South Ogden Post-acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Ogden, Utah.
- Location
- 5540 South 1050 East, Ogden, Utah 84405
- CMS Provider Number
- 465117
- Inspections on file
- 38
- Latest survey
- August 21, 2025
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at South Ogden Post-acute during CMS and state inspections, most recent first.
The facility failed to provide adequate kitchen staffing, resulting in late meal services. Observations showed breakfast and dinner were served later than scheduled, with residents filing grievances about meal timing and quality. Staffing challenges, including recent staff departures and incomplete training, contributed to the deficiency.
A facility failed to maintain an effective infection prevention and control program, as a resident's feeding tube was repeatedly observed uncapped and improperly handled, and staff did not use PPE during high-contact care. The resident, with serious medical conditions, was on Enhanced Barrier Precautions, but staff were unaware or did not adhere to protocols, indicating a deficiency in infection control practices.
The facility failed to provide food and drink that were palatable, attractive, and at a safe temperature. Several residents expressed dissatisfaction with the food quality, noting issues such as bad taste, inconsistency, and cold meals. Grievances were filed about hard English muffins, coffee shortages, and late, cold dinners. A test tray revealed soggy onion rings and improperly prepared beets. The Dietary Manager acknowledged addressing complaints and training staff, but issues persisted.
The facility failed to accurately assess two residents for serious mental illness, as indicated by their PASRR level II evaluations. The MDS assessments incorrectly marked them as not having a serious mental illness, despite diagnoses such as schizophrenia and schizoaffective disorder. The current MDS Coordinator acknowledged the error and showed a misunderstanding of conditions indicating serious mental illness.
Two residents did not receive timely vision and hearing services. One resident needed new glasses but had not been seen by an eye doctor despite a referral. Another resident reported difficulty hearing and a need for glasses, but no referrals were made. The facility failed to ensure these residents received necessary assessments and assistive devices.
A resident with a high fall risk was not provided with adequate supervision or assistance devices to prevent falls. Despite multiple incidents and a high Morse fall risk score, the resident was observed ambulating without a walker and without staff supervision. Staff interviews revealed a lack of consistent monitoring, and the absence of a reminder sign in the resident's room further contributed to the deficiency.
A resident with hypertension and other health conditions received blood pressure-lowering medications despite having systolic blood pressure readings below the physician-specified parameters. Nursing staff failed to hold the medication and notify the physician as expected, leading to the administration of unnecessary drugs.
A resident received five doses of oxycodone due to a transcription error in the MAR, where the medication order was mistakenly assigned to the wrong resident. The error was discovered after the resident reported not receiving her pain medication, leading to a review of her medical records. The ADON identified the mistake as a result of misordered physician orders and took steps to discontinue the incorrect order.
A resident with multiple health issues did not receive necessary dental care for missing teeth, nor did she receive a vision assessment, new glasses, or a hearing aid evaluation. The facility's social services department failed to submit referrals for these services, resulting in unmet care needs.
A resident with known allergies to fish and shellfish was served a crab cake, leading to an allergic reaction. Despite the allergies being documented in the medical record, the information was not included in the care plan, and staff were unaware of the allergies. The resident experienced a sore throat and rash, requiring Benadryl administration. The facility's dietary staff later reinforced the importance of checking meal tickets for allergies.
The facility failed to adhere to food safety standards, with the dish machine not reaching required sanitizing temperatures and lacking functional chemical strips for monitoring. Observations showed improperly stored food items and inadequate thawing practices. Interviews revealed insufficient monitoring and corrective actions by the CDM and RD, with discrepancies in temperature logs and improper dishwashing procedures.
A long-term care facility failed to maintain effective infection control practices, as staff were observed not performing hand hygiene between assisting residents with meals. Additionally, after a staff member tested positive for COVID-19, mask-wearing protocols were inconsistently followed, and there was confusion about exposure risk criteria. These deficiencies indicate lapses in adhering to the facility's infection prevention and control policies.
The facility failed to provide adequate respiratory care for four residents, lacking physician orders for oxygen use and improperly labeled oxygen tubing. A resident with COPD did not have a physician order for oxygen, and observations revealed the oxygen concentrator was running without proper use. Another resident had outdated oxygen equipment with no documentation of changes. The CNAC was responsible for changing supplies but did not document these changes, leading to deficiencies identified by surveyors.
The facility failed to secure medications properly, as observed when a medication cup was left unattended on an unlocked cart and a pill was found on the floor. Staff interviews confirmed that medications should not be left unattended and carts should be locked, highlighting lapses in medication management.
The facility failed to provide palatable and attractive food at safe temperatures for several residents. Complaints included bland, soggy, or improperly cooked meals, and issues with food presentation and availability. A test tray confirmed the food was not appealing or palatable. Despite monthly discussions, the facility did not resolve these concerns.
A resident received an incorrect dosage of Furosemide due to a failure to discontinue a previous 40 mg order when a new 20 mg order was issued. The resident received both doses on two separate days, resulting in a total of 60 mg being administered. The nursing staff was unaware of the need to discontinue the old order, and the resident was not informed of the medication change in advance.
A resident with multiple health conditions experienced food getting caught in the area of a recent tooth extraction, but the facility failed to document any monitoring or care adjustments. The DON admitted that staff should have monitored the resident's eating ability and pain control, but no progress notes were found in the medical records.
A resident with a history of unsafe smoking practices and cognitive impairments was observed smoking unsupervised, despite requiring supervision. The resident obtained cigarettes from others and smoked without staff present, contrary to the facility's policy. Staff interviews and documentation revealed inconsistencies in enforcing the resident's smoking supervision, leading to the deficiency.
A resident with a history of dysphagia was not receiving tube feeding at the updated prescribed rate, as recommended by the RD. Despite the RD's recommendation to adjust the feeding schedule to facilitate oral intake and prevent weight gain, the facility continued with the previous order. This indicates a communication gap and failure to implement dietary changes as per the facility's enteral nutrition policy.
A resident with chronic respiratory issues and on hospice care was observed coughing after consuming liquids, indicating potential aspiration. Despite being on a pureed diet, staff were unaware or unsure of how to address the issue. A dysphagia evaluation later confirmed the resident's risk of aspiration with various liquid consistencies.
The facility failed to prevent sexual abuse between two residents and neglected to supervise another resident, leading to their elopement. Resident 269, with severe cognitive impairment, was found naked on top of Resident 270, who was nonverbal. The incident occurred due to inadequate supervision. Separately, Resident 17, with a history of wandering, eloped from the facility due to a lack of a coordinated supervision plan.
The facility failed to maintain a safe environment and provide adequate supervision for residents, resulting in multiple falls and injuries for a resident with a history of falls. Additionally, medications were found on the floor in a resident's room, indicating a failure to follow proper medication administration protocols.
A resident with a fractured humerus was not consistently provided with a shoulder immobilizer as ordered, leading to significant pain. Despite the resident's repeated requests and documented pain levels, staff failed to ensure the immobilizer was worn daily, resulting in the resident feeling neglected and in severe pain.
The facility failed to implement policies to prevent abuse and assess residents' capacity to consent, leading to incidents of kissing among cognitively impaired residents without proper evaluation. Despite monitoring efforts, the interactions continued, highlighting deficiencies in the facility's procedures.
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards, as multiple observations showed uncovered food and drinks being delivered to resident rooms. The Dietary Manager confirmed that all food should be covered, but staff did not consistently follow these guidelines.
The facility failed to maintain effective infection control during a COVID-19 outbreak, with multiple staff members observed without PPE and improper handling of dirty linens. A resident with a complex medical history tested positive for COVID-19, and the facility delayed informing the public and reporting the outbreak to health authorities.
The facility failed to provide a safe, clean, comfortable, and homelike environment as required. Observations revealed that paper towel dispensers in several bathrooms of the memory care unit were not functioning. Interviews with housekeeping and maintenance staff indicated a lack of communication and responsibility regarding the maintenance of these dispensers.
A resident with multiple health conditions waited 35 minutes for feeding assistance after their meal was served. Staff interviews revealed inconsistencies in the process of assisting residents with feeding, leading to delays in providing necessary help.
A resident admitted on hospice care was not assessed upon admission, did not receive appropriate medications, and was not transferred to the memory care unit until the following day after the family requested it. The medical record showed discrepancies in medication orders and administration, and the admission assessments were left blank until several days after admission. Communication issues and lack of proper documentation were highlighted in interviews with staff.
A resident requiring continuous oxygen therapy was observed multiple times without their oxygen nasal cannula properly placed, and staff failed to reapply it. Despite the resident's chronic respiratory failure with hypoxia, staff did not follow the care plan or physician's orders, leaving the resident without necessary respiratory support for extended periods.
A facility failed to ensure that PRN orders for psychotropic medications were limited to 14 days and evaluated every 14 days by a physician. A resident with multiple diagnoses, including bipolar disorder and dementia, had a PRN order for a cream containing Haldol, Benadryl, and Ativan that was not limited to 14 days, and the required evaluations were not documented. The resident exhibited aggressive behaviors, and the PRN cream was used without adhering to the necessary limitations and evaluations.
A resident with hypertension did not receive her prescribed blood pressure medications due to confusion during the admission process. Discrepancies between the hospice physician's orders and the facility's medical record led to a delay in administering the correct medications. Interviews with staff revealed inconsistencies in the medication orders provided and entered into the medical record.
The facility failed to ensure that a feeding assistant had completed a state-approved training course before providing feeding assistance. The Dietary Manager, who was not certified, was observed assisting a resident with feeding, despite the resident's care plan indicating the need for extensive assistance.
