St. George Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in St. George, Utah.
- Location
- 1032 East 100 South, St. George, Utah 84770
- CMS Provider Number
- 465064
- Inspections on file
- 19
- Latest survey
- June 7, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at St. George Rehabilitation during CMS and state inspections, most recent first.
The facility failed to maintain sanitary conditions in food storage and preparation, affecting all residents. Staff did not label or date food items in nourishment refrigerators, and opened items were left for an indeterminate time. In the kitchen, staff did not follow hygiene practices, such as changing gloves and washing hands after touching high-contact surfaces. These actions violated facility policies and had the potential to impact 96 residents.
The facility failed to create care plans for two residents requiring supplemental oxygen due to respiratory failure. Despite medical records indicating oxygen therapy orders, neither resident had a care plan addressing their oxygen needs. Observations confirmed the use of nasal cannulas, and staff interviews highlighted the expectation for care plans to include diagnosis, rationale, and instructions for oxygen management.
A resident with severe cognitive impairment and a history of falls experienced two incidents where the care plan was not updated with necessary interventions. Despite the Fall Committee IDT identifying the need for appropriate footwear and a non-slip pad for the wheelchair, these were not added to the care plan, as confirmed by the DON and Administrator.
A resident with severe cognitive impairment and a history of stroke and hypertension was observed smoking while wearing a nicotine patch, contrary to a physician's order to hold the patch if smoking. Despite the resident's care plan indicating a potential for injury related to smoking, the patch was not held, as confirmed by the DON and facility Administrator.
A facility failed to maintain a medication error rate below 5%, resulting in a 5.88% error rate. An LPN did not prime insulin pens or wait the required time after injection for a resident with diabetes, contrary to manufacturer's instructions. The DON acknowledged the protocol was not followed.
A facility failed to protect residents from abuse, with incidents involving verbal abuse by an LPN and physical abuse between two residents. The LPN was reported to have raised her voice at a resident with severe cognitive impairment, while one resident physically attacked another on two occasions, causing injuries. The facility's investigations were inconclusive, and the abuse prevention policies were not effectively implemented.
A resident with severe cognitive impairment was verbally abused by an LPN, as witnessed by two CNAs. Despite facility policy requiring immediate reporting, the incident was not reported to the Administrator until hours later. The resident, who had a history of dementia and anxiety disorder, was involved in an altercation with the LPN, who raised her voice when the resident refused medication and attempted to hit her.
The facility failed to implement its abuse policy in two incidents. In one case, an LPN accused of verbal abuse was not removed from resident care, and in another, the facility did not interview the alleged perpetrator or other potential witnesses after a resident reported being poked in the breast by another resident. These actions were contrary to the facility's policy, highlighting deficiencies in handling abuse allegations.
Food Safety and Hygiene Deficiencies in LTC Facility
Penalty
Summary
The facility failed to store, prepare, and serve food in a sanitary manner, affecting the nourishment refrigerators and the kitchen. Observations revealed that food items brought in by visitors were not labeled or dated, and opened food items were left in the nourishment refrigerators for an indeterminate amount of time. Interviews with staff, including the Dietary Manager, Certified Nursing Assistants (CNAs), and the Director of Nursing (DON), indicated confusion and lack of clarity regarding responsibility for labeling, dating, and discarding food items. The facility's policies required that leftover food be labeled, dated, and discarded after three days, but these procedures were not consistently followed. In the kitchen, staff failed to adhere to proper hygiene practices during food preparation. Dietary Aide (DA) #16 was observed touching high-contact surfaces, such as a microphone button and refrigerator handle, without changing gloves or washing hands before handling food items. Additionally, DA #16 did not wash tomatoes before cutting them. DA #17 also failed to change gloves or wash hands after touching a drawer handle before handling bread rolls. Interviews with the Dietary Manager and the aides confirmed that these actions were against the facility's food safety policies, which required handwashing and glove changes after touching high-contact surfaces. The deficiencies in food storage and preparation practices had the potential to affect all 96 residents receiving food from the dietary department. The facility's policies on food safety and hygiene were not effectively implemented, leading to unsanitary conditions in food handling and storage. The lack of clear communication and responsibility among staff members contributed to these deficiencies, as evidenced by the conflicting statements regarding who was responsible for labeling and maintaining the nourishment refrigerators.
