Citations in Utah
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in Utah.
Statistics for Utah (Last 12 Months)
Financial Impact (Last 12 Months)
Some of the Latest Corrective Actions taken by Facilities in Utah
The facilities implemented several corrective actions to address the safety and supervision deficiencies.
- The facility assessed the resident for injuries, contacted police upon suspicion, and updated care plans as needed. Staff received training on abuse prevention and elopement protocols. (J - F0600 - UT)
- The Director of Nursing audited residents with medical devices to ensure proper care planning and staff training. Staff were trained on safe transfers and accident prevention, including appropriate transfer techniques. The Administrator ensured transportation staff were trained and competent in securing residents during transport. (J - F0726 - UT) (J - F0689 - UT)
- The facility partnered with an organization to provide training and new protocols for resident transport. Transportation staff were reeducated on proper securement procedures and underwent competency evaluations. The Quality Assurance Performance Improvement Committee approved the updated driver safety program and implemented ongoing audits. (G - F0689 - UT)
- The facility audited residents' transfer statuses to ensure appropriate equipment was used. Staff received re-education on changes in condition, appropriate lifts, and safe transfer methods. Department heads conducted spot checks to verify compliance with transfer protocols. (G - F0689 - UT)
Failure to Provide Timely Care and Monitoring for Residents
Penalty
Summary
The facility failed to provide appropriate treatment and care for two residents, leading to deficiencies in care. Resident 46 experienced ongoing emesis and abdominal pain, but the facility did not ensure timely monitoring or intervention. Despite receiving a stat order for an ultrasound, the facility delayed contacting the contracted radiology provider, resulting in a significant delay in obtaining the ultrasound. The resident continued to experience symptoms without adequate assessment or communication with the physician, ultimately leading to the resident's death. Resident 46 had a complex medical history, including hemiplegia, chronic obstructive pyelonephritis, severe sepsis, aspiration pneumonitis, acute kidney failure, supraventricular tachycardia, and bipolar disorder. Despite these conditions, the facility staff failed to document and communicate the resident's change in condition effectively. Multiple staff members observed the resident's deteriorating condition, including vomiting and abdominal pain, but there was a lack of coordinated response and communication with the medical team. Similarly, Resident 298, who had a history of dementia, hypertension, and acute kidney failure, did not receive timely diagnostic testing for a suspected deep vein thrombosis. The facility canceled a scheduled appointment and failed to ensure the ultrasound was performed promptly. This lack of timely intervention and communication with healthcare providers contributed to the deficiency in care for both residents.
Removal Plan
- The community management team implemented a morning Standup meeting with Nursing to get report from previous day's activities/concerns. If changes in condition are noted from communication notes, DON or ADON will verify MD team had been notified and if notification has not been made will do so at that time. Consultants will attend morning meetings when in-person and participate in random morning meetings when offsite to ensure compliance.
- The nursing team implemented a new shift communication form that will be relayed at shift change with oncoming nurse for concerns/follow-up items still pending at shift change. All forms will be left in the drawer at nurse's station for management review at the next morning standup meeting. Consultants will provide training on this process.
- A new CNA communication program/sheets implemented as a way for CNAs to communicate with oncoming shift and report to nurse. Sheets will be collected daily and reviewed during the daily standup meeting with department managers. Consultants will provide education and training on this process.
- Nursing implemented a new Communication and Follow-Up book that will remain at the nursing station. The book is a duplicate copy book with highlights and follow-up items from the previous day. The original will be removed and reviewed at daily manager Standup meeting. Consultants will provide education and training on this process.
- Communication improvements made between the building and MD team by adding the DON and Administrator to the secure messaging app between the MD group and Facility. Areas of concern or issues that arise will be addressed in the manager stand-up meeting.
- Representatives from the consulting organization reviewed and assessed the facility's policies and procedures regarding changes in resident condition. The consultants provided the community with a change of condition policy to adopt. The consultants provided education and training with licensed nursing and nursing assistants.
- Facility in coordination with the consulting organization, the consultants will complete record reviews of all residents to ensure no resident has experienced a change in condition not previously identified. Any findings of change of condition will be reported to the resident's attending physician and the resident's representative. This information will be communicated with the DON and Administrator at the manager stand-up meeting.
- The consultants ongoing will review daily progress notes to ensure documented changes of condition are timely identified and action steps are taken with resident changes of condition.