The facility did not maintain accurate medical records for two residents. One resident's record contained another resident's fall report, and another resident's record included a care plan belonging to a different resident. The DON confirmed that resident information should be correctly documented.
The facility failed to ensure proper coordination and documentation of hospice services for a resident with vascular dementia and other conditions. Issues included lost medications, poor communication between hospice and facility staff, and discrepancies in medication orders and administration. Additionally, there was no hospice plan of care in the resident's medical record, and the facility did not follow grievance procedures for the family's concerns.
Insufficient Kitchen Staffing Leads to Late Meal Service
Penalty
Summary
The facility failed to provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service, resulting in late meal services. Surveyors observed that breakfast and dinner were served later than the posted meal times on multiple occasions. Specifically, breakfast was not completed until 8:52 AM, and dinner service extended beyond the scheduled time, with the last tray served at 5:57 PM. Residents expressed dissatisfaction with the timing of meals, and grievances were filed regarding late and cold meals. The Ombudsman confirmed ongoing concerns about meal timing and quality, with reports of dinner being served as late as 7:00 PM. Interviews with the facility's Administrator and Dietary Manager revealed staffing challenges as a contributing factor to the deficiency. The facility had previously reduced kitchen staff due to a drop in census, but an increase in census and recent staff departures left the kitchen understaffed. The Dietary Manager acknowledged that new staff training was incomplete, impacting meal service timeliness. The Administrator noted that a no-show cook contributed to the late breakfast service on one occasion. Despite recent hiring efforts, the facility continued to face difficulties with staff retention and ensuring timely meal service.
Infection Control Deficiency: Improper Handling of Feeding Tube and PPE Use
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the improper handling of a resident's feeding tube and the lack of appropriate use of Personal Protective Equipment (PPE) by staff. Specifically, for one resident, the feeding tube was observed on multiple occasions to be uncapped and either lying on the floor or hanging from an IV pole, which could lead to contamination. The resident, who was admitted with diagnoses including encephalopathy, acute kidney failure, and adult failure to thrive, was on Enhanced Barrier Precautions (EBP) due to the feeding tube. Despite this, the facility staff did not adhere to the necessary precautions, as evidenced by a Certified Nursing Assistant (CNA) exiting the resident's room with a used brief without wearing PPE. Interviews with facility staff revealed a lack of awareness and adherence to the EBP protocols. The CNA was unsure if the resident was under EBP, and the Registered Nurse (RN) admitted to not capping the feeding tube when it was disconnected, contrary to the Director of Nursing's (DON) statement that the tube should be capped and hung on an IV pole when not in use. This lack of compliance with infection control measures highlights a deficiency in the facility's infection prevention and control program, as staff failed to follow established protocols for handling feeding tubes and using PPE during high-contact care.
Food Quality and Temperature Deficiency
Penalty
Summary
The facility failed to ensure that food and drink provided to residents were palatable, attractive, and served at a safe and appetizing temperature. Surveyors observed and interviewed several residents who expressed dissatisfaction with the quality of food. Resident 2 mentioned that the food often tasted bad, while Resident 40 noted that the food quality was inconsistent, being worse on weekends. Resident 63 generally found the food acceptable but occasionally unappetizing. Resident 26 reported being served cold cheese pizza on Christmas and described the soups as watered down. Resident 72 specifically criticized the potato soup for tasting like potato and water. Additionally, grievances were filed by residents regarding the quality and temperature of the food, including complaints about hard English muffins, frequent shortages of coffee, and late, cold dinners. During a test tray sampling by surveyors, the dinner meal consisting of chicken tenders, onion rings, pickled beets, and a fruit cup was found to be unsatisfactory. The onion rings were soggy, and the beets were not pickled as described on the menu, with beet juice dripping onto the onion rings. The Dietary Manager acknowledged that food complaints were addressed in the facility's food council and mentioned that kitchen staff were trained to follow meal preparation instructions. Each resident had a tray card listing their diet order and other pertinent information, but the issues with food quality persisted, as evidenced by the observations and resident interviews.
Inaccurate Resident Assessments for Serious Mental Illness
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected the residents' status, specifically regarding the presence of serious mental illness. For two residents, the assessments incorrectly indicated that they did not have a serious mental illness, despite their Preadmission Screening and Resident Review (PASRR) level II assessments documenting otherwise. Resident 45, who was diagnosed with paranoid schizophrenia, generalized anxiety disorder, post-traumatic stress disorder, and major depressive disorder, was marked as not having a serious mental illness on their Minimum Data Set (MDS) assessment. This was contrary to their PASRR level II evaluation, which confirmed the presence of a serious mental illness. Similarly, Resident 68, diagnosed with anxiety disorder and schizoaffective disorder depressive type, was also incorrectly assessed as not having a serious mental illness on their MDS assessment. The PASRR level II evaluation for this resident also indicated a serious mental illness. The MDS Coordinator, upon interview, acknowledged that the assessments were completed by a previous coordinator and expressed a need to review them. The coordinator also demonstrated a misunderstanding of the conditions that should be marked as serious mental illness, citing autism and epilepsy as examples.
Deficiency in Timely Vision and Hearing Services
Penalty
Summary
The facility failed to ensure that residents received timely vision and hearing services, resulting in deficiencies for two residents. Resident 63, who was admitted with type 2 diabetes mellitus, expressed a need for new glasses but had not been seen by an eye doctor despite a referral being sent in January. The Resident Advocate confirmed that the in-house vision provider had not updated their data census and that it was inappropriate for a resident to wait a quarter to be seen if they needed glasses. The resident had been added to the eye doctor list, but there was no follow-up to ensure the resident received the necessary services. Resident 2, admitted with chronic obstructive pulmonary disease, heart failure, dysphagia, and cognitive communication deficit, reported difficulty hearing and a need for new glasses. Despite notifying social services of these needs, no referrals were made for vision or hearing services. The Resident Advocate acknowledged that a different social worker was responsible for handling referrals at the time of admission and that no referral had been submitted for Resident 2. The facility's failure to act on these requests resulted in the residents not receiving the necessary assessments and assistive devices.
Failure to Prevent Falls for High-Risk Resident
Penalty
Summary
The facility failed to ensure that the environment was free from accident hazards and that adequate supervision was provided to prevent accidents for a resident identified as a high fall risk. Resident 81, who was admitted with diagnoses including dementia and chronic pain syndrome, had a Morse fall risk score of 90, indicating a high risk for falls. Despite this, interventions to prevent falls were not effectively implemented. Observations revealed that Resident 81 was ambulating without a walker and without staff supervision, and there was no signage in his room to remind him to use the call light for assistance. Multiple incidents of falls were documented for Resident 81, with interventions put in place after each fall. However, these interventions were not consistently effective or adhered to. For instance, on one occasion, Resident 81 fell while trying to open a door from his wheelchair, and on another, he fell while reaching for a tissue box. Despite these incidents, staff were not consistently present to supervise or assist Resident 81, and he continued to ambulate without a walker, increasing his risk of falls. Interviews with staff, including RNs and CNAs, highlighted that Resident 81 was known to be a fall risk and required frequent checks and assistance when ambulating. However, staff were not always present to provide the necessary supervision, and the resident often returned to his room unsupervised. The Director of Nursing and Assistant Director of Nursing were unaware that the sign reminding Resident 81 to use his call light was missing, indicating a lack of communication and oversight in ensuring the resident's safety measures were in place.
Failure to Monitor Blood Pressure Parameters for Medication Administration
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs due to inadequate monitoring. Specifically, nursing staff administered blood pressure-lowering medications to a resident when the resident's blood pressure was below the parameters specified by a physician's order. The resident, who had a history of essential primary hypertension, type 2 diabetes mellitus with hyperglycemia, mixed hyperlipidemia, and severe morbid obesity, was given metoprolol succinate and hydrochlorothiazide despite having systolic blood pressure readings below the threshold set by the physician. On two occasions, the resident received metoprolol succinate when their systolic blood pressure was recorded as 90 and 101, both below the physician's specified parameter of less than 110. Additionally, the resident received hydrochlorothiazide when their systolic blood pressure was 101. Interviews with registered nurses and the Director of Nursing revealed that the expectation was to hold the medication and notify the physician if the blood pressure was outside the specified parameters, which was not followed in this case.
Medication Error Due to Transcription Mistake
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by a mix-up in physician orders that led to a resident receiving medication not intended for them. Specifically, a physician's order for oxycodone was mistakenly transcribed to the wrong resident's Medication Administration Record (MAR), resulting in the resident receiving five doses of the medication. The resident, identified as Resident 60, was admitted with diagnoses including osteomyelitis of the vertebra, cauda equina syndrome, stimulant abuse, and discitis. The error was discovered when Resident 60 reported not receiving her pain medication since a specific date, prompting a review of her medical records. The Assistant Director of Nursing (ADON) explained that the error occurred due to a mix-up in the physician orders, which were emailed to the facility and split between two ADONs for entry into the MAR. On the day of the mistake, the pages of the orders were out of sequence, leading to the incorrect transcription. The ADON realized the error after speaking with the Medical Director and the resident, and the order was subsequently discontinued. The ADON also noted that the nurse on duty had expressed concerns about the resident potentially diverting the medication, which led to a temporary change in the administration method before the error was fully recognized.
Failure to Provide Necessary Dental and Other Services
Penalty
Summary
The facility failed to provide or obtain necessary dental services for a resident, identified as Resident 2, who was admitted with multiple diagnoses including chronic obstructive pulmonary disease, heart failure, dysphagia, and cognitive communication deficit. Despite the resident's expressed need for dental care due to missing teeth, the facility did not arrange for these services. Additionally, the resident reported not receiving a vision assessment, new glasses, or a hearing aid evaluation during her stay. The deficiency was further compounded by a lack of communication and follow-through within the facility's social services department. The Resident Advocate (RA) acknowledged that a previous social worker was responsible for handling referrals at the time of Resident 2's admission but failed to do so. The RA admitted to being unaware of the resident's requests and confirmed that no referrals for dental, vision, or hearing services had been submitted for Resident 2. This oversight resulted in the resident not receiving the necessary care and services to address her needs.
