after leaving without staff knowledge, while another was found outside the facility twice despite having a wander guard. The facility's safety systems were insufficient to prevent these incidents.
Two residents in an LTC facility did not receive appropriate wound care and documentation. One resident with a toe injury experienced a delay in treatment and lack of monitoring, while another resident with burns had no documented wound measurements. The facility failed to adhere to professional standards and care plans, leading to deficiencies in care.
The facility failed to maintain a sanitary environment in resident shower rooms, as black spots were observed on the baseboard near the shower entrance. Staff interviews revealed inconsistencies in cleaning responsibilities, with CNAs and housekeeping having different understandings of their roles. The Administrator identified the spots as potential mold or moisture, indicating a need for a deep clean.
A resident on hospice services with multiple diagnoses, including a brain bleed, was found on the floor with a laceration above the right eye. The facility failed to thoroughly investigate the incident, lacking interviews with key staff and detailed documentation of the resident's condition and preventive measures. Inconsistencies in records and inadequate assessment of the resident's fall risk contributed to the deficiency.
Two residents did not receive prescribed antibiotics due to transcription errors and failure to order from the pharmacy. One resident with a toe injury and another with severe burns were affected. The DON acknowledged the oversight and lack of a 24-hour chart check.
Failure to Maintain Clean and Safe Shower Rooms
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment in its shower rooms, as evidenced by multiple resident and staff interviews and direct observations. Several residents reported refusing to use the 100-hall shower room due to persistent unpleasant odors described as similar to soiled diapers, sewage, or urine. Staff corroborated these complaints, noting that the odor was strong and that some residents would not use the shower room because of it. Observations confirmed the presence of a strong urine and sewage-like odor, soiled linens in unlabeled garbage cans, a fabric chair with brown and white stains, and shower chairs with brown substances on the seat area. Large garbage cans, one without a liner and half full of briefs and trash, contributed to the odor, and the trash was not being emptied regularly according to staff interviews. In addition to odor issues, the physical condition of the shower rooms was found to be in disrepair. The south 300 hallway shower room had missing and broken tiles at the base of a divider wall, and the Maintenance Director acknowledged that the open gap between tiles could allow humidity to penetrate the wall, potentially causing further damage. Mold was observed around a sprinkler head and in a corner with a large water spot, and the toilet in the 200-hall shower room was out of order due to a broken main pipe and was covered with a plastic sheet. These maintenance issues were confirmed by the Maintenance Director, who stated that repairs were needed but had not been requested until a recent resident complaint. Communication and reporting of these issues were inconsistent. While some CNAs reported entering complaints into the maintenance system, others were unsure if the system was being utilized. The Assistant Director of Nursing was unaware of any complaints regarding the odor, and there was confusion among staff about responsibilities for emptying trash and reporting maintenance needs. Housekeeping staff stated that shower rooms were cleaned daily with disinfectant, odor control, and floor cleaner, but persistent odors and cleanliness issues remained. The Administrator was aware of the ongoing odor problem and noted that a plumber had previously worked on the issue, but the problem persisted intermittently.
Failure to Provide Palatable, Attractive, and Safe-Temperature Food
Penalty
Summary
The facility failed to provide food that was palatable, attractive, and served at a safe and appetizing temperature for a significant number of residents. Multiple residents reported that the food was often cold, bland, unappetizing, and sometimes unidentifiable. Several residents described the food as processed, lacking in variety, and not meeting their nutritional needs, with some specifically noting insufficient protein and small portion sizes. Observations confirmed that salads were not kept at the required temperature, with temperatures recorded well above the safe threshold prior to serving. Additionally, test trays revealed that hot foods were bland and cold foods, such as milk and salad, were served at improper temperatures. Resident council minutes and grievance forms documented ongoing complaints about food quality, including issues with food temperature, lack of adherence to meal tickets, and dissatisfaction with the taste and nutritional content of meals. Residents also reported receiving food items they disliked or were not supposed to have, and some noted that requests for snacks or alternative items were not accommodated. These complaints were consistent over several months, indicating a pattern of unresolved issues related to food service. Interviews with dietary staff and facility administration revealed a lack of awareness regarding the extent of the food quality and temperature issues. The Dietary Manager acknowledged that salads should have been kept refrigerated until use and recognized that improper handling led to elevated temperatures. The Administrator was unaware of the temperature problems and only generally aware of resident dissatisfaction with the food. These findings demonstrate that the facility did not ensure food was consistently palatable, attractive, and served at safe temperatures, as required.