Resident Found in Locked Therapy Room with Alleged Abuse by Staff
Penalty
Summary
The facility failed to protect a resident from abuse, resulting in an Immediate Jeopardy citation. A resident with a history of dementia and cognitive impairments was found missing by staff, and after a search, was discovered exiting a locked therapy room. The resident made statements indicating that a male staff member engaged in sexual actions with her. The therapy room was inaccessible to staff, and the resident was found pale, nauseated, and disoriented, with therapy paperwork in hand. Interviews with staff revealed that the therapy room was locked, and the resident was missing for approximately 20 minutes. Staff observed the resident exiting the therapy room, appearing sick and disoriented. The resident later disclosed to staff that she and a male staff member attempted to engage in sexual activity, which was reportedly consensual according to the resident. However, the resident's cognitive impairments raised concerns about her ability to consent. The male staff member, a Physical Therapy Assistant, was found in the facility after hours, contrary to previous instructions. Staff reported that the therapy room was usually unlocked, and the male staff member's presence in the facility after hours had been a concern. The facility's failure to ensure the safety and security of the resident, as well as the lack of access to the therapy room, contributed to the deficiency.
Removal Plan
- Resident and staff member were separated.
- Police contacted upon suspicion.
- Resident assessed; no injury noted.
- Notification to Physicians, POA, Incident reported by administrator to DHS, APS, Ombudsman.
- Resident interviewed with administrator.
- Hospital evaluation completed, no trauma noted.
- Resident care plan reviewed and updated as needed.
- Provider to assess/evaluate residents including medication review.
- Social Services wellness visits to be completed for resident and PRN.
- Behavioral health visit requested with local mental health provider.
- Therapy staff member was immediately placed on administrative leave, facility keys/badge provided to administrator.
- Therapy staff member was questioned and released by the police, pending potential charges.
- Employee file was reviewed.
- Therapy staff member will not return to the facility.
- Regional Director of Operations spoke to Therapy Regional Director and informed him that staff are not to stay in the facility after normal business hours without the approval of the facility administrator.
- Facility will ensure the therapy staff working in the facility have background checks (DACS) that are connected to the facility.
- All residents interviewed by administrator/designee to assess potential for abuse/neglect allegations.
- Locks will be removed from all doors and/or Master Key accessible to charge nurse on medication cart.
- Staff Members will not remain in the facility after normal business hours without the approval of the facility administrator.
- Administrator, DON and RNC reviewed Abuse & Neglect Policy.
- Administrator, DON and IDT were educated by RNC regarding Abuse & Neglect Policy.
- Administrator/DON/designee will complete Abuse & Neglect education with all staff.
- Education including post-test initiated for all facility staff on Abuse/Neglect.
- All employees will be educated at start of their next shift or if no scheduled shift by all staff meeting.
- The DON/designee will review incidents of sexually inappropriate behavior to ensure appropriate interventions are implemented and no trends are noted.
- The Administrator/designee will conduct random resident & staff interviews to ensure the Abuse & Neglect Policy have been followed and allegations have been investigated and reported.
- The facility administrator/designee will do random facility visits during off hours to ensure that only staff clocked in and assigned to be working are in the facility and that the charge nurse has a Master Key to all locked doors in the facility.
- The Administrator/designee will review employee files (including contracted therapist) to ensure they have completed abuse training, verification of license and background checks (DACS) is connected to the facility.
- Medical Director was informed of the incident and QAA Review & Recommendations.
- Results will be reported to the QAA committee from monitoring and follow-up.
Failure to Prevent Sexual Abuse and Elopement
Penalty
Summary
The facility failed to prevent an instance of sexual abuse between two residents and neglected to provide the necessary supervision to prevent the elopement of another resident. Resident 269, who had severe cognitive impairment and a history of wandering, was found naked from the waist down on top of Resident 270, who was also cognitively impaired and nonverbal. The incident occurred when the staff responsible for monitoring the memory care unit were occupied with other tasks, leaving the residents unsupervised. This lack of supervision allowed Resident 269 to enter Resident 270's room and engage in inappropriate behavior, which was only discovered when therapists were searching for Resident 269 for a therapy session. The facility's failure to monitor Resident 269's wandering behavior and provide adequate supervision directly led to the incident of sexual abuse, which was verified by the facility's investigation. In a separate incident, Resident 17, who had a history of wandering and severe cognitive impairment, eloped from the facility. The resident was found and returned by a police officer. The facility's records indicated that Resident 17 had been assessed as a high risk for wandering and required frequent safety checks. However, the facility failed to implement a coordinated plan to supervise the resident's whereabouts, leading to the elopement. The receptionist, who was assisting another resident outside, believed that Resident 17 eloped through the front door during this time. The facility's lack of a coordinated plan and failure to monitor Resident 17's wandering behavior resulted in the resident's elopement. Both incidents were determined to be noncompliant and constituted immediate jeopardy. The facility's failure to prevent the sexual abuse of Resident 270 and the elopement of Resident 17 highlighted significant lapses in supervision and monitoring of residents with known wandering behaviors and cognitive impairments. These deficiencies were identified through interviews, record reviews, and witness statements, which documented the events leading to the incidents and the facility's inadequate response to the residents' needs for supervision and safety.