Failure to Accommodate Resident's Food Allergies
Penalty
Summary
The facility failed to ensure that a resident with known food allergies received meals that accommodated these allergies. A resident with allergies to fish and shellfish was mistakenly served a crab cake, which led to an allergic reaction. The resident, who has cerebral palsy, type 2 diabetes mellitus, anxiety disorder, hyperlipidemia, and adult failure to thrive, experienced a sore throat and rash after consuming the meal. A registered nurse quickly administered Benadryl to mitigate the allergic reaction. The resident's medical record clearly listed allergies to fish and shellfish, but this information was not included in the resident's care plan. Interviews with facility staff revealed a lack of awareness and communication regarding the resident's allergies. The registered dietitian and certified dietary manager were unaware of the resident's allergies, despite the information being documented in the medical record and dietary profile. The facility's menu included Krabbycakes, which were served on the day of the incident. The dietary manager later held a meeting to emphasize the importance of checking meal tickets for allergies, but the initial oversight led to the resident's exposure to allergens.
Food Safety and Sanitation Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. During an initial walkthrough in the kitchen, it was observed that the dish machine was not reaching the required temperature to sanitize dishes, with wash and rinse temperatures recorded at 115 and 120 degrees Fahrenheit, respectively. Additionally, the facility lacked functional chemical strips to monitor the sanitizer levels in the dish machine and sanitation buckets, as the available strips were expired and no additional strips were found. Further observations revealed that food items in the freezer and dry storage room were improperly stored, with containers of cold cereal, beef pattie fritters, and Salisbury steak patties left open to air. Hot dogs were also observed sitting in water in a sink without running water, indicating improper thawing practices. The temperature log for the dish machine showed inconsistencies, with some entries missing and others showing incorrect chemical readings. Interviews with the Certified Dietary Manager (CDM) and Registered Dietitian (RD) highlighted a lack of proper monitoring and corrective actions. The CDM acknowledged issues with the dish machine's sanitizer suction and stated that staff were required to check temperatures during each meal cycle, but the logs showed discrepancies. The RD's inspections did not include verifying dish machine temperatures, relying instead on the temperature log. The CDM also noted that if the dish machine was not functioning properly, staff should use a three-compartment sink for dishwashing, but this procedure was not observed during the survey.
Inadequate Infection Control Practices in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple instances of inadequate hand hygiene practices during meal assistance. On several occasions, a Certified Nursing Assistant (CNA) was observed assisting multiple residents with eating without performing hand hygiene between residents. This included feeding residents, adjusting feeding tube pumps, and touching personal items such as face masks and hair without sanitizing hands. Interviews with staff, including the CNA and the Director of Nursing (DON), confirmed that hand hygiene was not consistently practiced as required, despite the facility's policy mandating hand sanitization between resident interactions. Additionally, the facility's response to a staff member testing positive for COVID-19 was inadequate. Although some staff were observed wearing masks, the DON was seen without a mask in a designated area where mask-wearing was required due to potential exposure. The facility's contact tracing efforts identified two residents as high-risk exposures, but there was confusion among staff regarding the rationale for mask usage and the criteria for determining exposure risk. The DON admitted to a lack of awareness regarding the cumulative nature of exposure time, which affected the implementation of appropriate infection control measures. The facility's Infection Prevention and Control Program Policy and Procedure, revised in February 2024, outlines the need for a comprehensive infection control program, including surveillance, data analysis, and outbreak management. However, the observed deficiencies indicate a failure to adhere to these established protocols, particularly in the areas of hand hygiene and COVID-19 source control. The lack of consistent hand hygiene practices and the improper use of masks during a COVID-19 exposure event highlight significant lapses in the facility's infection control efforts.
Deficiencies in Respiratory Care and Documentation
Penalty
Summary
The facility failed to provide adequate respiratory care for four residents, as evidenced by the lack of physician orders for oxygen use and improperly labeled oxygen tubing. Resident 39, who was admitted with chronic obstructive pulmonary disease (COPD) and other respiratory conditions, did not have a physician order for oxygen despite needing it 24 hours a day. Observations revealed that the resident's oxygen concentrator was running, but the tubing and cannula were not in use, and there was no documentation of oxygen orders in the medical records. Interviews with staff, including a CNA and RN, confirmed the absence of a physician order, and it was only after the surveyor's inquiry that an order was obtained. Resident 6 also experienced deficiencies in respiratory care. The resident's oxygen concentrator had an empty humidifier bottle and outdated tubing, with no physician order or documentation for changing the equipment. The care plan did not include interventions for changing the oxygen tubing, and the CNAC was observed changing the equipment without proper documentation. Similarly, Resident 51 had outdated oxygen tubing and humidifier, with no record of the changes being documented in the medical record, despite a physician order specifying the need for weekly changes. Resident 69's care was also deficient, with outdated oxygen supplies and no documentation of changes in the medical record. The CNAC stated that she was responsible for changing the oxygen supplies weekly but did not document these changes. The DON confirmed that oxygen supplies should be changed weekly and labeled, but there was no system in place to ensure this was done consistently. The lack of proper documentation and physician orders for oxygen use and equipment changes led to the deficiencies identified by the surveyors.
Medication Security and Management Lapses
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored and secured in locked compartments, as observed during a survey. On one occasion, a medication cup containing drugs was left unattended on top of an unlocked medication cart in the Cambridge Unit. This occurred while the Registered Nurse (RN) responsible for the cart was in the dining room, leaving the medications accessible to residents passing by. Additionally, a blue pill was found on the floor near the nurses' station and the south hall, indicating a lapse in medication management and security. Interviews with staff, including RN 1, the Assistant Director of Nursing (ADON), and the Director of Nursing (DON), confirmed that medications should not be left unattended and that medication carts should always be locked when not in use. The ADON and DON emphasized the importance of identifying and properly disposing of any medications found on the floor. These observations and interviews highlight the facility's failure to adhere to protocols for medication security and management, leading to the identified deficiencies.
Deficiency in Food Quality and Service
Penalty
Summary
The facility failed to provide food that was palatable, attractive, and at a safe and appetizing temperature for 9 out of 45 sampled residents. Residents reported various issues with the food quality, including complaints about the taste, temperature, and presentation of meals. Specific grievances included being served food that was on their dislikes list, meals with excessive carbohydrates, undercooked or overcooked vegetables, and cold food left at the bedside. Some residents noted that the food was bland, soggy, or not flavorful, and there were issues with the availability of certain food items like salads and coffee. Additionally, there were concerns about the consistency and appearance of certain foods, such as eggs and sandwiches. Observations of a test tray revealed that the food served was not visually appealing or palatable. The test tray included shredded pork, scalloped potatoes, and a vegetable blend, all of which were described as bland, mushy, or having an undesirable consistency. The Certified Dietary Manager acknowledged that food concerns were discussed during monthly food council meetings, and notes from these meetings indicated ongoing issues with meal components, such as condiments not being provided, hard potatoes, flavorless soups, and requests for more variety in meal options. Despite these discussions, the facility did not adequately address the residents' concerns, leading to continued dissatisfaction with the food service.
Medication Error Due to Unclear Discontinuation of Previous Order
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors. Specifically, a resident with multiple diagnoses, including chronic obstructive pulmonary disease, congestive heart failure, and chronic kidney disease, received an incorrect dosage of Furosemide. The physician had reduced the Furosemide dose from 40 mg to 20 mg, but the order to discontinue the 40 mg dose was not executed promptly. As a result, the resident received both 40 mg and 20 mg doses on two separate days, leading to a total of 60 mg being administered on those days. Interviews and record reviews revealed that the nursing staff was not aware of the need to discontinue the 40 mg dose when the new 20 mg order was given. The Director of Nursing confirmed that the old order should have been discontinued when the new order was issued, but this did not occur until several days later. The resident was not informed of the medication change in advance, and there was a lack of communication and clarification regarding the physician's orders, contributing to the medication error.
Lack of Post-Extraction Monitoring for Resident
Penalty
Summary
The facility failed to ensure that a resident received appropriate treatment and care following a tooth extraction, as per professional standards of practice. Resident 50, who had a history of hemiplegia, type 2 diabetes, alcoholic cirrhosis, chronic respiratory failure, dysphagia, repeated falls, shoulder pain, and anxiety, experienced food getting caught in the area where a tooth was extracted. Despite the resident's self-reported difficulty with food getting stuck and the need to brush frequently, there was no documented monitoring by the facility staff after the tooth extraction. The Director of Nursing (DON) acknowledged that nursing staff should have monitored the resident's ability to eat and provided alternative foods if necessary. Additionally, the staff should have monitored for signs of infection and pain control. However, the resident's medical records lacked any progress notes regarding monitoring after the tooth extraction, and the DON noted that the resident's pain scores were not higher than usual. The deficiency was identified through observation, interview, and record review, indicating a lapse in the facility's adherence to professional standards of care for post-extraction monitoring.