Unsanitary Food Handling and Surface Cleaning Deficiencies
Penalty
Summary
During a lunch service tray line, multiple instances of unsanitary food handling practices were observed among dietary staff. One dietary aide donned gloves and then touched various surfaces, including a thermometer, sink, and refrigerator handle, before touching the face of plates with the same gloved hand. A cook was also seen wearing gloves while touching oven doors, sink handles, and a spatula handle, then touching the face of plates prior to plating food for residents. Additionally, the cook slid plates across a white cutting board and used the same board to chop carrots without cleaning it before or after use. The chopped carrots were then plated and served to residents. Another staff member repositioned food on plates with gloved hands after touching multiple surfaces, including plates, covers, fridge door, cart, and sink handles, without performing hand hygiene or changing gloves before handling the food. Interviews with the cook and the dietary manager confirmed that staff should not touch the face of plates or food with dirty gloves and that gloves should be changed between tasks. Both acknowledged that the white cutting board, used for chopping food for mechanically soft diets, was not cleaned prior to use, despite being used to move plates along the tray line. The dietary manager admitted that this practice was inappropriate as the surface was dirty at the time food was prepared on it.
Failure to Offer and Administer Required Vaccinations
Penalty
Summary
The facility failed to ensure that residents were properly offered and administered influenza, pneumococcal, and COVID-19 vaccines as required. Specifically, two residents had signed consent forms indicating their acceptance of the 2024/2025 COVID-19 booster, but there was no documentation that the booster was administered to them. Additionally, one resident did not have any documentation showing that they were offered the influenza or COVID-19 booster vaccines for the 2024/2025 season. These findings were based on interviews and record reviews conducted by surveyors. The residents involved had various medical conditions, including epilepsy, chronic systolic heart failure, and Alzheimer's disease. The facility's process included obtaining vaccination consents during admission and pre-ordering vaccines, but the records reviewed did not show that the required vaccines were offered or administered as indicated by the residents' consents. The Regional Nurse Consultant confirmed the lack of documentation and administration for the affected residents.
Residents Denied Timely Access to Personal Funds
Penalty
Summary
The facility failed to provide two residents with ready and reasonable access to their personal funds, despite having been authorized to manage these funds. One resident reported being unable to access her money on weekends because no staff member with access to the funds was available outside of weekday business hours. She was told she would have to wait until Monday to obtain her money. Another resident had previously filed a grievance stating that there was no one available to distribute money on weekends, and the business office confirmed that funds were only accessible during the week. Interviews with facility staff, including the Business Office Manager and the Administrator, confirmed that residents could not access their funds on weekends. The Business Office Manager stated he was solely responsible for distributing funds and only worked Monday through Friday. The Administrator acknowledged gaps in the process, including times when no staff were available to distribute funds and instances when there was no cash available due to delays in obtaining money from the corporate office. These actions and inactions resulted in residents not having reasonable access to their personal funds as required.
Delay in Suture Removal Following Hospital Discharge
Penalty
Summary
A resident with a history of Alzheimer's disease, generalized anxiety disorder, lack of coordination, and major depressive disorder was admitted to the facility following a fall that resulted in a fractured nose and knee. Upon return from the hospital, the resident had sutures placed on the bridge of her nose and a brace on her left leg, with hospital discharge instructions specifying that the sutures should be removed in 7 days. Observations made more than two weeks after the incident revealed that the sutures were still present, with scabs forming over them, and the resident was seen tugging at the sutures. Interviews with facility staff indicated a lack of clarity regarding the appropriate timeframe for suture removal. One LPN believed the sutures should remain for 14-21 days, while the Director of Nursing confirmed that the sutures should have been removed on the date specified in the hospital discharge instructions. The delay in suture removal demonstrated that the resident did not receive care in accordance with professional standards of practice, the comprehensive care plan, or the resident's preferences and goals.
Failure to Maintain Complete Laboratory Records in Resident Chart
Penalty
Summary
A deficiency was identified when the facility failed to maintain complete, dated laboratory records in a resident's clinical record. Specifically, for one resident with multiple complex diagnoses, including benign neoplasm of the brain, chronic respiratory failure with hypoxia, heart failure, chronic obstructive pulmonary disease, and epilepsy, laboratory results for serum phenytoin and phenobarbital were not found in the electronic medical record. The pharmacy had recommended these labs due to the resident's medication regimen, and the attending physician had agreed to the orders. However, a review of the resident's chart revealed that no such lab results were present for the past six months, and there were no routine orders in place for these labs to be drawn. Interviews with facility staff revealed that diagnostic results were sent to medical records to be scanned and uploaded into the electronic medical record. The DON stated that this process typically took about a week, while the medical records staff indicated that she aimed to upload records the same day she received them and then destroyed the originals. Despite these procedures, the required laboratory reports for the resident were not located in the electronic medical record, resulting in incomplete documentation.