Removal Plan
- Resident was assessed for injury; no injuries were found.
- Facility representative spoke with family who reported that she had done this type of thing at home.
- Resident was determined to be a high risk for further elopements and would need to be moved to the secure unit. Resident was transferred to the secure unit to prevent further elopements.
- IDT reviewed the elopement.
- A training was conducted for the all staff meeting. Clinical training topics included labs, abuse reporting, and elopement prevention.
- Facility IDT met to review elopement process.
- Elopement binder was created for all high-risk residents on Cambridge.
- CNA Coordinator was given instructions to create tools for the staff, including a task sheet to alert staff of high-risk behaviors for residents and elopement sheets for the elopement binder.
- CNA Coordinator was given responsibility to round at least twice daily to verify the unit was running smoothly and that staff had the tools they needed to care for the residents.
- Administrator/Designee began holding meetings with CNA coordinator regarding the flow of the unit, communication, and the competency of the supervising staff on the unit.
- QAPI committee reviewed the events and identified the need for further interventions for elopement/abuse prevention.
- QAPI committee began creating care kits for memory care residents to decrease boredom, exit seeking, and help residents who were up at night.
- Residents were separated, and the abuse investigation was initiated.
- The police were notified, CMS was notified.
- The resident was placed on 1:1 with the intention to remain until the investigation was complete and interventions could identify how to prevent recurrence.
- The victim was moved off the unit.
- An internal meeting was held to review the investigation with the Regional Nurse Consultant, the Director of Clinical Services, the Corporate LCSW, the Facility Administrator, and Director of Nursing.
- Director of Nursing conducted an in-service with facility staff on Abuse Prevention with a post-test validation.
- The perpetrator was reviewed by the Behavioral Health Facility Committee to validate interventions were effective and further abuse prevented.
- Corporate LCSW provided a training with the Social Services Department on Sexual Intimacy in the LTC setting, Assessing Capacity to Consent, Care Planning, and appropriate Documentation.
- Corporate LCSW came to the facility and assessed the Perpetrator and reviewed the interventions in place.
- Cameras were set up to enhance visibility in the unit for staff.
- Computers in the unit were connected to be able to view halls for when CNAs were busy in rooms.
- Facility reviewed staffing patterns on the unit to validate that there was proper supervision on the unit.
- An investigation was conducted and found that the abuse program was not being run in accordance with facility policy and procedure.
- The administrator was terminated.
- A facility manager took over the facility with significant oversight of the RVP/Designee.
Inadequate Staff Training Leads to Resident Injury
Penalty
Summary
The deficiency involved a failure to ensure that nursing staff had the appropriate competencies and skill sets to provide safe and effective care for a resident, leading to a series of incidents that compromised the resident's well-being. A resident was transported in a facility van without proper securement of their wheelchair, resulting in the resident falling backward and sustaining a hyperextension injury to the neck. This incident led to a diagnosis of central cord syndrome and edema at the C6 and C7 levels of the cervical spine. The facility's failure to provide adequate training for staff responsible for transporting residents was a significant factor in this incident. Following the transport incident, the resident's care continued to be compromised. Upon returning to the facility, the resident's cervical collar, which was ordered to be worn at all times, was removed by CNAs during grooming and bathing. This removal occurred without proper supervision or understanding of the potential risks, as the CNAs were not adequately trained or informed about the necessity of the cervical collar. The resident was then unsuccessfully transferred to bed, resulting in the resident being assisted to the floor, further indicating a lack of competency in safe transfer techniques among the staff. The report highlights that the facility did not conduct proper orientation and training for newly hired nurse assistants and CNAs, which contributed to the inadequate care provided to the resident. The CNAs involved in the incidents were not properly trained on the use of medical devices such as the cervical collar, nor were they adequately supervised during critical care activities. This lack of training and supervision was a direct cause of the deficiencies observed, leading to the resident's compromised safety and well-being.
Removal Plan
- The Director of Nursing/Designee to do an audit of all residents to identify residents with medical devices or fixtures surgically placed, or otherwise applied to, or adjacent to their person. Identified devices reviewed to validate monitoring orders, care planning, and appropriate staff training are in place.
- The Director of Rehab/Designee to complete an assessment of all resident's transfer status, including type of transfer and number of staff to perform safely. Care Plans Reviewed and Updated as indicated to reflect current needs.
- The Director of Nursing/Designee to provide training on safe transfers and accident/hazards prevention to Facility Nurses and Nursing Assistants. Training to include proper transfer techniques utilized in the facility, the prohibition of using towel transfers, and where to find information in the care plan regarding individualized requirements for transfers. This training will be validated by a post-test to validate understanding of the material and Physical Therapist to complete return demonstration of transfer techniques with staff.
