Thatcher Brook Rehabilitation & Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Clearfield, Utah.
- Location
- 1795 South Chelemes Way, Clearfield, Utah 84015
- CMS Provider Number
- 465169
- Inspections on file
- 16
- Latest survey
- July 23, 2025
- Citations (last 12 mo.)
- 23
Citation history
Health deficiencies cited at Thatcher Brook Rehabilitation & Care Center during CMS and state inspections, most recent first.
Surveyors found that drugs and biologicals were not consistently labeled with open or expiration dates, including insulin vials and pens for two residents with diabetes. Medications such as sucralfate and daptomycin were improperly stored in a medication room sink, and a medication cart was observed left unlocked and unattended. Staff interviews confirmed these practices did not align with facility policy or professional standards.
Several residents reported dissatisfaction with meal quality, including unappetizing taste, tough meat, lack of seasoning, and cold or improperly prepared food. Observations of a test tray confirmed issues with food temperature and appearance. Dietary staff relied on informal feedback, and alternative menu options were not consistently offered or accessible.
Surveyors found that food items in the kitchen were not consistently stored, labeled, or sealed according to professional standards, with multiple items left open to air in freezers and refrigerators, and some lacking required dates. The stove and oven surfaces were also observed to be unclean, with crumbs, debris, grease, and powder present. Staff interviews confirmed that procedures for dating and sealing food were in place but not consistently followed.
Staff failed to consistently follow Enhanced Barrier Precautions and infection control protocols, including not donning required PPE, not performing hand hygiene during dressing changes, and improper cleaning techniques for central line care. PPE signage was inconsistently marked, and staff demonstrated confusion about EBP requirements, resulting in care for residents with wounds, central lines, and indwelling devices being provided without appropriate infection prevention measures.
A resident with limited mobility and dexterity, requiring assistance with eating, was observed being fed by a CNA who stood at the bedside rather than sitting, contrary to facility expectations. The DON confirmed that staff should be seated while feeding residents to maintain dignity and respect.
A resident with complex medical needs was emergently transferred to the hospital after a seizure, but the facility did not provide written notice of transfer or discharge, nor written information about the bed-hold policy, to the resident or their representative as required. Verbal notification was given, but no written documentation was included with the transfer or provided afterward.
Two residents with documented preferences for group and individual activities were only offered bingo three times a week, with no other scheduled activities provided. Interviews and review of the activities calendar confirmed the lack of variety, and both the Activities Director and Administrator acknowledged that other available materials and options were not actively promoted or scheduled.
A resident with severe cognitive impairment and a history of falls did not have new interventions added to their care plan after experiencing multiple falls. Despite repeated incidents and the resident's ongoing fall risk, staff relied on verbal communication and did not formally update the care plan with new measures following each event.
A resident with end stage renal disease, sepsis, and heart failure did not receive immediate monitoring or documentation of vital signs and dialysis fistula assessment upon return from dialysis. Staff relied on information from the dialysis center and performed assessments at other times, but did not follow facility expectations for immediate post-dialysis evaluation and documentation.
A resident with a prescribed soft-bite and pre-cut food diet did not receive appropriate menu substitutions for garlic bread and salad, as required by her dietary restrictions. Despite the menu indicating alternatives should be provided, the resident was served a meal without suitable substitutes, leading to dissatisfaction and a failure to meet her nutritional needs.
A resident with multiple chronic conditions and a documented dislike of pork and pork products was repeatedly served sausage, despite her preferences being clearly noted on her dietary records and meal tickets. Staff interviews and record reviews confirmed that the resident's dislikes were known, but pork products were still provided.
A resident with a history of recurrent UTIs was prescribed Macrobid daily as a prophylactic antibiotic without documented evidence of current infection or symptoms, and the order lacked a stop date. The facility's antibiotic stewardship policy required clear documentation of treatment duration and monitoring, but these protocols were not followed, resulting in a deficiency related to antibiotic use monitoring.
A resident with multiple chronic conditions received the initial PCV-13 pneumococcal vaccine, but the facility failed to document administration, offer, or declination of the second recommended pneumococcal vaccine dose. The resident's vaccination status was marked as 'unable to determine,' and there was no evidence that the required follow-up was completed according to facility policy.
