The Terrace Transitional
Inspection history, citations, penalties and survey trends for this long-term care facility in Ogden, Utah.
- Location
- 400 East 5350 South, Ogden, Utah 84405
- CMS Provider Number
- 465115
- Inspections on file
- 15
- Latest survey
- October 8, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at The Terrace Transitional during CMS and state inspections, most recent first.
A resident with a history of thoracic vertebra fracture and other conditions experienced a delay in care after complaining of leg numbness and weakness. Despite initial exams showing no abnormalities, the resident later reported paralysis, which was not communicated to the provider. The resident was eventually sent to the ER with severe symptoms and diagnosed with serious conditions, highlighting a lapse in timely notification and response.
The facility failed to provide sufficient support personnel for food and nutrition services, resulting in delayed and cold meals for residents. Observations showed meals were served later than scheduled, with residents expressing dissatisfaction. The Dietary Manager suggested nursing staff delays, but observations indicated meals left the kitchen late. The administrator expected meals to be served within a 5-10 minute window of posted times, which was not achieved.
The facility did not follow its abuse prevention policy by failing to verify the licenses of two staff members before they began working with residents. Employee 1, a Nursing Assistant, started work without any record of license verification, while Employee 2, a CNA, had their license verified months after starting. Interviews with HR and the Administrator revealed inconsistencies in the verification process, with no explanation for the delays.
The facility was found to have insufficient nursing staff, resulting in delayed responses to call lights and unmet resident needs. Observations and interviews revealed that residents experienced long wait times for assistance, particularly during night shifts and weekends. Staff acknowledged the challenges of staffing shortages, with some being asked to work overtime. Resident council minutes also highlighted concerns about staffing levels and care quality.
The facility failed to provide timely and accurate laboratory services for three residents, leading to deficiencies in meeting their medical needs. A resident did not have a urinalysis completed as ordered, while another experienced multiple issues with laboratory tests not being performed, including TSH and Valproic Acid levels. A third resident faced delays in completing TSH and Lipid Panel tests, with no follow-up order for a TSH recheck as required.
The facility failed to provide palatable and properly heated meals to residents, with multiple complaints about bland, overcooked, and cold food. Observations confirmed the lack of a heating system during meal delivery, and resident council notes documented ongoing dissatisfaction. Despite new kitchen staff, issues persisted.
The facility failed to maintain an effective infection control program, as observed in improper medication handling by an RN and multiple instances of CNAs neglecting hand hygiene during meal services. A resident received medication touched by bare hands, and CNAs were seen handling meal trays and assisting residents without washing hands, despite being trained to do so.
A resident with multiple health issues was transferred to a hospital after a fall, but the facility failed to document the transfer in the medical record or communicate necessary information to the hospital. The resident returned with diagnoses of altered mental status and vertebral compression fractures. An interview revealed that required transfer documentation was not provided.
The facility failed to provide written information about the bed-hold policy to two residents during hospital transfers. One resident with multiple diagnoses was hospitalized after showing concerning symptoms, and another was transferred following a fall. In both cases, the bed-hold documentation was not found in their medical records, despite claims that it was sent with them.
A resident with multiple medical conditions was observed being pulled backwards in a shower chair, covered in towels with exposed buttocks, through a hallway by a CNA. The resident expressed this was not usual practice, preferring to be fully dressed post-shower. The DON confirmed this was not standard practice, highlighting a failure to maintain resident dignity.
The facility breached confidentiality by leaving computer screens open and a nurse report exposed on medication carts, revealing resident information. An LPN and an RN left screens unattended in the 200 hallway, and a nurse report was left face up for 15 minutes. The DON confirmed that such actions are against protocol.
A LTC facility failed to provide adequate supervision for two residents, leading to deficiencies. One resident, identified as a high elopement risk, left the facility unattended despite having a wander guard and lacked a smoking assessment. Another resident experienced an unwitnessed fall without receiving necessary neurological checks. The facility's policies on elopement and smoking were not effectively implemented, contributing to these deficiencies.
A resident with chronic pain and multiple health conditions did not receive prescribed gabapentin due to a missing prescription, leading to unmanaged severe pain. Despite having a care plan, the facility failed to ensure the medication was available, relying instead on alternative pain management methods.