- The Director of Nursing to provide training to all Facility Nurses and Nursing Assistants on the definition of a fall and what documentation must be completed when a fall occurs. This training will be validated by a post-test to validate understanding of the material.
- The Administrator reviewed all individuals who perform transport duties and validated they have received training including securement of wheelchairs, securement of ambulatory residents, and securement of equipment in the transport van. A return demonstration checklist will be completed with transportation staff prior to their next transport.
- Any future staff member(s) providing transport services are to receive this training prior to beginning transport duties. Existing drivers to receive refresher training annually and as needed.
- The Chief Nursing Officer (CNO)/designee will provide education to the Inter-disciplinary team (IDT) about company policy on orientation and training to staff who provide direct patient care to residents of the facility and how to properly transfer residents.
- The Director of Nursing/Designee to review employees who have been hired in the past three months to verify orientation training has been completed. Any employee who does not have the orientation completed will meet with the Director of Nursing/Designee prior to the start of their next shift to create a plan to complete their training and review key interventions to keep residents safe.
- The Director of Nursing/Designee to create a summary of this training and put this in the agency binder, to provide agency staff resources to prevent accident/hazards.
- All Staff will receive training by Director of Nursing/Designee prior to their next working shift.
- The Director of Nursing/Designee to do interview with Charge Nurse(s) for each shift and review expectations for accident/hazards prevention and reporting until the IJ abatement is completed.
- The facility to review the 24-hour report in daily stand-up meetings, and as needed to validate that any accidents/hazards were followed up with in accordance with professional accepted standards of care. This audit to continue ongoing.
Facility's Failure to Ensure Resident Safety Leads to Multiple Incidents
Penalty
Summary
The facility failed to ensure a safe environment for its residents, resulting in multiple incidents of harm and immediate jeopardy. One significant incident involved a resident who was improperly secured in a wheelchair during transport in the facility van, leading to a fall that caused a hyperextension injury to the cervical spine, resulting in central cord syndrome. The resident's condition was further compromised when CNAs removed the cervical collar during grooming and bathing, which was against the medical order for the collar to be worn at all times. This lack of adherence to safety protocols and inadequate staff training on securing residents during transport and handling medical devices contributed to the resident's injury and subsequent complications. Additionally, the facility experienced several other incidents indicating a failure to maintain a hazard-free environment and provide adequate supervision. These included a resident sustaining a fractured hip after multiple falls, another resident tripping over a broken structural column, and a resident being unsafely discharged and found wandering. There were also instances of residents eloping from the facility, a resident being injured by another resident with a razor, and a resident being hit by a meal cart. These events highlight the facility's systemic issues in identifying and mitigating accident hazards and ensuring resident safety. The facility's deficiencies were compounded by inadequate staff training and oversight. The CNA Coordinator responsible for the transport incident had not received proper training on securing residents in the transport vehicle. Furthermore, the facility's documentation practices were insufficient, as evidenced by the lack of monitoring orders for the cervical collar and incomplete incident reports. These deficiencies underscore the need for comprehensive staff training and robust safety protocols to prevent future incidents and ensure resident well-being.
Removal Plan
- The Director of Nursing/Designee to do an audit of all residents to identify residents with medical devices or fixtures surgically placed, or otherwise applied to, or adjacent to their person. Identified devices reviewed to validate monitoring orders, care planning, and appropriate staff training are in place.
- The Director of Rehab/Designee to complete an assessment of all resident's transfer status, including type of transfer and number of staff to perform safely. Care Plans Reviewed and Updated as indicated to reflect current needs.
- The Director of Nursing/Designee to provide training on safe transfers and accident/hazards prevention to Facility Nurses and Nursing Assistants. Training to include proper transfer techniques utilized in the facility, the prohibition of using towel transfers, and where to find information in the care plan regarding individualized requirements for transfers. This training will be validated by a post-test to validate understanding of the material and Physical Therapist to complete return demonstration of transfer techniques with staff.
- The Director of Nursing to provide training to all Facility Nurses and Nursing Assistants on the definition of a fall and what documentation must be completed when a fall occurs. This training will be validated by a post-test to validate understanding of the material.
- The Administrator reviewed all individuals who perform transport duties and validated they have received training including securement of wheelchairs, securement of ambulatory residents, and securement of equipment in the transport van. A return demonstration checklist will be completed with transportation staff prior to their next transport.
- Any future staff member(s) providing transport services are to receive this training prior to beginning transport duties. Existing drivers to receive refresher training annually and as needed.
- The Chief Nursing Officer (CNO)/designee will provide education to the Inter-disciplinary team (IDT) about company policy on orientation and training to staff who provide direct patient care to residents of the facility and how to properly transfer residents.
- The Director of Nursing/Designee to review employees who have been hired in the past three months to verify orientation training has been completed. Any employee who does not have the orientation completed will meet with the Director of Nursing/Designee prior to the start of their next shift to create a plan to complete their training and review key interventions to keep residents safe.