Deficiencies in Medication Storage, Labeling, and Security
Penalty
Summary
Surveyors identified multiple deficiencies related to the storage and labeling of drugs and biologicals for four residents. For one resident with type 2 diabetes mellitus and end stage renal disease, an opened insulin vial was found without an open or expiration date. The responsible RN confirmed the vial was opened and subsequently labeled it during the observation. Another resident with diabetes had an insulin pen in the medication cart that was also missing an open or expiration date, and the LPN interviewed was unsure of the exact duration insulin remained viable after opening. This resident had already been discharged at the time of the observation. Additional deficiencies were observed with medications not being properly stored. A bubble pack of sucralfate for a resident with gastro-esophageal reflux and cyclical vomiting was found in the medication room sink with one tablet remaining. Similarly, compounded daptomycin vials for a resident with sepsis and pneumonia were also found in the medication room sink. The DON stated that medications should not be stored in the sink and explained that these were intended to be returned to the pharmacy, which collects unused medications twice daily. Surveyors also observed a medication cart left unlocked and unattended in a hallway. The DON and LPN confirmed that the cart should be locked when not attended, and the RN responsible for the cart stated she had left her keys with the LPN during her break but was unsure if the cart had been left unlocked. The DON reiterated that medication carts should always be locked when unattended and that no medications or resident information should be left exposed.
Failure to Provide Palatable, Attractive, and Properly Tempered Meals
Penalty
Summary
The facility failed to provide food and drink that was palatable, attractive, and at a safe and appetizing temperature for 8 of 26 sampled residents. Multiple residents reported dissatisfaction with the quality, taste, and temperature of the meals served. Specific complaints included food being unappetizing, tough meat, lack of seasoning, cold vegetables, and not receiving menu-listed items or appropriate condiments. Some residents stated they were not offered alternatives and, in some cases, resorted to ordering food from outside sources due to dissatisfaction with facility meals. Observations of meal service and a test tray revealed further issues. The test tray included pork roast that was dry, tough, and served at 124.9°F, wild rice pilaf that was lukewarm and unsavory, overcooked and bland asparagus at 117.3°F, a flattened and unappetizing apple crisp dessert at 53.1°F, and a dinner roll at 70.3°F. These findings confirmed that food was not consistently served at appetizing temperatures or in an appealing manner. Additionally, the test tray and resident interviews indicated that food preparation methods did not conserve flavor or appearance. Interviews with dietary staff revealed that while the Registered Dietitian (RD) and Dietary Manager (DM) were involved in resident assessments and occasional tray audits, feedback mechanisms were informal and not consistently documented. The alternative menu was not readily accessible to all residents, as it was separate from the main menu and only provided upon request. These actions and inactions contributed to the deficiency in providing meals that met regulatory standards for palatability, appearance, and temperature.
Improper Food Storage and Kitchen Cleanliness
Penalty
Summary
Surveyors observed multiple instances where food items in the facility's kitchen were not stored, prepared, or maintained according to professional food service safety standards. During walk-throughs, several food items in both the walk-in and reach-in freezers, such as diced carrots, peas, French toast, cookie dough, sausage links, and dinner rolls, were found open to the air. Additionally, the stove and the top of the oven were noted to have crumbs, debris, grease, and a white powder, indicating a lack of cleanliness. In the walk-in refrigerator, containers of chicken breasts and pork roast were covered with plastic wrap but were not dated, and a large bucket of pickles did not have an open date. Interviews with kitchen staff and the Dietary Manager revealed that food items were supposed to be dated when received and when opened, and that cleaning duties were assigned to all kitchen staff. The Dietary Manager confirmed that food in the refrigerator should be dated even if it was to be used the same day, and that food in the freezer should be sealed to prevent freezer burn. Despite these stated procedures, the observed deficiencies indicated that these practices were not consistently followed, resulting in improper food storage and cleanliness issues.
Failure to Implement and Adhere to Enhanced Barrier Precautions and Infection Control Protocols
Penalty
Summary
Surveyors identified that the facility failed to maintain an effective infection prevention and control program for three out of twenty-six sampled residents. Staff were observed not donning required Personal Protective Equipment (PPE) for residents on Enhanced Barrier Precautions (EBP), not performing hand hygiene during dressing changes, and engaging in cross-contamination during a central line dressing change. Specifically, signage for PPE requirements was inconsistently marked, and staff demonstrated confusion regarding when and what type of PPE was necessary for care activities involving residents with indwelling devices or wounds. For one resident with a central line for IV antibiotic administration due to infective endocarditis, staff did not wear a gown during medication administration or dressing changes, despite EBP policy requiring both gown and gloves for such high-contact care. Additionally, hand hygiene was not performed prior to donning sterile gloves, and improper technique was used when cleaning the central line insertion site, with the nurse going back over the insertion site after cleaning outward. The PPE signage outside the resident’s room was not properly marked until after the dressing change, and staff interviews revealed a lack of understanding about EBP requirements. Other residents with wounds, feeding tubes, or indwelling urinary catheters also had EBP signage posted, but staff were observed providing care and assistance, including transfers and therapy, without donning the required PPE. Interviews with staff indicated inconsistent knowledge and application of EBP protocols, and in some cases, there were no physician orders for EBP found in the records. The facility’s policy required gown and gloves for high-contact care activities for residents with wounds or indwelling devices, but these procedures were not consistently followed.