Failure to Develop Care Plans for Oxygen Therapy
Penalty
Summary
The facility failed to develop a comprehensive care plan addressing the supplemental oxygen usage for two residents, both of whom had a medical history of acute and chronic respiratory failure. Resident #37 was admitted with diagnoses of acute respiratory failure with hypoxia and chronic respiratory failure with hypercapnia. Despite receiving oxygen therapy as indicated in their medical records, there was no evidence of a care plan that addressed their supplemental oxygen usage. Observations confirmed the resident was using a nasal cannula, and staff interviews revealed that the resident consistently wore the oxygen device while in bed. Similarly, Resident #76, who was readmitted with a diagnosis of acute and chronic respiratory failure with hypoxia, also lacked a care plan for their supplemental oxygen usage. The resident's medical records showed an order for oxygen therapy, yet the care plan did not reflect this need. Observations and staff interviews confirmed the resident's use of a nasal cannula. Interviews with nursing staff, including the Assistant Director of Nursing and the Director of Nursing, indicated an expectation for a care plan to be in place for residents with supplemental oxygen orders, detailing the diagnosis, rationale, and specific instructions for oxygen therapy management.
Failure to Update Care Plan After Resident Falls
Penalty
Summary
The facility failed to revise the care plan for a resident after two separate fall incidents, which is a deficiency in adhering to their policy of updating care plans with resident changes. The resident, who was admitted with a history of cerebral infarction and hypertension, had a severe cognitive impairment and required assistance with toileting. The care plan initially identified the resident as being at risk for falls due to weakness and decreased mobility. However, after a fall incident where the resident slipped during a transfer due to slippery socks, the care plan was not updated to include the intervention of using appropriate footwear. A subsequent fall occurred when the resident attempted to return from the smoking area, resulting in the wheelchair rolling out from underneath them. Although the Fall Committee IDT noted the need for a non-slip pad on the wheelchair seat to prevent further slipping, this intervention was also not added to the care plan. Interviews with the DON and the Administrator confirmed that these interventions should have been included in the care plan but were not, indicating a lapse in following the facility's care planning policy.
Failure to Follow Physician's Order for Nicotine Patch Administration
Penalty
Summary
The facility failed to adhere to a physician's order regarding the administration of a nicotine patch for a resident with severe cognitive impairment. The resident, who had a history of cerebral infarction and hypertension, was admitted to the facility and had a care plan indicating a potential for injury related to smoking. The physician's order specified that the nicotine patch should be held if the resident was smoking. However, on a specific date, a Licensed Practical Nurse (LPN) applied the nicotine patch to the resident's arm, and later that day, the resident was observed smoking while still wearing the patch. Interviews with the resident and staff revealed that the resident smoked one to two times a day and did not wish to stop smoking. The Director of Nursing (DON) acknowledged that the resident had been wearing the nicotine patch since a specified date and continued to smoke, indicating that the patch was not held as per the physician's order. The DON and the facility Administrator both expressed that their expectation was for medications to be administered according to physician orders, highlighting a failure in the facility's medication administration process.
Medication Administration Errors Lead to Deficiency
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, resulting in a rate of 5.88% due to 2 errors out of 34 opportunities. This deficiency affected one resident who was observed during medication administration. The resident, admitted on 03/04/2021, had a medical history of type two diabetes mellitus with diabetic neuropathy and was prescribed insulin glargine and NovoLog. The errors occurred during the administration of these medications. During an observation, an LPN did not prime the insulin pens before injection and removed the needles immediately after administration, contrary to the manufacturer's instructions. The manufacturer's guidelines specified performing a safety test by priming the pen to ensure accurate dosing and waiting a specified time after injection to ensure the full dose was delivered. The LPN acknowledged the errors, and the DON confirmed that the nurse should have followed the protocol for effective medication administration.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from verbal and physical abuse, as evidenced by incidents involving two residents and a staff member. On one occasion, a Licensed Practical Nurse (LPN) was reported to have verbally abused a resident with severe cognitive impairment. The incident was witnessed by two Certified Nursing Assistants (CNAs), who reported hearing the LPN raise her voice at the resident. The LPN admitted to raising her voice but claimed it was to ensure the resident could hear her. The facility's investigation into the incident was inconclusive, and the LPN felt she did nothing wrong. In another incident, a resident with severe cognitive impairment physically abused another resident on two separate occasions. The first altercation resulted in knuckle marks on the victim's forehead, while the second incident led to scratches on the victim's face. Both incidents were witnessed by staff members, who intervened to separate the residents. The facility's follow-up investigations were inconclusive, with reports indicating a lack of clarity on what led to the incidents and the extent of the injuries sustained by the victim. The facility's policies on abuse prevention and prohibition were not effectively implemented, as evidenced by the repeated incidents of abuse. The facility's investigations into the incidents were unable to substantiate the abuse claims, despite evidence of physical harm to the victim. The facility's failure to protect residents from abuse and to conduct thorough investigations into reported incidents highlights a deficiency in ensuring the safety and well-being of its residents.