Resident Smokes Unsupervised Despite Supervision Requirement
Penalty
Summary
The facility failed to ensure adequate supervision and assistive devices to prevent accidents for a resident who was assessed as requiring supervision while smoking. The resident, who had a history of unsafe smoking practices and cognitive impairments, was observed smoking unsupervised on multiple occasions. Despite being instructed by a registered nurse to wait until a designated time to smoke, the resident obtained a cigarette from another resident and smoked without supervision. The resident's care plan and safety smoking evaluation indicated that she required full supervision when smoking due to her medical conditions, including hemiplegia, hemiparesis, and a history of falls. The interdisciplinary team had determined that the resident needed staff to hold onto smoking paraphernalia and required assistance to and from the smoking area. However, observations revealed that the resident was able to access cigarettes from other residents and smoke without staff supervision, contrary to the facility's policy. Interviews with staff and residents confirmed that the resident was known to sneak out to smoke and obtain cigarettes from others. The facility's administrator and staff acknowledged the need for supervision but failed to consistently enforce the policy, leading to the resident smoking unsupervised. The facility's documentation and staff interviews highlighted inconsistencies in the resident's smoking supervision status, contributing to the deficiency.
Failure to Implement Updated Tube Feeding Orders
Penalty
Summary
The facility failed to ensure that a resident who was fed by enteral means received the appropriate treatment. Specifically, the tube feeding for a resident was not infusing at the prescribed infusion rate. The resident, who had a history of dysphagia following a cerebral infarction, was observed multiple times with the tube feeding infusing at a rate of 90 ml/hr, which was consistent with the physician's order. However, the Registered Dietitian (RD) had recommended a change in the tube feeding schedule to facilitate the resident's oral intake and decrease excessive weight gain, which was not implemented. The resident's medical record indicated that the RD had recommended the tube feeding to be started at 8:00 PM and turned off at 6:00 AM, providing a specific caloric and fluid intake. Despite these recommendations, the facility continued to follow the previous order, which did not align with the RD's updated guidance. Interviews with the RD and nursing staff revealed a communication gap, as the RD's recommendations were not effectively communicated or implemented by the nursing staff. The facility's policy on enteral nutrition required that the interdisciplinary team, including the dietitian, conduct a full nutritional assessment and make appropriate recommendations. However, the failure to update the resident's tube feeding orders according to the RD's recommendations indicated a breakdown in the process of implementing dietary changes. This deficiency highlights the need for effective communication and adherence to updated dietary recommendations to ensure residents receive appropriate nutritional support.
Resident's Dietary Needs Not Met, Leading to Aspiration Risk
Penalty
Summary
The facility failed to ensure that a resident received food and liquids prepared in a form designed to meet their individual needs, leading to repeated episodes of coughing during meal times. The resident, who was on hospice care, had a history of chronic respiratory failure with hypoxia, Alzheimer's disease, and other conditions that increased their risk for altered nutritional status and dehydration. Despite being on a pureed diet with thin liquids, the resident was observed coughing after consuming liquids on multiple occasions, indicating potential aspiration issues. Interviews with facility staff revealed a lack of awareness and action regarding the resident's coughing and potential aspiration. The Registered Nurse acknowledged the resident's coughing but was unsure of how to address it, while a CNA was unaware of the issue. The Registered Dietitian stated that speech therapy evaluations were not typically conducted for hospice patients, although the Director of Nursing indicated that such evaluations could be performed. A dysphagia evaluation later confirmed the resident's moderately severe pharyngeal dysphagia and risk of aspiration with various liquid consistencies.
Failure to Prevent Sexual Abuse and Elopement
Penalty
Summary
The facility failed to prevent an instance of sexual abuse between two residents and neglected to provide the necessary supervision to prevent the elopement of another resident. Resident 269, who had severe cognitive impairment and a history of wandering, was found naked from the waist down on top of Resident 270, who was also cognitively impaired and nonverbal. The incident occurred when the staff responsible for monitoring the memory care unit were occupied with other tasks, leaving the residents unsupervised. This lack of supervision allowed Resident 269 to enter Resident 270's room and engage in inappropriate behavior, which was only discovered when therapists were searching for Resident 269 for a therapy session. The facility's failure to monitor Resident 269's wandering behavior and provide adequate supervision directly led to the incident of sexual abuse, which was verified by the facility's investigation. In a separate incident, Resident 17, who had a history of wandering and severe cognitive impairment, eloped from the facility. The resident was found and returned by a police officer. The facility's records indicated that Resident 17 had been assessed as a high risk for wandering and required frequent safety checks. However, the facility failed to implement a coordinated plan to supervise the resident's whereabouts, leading to the elopement. The receptionist, who was assisting another resident outside, believed that Resident 17 eloped through the front door during this time. The facility's lack of a coordinated plan and failure to monitor Resident 17's wandering behavior resulted in the resident's elopement. Both incidents were determined to be noncompliant and constituted immediate jeopardy. The facility's failure to prevent the sexual abuse of Resident 270 and the elopement of Resident 17 highlighted significant lapses in supervision and monitoring of residents with known wandering behaviors and cognitive impairments. These deficiencies were identified through interviews, record reviews, and witness statements, which documented the events leading to the incidents and the facility's inadequate response to the residents' needs for supervision and safety.
Removal Plan
- Resident was assessed for injury; no injuries were found.
- Facility representative spoke with family who reported that she had done this type of thing at home.
- Resident was determined to be a high risk for further elopements and would need to be moved to the secure unit. Resident was transferred to the secure unit to prevent further elopements.
- IDT reviewed the elopement.
- A training was conducted for the all staff meeting. Clinical training topics included labs, abuse reporting, and elopement prevention.
- Facility IDT met to review elopement process.
- Elopement binder was created for all high-risk residents on Cambridge.
- CNA Coordinator was given instructions to create tools for the staff, including a task sheet to alert staff of high-risk behaviors for residents and elopement sheets for the elopement binder.
- CNA Coordinator was given responsibility to round at least twice daily to verify the unit was running smoothly and that staff had the tools they needed to care for the residents.
- Administrator/Designee began holding meetings with CNA coordinator regarding the flow of the unit, communication, and the competency of the supervising staff on the unit.
- QAPI committee reviewed the events and identified the need for further interventions for elopement/abuse prevention.
- QAPI committee began creating care kits for memory care residents to decrease boredom, exit seeking, and help residents who were up at night.
- Residents were separated, and the abuse investigation was initiated.
- The police were notified, CMS was notified.
- The resident was placed on 1:1 with the intention to remain until the investigation was complete and interventions could identify how to prevent recurrence.
- The victim was moved off the unit.
- An internal meeting was held to review the investigation with the Regional Nurse Consultant, the Director of Clinical Services, the Corporate LCSW, the Facility Administrator, and Director of Nursing.
- Director of Nursing conducted an in-service with facility staff on Abuse Prevention with a post-test validation.
- The perpetrator was reviewed by the Behavioral Health Facility Committee to validate interventions were effective and further abuse prevented.
- Corporate LCSW provided a training with the Social Services Department on Sexual Intimacy in the LTC setting, Assessing Capacity to Consent, Care Planning, and appropriate Documentation.
- Corporate LCSW came to the facility and assessed the Perpetrator and reviewed the interventions in place.
- Cameras were set up to enhance visibility in the unit for staff.
- Computers in the unit were connected to be able to view halls for when CNAs were busy in rooms.
- Facility reviewed staffing patterns on the unit to validate that there was proper supervision on the unit.
- An investigation was conducted and found that the abuse program was not being run in accordance with facility policy and procedure.
- The administrator was terminated.
- A facility manager took over the facility with significant oversight of the RVP/Designee.
Failure to Prevent Falls and Ensure Medication Safety
Penalty
Summary
The facility failed to ensure that the resident environment remained as free of accident hazards as possible and that each resident received adequate supervision and assistance devices to prevent accidents. Specifically, for 11 out of 45 sampled residents, a resident with a history of several falls did not always have preventative interventions in place after each fall. This resident sustained multiple injuries, including a closed head injury, sacral insufficiency fracture, nasal fracture, and lacerations requiring stitches and staples. Despite these incidents, no new fall interventions were implemented after each fall, and the resident continued to experience falls and injuries. Resident 170, who had diagnoses including bilateral primary osteoarthritis of the knee, repeated falls, Alzheimer's disease, and dementia with other behavioral disturbances, experienced multiple falls. The care plan for Resident 170 included various interventions to prevent falls, such as ensuring a safe environment, appropriate footwear, physical therapy, and frequent safety checks. However, these interventions were not consistently implemented or updated after each fall. The resident's falls were often unwitnessed, and the staff did not always put new fall interventions in place after each incident. Additionally, the facility failed to ensure that medications were properly administered and monitored. A family member found medications on the floor in a resident's room and bathroom. The nurse on duty discarded the pills without investigating how they ended up on the floor. The resident's medical record indicated severe cognitive impairment, and the facility's policy required nurses to stay in the room until the resident swallowed the medications. This failure to follow protocol further highlights the lack of adequate supervision and attention to resident safety in the facility.
Failure to Provide Consistent Pain Management for Resident with Fractured Humerus
Penalty
Summary
The facility did not ensure that pain management was provided to a resident who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. Specifically, for one resident who sustained a right humerus fracture, the facility failed to offer a shoulder immobilizer daily as ordered to help mitigate pain. The resident, who had a history of multiple medical conditions including a displaced fracture of the surgical neck of the right humerus, type 2 diabetes mellitus, and chronic respiratory failure, reported significant pain and was observed without the prescribed shoulder immobilizer on multiple occasions. The resident's medical records indicated that she was supposed to wear a right shoulder immobilizer at all times, except during bathing, as per the orthopedics order. However, interviews with the resident and staff revealed that the resident had not been wearing the immobilizer consistently for the past few months. The resident expressed that she had repeatedly asked for a sling but was told by nurses that they did not have one for her. This lack of adherence to the care plan resulted in the resident experiencing significant pain, which she reported multiple times, with pain levels often reaching 8 or 9 out of 10. Further interviews with the Director of Nursing (DON) and other staff members confirmed that the resident was supposed to wear the shoulder immobilizer to help manage her pain. However, there were no progress notes documenting the resident's refusal to wear the immobilizer, contradicting the DON's statement that the resident almost always refused it. Additionally, a Registered Nurse (RN) mentioned that the resident often lost the sling and that staff had to make a makeshift sling out of ace wrap because they could not find the original one. This inconsistency in providing the prescribed pain management measures led to the resident feeling neglected and in severe pain.