Missing Signed and Dated Chest X-ray Report in Resident Record
Penalty
Summary
A deficiency was identified when the facility failed to file a signed and dated chest x-ray report in the clinical record of a resident who was being treated for pneumonia. The resident, who had a history of chronic respiratory failure with hypoxia, transient cerebral ischemic attack, and chronic obstructive pulmonary disease, was admitted with these diagnoses and subsequently received two different antibiotics for infectious pneumonitis and pneumonia. Documentation in the medical record included orders for Amoxicillin-Potassium Clavulanate and Doxycycline, as well as nursing notes referencing the treatment for pneumonia. Despite the clinical indications and treatment for pneumonia, a review of the resident's medical record revealed that the chest x-ray report, which would have confirmed the diagnosis, was not present in the file. Interviews with nursing staff and the regional nurse consultant confirmed that a chest x-ray would have been ordered to support the diagnosis, but the report was not located in the record at the time of review. The absence of a signed and dated radiological report in the resident's clinical record constituted the deficiency.
Failure to Accommodate Documented Food Allergies
Penalty
Summary
A deficiency occurred when a resident with documented allergies, including peas, was served fried rice containing peas. The resident reported that she is allergic to peas due to an enzyme deficiency that causes her stomach upset, and stated that she is served foods she is allergic to at least once a week. Observation confirmed the presence of peas on her lunch tray, and the meal ticket clearly listed peas as an allergy and as a strong dislike. The resident's medical record and care plan both documented her allergies, including peas, and her history of multiple medical conditions such as IBS, GERD, obesity, and eating disorders. Despite these documented allergies and clear instructions on the meal ticket, the resident continued to receive foods containing her allergens. A previous grievance report indicated that the resident had complained about being served her allergens, and staff had been educated on the issue. However, the deficiency persisted, as evidenced by the recent incident where the resident was again served peas. The Dietary Manager acknowledged that allergies are highlighted on meal tickets and that multiple staff are supposed to check trays, but was unable to explain how the error occurred.
Non-Functioning Call Light System in Shower and Bathing Areas
Penalty
Summary
The facility failed to ensure that a functioning call system was available in each resident's bathroom and bathing area, as required. Observations revealed that in the 200 and north 300-hall shower rooms, at least one call light was not operational, and there were no cords attached to the call lights in the 100, 200, and north 300-hall shower rooms. Multiple residents and staff confirmed that the call lights either did not work or were missing cords, making it impossible for residents to call for assistance if needed. In one instance, a resident reported concern about being unable to summon help if she became stuck in the shower. Another resident stated that the call light in the 200-hall shower room had not worked since repairs were made, and staff had to remain present during his showers due to the non-functioning system. Further observations showed that in some shower rooms, the call light switches were present but lacked cords, and in at least one case, activating the call light did not result in any visible signal in the hallway. Staff interviews confirmed awareness of the issue, with maintenance staff noting that cords should be long enough to reach residents on the floor, and CNAs describing the need to check on residents frequently due to the lack of a working call system. The facility administrator acknowledged that the call light system was old and prone to frequent bulb outages, and that audits of the system had only recently begun.
Inadequate Supervision and Safety Measures Lead to Resident Elopements
Penalty
Summary
The facility failed to ensure a safe environment for residents, leading to two significant incidents involving elopement and inadequate supervision. Resident 26, who had a history of wandering and was identified as a high elopement risk, managed to leave the facility without staff knowledge. Despite having a wander guard, the resident was able to remove it and elope, resulting in severe burns after falling on hot pavement. The resident's medical history included cognitive impairments and a history of wandering, which were not adequately addressed by the facility's safety measures. In another incident, Resident 10, who was admitted with conditions such as Wernicke's encephalopathy and alcohol abuse, also eloped from the facility. The resident was found outside the facility on two occasions, despite having a wander guard. The facility's records indicated that the resident was confused and exhibited wandering behaviors, yet the safety measures in place were insufficient to prevent the elopements. The facility's doors did not have a comprehensive wander guard system, and the alarms were either not functioning or not responded to by staff. Both incidents highlight the facility's failure to maintain a secure environment and provide adequate supervision for residents at risk of elopement. The lack of effective monitoring and the inability to ensure that safety devices were properly used and maintained contributed to these deficiencies. The facility's response to these incidents, including the submission of investigations to the State Survey Agency, confirmed the occurrences but did not prevent the initial failures in resident safety.