Failure to Immediately Report Verbal Abuse Incident
Penalty
Summary
The facility failed to ensure an allegation of verbal abuse was reported immediately to the Administrator for a resident with severe cognitive impairment. On the evening of August 21, 2023, two CNAs heard an LPN verbally abuse a resident. Despite the facility's policy requiring immediate reporting of abuse allegations to the Administrator, the incident was not reported until 10:15 PM, several hours after it occurred. The resident involved had a history of dementia with behavioral disturbance and anxiety disorder, and was known to have adequate hearing. The investigation revealed that one CNA heard the LPN yell at the resident and witnessed the resident swing at the nurse, while another CNA heard yelling but could not recall the specific words. The LPN involved stated that the resident refused medication and attempted to hit her, prompting her to raise her voice. Both CNAs identified the incident as verbal abuse, with one reporting it to the Administrator via text message after her shift. The Administrator expected staff to ensure resident safety and report abuse immediately, which did not occur in this instance.
Failure to Implement Abuse Policy and Conduct Thorough Investigations
Penalty
Summary
The facility failed to implement its abuse policy in two separate incidents involving residents. In the first incident, a Licensed Practical Nurse (LPN) was reported to have verbally abused a resident with severe cognitive impairment. Despite the report, the accused LPN continued to care for residents without being removed from duty, as required by the facility's policy. The facility's investigation revealed that the LPN admitted to raising her voice at the resident, but she was not suspended pending the investigation, contrary to the policy. In the second incident, the facility did not follow its abuse investigation protocol after an allegation of sexual abuse between two residents. The alleged victim, who had a history of trauma, reported being poked in the breast by another resident. The facility's investigation did not include interviews with the alleged perpetrator or other residents who might have witnessed the incident, as mandated by the facility's policy. The Administrator acknowledged the failure to interview surrounding residents and did not document an interview with the alleged perpetrator, although he claimed to have spoken with them. Both incidents highlight the facility's failure to adhere to its own abuse prevention and investigation policies. The Administrator and staff did not ensure that all residents were protected from harm during and after the investigations, as required. The lack of thorough investigation and immediate protective measures for residents indicates a significant deficiency in the facility's handling of abuse allegations.
Latest citations in Utah
A resident with Parkinson’s Disease was being transferred from bed to a chair using a mechanical (Hoyer) lift operated by two CNAs when a sling strap snapped, causing the resident to fall and strike the back of the head. The resident sustained an abrasion, a 1 cm scalp laceration with bleeding, and severe back pain rated 9/10, and was sent to the hospital for evaluation. Manufacturer instructions required staff to inspect slings and straps for wear before each use, but there was no evidence the specific sling used in this transfer had been inspected for integrity, and the Administrator acknowledged that the strap breakage led to the resident’s fall and injury.
The facility failed to timely report alleged abuse to SSA and APS after staff twice observed a resident with dementia and acute systolic CHF receiving zealous, open-mouthed kisses on the mouth from her brother. On two separate occasions, a CNA and an LPN witnessed or were informed of these unusual kissing interactions, which they later described as awkward and not typical of a sibling relationship. Despite this, the nursing staff did not immediately report the incidents as potential abuse to the Administrator, and the allegation was not brought forward until a staff meeting days later, resulting in the required notifications to external authorities not being made within the mandated 2-hour timeframe.
A resident with muscle weakness, gait abnormalities, atrial fibrillation, and on a blood thinner sustained an unwitnessed bathroom fall, reported hitting her head, and developed rapidly worsening right facial swelling and a swollen‑shut eye that prevented pupillary assessment. Initial vitals and neuro checks were performed, oxygen was applied, and x‑rays were ordered, but despite the significant change in condition and the resident’s anticoagulation status, the provider was not notified of the worsening condition at the time it occurred and the resident was not sent to the hospital until the next day when an NP assessed her and ordered transfer. In the ED, the physician documented that no evaluation for the injuries had occurred the prior evening and CT imaging showed traumatic subdural and subarachnoid hemorrhages and a large facial hematoma, demonstrating that the facility failed to provide timely, standard‑of‑care treatment and hospital transfer after the fall and subsequent change in condition.