Two residents in an LTC facility experienced medication management deficiencies. One resident received blood pressure medication outside of physician-ordered parameters due to staff confusion. Another resident missed multiple doses of Abilify and Torsemide due to dialysis scheduling conflicts, and was administered insulin outside prescribed parameters. Staff interviews confirmed these issues.
The facility failed to ensure proper storage and labeling of medications. An insulin vial exceeded its expiration date, and a glargine insulin pen lacked an open date. A nurse administered medication from a bubble pack that had been improperly taped back. Additionally, an intravenous antibiotic was left unattended on a medication cart. The DON confirmed these practices were against protocol.
A facility failed to establish an antibiotic stewardship program, leading to a deficiency in monitoring antibiotic use. A resident with recurrent UTIs was prescribed prophylactic antibiotics, but staff were unaware of the specific reasons for the prescription, and there was no supporting documentation from a urologist. Interviews revealed a lack of clarity and communication regarding the antibiotic regimen, highlighting the facility's failure to implement a comprehensive program.
Delay in Care for Resident with Leg Paralysis
Penalty
Summary
A delay in care was identified for a resident who complained of leg numbness and weakness. The resident, who had a history of a wedge compression fracture of the thoracic vertebra, multiple rib fractures, muscle weakness, cognitive communication deficit, and schizophrenia, was admitted to the facility and later discharged with these diagnoses. On June 26, 2024, a provider conducted a cranial nerve and neurological exam due to the resident's complaints of being unable to move or feel their legs, but no abnormalities were noted at that time. However, on June 29, 2024, licensed practical nurses documented the resident's complaints of lower extremity paralysis, but there was no evidence that the provider was informed of this change in condition. The situation escalated when, on June 30, 2024, a registered nurse documented that the resident was seen by a provider and sent to the emergency room due to hypoxia, nausea, and new onset paralysis of the lower extremities. The resident was diagnosed with cauda equina compression, epidural abscess, and osteomyelitis of the thoracic vertebra during a five-day hospital admission. Interviews with the facility's administrator and nurse practitioner revealed a lack of documentation regarding the resident's condition on June 29, 2024, and uncertainty about the resident's symptoms. The nurse practitioner noted that the resident's condition worsened suddenly, leading to the decision to send them to the hospital, but there was no prior notification of the change in condition.
Insufficient Support Personnel in Food and Nutrition Services
Penalty
Summary
The facility was found to have insufficient support personnel to effectively manage the food and nutrition services, leading to delays in meal service and resident dissatisfaction. Surveyors observed that meals were consistently served later than the posted meal times, with residents receiving their food cold. Multiple resident complaints were documented, both through direct interviews and in resident council notes, indicating that meals were not served hot and were often delayed. Specific observations noted that meal service in the dining room and hallways did not align with the scheduled times, with significant delays in serving residents in different halls. Interviews with residents and staff further highlighted the issue, with residents expressing dissatisfaction with the temperature and timing of their meals. The Dietary Manager claimed that meals were delivered from the kitchen on time, suggesting that delays might be due to nursing staff being behind on passing trays. However, observations contradicted this claim, showing that meals left the kitchen after the scheduled times. The facility administrator acknowledged the expectation for meals to be served within a 5-10 minute window of the posted times, which was not being met.
Failure to Verify Employee Licenses Before Resident Interaction
Penalty
Summary
The facility failed to develop and implement written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents. Specifically, the facility did not adhere to its abuse policy by failing to screen prospective employees' licenses before they began working with residents. This deficiency was identified in the cases of two staff members. Employee 1, a Nursing Assistant, was hired and began working without any record of their license being checked to verify that a previous license had not been obtained. Employee 2, a Certified Nursing Assistant, had their license verified several months after starting work, contrary to the facility's policy. Interviews with the Human Resources (HR) department and the Administrator (ADM) revealed inconsistencies in the verification process. The HR department stated that license or certification verification was supposed to be completed upon hire and before employees worked with residents. However, there was no proof of license verification for Employee 1, and Employee 2's license was verified months after they started working. The ADM confirmed that the HR department was responsible for verifying licenses and that this should occur before employees accessed computers or worked with residents. The ADM was unable to explain why the verification process was delayed or incomplete for these employees.