Deficiencies in Wound Care and Documentation
Penalty
Summary
The facility failed to provide appropriate treatment and care according to professional standards and the residents' care plans for two residents. Resident 15, who was admitted with multiple diagnoses including congestive heart failure and difficulty walking, suffered a laceration and dislocation of the right fifth toe after an incident involving a wheelchair. Despite hospital discharge instructions to buddy tape the toes and monitor the wound, the facility did not document the completion of dressing changes or monitoring for infection. Additionally, there was a four-day delay in implementing the ordered Medihoney treatment for the wound, and the resident's toe was noted to be discolored and detached. Resident 26, who had a history of hemiplegia, epilepsy, and burns, did not have documented measurements for their burn wounds on the back and buttocks. The resident sustained second and third-degree burns after an incident involving methamphetamine use and prolonged exposure to hot pavement. Although the facility had a wound nurse and NP to assess wounds weekly, the NP was unable to obtain accurate measurements due to the nature of the burns. The lack of documented measurements hindered the ability to track wound healing and make necessary adjustments to the care plan. The Director of Nursing acknowledged the importance of wound measurements for assessing healing and adjusting care but confirmed that measurements were not consistently documented for Resident 26. This oversight in documentation and treatment implementation for both residents indicates a failure to adhere to professional standards and the residents' comprehensive care plans, resulting in deficiencies in the care provided.
Inadequate Cleaning Practices in Resident Shower Rooms
Penalty
Summary
The facility failed to maintain a sanitary, orderly, and comfortable environment in the resident shower rooms, as evidenced by the presence of black spots on the lower corner baseboard near the shower entrance. Observations made on the 200-hall resident shower room revealed these black spots, which were identified by the Administrator as potentially being mold or moisture spots requiring a deep clean. This deficiency was noted during an observation conducted on August 13, 2024. Interviews with facility staff revealed inconsistencies in the cleaning responsibilities and practices for the shower rooms. Housekeeping staff indicated that certified nursing assistants (CNAs) were responsible for cleaning the resident shower rooms, while housekeeping only cleaned resident rooms and common areas. A CNA stated that housekeeping cleaned the showers once a week, and CNAs were responsible for cleaning up after resident showers, including sanitizing shower chairs. The Assistant Director of Nursing confirmed that housekeeping disinfected shower floors and toilets, but the presence of black spots suggested inadequate cleaning practices.
Failure to Investigate Allegation of Neglect
Penalty
Summary
The facility failed to thoroughly investigate an allegation of neglect involving a resident who was admitted on hospice services with multiple diagnoses, including traumatic subdural hemorrhage and chronic obstructive pulmonary disease. The incident occurred when the resident was found on the floor with a laceration above the right eye. The staff did not conduct a comprehensive investigation to determine the circumstances leading to the fall, such as the resident's condition prior to the fall, the position of the bed, or whether routine checks were being performed. The report highlights that the resident was a high fall risk due to increased weakness and disorientation, as noted in hospice documentation. Despite this, there was no evidence that the facility had adequately assessed or documented the resident's risk factors or preventive measures in place at the time of the incident. The facility's records did not include interviews with the CNA who discovered the resident or detailed information about the resident's condition before the fall. Additionally, there were inconsistencies in the documentation regarding the resident's primary diagnosis and the use of the term "terminal agitation" after the fall. The nurse involved in the incident later stated that they would not have used the term "terminal agitation" and believed that routine checks were being conducted, although they were unsure of the specifics. This lack of thorough investigation and documentation contributed to the deficiency identified by the surveyors.
Failure to Administer Prescribed Antibiotics
Penalty
Summary
The facility failed to ensure that two residents were free from significant medication errors. Resident 15, who was admitted with multiple diagnoses including congestive heart failure and difficulty swallowing, suffered a laceration and dislocation of the right fifth toe after an incident involving his wheelchair. The emergency department prescribed Cephalexin to prevent infection, but the medication was neither transcribed onto the medication administration records (MARs) nor ordered from the pharmacy, resulting in the resident not receiving the prescribed antibiotics. Resident 26, who was readmitted with severe burns and other complex medical conditions, also did not receive prescribed antibiotics. An order for Keflex was issued to treat the burns, but it was not transcribed into the electronic medical record. Despite an interdisciplinary review identifying this oversight, the antibiotics were not administered in a timely manner. The Director of Nursing acknowledged the failure to implement the order and the lack of a 24-hour chart check to ensure new orders were followed.
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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