A resident with cognitive impairment, neurological conditions, and substance-related diagnoses was assessed as being at risk for elopement and documented as having poor safety awareness, poor judgment, and wandering behavior requiring frequent redirection. Nursing staff observed the resident wandering in the hall and behind the nurse’s station and communicated during shift report that a WanderGuard was recommended, but no device was applied because staff did not know where to obtain one. The resident later left the building through the front door, was not immediately detected as missing, and was ultimately found by a medication technician about a mile away walking on a sidewalk near a restaurant, demonstrating a failure to provide adequate supervision and timely elopement interventions.
A nurse failed to follow professional standards for medication administration by not properly identifying a resident before giving medications, resulting in the administration of Lorazepam and Carvedilol that were intended for another resident. The error was discovered and documented, with monitoring showing the resident remained stable and without distress, and the hospice nurse, NP, and family were notified. Leadership, including the DON and administrators, acknowledged that the failure to correctly verify the resident’s identity led to the wrong medications being administered.
A resident with multiple comorbidities and an above-knee amputation requested that staff heat prepackaged ramen soup in a microwave at the nutrition station; staff followed package directions and returned the hot soup, which the resident, who used a motorized wheelchair and insisted on carrying items independently, then spilled while turning, causing a third-degree burn to the palmar side of the left wrist. Staff interviews showed that, before this incident, CNAs and an LPN heated food based on package instructions and judged safety by touch without thermometers, and the DON confirmed that no thermometers were available and that staff relied on touch to determine if food was safe to serve.
The facility failed to provide sufficient nursing staff with appropriate skills to respond promptly to call lights and assist residents with toileting, resulting in multiple residents experiencing incontinence and being left unattended on the toilet. Several residents with significant mobility and medical issues reported waiting long periods, including up to 30–45 minutes or more, for call lights to be answered, particularly during evenings, nights, shift changes, and weekends. Surveyors directly observed call lights sounding for 8–13 minutes before staff responded. Staff reported that CNA hours had been cut after a change in ownership, many staff had quit, and they were unable to complete all care tasks due to understaffing. Grievances and resident council notes over several months documented repeated complaints about slow call light response times, residents being left on the toilet for extended periods, and delays in getting to meals, while leadership acknowledged staffing was based on census rather than acuity despite the written facility assessment describing an acuity-based approach.
Multiple residents and a family member reported that meals were bland, unappetizing, sometimes raw or over-roasted, difficult to chew, and often cold by the time they reached residents’ rooms, with no consistent offer of alternatives when food was disliked. Resident council minutes and grievances documented concerns about cold meals, limited variety, lack of fruit, and meals perceived as too high in carbohydrates. A test tray showed hot items, including chicken tenders and tater tots, were served at low temperatures, with mushy, cold textures and dry, tough meat, and there was no plate warmer used while CNAs, rather than dietary staff, passed trays on the halls after a change in kitchen operations.
A resident with a right humerus fracture, chronic right arm pain, dementia (BIMS 9), and impaired use of one upper extremity required setup/clean-up assistance with eating, including cut food and opened containers, as reflected in the MDS and care plan. Despite this, surveyors observed multiple meals where the resident’s food was not consistently cut into bite-sized pieces and containers (such as lidded bowls, syrup packets, and juice boxes) were left unopened, leading family members to cut food on at least one occasion. The diet order and meal card lacked instructions for cut-up food or setup assistance, and interviews with CNAs, the DM, the MDS coordinator, and an RN confirmed that the resident needed this help but that it was not incorporated into formal orders or consistently implemented.
Two residents on modified diets for dementia and chewing/swallowing concerns were given snacks that did not match their ordered textures. One resident on a pureed diet, ordered after staff observed food being held in the mouth and poor chewing, was repeatedly provided ham sandwiches, potato chips, and an ice cream cone. Another resident on a minced & moist Level 5 diet with cut‑up foods was served a peanut cluster and later offered a crunchy “bird’s nest” snack with chow mein noodles and candy. Staff interviews revealed that activities staff supplied their own snacks without verifying diet orders, that the ST had not been consulted for a swallow evaluation in at least one case, and that nursing and dietary staff expected physician diet orders to be followed.