Staffing Shortages Lead to Delayed Resident Care
Penalty
Summary
The facility was found to have insufficient nursing staff to meet the needs of its residents, as evidenced by observations, interviews, and record reviews. Specifically, call lights were observed to be unanswered for extended periods, with some residents waiting up to 30 minutes or more for assistance. This delay in response was noted across multiple rooms and times, indicating a systemic issue rather than isolated incidents. Residents expressed dissatisfaction with the long wait times, particularly during night shifts and weekends, when staffing appeared to be more strained. Interviews with residents revealed a consistent pattern of complaints regarding the timeliness of staff responses to call lights. Several residents reported waiting for assistance with personal care needs, such as changing wet briefs, which were not addressed promptly, leading to discomfort and distress. The residents also noted that the staff seemed overworked and unable to provide adequate care, with some residents resorting to calling the front desk for help when call lights went unanswered. Staff interviews corroborated the residents' concerns, with several staff members acknowledging the challenges posed by staffing shortages. Registered nurses and CNAs reported being asked to work overtime and cover additional shifts due to the lack of sufficient staff. The absence of management during weekends further exacerbated the issue, as staff struggled to manage the workload and respond to residents' needs in a timely manner. The facility's resident council minutes also highlighted ongoing concerns about staffing levels and the impact on care quality, particularly during night shifts.
Deficiencies in Laboratory Services for Residents
Penalty
Summary
The facility failed to provide timely and accurate laboratory services for three residents, leading to deficiencies in meeting their medical needs. Resident 58, who was admitted with multiple diagnoses including bipolar disorder and a history of urinary tract infections, did not have a urinalysis with culture and sensitivity completed as ordered by the physician. Despite the order being marked as completed, the results were not found, and the Director of Nursing (DON) was unable to locate the lab results or relevant progress notes. Resident 22, with a complex medical history including hypothyroidism and epilepsy, experienced multiple issues with laboratory tests not being performed. A TSH test was not rechecked after an initial low result, and subsequent orders for CBC, CMP, and Valproic Acid levels were not completed due to issues such as insufficient specimens and incorrect tubes being sent to the laboratory. Despite attempts to notify the physician, there were no new orders or follow-ups to ensure the tests were completed. Resident 34, who had diagnoses including type 1 diabetes and Alzheimer's disease, also faced issues with laboratory orders not being completed in a timely manner. Orders for TSH and Lipid Panel tests were repeatedly not completed as scheduled, and there was a delay in collecting and reporting the results. Additionally, there was no follow-up order for a TSH recheck six weeks after the initial tests, as should have been done according to the facility's policy.
Deficiency in Food Quality and Temperature
Penalty
Summary
The facility failed to provide food that was palatable, attractive, and served at an appetizing temperature for 10 out of 36 sampled residents. Multiple residents reported dissatisfaction with the quality of the food, citing issues such as blandness, overcooked meals, and food that was either too spicy or not served hot. Specific complaints included diarrhea and constipation linked to certain meals, and some residents resorted to having food brought in from outside the facility. Observations confirmed that meals were served without the use of a heating pellet system, which is intended to keep food warm during delivery. The facility's resident council notes from March to August 2024 consistently documented complaints about cold food and other issues such as items being out of stock. A test tray revealed that the food did not match the menu description and was of poor quality, with the meat being dry and chewy and the vegetables overcooked. Interviews with the Dietary Manager and the facility administrator highlighted that the pellet system was not consistently used, and there were logistical issues with the return of trays and availability of pellets. Despite recent efforts to improve food quality with new kitchen staff, the deficiency persisted.
Infection Control Deficiencies in Medication Handling and Meal Service
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by two main deficiencies. Firstly, a registered nurse (RN) was observed handling medication improperly by touching a pill with bare hands after it was taped back into a bubble pack, and then administering it to a resident. The RN acknowledged the error, stating that the medication should have been discarded instead of being given to the resident. The Director of Nursing (DON) was unaware of this practice and confirmed that medications should not be taped back into bubble packs. Secondly, during meal services, multiple instances of improper hand hygiene were observed among certified nursing assistants (CNAs). CNAs were seen handling meal trays and assisting residents without performing hand hygiene before and after these tasks. This included touching food items, delivering trays, and assisting residents without washing hands, even when enhanced barrier precautions were required. Interviews with CNAs revealed that they were trained to perform hand hygiene in these situations, yet failed to adhere to these protocols during the observed meal services.