Failure to Implement Policies to Prevent Abuse and Assess Consent Capacity
Penalty
Summary
The facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents, and did not establish policies and procedures to investigate such allegations. Specifically, for four residents in the memory care unit, there were incidents of residents kissing without a full evaluation of their capacity to consent. The residents involved had varying degrees of cognitive impairment, with BIMS scores indicating severe cognitive impairment for some of them. Despite the facility's efforts to monitor and redirect the residents, the interactions continued, raising concerns about the residents' ability to consent and the facility's handling of the situation. Resident 17, who had severe cognitive impairment, was noted to have initiated kissing with Resident 21, who also had moderate cognitive impairment. Staff observed that Resident 17 believed Resident 21 was her boyfriend and frequently sought to kiss him. Although the facility conducted assessments and IDT meetings to evaluate the residents' capacity to consent, the interactions persisted. Resident 21 was also involved in similar interactions with other residents, including Resident 41 and Resident 48, both of whom had severe cognitive impairments. The facility's investigation revealed that the interactions were generally brief and did not escalate to inappropriate contact or sexual abuse. However, the facility's failure to adequately assess and document the residents' capacity to consent, as well as the lack of clear policies and procedures to address such situations, led to the deficiency. Interviews with staff and medical professionals indicated that while some measures were taken to monitor and redirect the residents, the facility did not have a comprehensive approach to prevent and investigate potential abuse or exploitation effectively.
Uncovered Food and Drinks During Meal Delivery
Penalty
Summary
The facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, multiple observations were made where food and drinks were uncovered when being delivered to resident rooms. On several occasions, desserts and drinks were observed uncovered on meal trays being delivered to various rooms across different hallways, including the North Rehab, South Rehab, and Colonial hallways. These observations were made over multiple days and times, indicating a consistent issue with food safety practices during meal delivery. During an interview, the Dietary Manager (DM) confirmed that the expectation was for all food to be covered when delivered to resident rooms. The DM stated that main meals were covered with heavy-duty covers, and all desserts, fruits, and drinks should also be covered. Additionally, the DM mentioned that drinks should either be poured right outside a resident's room or covered if transported through the hallway. Despite these expectations, the observations showed that the facility staff did not consistently follow these guidelines, leading to the identified deficiencies.
Infection Control Deficiencies During COVID-19 Outbreak
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple observations of staff not wearing Personal Protective Equipment (PPE) during a COVID-19 outbreak. On several occasions, staff members, including CNAs, RNs, and other personnel, were observed in various areas of the facility without surgical masks, despite the presence of a COVID-19 positive resident and staff members. The CNA Coordinator, who tested positive for COVID-19, continued to work in the facility without wearing a mask, potentially exposing other residents and staff to the virus. Resident 58, who had a complex medical history including chronic respiratory failure and other significant conditions, tested positive for COVID-19 and was placed in isolation. However, the facility failed to promptly inform the public and provide PPE at the entrance. Additionally, the Infection Preventionist (IP) confirmed that the facility did not report the outbreak to the County Health Department within the required timeframe. The IP also noted that the facility's policy did not mandate mask-wearing for staff exposed to COVID-19 if they tested negative or were asymptomatic. Furthermore, the facility did not adhere to proper protocols for handling dirty linens. CNA 3 was observed transporting uncovered dirty linens through the common area, contrary to the facility's policy that required all laundry to be bagged. This lapse in protocol was acknowledged by both the Housekeeping Supervisor and CNA 3 during interviews. These deficiencies highlight significant gaps in the facility's infection control practices, particularly during a COVID-19 outbreak.
Non-Functional Paper Towel Dispensers in Memory Care Unit
Penalty
Summary
The facility did not provide a safe, clean, comfortable, and homelike environment as required. Specifically, the paper towel dispensers in the bathrooms of the memory care unit were not functioning. Observations on multiple occasions revealed that the paper towel dispensers in several rooms did not work. Interviews with housekeeping staff, a CNA, and the Maintenance Director indicated that there was a lack of communication and responsibility regarding the maintenance of these dispensers. Housekeeping staff were responsible for refilling the paper towels, while the maintenance department was responsible for replacing the batteries. However, the Maintenance Director stated he had not been notified about the non-functional dispensers, and housekeeping staff indicated they needed batteries from maintenance to fix the issue. The deficiency was observed on two separate dates, with multiple rooms being affected each time. Housekeeping and maintenance staff provided conflicting information about their responsibilities and the process for addressing non-functional dispensers. The Maintenance Director mentioned an application system for reporting issues, but it appeared that this system was not effectively used or communicated to all staff. The HK Supervisor confirmed that housekeepers checked the dispensers daily, but the issue persisted, indicating a breakdown in the process of ensuring the dispensers were operational.
Delay in Feeding Assistance for Resident
Penalty
Summary
The facility did not provide necessary services to maintain good nutrition for a resident who was unable to carry out activities of daily living. Specifically, a resident who required assistance with eating waited 35 minutes to get assistance by staff after the meal was served. The resident, identified as having myasthenia gravis, a displaced fracture of the right humerus, moderate dementia, psychotic disturbance, mood disturbance, anxiety, and type 2 diabetes mellitus with diabetic neuropathy, was observed to have their lunch tray placed on the bedside table at 11:44 AM. However, it was not until 12:19 PM that the Dietary Manager noticed the resident had not started eating and began to assist them. The resident expressed that this was not the first time they had been bypassed for lunch. Interviews with staff revealed inconsistencies in the process of assisting residents with feeding. The CNA Coordinator expected immediate feeding of residents after being served their food tray, and CNAs were trained to pass out food trays and then assist with feeding. However, one CNA stated that they would wait until the end of the hall's meal pass to serve those requiring assistance, indicating a delay in providing necessary help. This discrepancy in staff actions led to the resident waiting an extended period before receiving assistance with eating, highlighting a deficiency in the facility's care practices.
Failure to Provide Appropriate Treatment and Care for Hospice Resident
Penalty
Summary
The facility failed to ensure that Resident 119 received treatment and care in accordance with professional standards of practice. Resident 119, who was admitted on hospice care, was not assessed upon admission, did not receive the appropriate medications, and was not transferred to the memory care unit until the following day after the family requested it. The resident's medical record showed discrepancies in medication orders and administration, and the admission assessments were left blank until several days after admission. Upon admission, Resident 119 did not receive her blood pressure medications due to confusion about the orders. The family member of Resident 119 reported that the resident was not moved to the memory care unit until the day after the request was made. The medical record review revealed that the resident's medications were not administered on the first two days of admission, and there were inconsistencies in the medication orders provided by the hospice and those entered into the facility's system. Interviews with the hospice RN, DON, ADON, and other staff highlighted communication issues and a lack of proper documentation. The hospice RN did not provide the facility with the necessary paperwork, and there was confusion about the medication orders. The DON admitted that the admission assessments were not completed on time, and there was a lack of coordination between the hospice and facility staff. The resident's family also expressed concerns about the level of care and structure provided to the resident, leading to the decision to move her to the memory care unit.
Failure to Provide Continuous Oxygen Therapy
Penalty
Summary
The facility did not ensure that a resident who required continuous oxygen therapy was provided with the necessary respiratory care. Specifically, the resident was observed multiple times without their oxygen nasal cannula properly placed, and staff failed to reapply the oxygen nasal cannula. The resident, who had a history of chronic respiratory failure with hypoxia, was dependent on oxygen therapy to maintain adequate oxygen saturation levels. Despite this, the resident was left without oxygen for extended periods, and staff did not follow the care plan or physician's orders to ensure continuous oxygen therapy. On several occasions, the resident's oxygen nasal cannula was found on the floor or near the resident's mouth but not properly positioned. Staff, including registered nurses and certified nursing assistants, were observed entering and exiting the resident's room without reapplying the oxygen nasal cannula. The resident's oxygen saturation levels were documented to be below the target of 90% on multiple occasions, indicating that the resident was not receiving adequate oxygen therapy as required. Interviews with staff revealed that the resident frequently removed the oxygen nasal cannula, but staff did not consistently check and reapply it. The Director of Nursing stated that staff should check on residents every two hours, but observations showed that this was not done consistently for the resident in question. The facility's policy for oxygen administration was not followed, leading to the resident being without necessary respiratory support for significant periods, which could have compromised the resident's health and well-being.
Failure to Limit PRN Psychotropic Medication Orders to 14 Days
Penalty
Summary
The facility did not ensure that residents did not receive psychotropic drugs pursuant to an as-needed (PRN) order unless the PRN order for psychotropic drugs was limited to 14 days. Specifically, for one resident, a PRN order for a cream containing Haldol, Benadryl, and Ativan was not limited to 14 days, and the physician or prescribing practitioner had not evaluated the resident for the appropriateness of the medication. The resident had multiple diagnoses, including bipolar disorder and dementia with behavioral disturbances, and was admitted to the facility with these conditions. The care plan for the resident included administering psychotropic medications as ordered and monitoring for side effects and effectiveness every shift, with a quarterly review for dosage reduction when clinically appropriate. The resident's medical record showed that the PRN order for the cream was initially scheduled for 30 days and later changed to PRN at the request of the resident's daughter. The order was not limited to 14 days, and there was no documented evaluation by the attending physician or prescribing practitioner every 14 days to assess the appropriateness of the medication. The cream was administered multiple times over several months, with varying effectiveness. The resident exhibited verbal and physical aggression, and the PRN cream was used to manage these behaviors, but the required evaluations and limitations were not documented. Interviews with the Director of Nursing (DON) revealed that the facility had behavior tracking for psychotropic medications and reviewed PRN medication usage during psychotropic meetings. However, the facility did not adhere to the requirement of limiting PRN orders for psychotropic drugs to 14 days and ensuring evaluations by the attending physician or prescribing practitioner every 14 days. The resident's care involved multiple medication changes and consultations with an outpatient psychologist, but the necessary documentation and evaluations for the PRN order were not present in the medical record.