- The Director of Nursing/Designee to create a summary of this training and put this in the agency binder, to provide agency staff resources to prevent accident/hazards.
- All Staff will receive training by Director of Nursing/Designee prior to their next working shift.
- The Director of Nursing/Designee to do interview with Charge Nurse(s) for each shift and review expectations for accident/hazards prevention and reporting until the IJ abatement is completed.
- The facility to review the 24-hour report in daily stand-up meetings, and as needed to validate that any accidents/hazards were followed up with in accordance with professional accepted standards of care. This audit to continue ongoing.
Resident Injury Due to Improper Securement During Transport
Penalty
Summary
The facility failed to ensure that a resident received the necessary supervision and assistance devices to prevent an accident during transportation. Specifically, a resident was not properly secured in a facility vehicle, leading to the resident sliding out of their wheelchair and sustaining a femur fracture. The incident occurred when the transportation driver had to brake suddenly, and it was later revealed that the lap belt was not secured on the resident. The resident involved had a medical history that included diabetes mellitus type 2, hypotension, muscle weakness, and required assistance with personal care and mobility. The resident used a wheelchair and had moderately impaired cognition, as indicated by a BIMS score of 11. On the day of the incident, the resident was being transported back from a doctor's appointment when the accident occurred, resulting in injuries that required hospitalization. The transportation driver admitted to neglecting to secure the lap belt, although the wheelchair was harnessed at four points. The incident was reported to the Survey State Agency, and the facility's investigation confirmed the oversight in securing the resident properly. The resident was evaluated by a facility nurse and emergency medical services were called, leading to the resident's transport to an acute care hospital where a left femur fracture was diagnosed.
Removal Plan
- The facility entered into an agreement with an organization to implement and provide training and new protocols to transport facility residents.
- All staff who performed transportation services for the facility were reeducated on proper securement of residents during transport, which included training videos produced by the contracted organization.
- Transportation staff attested to the completion of the training by signing training records.
- Transportation staff were required to complete a post-training test.
- All staff members who performed transportation services were required to read and sign the Fleet Safety Program book.
- Staff members were interviewed regarding safety during transportation.
- Administrative staff interviewed residents to determine if there were additional concerns about safety during transportation.
- The facility's Quality Assurance Performance Improvement (QAPI) Committee approved the updated driver safety training program.
- The transportation supervisor will audit the transport of each driver daily for 2 weeks, followed by audits on 3 random days of the week for 1 week, with an audit 1 day per week for 1 week.
- The transportation supervisor will perform ongoing random audits.
- The transportation supervisor or designee will validate transportation driver's pre and post-securement, documenting the results every week for 4 weeks then bi-weekly for 2 weeks, and 3 random audits every month thereafter.
- The transportation supervisor will report any trends or concerns to the QAPI committee for review for 90 days.
- Any discrepancies will be addressed at time of discovery.
Inadequate Supervision and Improper Transfer Method Result in Resident Injury
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices for a resident, leading to an accident. Resident 217, who had a history of cerebrovascular accident, right bundle branch block, heart failure, and major depressive disorder, was dependent on staff for transfers due to his inability to stand. Despite this, on a specific date, CNA 4 used a sit-to-stand device to transfer the resident, contrary to the care plan that required a Hoyer lift with two-person assistance. During the transfer, the resident was unable to bear weight, causing his arms to move upward, but the transfer was completed without immediate signs of pain. Subsequently, the resident was found to have a swollen and bruised left shoulder, which was later diagnosed as a fracture of the left humeral surgical neck. The facility's investigation revealed that the injury likely occurred during the improper transfer by CNA 4. The resident's condition, compounded by his non-verbal status due to the cerebrovascular accident, meant he could not communicate pain effectively, delaying the recognition of the injury. The facility's documentation and communication were also found lacking. The weekly skin assessment inaccurately reported no skin issues, despite bruising being observed earlier. Additionally, the bruising was not reported to management until two days after it was first noticed. This delay in reporting and the initial use of an inappropriate transfer method contributed to the harm experienced by the resident.
Removal Plan
- Audit all residents with current sit to stand transfers to ensure the current lift being used is appropriate for the resident status.
- Perform re-education 1:1 in huddles or over the phone regarding change of condition, bruising, range of motion, and which lift is appropriate for resident current condition.
- Complete audits with department heads on spot checking rooms to ensure staff members are using the appropriate lift with two-person transfer.
- Make unit managers aware of any changes with therapy evaluation with the lifts.
Latest Citations in Utah
A resident who required extensive assistance with transfers was left in the shower without access to a call light, as the only available call light was out of reach from the shower chair. The resident, who preferred to shower independently after being assisted in, was unable to signal for help and had to use the shower head to attract attention until a CNA arrived.