Lack of Transfer Documentation for Hospitalized Resident
Penalty
Summary
The facility failed to ensure proper documentation and communication during the transfer of a resident to a hospital. Specifically, for one resident, there was no transfer documentation in the medical record when the resident was transferred to the hospital. The resident, who had multiple diagnoses including neuropathy, asthma, and cognitive communication deficit, was found on the floor by a roommate after reportedly hitting her head. Emergency medical services were called, and the resident was transported to the hospital. Upon return from the hospital, the resident was diagnosed with altered mental status and compression fractures of the L5 and T12 vertebrae. An interview with the Corporate Resource Nurse revealed that typically, a face sheet, a list of medications, and a copy of the bed hold agreement should accompany a resident during a transfer. However, there was no information available regarding the transfer of this particular resident, indicating a lapse in the facility's protocol for documenting and communicating necessary information during resident transfers.
Failure to Provide Bed-Hold Policy Information
Penalty
Summary
The facility failed to provide written information to residents or their representatives regarding the duration of the state bed-hold policy during hospital transfers or therapeutic leaves. This deficiency was identified for two residents out of a sample of 36. Resident 56, who had multiple diagnoses including hemiplegia and type 2 diabetes, was transported to the hospital after exhibiting symptoms such as slurred speech and drowsiness. Despite the Corporate Resource Nurse's claim that a bed-hold form was included in the paperwork sent to the hospital, no such documentation was found in the resident's medical record. Similarly, Resident 8, with diagnoses including hereditary neuropathy and major depressive disorder, was transferred to the hospital after a fall that resulted in a compression fracture. The Corporate Resource Nurse stated that a packet containing the bed-hold agreement was given to EMS, but it was not returned with the resident from the hospital. In both cases, the absence of documentation in the medical records indicates a failure to comply with the requirement to inform residents or their representatives about the bed-hold policy.
Resident Dignity Compromised During Transport
Penalty
Summary
The facility failed to treat a resident with respect and dignity, as observed during a survey. A resident, who had been admitted with multiple diagnoses including hemiplegia, type 2 diabetes, and cognitive communication deficit, was seen being pulled backwards in a shower chair by a CNA. The resident was covered in towels, with the sides of her buttocks exposed, as she was moved through the hallway. This incident occurred despite the resident's care plan indicating a need for staff assistance with bathing due to her medical conditions. During an interview, the resident expressed that this was the first time she had been transported in such a manner and stated a preference to be fully dressed after her shower before returning to her room. The CNA involved mentioned that it was common practice to transport residents covered in towels to prevent their clothes from getting wet. However, the Director of Nursing clarified that it was not standard practice for residents to be wheeled through the hallway in towels with sensitive areas exposed, indicating a deviation from the facility's expected procedures.
Confidentiality Breach of Resident Records
Penalty
Summary
The facility failed to maintain the confidentiality of residents' personal and medical records for four out of 36 sampled residents. On multiple occasions, staff members left computer screens open on medication carts, exposing resident information. Specifically, an LPN left a computer screen open and unattended in the 200 hallway, with residents nearby. Similarly, an RN left a computer screen open while attending to a resident in a room, with another resident walking by the cart. Additionally, a nurse shift report containing resident information was left face up and unattended on a medication cart for 15 minutes, with a resident walking in the vicinity. The Director of Nursing acknowledged that computer screens should be locked when unattended and that resident information should not be left exposed.
Inadequate Supervision and Policy Implementation in LTC Facility
Penalty
Summary
The facility failed to provide adequate supervision to prevent accidents for two residents. Resident 185, who was identified as a high risk for elopement, managed to leave the facility unattended despite having a wander guard. The resident had a history of attempting to leave the facility and had expressed a strong desire to leave, even threatening to exit through a window. Despite interventions such as verbal consent for a wander guard and education on safety, the resident was able to remove the wander guard multiple times. On one occasion, the resident left the facility with a friend and did not return until later that night, prompting a police search. The resident's care plan did not include a smoking assessment, and there was no care plan addressing smoking, despite the resident being a smoker. Another resident, Resident 59, experienced an unwitnessed fall and did not receive the necessary neurological checks afterward. The resident had a history of falls and was assessed as a high risk for falls. Despite this, after a fall in the shower, there were no neurological assessments documented in the resident's medical record. The facility's policy required neurological assessments for unwitnessed falls, but this was not followed in this case. The facility's policies on elopement and smoking were not adequately implemented, leading to these deficiencies. The elopement policy required individualized care plans and interventions for high-risk residents, which were not effectively executed for Resident 185. Similarly, the smoking policy required assessments and care plans for residents who smoked, which were not completed for Resident 185. These oversights contributed to the residents' unsafe situations and the facility's failure to prevent accidents.