Staff Stood While Feeding Dependent Resident
Penalty
Summary
A deficiency was identified when a certified nursing assistant (CNA) was observed standing while feeding a resident who was lying in bed with the head of the bed elevated and the bed in its highest position. The resident, who had a history of cellulitis, sepsis, and hypertension, required assistance with eating due to difficulty with dexterity and was dependent on a Hoyer lift for mobility. During interviews, staff confirmed that the resident struggled to feed herself and that CNAs were expected to sit while feeding residents, as stated by the Director of Nursing (DON). However, the observed practice did not align with this expectation, resulting in a failure to treat the resident with respect and dignity and to provide care in a manner that promoted the resident's quality of life and recognized her individuality.
Failure to Provide Written Transfer/Discharge and Bed-Hold Policy Notification
Penalty
Summary
A deficiency was identified when a resident with multiple medical conditions, including a left tibia and fibula fracture, respiratory failure with hypoxia, neuralgia, type 2 diabetes, anxiety disorder, epilepsy, and morbid obesity, was emergently transferred to the hospital after experiencing a seizure and becoming unresponsive. Although internal discharge paperwork was completed, there was no discharge documentation found in the resident's medical record. The facility's policy requires that notice of transfer or discharge, including the reason for transfer and bed-hold policy details, be provided to the resident and their representative in writing as soon as practicable, especially in emergency situations. Interviews with the DON and Administrator revealed that while some paperwork, such as a face sheet, resident orders, and a POLST form, was sent with the resident, no written notice of transfer or discharge or bed-hold policy was provided to the resident or their representative. The DON stated that the bed-hold policy was communicated verbally but not in writing, and the Administrator confirmed that a bed-hold agreement was not sent with residents transferred to the hospital. This failure to provide required written notifications and documentation at the time of transfer or discharge constituted the deficiency.
Failure to Provide Comprehensive Activity Program for Residents
Penalty
Summary
The facility failed to provide an ongoing program of activities to meet the interests and support the physical, mental, and psychosocial well-being of its residents, as required. For two out of 26 sampled residents, it was observed and confirmed through interviews that the only scheduled activity was bingo, which occurred three times a week, with no other group or individual activities offered. The activities calendar reflected this lack of variety, listing only bingo on select days and leaving other days, including weekends, blank. Residents expressed dissatisfaction, stating there were no other activities available and some days had no activities at all. Review of the residents' medical records showed that both had expressed preferences for group activities and participation in their favorite pastimes, as documented in their Minimum Data Set (MDS) assessments and care plans. Despite these documented preferences, the only interventions listed were to acquaint residents with the facility and its routines. The Activities Director (AD) confirmed that activity packets with puzzles and word games were distributed, and that some materials like books and board games were available, but these were not actively promoted or scheduled as part of a structured program. The AD also stated she had no helpers and had not received training. The Administrator acknowledged the lack of variety in activities and that residents were not informed about available options beyond bingo and activity packets.
Failure to Update Fall Interventions After Multiple Resident Falls
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment, generalized weakness, and a history of falls did not have new interventions implemented after experiencing multiple falls. The resident, who was at risk for falls due to lack of coordination and recent hospitalization, experienced at least three documented falls within a short period. Despite these incidents, the care plan was not updated with new interventions following the falls on 7/3/25 and 7/12/25. The existing care plan included general fall prevention measures such as therapy, use of gait belts, frequent safety checks, and encouragement to use the call light, but did not address the specific circumstances or patterns of the recent falls. Interviews with nursing staff and administration revealed inconsistent practices regarding the updating of care plans and communication of interventions. The DON and ADON indicated that interventions were not always updated after each fall, and that staff were often informed of required interventions verbally rather than through formal documentation. The care plan was reviewed only every 30 days, and there was no evidence of new interventions being added after the most recent falls, despite the resident's ongoing risk and repeated incidents.
Failure to Provide Immediate Post-Dialysis Assessment and Documentation
Penalty
Summary
A deficiency was identified in the care of a resident with end stage renal disease, sepsis, and heart failure who required dialysis services. Upon review of the resident's medical record and interviews with the resident, nursing staff, and the Director of Nursing (DON), it was found that the facility did not provide immediate monitoring and documentation of the resident's vital signs or assessment of the dialysis fistula upon the resident's return from the dialysis treatment center. The resident reported that after returning from dialysis, a Certified Nursing Assistant (CNA) assisted him to his room, but no vital signs were taken and a nurse did not assess his dialysis fistula at that time. Further interviews revealed that the LPN relied on the Dialysis Progress Note from the dialysis center, which included vital signs, weights, and new orders, and stated that vital signs were taken in the morning before dialysis and again in the evening, with fistula assessments completed every morning. However, there was no documentation in the resident's medical record of immediate post-dialysis vital signs or fistula assessment. The DON confirmed that facility policy expected nurses to assess the resident and the dialysis fistula immediately upon return from dialysis and to document these findings, but this was not done in this case.