Significant Medication Error Due to Admission Confusion
Penalty
Summary
The facility did not ensure that Resident 119 was free from significant medication errors. Resident 119, who was admitted with diagnoses including sarcopenia, blindness, hypertension, and cardiovascular disease, did not receive her prescribed blood pressure medications due to confusion during the admission process. The resident's family member reported that the blood pressure medications were not administered because of this confusion. A review of the resident's medical records revealed discrepancies between the medications listed in the hospice physician's telephone order and those entered into the facility's medical record. Specifically, there was no order for blood pressure medication initially, and the type of Metoprolol to be administered was not specified. The nursing progress notes indicated that the resident was minimally responsive and had a change in condition upon admission. The Director of Nursing (DON) and other staff members received the nurse-to-nurse report and admission orders, but there was a mix-up regarding the blood pressure medications. The DON entered the medications into the resident's medical record, but the family later brought in additional medications, leading to further confusion. The facility nurse was instructed to call the hospice company for order clarification, but the correct blood pressure medications were not administered for a few days after admission. Interviews with the hospice Registered Nurse (RN), the DON, the Assistant Director of Nursing (ADON), and the Regional Nurse Consultant (RNC) revealed that there were different physician orders provided via email and telephone, leading to inconsistencies in the resident's medical record. The hospice RN confirmed that there was a mix-up regarding the blood pressure medications, and the DON acknowledged that the orders received were different from those entered into the medical record. The ADON and RNC also noted discrepancies in the type of Metoprolol to be administered, further contributing to the medication error.
Unqualified Staff Providing Feeding Assistance
Penalty
Summary
The facility did not ensure that a feeding assistant had completed a state-approved training course before providing feeding assistance to residents. Specifically, the Dietary Manager (DM) was observed assisting Resident 29 with feeding without having completed the required training. Resident 29, who has diagnoses including myasthenia gravis, moderate dementia, and type 2 diabetes mellitus with diabetic neuropathy, was admitted to the facility with a care plan indicating the need for extensive assistance with eating. The DM was observed assisting Resident 29 with feeding, despite not holding the necessary certification for this task. Interviews with the Certified Nursing Assistant (CNA) Coordinator and the DM confirmed that only nurses and CNAs were qualified to assist with resident feeding. The DM acknowledged that she did not hold a CNA certificate and was not certified to provide feeding assistance, despite having some previous training. This incident highlights a lapse in ensuring that only properly trained and certified staff provide feeding assistance to residents, as required by the facility's policies and state regulations.
Inaccurate Medical Records Documentation
Penalty
Summary
The facility did not maintain accurate medical records for two residents. Resident 56's medical record, reviewed between 3/11/24 and 3/21/24, contained an unwitnessed fall documentation that belonged to another resident. Resident 17's medical record, reviewed during the same period, included a care plan dated 2/23/24 that belonged to another resident. The Director of Nursing confirmed that resident information should be correctly documented in their respective medical records.
Deficiency in Hospice Service Coordination and Documentation
Penalty
Summary
The facility did not ensure that hospice services met professional standards and principles, particularly in obtaining necessary nursing notes, coordination of care notes, and correct physician's orders for Resident 119. Resident 119, a 97-year-old female with vascular dementia, sarcopenia, blindness, hypertension, and cardiovascular disease, was admitted to the facility and experienced a series of deficiencies in care coordination and medication management. The resident's family member reported that the facility lost the resident's medications and that communication between the hospice and the facility was poor. The medical record review revealed discrepancies in medication orders and administration. For instance, the hospice physician's orders included medications such as Losartan and Metoprolol, but these were not consistently administered or documented in the facility's records. Additionally, there was no hospice plan of care or documentation of hospice services received in the resident's medical record. Interviews with the hospice RN and facility staff indicated a lack of proper communication and documentation practices, including the absence of a coordination of care process and failure to provide necessary paperwork. Further interviews with the facility's RA, Administrator, and DON highlighted additional issues, such as the resident being found in the wrong clothing and the lack of a grievance procedure for the family's concerns. The DON acknowledged that the admission assessments for Resident 119 were incomplete and that there were inconsistencies in the physician orders entered into the medical record. Overall, the facility failed to ensure proper coordination and documentation of hospice services, leading to significant gaps in the resident's care.
Latest citations in Utah
A resident with Parkinson’s Disease was being transferred from bed to a chair using a mechanical (Hoyer) lift operated by two CNAs when a sling strap snapped, causing the resident to fall and strike the back of the head. The resident sustained an abrasion, a 1 cm scalp laceration with bleeding, and severe back pain rated 9/10, and was sent to the hospital for evaluation. Manufacturer instructions required staff to inspect slings and straps for wear before each use, but there was no evidence the specific sling used in this transfer had been inspected for integrity, and the Administrator acknowledged that the strap breakage led to the resident’s fall and injury.
The facility failed to timely report alleged abuse to SSA and APS after staff twice observed a resident with dementia and acute systolic CHF receiving zealous, open-mouthed kisses on the mouth from her brother. On two separate occasions, a CNA and an LPN witnessed or were informed of these unusual kissing interactions, which they later described as awkward and not typical of a sibling relationship. Despite this, the nursing staff did not immediately report the incidents as potential abuse to the Administrator, and the allegation was not brought forward until a staff meeting days later, resulting in the required notifications to external authorities not being made within the mandated 2-hour timeframe.
A resident with muscle weakness, gait abnormalities, atrial fibrillation, and on a blood thinner sustained an unwitnessed bathroom fall, reported hitting her head, and developed rapidly worsening right facial swelling and a swollen‑shut eye that prevented pupillary assessment. Initial vitals and neuro checks were performed, oxygen was applied, and x‑rays were ordered, but despite the significant change in condition and the resident’s anticoagulation status, the provider was not notified of the worsening condition at the time it occurred and the resident was not sent to the hospital until the next day when an NP assessed her and ordered transfer. In the ED, the physician documented that no evaluation for the injuries had occurred the prior evening and CT imaging showed traumatic subdural and subarachnoid hemorrhages and a large facial hematoma, demonstrating that the facility failed to provide timely, standard‑of‑care treatment and hospital transfer after the fall and subsequent change in condition.
A resident with cognitive impairment, neurological conditions, and substance-related diagnoses was assessed as being at risk for elopement and documented as having poor safety awareness, poor judgment, and wandering behavior requiring frequent redirection. Nursing staff observed the resident wandering in the hall and behind the nurse’s station and communicated during shift report that a WanderGuard was recommended, but no device was applied because staff did not know where to obtain one. The resident later left the building through the front door, was not immediately detected as missing, and was ultimately found by a medication technician about a mile away walking on a sidewalk near a restaurant, demonstrating a failure to provide adequate supervision and timely elopement interventions.
A nurse failed to follow professional standards for medication administration by not properly identifying a resident before giving medications, resulting in the administration of Lorazepam and Carvedilol that were intended for another resident. The error was discovered and documented, with monitoring showing the resident remained stable and without distress, and the hospice nurse, NP, and family were notified. Leadership, including the DON and administrators, acknowledged that the failure to correctly verify the resident’s identity led to the wrong medications being administered.
A resident with multiple comorbidities and an above-knee amputation requested that staff heat prepackaged ramen soup in a microwave at the nutrition station; staff followed package directions and returned the hot soup, which the resident, who used a motorized wheelchair and insisted on carrying items independently, then spilled while turning, causing a third-degree burn to the palmar side of the left wrist. Staff interviews showed that, before this incident, CNAs and an LPN heated food based on package instructions and judged safety by touch without thermometers, and the DON confirmed that no thermometers were available and that staff relied on touch to determine if food was safe to serve.
The facility failed to provide sufficient nursing staff with appropriate skills to respond promptly to call lights and assist residents with toileting, resulting in multiple residents experiencing incontinence and being left unattended on the toilet. Several residents with significant mobility and medical issues reported waiting long periods, including up to 30–45 minutes or more, for call lights to be answered, particularly during evenings, nights, shift changes, and weekends. Surveyors directly observed call lights sounding for 8–13 minutes before staff responded. Staff reported that CNA hours had been cut after a change in ownership, many staff had quit, and they were unable to complete all care tasks due to understaffing. Grievances and resident council notes over several months documented repeated complaints about slow call light response times, residents being left on the toilet for extended periods, and delays in getting to meals, while leadership acknowledged staffing was based on census rather than acuity despite the written facility assessment describing an acuity-based approach.
Multiple residents and a family member reported that meals were bland, unappetizing, sometimes raw or over-roasted, difficult to chew, and often cold by the time they reached residents’ rooms, with no consistent offer of alternatives when food was disliked. Resident council minutes and grievances documented concerns about cold meals, limited variety, lack of fruit, and meals perceived as too high in carbohydrates. A test tray showed hot items, including chicken tenders and tater tots, were served at low temperatures, with mushy, cold textures and dry, tough meat, and there was no plate warmer used while CNAs, rather than dietary staff, passed trays on the halls after a change in kitchen operations.