A registered nurse engaged in inappropriate and abusive conduct with a resident with severe dementia, as captured on video, and two other residents later reported similar inappropriate interactions involving the same nurse. The incidents included unzipping pants, inappropriate touching, and applying cream without a physician's order, resulting in substantiated findings of abuse and significant distress for the residents involved.
A resident with multiple chronic conditions reported that a nurse yelled at him after a prolonged wait for assistance, but the facility did not immediately report the allegation of verbal abuse to the State Survey Agency. The incident was not documented in the medical record, and leadership did not initiate a formal investigation or report until prompted by a surveyor, resulting in a deficiency for failure to follow required reporting procedures.
A resident with multiple chronic conditions reported that a nurse yelled at him after he waited a prolonged period for assistance. The incident was not documented in the medical record, and no abuse or neglect investigation was initiated by the DON or AIT, nor was it reported to the State Survey Agency. A grievance was only completed after surveyor inquiry, and facility leadership initially minimized the event, resulting in a failure to respond appropriately to the alleged violation.
A resident with limited mobility and chronic conditions was not provided with an assistive device for bed mobility despite repeated requests, due to facility policy classifying such devices as restraints. The resident resorted to using unstable objects like a nightstand drawer and walker for support, while staff acknowledged these makeshift solutions but did not escalate the issue. Facility leadership maintained a restraint-free policy, resulting in the resident's needs and preferences not being accommodated.
Staff, including a CNA and CNAC, were observed delivering and setting up meal trays for multiple residents without performing required hand hygiene before or after entering rooms or handling residents' items. Interviews with the CNAC and DON confirmed that hand hygiene is expected during these tasks, but observations showed repeated non-compliance, resulting in a deficiency in the facility's infection prevention and control program.
A resident with a history of diabetes and chronic kidney disease experienced a delay in treatment for a suspected UTI when lab results were not promptly obtained or reported to the provider. Although the urine sample was collected and showed signs of infection, there was a nine-day gap before the provider was notified and antibiotics were started. The DON acknowledged that the process for following up on lab results was not followed, leading to the delay in care.
A resident who recently returned from a hospital stay for pneumonia suffered a fall resulting in a femur fracture and required transfer to the ED. Staff attempted to contact the primary emergency contact multiple times without success and did not notify additional emergency contacts as required. The family was not informed of the injury or hospitalization until two days later, learning of the situation from the hospital.
Two residents with ADL deficits did not receive scheduled bathing assistance, with documentation showing multiple missed showers and some showers provided by a family member instead of staff. Staff interviews confirmed that showers were often missed and not documented, and the facility could not provide records showing that showers were offered or completed as scheduled.
A resident with paralysis and aphasia requiring maximal assistance did not receive scheduled showers or twice-daily oral care as required. Documentation showed multiple missed showers and frequent lapses in oral hygiene, with facility staff confirming that care not documented was likely not completed.
Resident Left Without Accessible Call Light During Shower
Penalty
Summary
A deficiency occurred when a resident who required extensive assistance with transfers was left in the shower without access to a call light. The resident preferred to be assisted into and out of the shower but to complete the shower independently, with CNAs checking in periodically. On the day of the incident, a CNA assisted the resident into the shower and then left, leaving the resident unable to reach the call light from the shower chair. The resident completed the shower and attempted to call out for assistance but was unable to get help until another CNA eventually arrived. The resident used the shower head to hit the wall in an attempt to signal for help. Observation of the bathroom revealed that the call light was positioned next to the toilet and was not accessible from the shower chair. Staff interviews confirmed that the resident often took long showers and preferred privacy, with CNAs waiting outside and sometimes completing other tasks while the resident showered. The incident was further corroborated by the resident's medical record, which indicated a need for one-person extensive assistance with transfers.
Failure to Protect Residents from Sexual Abuse by Registered Nurse
Penalty
Summary
The facility failed to protect residents from abuse, resulting in multiple incidents involving a registered nurse (RN). On one occasion, video footage captured the RN at the bedside of a resident with severe dementia, with his pants unzipped and his hand under the resident's blanket in the abdominal/pelvic area. There was no documented care need that would have required this action, and the resident was unable to communicate due to severe cognitive impairment. The incident was reported by the facility's administrator, and the evidence collected substantiated sexual abuse of a vulnerable resident. During the investigation of this incident, two additional residents reported inappropriate interactions with the same RN. One resident described an incident where the RN rubbed her back, moved his hands lower, and exposed himself, causing her significant distress and discomfort in participating in facility activities. Another resident reported that the RN applied cream to her neck without a physician's order and inappropriately touched her upper chest and nipples during the process. Both residents had some memory issues but were mostly alert and oriented, and neither had previously reported allegations of sexual abuse. A prior allegation involving the same RN was reported several months earlier, in which a resident alleged inappropriate physical touch. The facility investigated and reported the incident to authorities, but it was not substantiated at that time. The repeated nature of the allegations and the evidence from video footage demonstrate a failure by the facility to ensure residents were free from abuse, as required by federal regulations.