Failure to Provide Appropriate Menu Substitutions for Special Diet
Penalty
Summary
A deficiency was identified when a resident with special dietary needs did not receive appropriate menu substitutions in accordance with her prescribed diet. The resident, who had recently discontinued tube feedings and was transitioning back to oral intake, was observed at lunch receiving spaghetti with small pieces of meat and green peas, along with a pudding-type dessert. The menu for that meal listed spaghetti, garlic bread, and a green salad, but the resident did not receive suitable substitutes for the garlic bread or salad, despite her dietary restrictions. The resident expressed disappointment with her meal, noting the lack of appropriate alternatives. Review of the resident's medical record showed she required a soft-bite and pre-cut food diet, as approved by the Registered Dietitian (RD), and had specific restrictions to avoid certain foods due to severe inflammation and gastric irritants. The daily menu spreadsheet indicated that substitutions should have been provided, such as soft steamed vegetables or mashed vegetables for salad, and pureed bread for garlic bread. The Dietary Manager confirmed that changes to diet orders were communicated by the RD and entered into the dietary system, but acknowledged that appropriate substitutions were not made for this resident's meal.
Failure to Accommodate Resident's Documented Food Preferences
Penalty
Summary
A deficiency was identified when a resident with multiple medical diagnoses, including infective endocarditis, atrial fibrillation, chronic kidney disease, cystitis, type 2 diabetes mellitus, bacteremia, hypolipidemia, and hypokalemia, received food items that did not accommodate her documented dietary preferences and dislikes. The resident had a clearly documented dislike of pork and pork products, including ham and sausage, as noted on her Nutrition Screening Intake Form and her meal ticket. Despite these documented preferences, the resident reported receiving pork products, specifically sausage, on multiple occasions, including during a breakfast observation where a sausage patty was present on her tray. Interviews with the resident, a CNA, and a staff member responsible for dietary preferences confirmed that the resident's dislikes were known and documented, and that pork products should not have been served. The staff member acknowledged that the resident's meal ticket listed pork, ham, and sausage as dislikes and that eggs were typically provided as an alternative. The presence of sausage on the resident's tray was verified by both the CNA and the kitchen, indicating a failure to follow the resident's documented dietary preferences.
Failure to Monitor and Document Antibiotic Use per Stewardship Protocols
Penalty
Summary
A deficiency was identified when a resident with a history of recurrent urinary tract infections (UTIs), neoplasm of the right kidney, and hypertension was prescribed Macrobid (nitrofurantoin) 100 mg daily as a prophylactic antibiotic for chronic UTIs. The physician's order for the antibiotic was open-ended, lacking a stop date, and was continued without documented evidence of current infection or symptoms. Medical records and progress notes indicated that the resident did not exhibit signs or symptoms of a UTI during the period the antibiotic was administered, and a urine dip was negative. There was also no documentation that a urinalysis was performed as ordered. The facility's antibiotic stewardship policy required that antibiotic orders include a duration of treatment, specifying start and stop dates or the number of days of therapy. The policy also emphasized monitoring antibiotic use and providing education on the risks associated with antibiotics. Despite this, the resident received ongoing prophylactic antibiotic treatment without adherence to these protocols, and the facility did not ensure that its antibiotic stewardship program included effective monitoring or protocols for antibiotic use as required.
Failure to Document and Offer Second Pneumococcal Vaccine Dose
Penalty
Summary
A deficiency was identified when the facility failed to offer or document the administration or declination of the second dose of the pneumococcal immunization series for one resident. The resident, who had a medical history including a right fibula fracture, congestive heart failure, chronic kidney disease, type 2 diabetes mellitus, a prosthetic heart valve, cardiomyopathy, and hypertension, had received the PCV-13 pneumococcal vaccine. However, there was no documentation in the medical record indicating that the resident was administered, offered, or declined the subsequent recommended pneumococcal vaccine. The facility's process involved the ADON checking the Statewide Immunization Information System for new admissions and completing a vaccine form. In this case, the resident's vaccination consent form was marked as "unable to determine" for the pneumococcal vaccine, and the DON confirmed that there was no evidence of the second vaccine being offered or declined. The facility's policy required assessment and offering of the pneumococcal vaccine series upon admission, with documentation of administration or refusal, but this was not followed for the resident in question.
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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