A resident with a right humerus fracture, chronic right arm pain, dementia (BIMS 9), and impaired use of one upper extremity required setup/clean-up assistance with eating, including cut food and opened containers, as reflected in the MDS and care plan. Despite this, surveyors observed multiple meals where the resident’s food was not consistently cut into bite-sized pieces and containers (such as lidded bowls, syrup packets, and juice boxes) were left unopened, leading family members to cut food on at least one occasion. The diet order and meal card lacked instructions for cut-up food or setup assistance, and interviews with CNAs, the DM, the MDS coordinator, and an RN confirmed that the resident needed this help but that it was not incorporated into formal orders or consistently implemented.
Two residents on modified diets for dementia and chewing/swallowing concerns were given snacks that did not match their ordered textures. One resident on a pureed diet, ordered after staff observed food being held in the mouth and poor chewing, was repeatedly provided ham sandwiches, potato chips, and an ice cream cone. Another resident on a minced & moist Level 5 diet with cut‑up foods was served a peanut cluster and later offered a crunchy “bird’s nest” snack with chow mein noodles and candy. Staff interviews revealed that activities staff supplied their own snacks without verifying diet orders, that the ST had not been consulted for a swallow evaluation in at least one case, and that nursing and dietary staff expected physician diet orders to be followed.
Failure to Inspect Mechanical Lift Sling Results in Resident Fall and Injury
Penalty
Summary
The deficiency involved the facility’s failure to ensure a resident’s environment was free from accident hazards and that equipment used for transfers was in safe, functional condition. A resident with Parkinson’s Disease was being transferred from bed to a chair using a mechanical (Hoyer) lift operated by two CNAs. One CNA reported that when she arrived to assist, the resident was already positioned in the sling, and as the lift was raised, a sling strap snapped, causing the resident to fall and strike the back of the head. Review of the manufacturer’s instructions for the lift and slings showed that staff were required to inspect slings and lifting straps for signs of wear, fraying, or weakness prior to every use. Record review showed that the resident sustained an abrasion to the back of the head, a 1 cm scalp laceration, and reported pain in the shoulders and neck following the fall, and was transferred to the hospital for evaluation. Subsequent NP documentation confirmed the 1 cm scalp laceration was bleeding and that the resident rated back pain as 9/10 on a numeric pain scale. Although maintenance records reflected a general audit of equipment had been conducted several weeks before the incident, there was no evidence that the specific sling used for this transfer had been inspected for integrity prior to use. During interview, the Administrator acknowledged that the equipment failure and strap breakage resulted in the resident’s fall and injury.
Failure to Timely Report Alleged Sexual Abuse to SSA and APS
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse and neglect were reported immediately, but no later than two hours after the allegation was made, to the State Survey Agency (SSA) and Adult Protective Services (APS). Resident 3, who was admitted with unspecified dementia and acute systolic congestive heart failure, was involved in two separate incidents in which her brother was observed kissing her on the mouth in a manner staff described as zealous, enthusiastic, sloppy, and not typical of a brother-sister interaction. On 12/28/25, CNA 1 observed a well-dressed man enter Resident 3's room, hug her, and give her a zealous kiss on the mouth. CNA 1 assumed the man was the resident's husband and reported this to LPN 1, who knew the visitor was the resident's brother. LPN 1 looked into the room and did not see anything out of the ordinary, and neither CNA 1 nor LPN 1 reported this incident as a potential allegation of abuse to the Administrator at that time. On 1/4/26, LPN 1 and CNA 1 entered Resident 3's room to address the resident's pain and request for catheter removal and to assist with a brief and linen change. Resident 3 had two visitors present, including her brother. When asked to step out for privacy, the female visitor left, but the brother hesitated and then gave Resident 3 a sloppy, open-mouthed kiss on the mouth lasting about three seconds, again in the presence of staff. The brother stated that Resident 3 was his older sister and that she had taken care of him since they were very small. LPN 1 did not report either the 12/28/25 or 1/4/26 kissing incidents to the Administrator. The Administrator later stated that the alleged abuse was first mentioned during a meeting on 1/6/26, at which time staff described the kiss as a weird, awkward kiss and not a typical brother-sister kiss, and acknowledged that nursing staff had not reported the suspicious activity in a timely manner, resulting in failure to notify SSA and APS within two hours of the allegation.
Delayed Hospital Transfer After Fall With Head Trauma and Anticoagulation
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident who experienced a fall with head trauma and was on anticoagulation received timely treatment and care in accordance with professional standards of practice. The resident had diagnoses including generalized muscle weakness, gait and mobility abnormalities, and unspecified atrial fibrillation, and was on a blood thinner. On the evening of the fall, nursing documentation showed that the resident was found on the bathroom floor after her roommate called out. The resident reported hitting her head, had facial pain rated 5/10, and initial vital signs showed an O2 saturation of 88–90% with other vitals within normal limits. A neurological assessment was initiated, oxygen was applied, and the on‑call provider was notified, who ordered x‑rays of the resident’s head and left hand. As the evening progressed, the resident’s condition changed. The nurse documented that the resident’s right eye became increasingly swollen to the point that by 9:15 PM it was swollen shut and pupillary reactivity could no longer be assessed, while the left eye remained equal and reactive to light. The neurological exam form recorded that the provider was notified of the fall at 8:00 PM, but did not indicate that the provider was notified when the right eye became swollen shut at 9:15 PM. The DON later stated that this change in the resident’s condition occurred at 9:15 PM and that the medical provider was not notified of this change until the provider came to the facility the following day. The DON also stated that if a resident on a blood thinner experienced a fall with head strike, she expected staff to send the resident to the hospital, and that she was not sure why this resident was not immediately sent. The resident remained in the facility overnight while x‑rays were obtained around 1:00–1:30 AM, with results reportedly available sometime between early morning hours and mid‑morning. The next morning, the NP assessed the resident due to the fall and documented significant right facial swelling, focal tenderness over the zygoma, difficulty visualizing the right eye, and concern for occult injury and possible orbital blowout fracture in the context of anticoagulation. The NP ordered transfer to the emergency department for CT imaging of the head and face. In the emergency department, the physician documented that no evaluation for the resident’s injuries had occurred the previous evening and that the facility had reported the resident seemed slightly altered the prior night and had worsening swelling by the time EMS was called. CT imaging revealed traumatic small subdural and subarachnoid hemorrhages without mass effect and a large facial hematoma. Interviews with nursing staff showed that the RN on duty was very concerned about the resident’s rapidly increasing facial swelling and difficulty administering medications due to lip swelling, but was waiting for a physician order to send the resident to the hospital and was unaware at the time that she could initiate a hospital transfer without such an order. These actions and inactions resulted in a delay in sending the resident to the hospital after a significant change in condition following a fall with head trauma while on a blood thinner. The facility’s Change of Condition/SBAR Evaluation Policy outlined expectations for describing changes in condition, documenting vital signs, identifying changes from baseline (including neurological status changes), and notifying the provider and responsible party, as well as documenting immediate actions and outcomes such as transfer to the hospital. Despite this policy, the neurological exam form did not reflect timely provider notification when the resident’s right eye became swollen shut, and the resident was not transferred until the following day after the NP’s in‑person assessment. The DON confirmed that the change in condition at 9:15 PM was not communicated to the provider until the next day. The surveyors determined that, for this resident, the facility did not ensure timely hospital transfer and did not provide treatment and care in accordance with professional standards of practice after a fall with head injury and subsequent change in condition.
Failure to Implement Elopement Precautions and Supervision for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and implement elopement precautions for a cognitively impaired resident who was identified as being at risk for elopement. The resident was admitted with multiple neurological and substance-related diagnoses, including cerebral infarction, ataxia, Wernicke’s encephalopathy, alcohol and opioid dependence, and traumatic subdural hemorrhage. On admission, the resident’s elopement risk screening showed a score of 12, indicating elopement risk, and nursing documentation described poor safety awareness, poor judgment, and a need for continuous cues with self-care and ADLs. The resident was also noted to require 1:1 supervision during meals due to quick eating behavior. In the hours leading up to the elopement, nursing staff observed the resident wandering in the hallway and behind the nurse’s station and reported that he required constant redirection. The night shift RN informed the day shift LPN during report that the resident had been wandering since early morning and that a WanderGuard was recommended. Despite this, no WanderGuard was applied before the resident left the building. The LPN later stated that she did not know where to obtain a WanderGuard, and the DON confirmed that both the RN and LPN had not placed a WanderGuard because they did not know its location. On the day of the incident, the resident went to the kitchen and requested water, and kitchen staff noticed a fall risk bracelet on his wrist. After this interaction, staff discovered that the resident was no longer in the building. Facility investigation determined that the resident exited through the front door at approximately 9:37 AM and was later found off premises, about one mile away, walking on a sidewalk near a restaurant. A medication technician, who had previously seen the resident wandering in only a gown and had informed the nurse, located the resident and returned him to the facility. These events demonstrate that, despite known elopement risk and observed wandering behavior, the facility did not implement timely elopement precautions or ensure adequate supervision to prevent the resident from eloping.
Medication Administration Error Due to Failure to Verify Resident Identity
Penalty
Summary
The deficiency involves a failure to provide necessary care and services in accordance with professional standards of practice during medication administration. For one resident reviewed for medication administration, a nurse did not follow the Five Rights of medication administration, specifically failing to properly identify the resident before giving medications. As a result, the nurse administered 0.25 mL of Lorazepam, an anti-anxiety medication, and 25 mg of Carvedilol, a beta-blocker used for blood pressure, that were intended for a different resident to Resident #1. Following the administration error, Resident #1’s vital signs were monitored throughout the night, and documentation indicated the resident remained stable, alert, and without signs of distress during the shift. The hospice nurse, nurse practitioner, and family were notified of the error. During interviews, the Administrator and DON acknowledged the medication error, and the DON confirmed that the nurse’s failure to correctly identify the resident prior to administering the medications was the cause of the wrong medications being given.