Failure to Timely Report Alleged Verbal Abuse to State Agency
Penalty
Summary
The facility failed to immediately report an allegation of abuse or neglect to the State Survey Agency after a resident reported that a nurse yelled at him during a delayed response to his call light. The resident, who had multiple medical conditions including type 2 diabetes mellitus, chronic wounds, osteomyelitis, and a lumbar vertebra fracture, stated that he waited for nearly an hour for assistance, became anxious, and began yelling for help. When a nurse finally entered, she reportedly yelled at the resident in a gruff tone, which the resident found distressing. The resident communicated his concerns to management, expressing that he felt uncared for and upset by the staff's response. Upon review, there was no documentation of the incident in the resident's medical record. Interviews with facility leadership revealed that the DON was aware of the complaint and conducted an informal investigation, speaking with both the nurse and the resident. The DON determined, based on the nurse's account, that the incident did not constitute abuse and did not follow up further with the resident. The AIT, who was responsible for reporting abuse allegations, was not fully aware of the details and did not report the incident to the State Survey Agency or document an investigation at the time. A grievance form was only initiated after the surveyor inquired about the incident, and the facility's policy defined verbal abuse as including yelling with intent to intimidate. The facility's leadership acknowledged that the event should have been investigated and potentially reported, but no immediate report or formal investigation was made until prompted by the survey process. This failure to report the allegation of abuse or neglect in a timely manner constituted the deficiency.
Failure to Investigate Alleged Verbal Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse or neglect involving a resident who reported that a nurse yelled at him after he waited for an extended period for assistance. The resident, who had multiple medical conditions including type 2 diabetes mellitus, chronic wounds, osteomyelitis, and a lumbar vertebra fracture, stated that he waited nearly an hour for help, used his call light, and eventually began yelling to get staff attention. When a nurse entered, she reportedly yelled at the resident in a gruff tone, which the resident found distressing. The resident communicated his concerns to management, expressing that he felt uncared for and upset by the staff's response. Despite the resident's report, there was no documentation of the incident in his medical record, and the facility did not initiate an abuse or neglect investigation at the time. Interviews with the DON and AIT revealed that while the DON was aware of the complaint and spoke with the nurse involved, she did not follow up with the resident after the initial interview and did not document an investigation. The AIT, responsible for investigating abuse allegations, was unaware of the full extent of the complaint and did not report or document the incident as required. The incident was not reported to the State Survey Agency, and no formal investigation was conducted until prompted by the surveyor's inquiry. A grievance form regarding the incident was only completed after the surveyor asked about the event, and the facility's policy defined verbal abuse as including yelling with the intent to intimidate. However, the initial response from facility leadership was to minimize the incident, with the RDO suggesting it may have been a misunderstanding and not meeting the threshold for verbal abuse. The lack of timely and thorough investigation, documentation, and reporting constituted a failure to respond appropriately to an alleged violation.
Failure to Provide Assistive Device for Bed Mobility
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of a resident who required assistive devices for bed mobility. The resident, who had diagnoses including type 2 diabetes mellitus, chronic wounds, and a lumbar vertebra fracture, reported having previously used a bed rail at another facility to assist with repositioning. Despite multiple requests to CNAs, nurses, and therapy staff for a similar device, the resident was informed that such devices were not allowed due to facility policy. The resident expressed that having a positioning bar would help with bed mobility and make him feel more secure, especially when staff were not always available in pairs to assist with changing his brief. Observations and interviews revealed that the resident attempted to use alternative objects, such as the nightstand drawer and his walker, to aid in repositioning, but these were unstable and potentially unsafe. Staff interviews confirmed that the resident required moderate to extensive assistance with bed mobility and that he often held onto the nightstand drawer or walker for support. Some staff acknowledged that a positioning device might be helpful, but none had notified therapy or nursing about the resident's use of these makeshift supports. The care plan indicated a goal to increase the resident's strength and independence, with approaches to encourage participation in ADLs, but did not address the specific need for an assistive device for bed mobility. Facility leadership, including the DON and Director of Rehab, stated that the facility was restraint-free per corporate policy and that devices such as bed canes or side rails were considered restraints and therefore not permitted. While a trapeze was available for some residents, it was not deemed helpful for side-to-side movement, and the resident had declined its use. The facility's policy and lack of individualized assessment for the requested device resulted in the resident not receiving reasonable accommodation for his bed mobility needs.