Failure to Provide Prescribed Medication for Pain Management
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident, specifically by not ensuring the availability of gabapentin for a resident with chronic pain. The resident, who had a history of acute on chronic combined systolic and diastolic heart failure, type 2 diabetes mellitus, morbid obesity, reduced mobility, and muscle weakness, was not administered gabapentin as prescribed on two occasions. The medication was not available because a prescription was needed from the pharmacy, as noted in the nursing progress notes. Interviews with the resident and staff revealed that the resident experienced severe pain, rated 10 out of 10, which disrupted her sleep and daily activities. Despite having a care plan in place to manage chronic pain, the resident did not receive the prescribed gabapentin, which was intended to manage her neuropathy. Other pain management interventions, such as cyclobenzaprine and a Lidocaine patch, were used, but the lack of gabapentin administration was a significant oversight in her care.
Medication Management Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure that each resident's drug regimen was free from unnecessary drugs, as evidenced by the administration of blood pressure medication outside of physician-ordered parameters for one resident and missed medication doses for another. Resident 22, who had multiple diagnoses including hypertension and schizophrenia, was administered Propranolol despite blood pressure readings being outside the specified parameters. Interviews with nursing staff revealed confusion and lack of understanding regarding the specific parameters, leading to improper administration of the medication. Resident 34, with diagnoses including type 1 diabetes and end-stage renal disease, missed multiple doses of Abilify and Torsemide due to being absent from the facility for scheduled dialysis. The facility failed to adjust medication administration times to accommodate the resident's dialysis schedule. Additionally, Resident 34 was administered insulin outside of the prescribed parameters, indicating a lack of adherence to physician orders. Interviews with facility staff, including the Corporate Resource Nurse, confirmed these deficiencies. The CRN acknowledged that the facility did not follow the insulin parameters and failed to communicate with the physician to adjust medication schedules for Resident 34. These actions and inactions led to the identified deficiencies in medication management for the residents involved.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure the safe and secure storage of drugs and biologicals, as well as proper labeling in accordance with accepted professional principles. During an inspection of the medication cart in the 100 hallway, a Lispro insulin vial was found with an open date exceeding the 28-day expiration period, and a glargine insulin pen lacked an open or expiration date. A Registered Nurse (RN) acknowledged the oversight, stating that opened insulin should be discarded after 28 days. Additionally, a medication bubble pack was observed to have medication taped back in, which was then administered to a resident. The RN involved admitted that medications should not be taped back into bubble packs and should be discarded instead. Further observations revealed an intravenous antibiotic ball left unattended on top of the medication cart. The Director of Nursing (DON) confirmed that medications should not be left unattended at any time. These findings indicate lapses in medication management and storage protocols, which were acknowledged by the nursing staff and the DON during interviews.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to establish an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use. This deficiency was identified during a review of the care provided to a resident who was prescribed prophylactic antibiotics. The resident, who had a history of recurrent urinary tract infections (UTIs), was on antibiotic therapy as part of their care plan. However, staff were not aware of the specific reasons for the prophylactic antibiotic prescription, nor was there documentation from a urologist to support the use of Keflex for this purpose. Interviews with the Director of Nursing and the Corporate Resource Nurse revealed a lack of clarity and communication regarding the initiation of the antibiotic regimen. The Director of Nursing acknowledged the resident's history of recurrent UTIs but was unable to provide details about the last occurrence. The Corporate Resource Nurse was uncertain about which provider initiated the Keflex prescription and noted the absence of information from a urologist. This lack of awareness and documentation highlights the facility's failure to implement a comprehensive antibiotic stewardship program, leading to the deficiency noted in the report.
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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