Burn Injury from Hot Soup Due to Inadequate Supervision and Temperature Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and accident prevention for a resident who sustained a burn injury from hot food. One resident with end stage renal disease, type 2 diabetes mellitus, pericardial effusion, chronic obstructive pulmonary disease, and an above-knee amputation of the left leg requested that staff heat a prepackaged ramen soup. Facility staff heated the soup in a microwave located in the nutrition station behind the nurse’s station according to the package directions and then returned the hot soup to the resident. After receiving the heated soup, the resident, who used a motorized wheelchair and was described as very independent, turned in his power wheelchair, causing the ramen to spill and the hot liquid to burn the palmar side of his left wrist. A progress note documented that the resident received a burn to his left wrist after spilling the hot soup, that the wound was assessed, wound care was provided, and new orders were placed following consultation with a wound provider. The resident reportedly tolerated treatment well and denied pain or other concerns at that time. Subsequent documentation by a wound provider classified the burn on the resident’s left wrist as a third-degree burn. Staff interviews revealed that, prior to this incident, staff heated residents’ food according to package directions and determined whether it was safe to return based on touch, without using thermometers to verify temperature. A CNA reported that the resident often asked CNAs to heat food and insisted on carrying it himself, and that staff declined to heat his food when he refused to allow them to carry it due to safety concerns. An LPN and the DON both confirmed that thermometers were not available for use before the burn occurred and that staff relied on touch to judge food temperature.
Insufficient Nursing Staff and Delayed Call Light Response Leading to Incontinence and Unattended Toileting
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff with appropriate competencies and skills to meet residents’ needs, particularly in timely response to call lights and assistance with toileting, which resulted in incontinent episodes and residents being left unattended. Multiple residents reported long call light wait times, especially during evening and night shifts and on weekends, when there were as few as three CNAs for the entire building. Residents with significant physical limitations, including recent hip fractures, hemiplegia, and other serious conditions, described being unable to get to the bathroom without staff assistance and experiencing incontinence because staff did not respond promptly to their call lights. One resident with a periprosthetic hip fracture, hemiplegia, an artificial hip joint, major depressive disorder, and anxiety reported that from 6:00 PM to 6:00 AM there were only three CNAs for three hallways, resulting in long waits for call light responses. This resident stated she had incontinent bladder episodes when she first arrived because she could not hold her urine while waiting for help, including one instance where she waited 35 minutes for a response. Another resident with a left femur fracture, chronic pain, lupus, and epilepsy reported waiting an hour for her call light to be answered, leading to urinating in her brief because staff did not arrive in time to take her to the bathroom. A third resident with metabolic encephalopathy, acute respiratory failure with hypoxia, pneumonia, UTI, and end-stage renal disease on dialysis stated she had been left on the toilet and had to get herself off and back to bed due to lack of staff. CNA documentation showed multiple incontinent episodes for these residents despite staff describing them as continent of bowel and bladder. Additional residents and a family member reported frequent long call light wait times, including waits of 30–45 minutes, particularly during shift changes and on weekends. The Resident Council President reported that since a change in ownership, residents complained that call lights took 30–40 minutes to be answered and that there were not enough CNAs on the night shift to handle residents’ needs during evening and bedtime hours. Direct observations by surveyors documented call lights sounding for 8 to 13 minutes before being answered on multiple occasions. Staff interviews confirmed that CNA hours had been cut after the ownership change, that many staff had quit, and that staff were asked to work a lot of overtime and were sometimes unable to complete showers due to understaffing. One staff member reported a resident had an incontinent episode after waiting about 45 minutes for a call light response. Grievance records and resident council notes showed a repeated pattern of complaints over several months about slow call light response times, residents being left on the toilet for extended periods, and delays in getting to meals due to insufficient staff. Grievances included reports of residents waiting over an hour to be taken to breakfast, feeling ignored when requests were not fulfilled, and being left on the toilet for almost three hours, causing discomfort. Resident council notes repeatedly documented concerns about call lights taking a long time to be answered, not enough CNAs in the dining room at mealtimes, and residents being left on the toilet or not getting to breakfast on time. Although the facility’s written facility assessment and staffing plan referenced using acuity and tools such as the MDS and RAI to determine staffing, the DON stated that in practice staffing coverage was based on census rather than acuity and acknowledged there had been many issues with call lights since staffing was cut after the change in ownership.
Failure to Provide Palatable, Attractive Meals at Appropriate Temperatures
Penalty
Summary
The deficiency involves the facility’s failure to consistently provide food and drink that were palatable, attractive, and served at safe and appetizing temperatures for multiple residents. Several residents reported that the food was bland, horrible, disgusting, or generally “not good,” and one resident stated that if she did not like what was served, staff did not offer an alternative and that she repeatedly received dark meat she did not like. A family member reported that a resident with a poor appetite received chicken that was dry and needed more moisture. Resident council minutes documented concerns that hamburgers were sometimes too raw, vegetables were roasted to the point of tasting burned, pork chops were difficult to cut or chew, and that food delivered to rooms was cold by the time it arrived when CNAs passed trays. Surveyors’ direct observation of a test tray showed that hot items were not maintained at appetizing temperatures and were of poor quality. After the last tray was plated and placed in the cart, CNAs—not dietary staff—were responsible for passing trays to residents, and there was no plate warmer between the plate and the plastic base. When the test tray was checked, the chicken tender and tater tots were below typical hot-holding temperatures, with the tater tots described as mushy and cold and the chicken tender as dry, tough to chew, and salty. The cold item, a carrot coin salad, was measured at a chilled temperature. Grievances documented that meals were served too cold and that residents were dissatisfied with the variety, fruit options, and perceived high carbohydrate content of the meals. The Dietary Manager acknowledged that dietary staff no longer delivered trays to residents after a change in ownership and attributed cold food to CNAs not passing trays quickly enough, while the Administrator acknowledged there had been complaints about food quality.
Failure to Provide Required Meal Setup and Cut Food Assistance for Resident With Upper Extremity Impairment
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate treatment and services to maintain or improve a resident’s ability to perform ADLs related to dining and eating, specifically cutting food into bite-sized pieces and opening containers as assessed and care planned. A resident with a right humerus fracture, chronic right arm pain, dementia with moderate cognitive impairment (BIMS 9), polyneuropathy, osteoarthritis, chronic pain syndrome, and a right artificial shoulder joint reported being unable to cut her own food and demonstrated that she had to guide her right arm with her left hand. Surveyors observed on multiple occasions that her meals were not consistently prepared or set up to match her assessed need for setup/clean-up assistance with eating. At one meal, her family reported they had to cut up her food and that this was not the first time. At another meal, her breakfast tray included whole sausage links, a lidded bowl, an unopened syrup packet, and a closed juice box with the straw still wrapped, despite her limited use of one arm. The resident’s MDS indicated impairment in one upper extremity and a need for setup or clean-up assistance with eating, and her care plan documented a focus on ADL self-care performance deficit related to dementia and impaired balance, with an intervention that she required setup or clean-up assistance to eat. However, her physician’s diet order specified only a regular diet with regular texture and consistency, with no instruction for cut-up food or meal setup assistance. The Dietary Manager confirmed there were no directions on the resident’s meal card to cut up her food and stated that food was sometimes cut into strips, including pork cutlets, based on the type of food. The MDS Coordinator and an RN both stated that the resident needed her food cut up and lids removed for meal setup and that it would be too difficult for her to manage with one arm, but acknowledged these needs were not reflected in physician orders. Staff also noted that the resident likely could not cut her own food due to right arm pain and limited function and that she would not usually ask for help even when needed, yet the kitchen and nursing staff did not consistently ensure her food was cut into bite-sized pieces or that containers were opened for her.
Failure to Provide Ordered Diet Textures During Nursing and Activities Snacks
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents received food in the texture ordered to meet their individual needs. One resident with dementia and Alzheimer’s disease had a physician’s order for a pureed diet after nursing, the DON, and the nurse practitioner observed that she was not eating well on a regular diet, was cheeking food, holding it in her mouth, and not chewing. Despite this pureed diet order, multiple nursing progress notes documented that she was given ham sandwiches and potato chips on several nights, and an activities note documented that she ate an ice cream cone. Staff interviews confirmed that she was on a pureed diet because she would let food sit in her mouth and that chips and sandwiches are not part of a pureed diet. The speech therapist stated he had not been asked to evaluate her swallowing, that he normally would want to screen residents whose diets were downgraded, and that non‑pureed foods for someone who holds food in their mouth would be a choking concern. Another resident with dementia and a severe cognitive impairment, as evidenced by a BIMS score of 3, had a physician’s order for a regular diet with minced and moist (Level 5) texture and cut‑up foods due to loose teeth. Nonetheless, an activities progress note documented that she ate a peanut cluster during a cooking social, and the Activities Director later reported that she was also given a “bird’s nest” snack made of crunchy chow mein noodles with candy on top, which she did not eat. Nursing staff stated that this resident did not have the mental capacity to chew, required extensive cueing, and that they would be concerned about choking if she were served non‑minced and moist foods. The Dietary Manager reported that the Activities Department provided its own snacks and did not ensure residents received the correct diet textures, and the DON stated that staff were expected to follow physician orders for diet textures despite limited availability of the speech therapist.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