Failure to Perform Hand Hygiene During Meal Tray Delivery
Penalty
Summary
The facility failed to establish and implement an effective infection prevention and control program, as evidenced by multiple instances where staff did not perform hand hygiene during meal tray delivery. Observations on several occasions showed that a Certified Nursing Assistant (CNA) and a Certified Nursing Assistant Coordinator (CNAC) delivered food trays to residents' rooms, set up meals, and handled residents' items without using hand sanitizer or washing hands before or after entering and exiting rooms. This included actions such as moving bedside tables, uncovering drinks, arranging meal items, and handling room curtains, all without performing hand hygiene between resident contacts. Interviews with the CNAC and the Director of Nursing (DON) confirmed that staff are expected to use hand sanitizer each time they enter or exit a resident's room and when handling meal trays or residents' items. Despite this expectation, direct observations revealed consistent non-compliance with hand hygiene protocols during meal service, contributing to the deficiency in the facility's infection prevention and control program.
Delay in Reporting Lab Results and Initiating Treatment for UTI
Penalty
Summary
A deficiency occurred when the facility failed to promptly obtain and report laboratory results for a resident who was experiencing urinary retention, dysuria, and other symptoms suggestive of a urinary tract infection. The resident, who had a history of generalized muscle weakness, type II diabetes, and chronic kidney disease stage 3, had a physician's order for a urinalysis and urine culture. The urine sample was collected and sent to the lab, and results indicating infection were available. However, there was a delay of nine days before the provider was notified of the results, during which time the resident continued to experience symptoms. Interviews with nursing staff and the DON revealed that the facility's process involved the lab faxing results to the facility, with nurses responsible for forwarding results to the provider. In this instance, the DON acknowledged that the final lab result was not received as expected and that she did not follow up with the lab until the provider inquired about the results. The delay resulted in the resident not receiving antibiotics until after the provider was made aware of the infection, despite the facility having access to an emergency kit containing antibiotics.
Failure to Notify Resident Representatives After Serious Injury
Penalty
Summary
Staff failed to immediately notify a resident's representatives following a significant accident that resulted in injury and required physician intervention. The resident, who had recently returned from a hospital stay for pneumonia, experienced a fall that led to a displaced femur fracture. Staff assessed the resident, contacted the provider, and obtained an X-ray confirming the fracture. The provider instructed staff to contact the family to determine their wishes for treatment. Multiple attempts were made to reach the primary emergency contact (POA) by phone, but staff were unable to make contact and only possibly left a voicemail. Despite being unable to reach the primary contact, staff did not attempt to notify any additional emergency contacts as required by facility expectations. The resident was transferred to the emergency department for further care. The family was not informed of the hospitalization and injury until two days later, having first learned of the hospital admission from the hospital itself. Interviews confirmed that staff did not consider the incident critical enough to warrant contacting other emergency contacts, contrary to facility policy.
Failure to Provide Scheduled Bathing Assistance to Residents
Penalty
Summary
Surveyors determined that two residents were not provided with the necessary assistance to maintain their ability to perform activities of daily living, specifically bathing and showering. One resident, who had a care plan indicating a self-care performance deficit and required substantial to maximal assistance with bathing, was scheduled to receive showers twice a week. Documentation showed that in one month, the resident received only two showers, both provided by her husband, and missed six out of eight scheduled showers. In the following month, the resident was offered or received four showers, missing three out of eight scheduled, with one again provided by her husband. Interviews with facility administrators confirmed that staff were responsible for offering and documenting showers, and that lack of documentation indicated the care was not completed. Another resident's records revealed that only two showers were documented over the course of a month. Interviews with staff members confirmed that resident showers were often missed, and the facility was unable to provide documentation that showers were offered or completed on the missing dates for both residents. These findings indicate that the facility did not ensure residents received the appropriate treatment and services to maintain or improve their ability to carry out activities of daily living as required.
Failure to Provide Scheduled Showers and Oral Care for Dependent Resident
Penalty
Summary
A deficiency was identified for failing to provide necessary services to maintain good nutrition, grooming, and personal and oral hygiene for a resident who was unable to perform activities of daily living independently. The resident had a history of left-sided paralysis and aphasia following a cerebrovascular accident (CVA), resulting in a need for substantial to maximal assistance with bathing, showering, and complete dependence on staff for personal hygiene. Despite being scheduled for showers twice a week, documentation showed that the resident missed 6 out of 8 scheduled showers in one month and 4 out of 7 in the following month, with one missed due to a lack of soap. Additionally, the resident required oral care twice daily, but records indicated that this care was missed on 22 out of 25 days reviewed. Interviews with facility administrators confirmed that the resident required assistance with all personal care and that showers and oral care should be documented when completed. The administrators acknowledged that if care was not documented, it was likely not provided. No documentation could be found to show that showers and oral care were offered or completed on the missing dates, confirming the deficiency in providing necessary care for the resident.