Failure to Inspect Mechanical Lift Sling Results in Resident Fall and Injury
Penalty
Summary
The deficiency involved the facility’s failure to ensure a resident’s environment was free from accident hazards and that equipment used for transfers was in safe, functional condition. A resident with Parkinson’s Disease was being transferred from bed to a chair using a mechanical (Hoyer) lift operated by two CNAs. One CNA reported that when she arrived to assist, the resident was already positioned in the sling, and as the lift was raised, a sling strap snapped, causing the resident to fall and strike the back of the head. Review of the manufacturer’s instructions for the lift and slings showed that staff were required to inspect slings and lifting straps for signs of wear, fraying, or weakness prior to every use. Record review showed that the resident sustained an abrasion to the back of the head, a 1 cm scalp laceration, and reported pain in the shoulders and neck following the fall, and was transferred to the hospital for evaluation. Subsequent NP documentation confirmed the 1 cm scalp laceration was bleeding and that the resident rated back pain as 9/10 on a numeric pain scale. Although maintenance records reflected a general audit of equipment had been conducted several weeks before the incident, there was no evidence that the specific sling used for this transfer had been inspected for integrity prior to use. During interview, the Administrator acknowledged that the equipment failure and strap breakage resulted in the resident’s fall and injury.
Failure to Timely Report Alleged Sexual Abuse to SSA and APS
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse and neglect were reported immediately, but no later than two hours after the allegation was made, to the State Survey Agency (SSA) and Adult Protective Services (APS). Resident 3, who was admitted with unspecified dementia and acute systolic congestive heart failure, was involved in two separate incidents in which her brother was observed kissing her on the mouth in a manner staff described as zealous, enthusiastic, sloppy, and not typical of a brother-sister interaction. On 12/28/25, CNA 1 observed a well-dressed man enter Resident 3's room, hug her, and give her a zealous kiss on the mouth. CNA 1 assumed the man was the resident's husband and reported this to LPN 1, who knew the visitor was the resident's brother. LPN 1 looked into the room and did not see anything out of the ordinary, and neither CNA 1 nor LPN 1 reported this incident as a potential allegation of abuse to the Administrator at that time. On 1/4/26, LPN 1 and CNA 1 entered Resident 3's room to address the resident's pain and request for catheter removal and to assist with a brief and linen change. Resident 3 had two visitors present, including her brother. When asked to step out for privacy, the female visitor left, but the brother hesitated and then gave Resident 3 a sloppy, open-mouthed kiss on the mouth lasting about three seconds, again in the presence of staff. The brother stated that Resident 3 was his older sister and that she had taken care of him since they were very small. LPN 1 did not report either the 12/28/25 or 1/4/26 kissing incidents to the Administrator. The Administrator later stated that the alleged abuse was first mentioned during a meeting on 1/6/26, at which time staff described the kiss as a weird, awkward kiss and not a typical brother-sister kiss, and acknowledged that nursing staff had not reported the suspicious activity in a timely manner, resulting in failure to notify SSA and APS within two hours of the allegation.
Delayed Hospital Transfer After Fall With Head Trauma and Anticoagulation
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident who experienced a fall with head trauma and was on anticoagulation received timely treatment and care in accordance with professional standards of practice. The resident had diagnoses including generalized muscle weakness, gait and mobility abnormalities, and unspecified atrial fibrillation, and was on a blood thinner. On the evening of the fall, nursing documentation showed that the resident was found on the bathroom floor after her roommate called out. The resident reported hitting her head, had facial pain rated 5/10, and initial vital signs showed an O2 saturation of 88–90% with other vitals within normal limits. A neurological assessment was initiated, oxygen was applied, and the on‑call provider was notified, who ordered x‑rays of the resident’s head and left hand. As the evening progressed, the resident’s condition changed. The nurse documented that the resident’s right eye became increasingly swollen to the point that by 9:15 PM it was swollen shut and pupillary reactivity could no longer be assessed, while the left eye remained equal and reactive to light. The neurological exam form recorded that the provider was notified of the fall at 8:00 PM, but did not indicate that the provider was notified when the right eye became swollen shut at 9:15 PM. The DON later stated that this change in the resident’s condition occurred at 9:15 PM and that the medical provider was not notified of this change until the provider came to the facility the following day. The DON also stated that if a resident on a blood thinner experienced a fall with head strike, she expected staff to send the resident to the hospital, and that she was not sure why this resident was not immediately sent. The resident remained in the facility overnight while x‑rays were obtained around 1:00–1:30 AM, with results reportedly available sometime between early morning hours and mid‑morning. The next morning, the NP assessed the resident due to the fall and documented significant right facial swelling, focal tenderness over the zygoma, difficulty visualizing the right eye, and concern for occult injury and possible orbital blowout fracture in the context of anticoagulation. The NP ordered transfer to the emergency department for CT imaging of the head and face. In the emergency department, the physician documented that no evaluation for the resident’s injuries had occurred the previous evening and that the facility had reported the resident seemed slightly altered the prior night and had worsening swelling by the time EMS was called. CT imaging revealed traumatic small subdural and subarachnoid hemorrhages without mass effect and a large facial hematoma. Interviews with nursing staff showed that the RN on duty was very concerned about the resident’s rapidly increasing facial swelling and difficulty administering medications due to lip swelling, but was waiting for a physician order to send the resident to the hospital and was unaware at the time that she could initiate a hospital transfer without such an order. These actions and inactions resulted in a delay in sending the resident to the hospital after a significant change in condition following a fall with head trauma while on a blood thinner. The facility’s Change of Condition/SBAR Evaluation Policy outlined expectations for describing changes in condition, documenting vital signs, identifying changes from baseline (including neurological status changes), and notifying the provider and responsible party, as well as documenting immediate actions and outcomes such as transfer to the hospital. Despite this policy, the neurological exam form did not reflect timely provider notification when the resident’s right eye became swollen shut, and the resident was not transferred until the following day after the NP’s in‑person assessment. The DON confirmed that the change in condition at 9:15 PM was not communicated to the provider until the next day. The surveyors determined that, for this resident, the facility did not ensure timely hospital transfer and did not provide treatment and care in accordance with professional standards of practice after a fall with head injury and subsequent change in condition.
Failure to Implement Elopement Precautions and Supervision for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and implement elopement precautions for a cognitively impaired resident who was identified as being at risk for elopement. The resident was admitted with multiple neurological and substance-related diagnoses, including cerebral infarction, ataxia, Wernicke’s encephalopathy, alcohol and opioid dependence, and traumatic subdural hemorrhage. On admission, the resident’s elopement risk screening showed a score of 12, indicating elopement risk, and nursing documentation described poor safety awareness, poor judgment, and a need for continuous cues with self-care and ADLs. The resident was also noted to require 1:1 supervision during meals due to quick eating behavior. In the hours leading up to the elopement, nursing staff observed the resident wandering in the hallway and behind the nurse’s station and reported that he required constant redirection. The night shift RN informed the day shift LPN during report that the resident had been wandering since early morning and that a WanderGuard was recommended. Despite this, no WanderGuard was applied before the resident left the building. The LPN later stated that she did not know where to obtain a WanderGuard, and the DON confirmed that both the RN and LPN had not placed a WanderGuard because they did not know its location. On the day of the incident, the resident went to the kitchen and requested water, and kitchen staff noticed a fall risk bracelet on his wrist. After this interaction, staff discovered that the resident was no longer in the building. Facility investigation determined that the resident exited through the front door at approximately 9:37 AM and was later found off premises, about one mile away, walking on a sidewalk near a restaurant. A medication technician, who had previously seen the resident wandering in only a gown and had informed the nurse, located the resident and returned him to the facility. These events demonstrate that, despite known elopement risk and observed wandering behavior, the facility did not implement timely elopement precautions or ensure adequate supervision to prevent the resident from eloping.
Medication Administration Error Due to Failure to Verify Resident Identity
Penalty
Summary
The deficiency involves a failure to provide necessary care and services in accordance with professional standards of practice during medication administration. For one resident reviewed for medication administration, a nurse did not follow the Five Rights of medication administration, specifically failing to properly identify the resident before giving medications. As a result, the nurse administered 0.25 mL of Lorazepam, an anti-anxiety medication, and 25 mg of Carvedilol, a beta-blocker used for blood pressure, that were intended for a different resident to Resident #1. Following the administration error, Resident #1’s vital signs were monitored throughout the night, and documentation indicated the resident remained stable, alert, and without signs of distress during the shift. The hospice nurse, nurse practitioner, and family were notified of the error. During interviews, the Administrator and DON acknowledged the medication error, and the DON confirmed that the nurse’s failure to correctly identify the resident prior to administering the medications was the cause of the wrong medications being given.
Burn Injury from Hot Soup Due to Inadequate Supervision and Temperature Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and accident prevention for a resident who sustained a burn injury from hot food. One resident with end stage renal disease, type 2 diabetes mellitus, pericardial effusion, chronic obstructive pulmonary disease, and an above-knee amputation of the left leg requested that staff heat a prepackaged ramen soup. Facility staff heated the soup in a microwave located in the nutrition station behind the nurse’s station according to the package directions and then returned the hot soup to the resident. After receiving the heated soup, the resident, who used a motorized wheelchair and was described as very independent, turned in his power wheelchair, causing the ramen to spill and the hot liquid to burn the palmar side of his left wrist. A progress note documented that the resident received a burn to his left wrist after spilling the hot soup, that the wound was assessed, wound care was provided, and new orders were placed following consultation with a wound provider. The resident reportedly tolerated treatment well and denied pain or other concerns at that time. Subsequent documentation by a wound provider classified the burn on the resident’s left wrist as a third-degree burn. Staff interviews revealed that, prior to this incident, staff heated residents’ food according to package directions and determined whether it was safe to return based on touch, without using thermometers to verify temperature. A CNA reported that the resident often asked CNAs to heat food and insisted on carrying it himself, and that staff declined to heat his food when he refused to allow them to carry it due to safety concerns. An LPN and the DON both confirmed that thermometers were not available for use before the burn occurred and that staff relied on touch to judge food temperature.
Insufficient Nursing Staff and Delayed Call Light Response Leading to Incontinence and Unattended Toileting
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff with appropriate competencies and skills to meet residents’ needs, particularly in timely response to call lights and assistance with toileting, which resulted in incontinent episodes and residents being left unattended. Multiple residents reported long call light wait times, especially during evening and night shifts and on weekends, when there were as few as three CNAs for the entire building. Residents with significant physical limitations, including recent hip fractures, hemiplegia, and other serious conditions, described being unable to get to the bathroom without staff assistance and experiencing incontinence because staff did not respond promptly to their call lights. One resident with a periprosthetic hip fracture, hemiplegia, an artificial hip joint, major depressive disorder, and anxiety reported that from 6:00 PM to 6:00 AM there were only three CNAs for three hallways, resulting in long waits for call light responses. This resident stated she had incontinent bladder episodes when she first arrived because she could not hold her urine while waiting for help, including one instance where she waited 35 minutes for a response. Another resident with a left femur fracture, chronic pain, lupus, and epilepsy reported waiting an hour for her call light to be answered, leading to urinating in her brief because staff did not arrive in time to take her to the bathroom. A third resident with metabolic encephalopathy, acute respiratory failure with hypoxia, pneumonia, UTI, and end-stage renal disease on dialysis stated she had been left on the toilet and had to get herself off and back to bed due to lack of staff. CNA documentation showed multiple incontinent episodes for these residents despite staff describing them as continent of bowel and bladder. Additional residents and a family member reported frequent long call light wait times, including waits of 30–45 minutes, particularly during shift changes and on weekends. The Resident Council President reported that since a change in ownership, residents complained that call lights took 30–40 minutes to be answered and that there were not enough CNAs on the night shift to handle residents’ needs during evening and bedtime hours. Direct observations by surveyors documented call lights sounding for 8 to 13 minutes before being answered on multiple occasions. Staff interviews confirmed that CNA hours had been cut after the ownership change, that many staff had quit, and that staff were asked to work a lot of overtime and were sometimes unable to complete showers due to understaffing. One staff member reported a resident had an incontinent episode after waiting about 45 minutes for a call light response. Grievance records and resident council notes showed a repeated pattern of complaints over several months about slow call light response times, residents being left on the toilet for extended periods, and delays in getting to meals due to insufficient staff. Grievances included reports of residents waiting over an hour to be taken to breakfast, feeling ignored when requests were not fulfilled, and being left on the toilet for almost three hours, causing discomfort. Resident council notes repeatedly documented concerns about call lights taking a long time to be answered, not enough CNAs in the dining room at mealtimes, and residents being left on the toilet or not getting to breakfast on time. Although the facility’s written facility assessment and staffing plan referenced using acuity and tools such as the MDS and RAI to determine staffing, the DON stated that in practice staffing coverage was based on census rather than acuity and acknowledged there had been many issues with call lights since staffing was cut after the change in ownership.
Failure to Provide Palatable, Attractive Meals at Appropriate Temperatures
Penalty
Summary
The deficiency involves the facility’s failure to consistently provide food and drink that were palatable, attractive, and served at safe and appetizing temperatures for multiple residents. Several residents reported that the food was bland, horrible, disgusting, or generally “not good,” and one resident stated that if she did not like what was served, staff did not offer an alternative and that she repeatedly received dark meat she did not like. A family member reported that a resident with a poor appetite received chicken that was dry and needed more moisture. Resident council minutes documented concerns that hamburgers were sometimes too raw, vegetables were roasted to the point of tasting burned, pork chops were difficult to cut or chew, and that food delivered to rooms was cold by the time it arrived when CNAs passed trays. Surveyors’ direct observation of a test tray showed that hot items were not maintained at appetizing temperatures and were of poor quality. After the last tray was plated and placed in the cart, CNAs—not dietary staff—were responsible for passing trays to residents, and there was no plate warmer between the plate and the plastic base. When the test tray was checked, the chicken tender and tater tots were below typical hot-holding temperatures, with the tater tots described as mushy and cold and the chicken tender as dry, tough to chew, and salty. The cold item, a carrot coin salad, was measured at a chilled temperature. Grievances documented that meals were served too cold and that residents were dissatisfied with the variety, fruit options, and perceived high carbohydrate content of the meals. The Dietary Manager acknowledged that dietary staff no longer delivered trays to residents after a change in ownership and attributed cold food to CNAs not passing trays quickly enough, while the Administrator acknowledged there had been complaints about food quality.
Failure to Provide Required Meal Setup and Cut Food Assistance for Resident With Upper Extremity Impairment
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate treatment and services to maintain or improve a resident’s ability to perform ADLs related to dining and eating, specifically cutting food into bite-sized pieces and opening containers as assessed and care planned. A resident with a right humerus fracture, chronic right arm pain, dementia with moderate cognitive impairment (BIMS 9), polyneuropathy, osteoarthritis, chronic pain syndrome, and a right artificial shoulder joint reported being unable to cut her own food and demonstrated that she had to guide her right arm with her left hand. Surveyors observed on multiple occasions that her meals were not consistently prepared or set up to match her assessed need for setup/clean-up assistance with eating. At one meal, her family reported they had to cut up her food and that this was not the first time. At another meal, her breakfast tray included whole sausage links, a lidded bowl, an unopened syrup packet, and a closed juice box with the straw still wrapped, despite her limited use of one arm. The resident’s MDS indicated impairment in one upper extremity and a need for setup or clean-up assistance with eating, and her care plan documented a focus on ADL self-care performance deficit related to dementia and impaired balance, with an intervention that she required setup or clean-up assistance to eat. However, her physician’s diet order specified only a regular diet with regular texture and consistency, with no instruction for cut-up food or meal setup assistance. The Dietary Manager confirmed there were no directions on the resident’s meal card to cut up her food and stated that food was sometimes cut into strips, including pork cutlets, based on the type of food. The MDS Coordinator and an RN both stated that the resident needed her food cut up and lids removed for meal setup and that it would be too difficult for her to manage with one arm, but acknowledged these needs were not reflected in physician orders. Staff also noted that the resident likely could not cut her own food due to right arm pain and limited function and that she would not usually ask for help even when needed, yet the kitchen and nursing staff did not consistently ensure her food was cut into bite-sized pieces or that containers were opened for her.
Failure to Provide Ordered Diet Textures During Nursing and Activities Snacks
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents received food in the texture ordered to meet their individual needs. One resident with dementia and Alzheimer’s disease had a physician’s order for a pureed diet after nursing, the DON, and the nurse practitioner observed that she was not eating well on a regular diet, was cheeking food, holding it in her mouth, and not chewing. Despite this pureed diet order, multiple nursing progress notes documented that she was given ham sandwiches and potato chips on several nights, and an activities note documented that she ate an ice cream cone. Staff interviews confirmed that she was on a pureed diet because she would let food sit in her mouth and that chips and sandwiches are not part of a pureed diet. The speech therapist stated he had not been asked to evaluate her swallowing, that he normally would want to screen residents whose diets were downgraded, and that non‑pureed foods for someone who holds food in their mouth would be a choking concern. Another resident with dementia and a severe cognitive impairment, as evidenced by a BIMS score of 3, had a physician’s order for a regular diet with minced and moist (Level 5) texture and cut‑up foods due to loose teeth. Nonetheless, an activities progress note documented that she ate a peanut cluster during a cooking social, and the Activities Director later reported that she was also given a “bird’s nest” snack made of crunchy chow mein noodles with candy on top, which she did not eat. Nursing staff stated that this resident did not have the mental capacity to chew, required extensive cueing, and that they would be concerned about choking if she were served non‑minced and moist foods. The Dietary Manager reported that the Activities Department provided its own snacks and did not ensure residents received the correct diet textures, and the DON stated that staff were expected to follow physician orders for diet textures despite limited availability of the speech therapist.
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