Bella Terra St George
Inspection history, citations, penalties and survey trends for this long-term care facility in St. George, Utah.
- Location
- 178 South 1200 East, St. George, Utah 84790
- CMS Provider Number
- 465152
- Inspections on file
- 21
- Latest survey
- January 8, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Bella Terra St George during CMS and state inspections, most recent first.
The facility failed to protect residents from abuse and neglect, as evidenced by incidents of inappropriate sexual behavior and inadequate assessment of residents' capacity to consent. One resident with cognitive impairment exhibited repeated inappropriate behaviors, while another resident was involved in a consensual kiss without proper capacity assessment. Additionally, a resident was found wandering outside the facility, indicating a lapse in supervision.
The facility was found to have insufficient nursing staff, resulting in delayed care and unmet needs for several residents. A resident with dementia and a history of falls experienced incontinence and a fall due to delayed assistance. Another resident, who requires help with bathing, was observed in the same clothing for days, indicating missed showers. Observations and interviews revealed that residents often waited long periods for incontinence care, and staff were unable to meet the care demands due to understaffing, particularly at night.
A long-term care facility was found to have multiple deficiencies due to inadequate nursing staff competencies and oversight. The Director of Nursing failed to provide adequate oversight, leading to system failures in resident care, including the lack of comprehensive care plans, insufficient assistance with daily activities, and inadequate treatment for pressure ulcers. Residents did not receive meals accommodating their allergies, and infection control measures were lacking. Additionally, necessary immunizations were not documented, and behavioral health services were insufficient, resulting in a resident overdose.
The facility exhibited significant deficiencies affecting 45 residents, including failure to prevent abuse, neglect, and inadequate care for pressure ulcers. Residents experienced falls due to damaged equipment, and there were delays in treating urinary tract infections. Insufficient staffing led to unmet care needs, and behavioral health services were lacking, resulting in an overdose incident. Dietary services were also inadequate, with meals served late, causing resident dissatisfaction.
The facility failed to protect residents from abuse and neglect, with incidents of unwanted sexual contact, involuntary seclusion, and inadequate treatment for pressure ulcers. Safety concerns included falls due to damaged equipment and insufficient supervision. Staffing shortages led to unmet care needs, delayed meal services, and inadequate behavioral health support, resulting in an overdose incident.
A resident with cognitive communication deficits was involuntarily moved to a locked memory care unit for non-compliance with the smoking policy. Despite being alert and fully oriented, the resident was relocated without proper assessments or family consent, constituting involuntary seclusion. The move was reversed after the resident's daughter intervened.
A resident with pressure ulcers experienced a malfunctioning wound VAC for 24 hours without physician notification, leading to hospitalization for possible septic shock. The resident, with a history of sepsis, was found somnolent, and a CT scan revealed abscesses and osteomyelitis. The DON stated that wound VACs are checked during changes, and nurses should contact providers if issues arise, but no documentation showed the physician was informed before the resident's condition worsened.
The facility failed to maintain a safe environment, leading to multiple resident falls and injuries. A resident fell due to a damaged Hoyer lift sling, while another experienced several falls with significant injuries due to inadequate supervision and care plan updates. A third resident fell while waiting for staff assistance, with observations showing non-compliance with care plan interventions. These incidents highlight deficiencies in equipment safety, staff responsiveness, and care plan adherence.
The facility failed to provide timely and appropriate care for three residents, leading to deficiencies in managing UTIs and continence care. One resident experienced a delay in UTI treatment due to a system glitch and lack of follow-up, while another was not provided with a bladder retraining program, resulting in incontinence and falls. A third resident with a suprapubic catheter did not receive consistent care, leading to ongoing infections and premature discontinuation of medication.
A resident with a history of suicidal ideation and multiple mental health diagnoses overdosed on Tylenol after the facility failed to provide necessary behavioral health care and monitoring. The resident's mother, also a resident, had recently passed away, exacerbating the resident's mental health issues. Staff were unaware of the resident's suicidal history, and the care plan did not address her mental health needs adequately. The facility lacked a full-time RA or LCSW, and there was insufficient documentation and monitoring of the resident's behavior, leading to the overdose.
The facility failed to provide adequate staffing in the food and nutrition services, resulting in delayed meal times and resident dissatisfaction. A resident with a history of cerebral infarction and diabetes expressed frustration over late and insufficient meals, while staff interviews revealed understaffing and confusion in meal delivery. The Registered Dietitian noted ongoing issues with meal delivery, highlighting the need for more dietary personnel.
The facility failed to provide adequate dietary services, affecting 30 residents. Meals were served late, portion sizes were inappropriate, and food was unpalatable. The kitchen was unsanitary, and residents' dietary needs and preferences were not met. The Registered Dietitian and Dietary Manager were aware of these issues but had not implemented effective solutions.
The facility's kitchen was found to be unsanitary, with food items improperly stored and labeled, and staff not following hygiene protocols. The dishwashing process was inadequate, with the ADM unaware of proper sanitization temperatures and lacking verification methods. A resident reported unclean mugs, leading her to wash them in her bathroom sink, highlighting the facility's failure to maintain proper food service standards.
The facility failed to maintain an effective infection control program, with staff not performing hand hygiene during meal service and medication pass. Additionally, the facility lacked a Legionella prevention plan in their water management program, as the new Maintenance Supervisor was unaware of any such plan. These deficiencies highlight significant gaps in infection control measures.
The facility failed to provide a safe, clean, and homelike environment for several residents, leading to complaints about cold room temperatures, uncleaned rooms, leaking fixtures, and missing personal belongings. Maintenance and housekeeping staff were short-staffed, and there was a lack of organization in addressing grievances related to missing items.
Two residents reported missing personal items, including clothing and dentures, but the facility failed to resolve these grievances. Despite being cognitively intact, one resident's complaints were not documented or addressed, and the staff did not update inventory lists. The grievance process was inadequate, with residents unsure how to file grievances and outdated information on procedures.
The facility failed to implement adequate policies to prevent abuse and inappropriate sexual behavior among residents. Several residents, including those with cognitive impairments, were involved in inappropriate sexual interactions without proper assessments of their capacity to consent. Despite existing care plans and interventions, the facility did not reassess residents' capacity to consent, leading to multiple incidents of inappropriate behavior.
The facility failed to report several incidents of abuse, neglect, and mistreatment to the SSA within the required timeframe. Incidents involved residents experiencing sexual abuse, falls, exploitation, involuntary seclusion, and elopement. The facility's policy requires immediate reporting, but this was not followed. Specific cases included a consensual kiss between residents, a fall resulting in a shoulder fracture, an online scam, a resident leaving AMA, involuntary seclusion due to smoking noncompliance, and a fall from a hoyer lift.
The facility failed to provide written notification of the bed hold policy to three residents or their representatives during hospital transfers. Residents with various medical conditions were transferred without being informed of the policy, as required by the facility's procedures. Interviews with staff confirmed the lack of documentation and communication regarding the bed hold policy.
A facility failed to accurately assess a resident's discharge status, resulting in an incorrect MDS assessment. The resident, admitted with a femur fracture, was documented in the MDS as discharged to a hospital, while the discharge note indicated a discharge to a private residence. The MDS Coordinator could not explain the discrepancy.
The facility failed to develop and implement baseline care plans within 48 hours of admission for four residents, including those with complex medical conditions such as intracerebral hemorrhage, dementia, and acute hepatic failure. Delays ranged from four days to 39 days post-admission, with the Director of Nursing and Administrator acknowledging the lapses. These deficiencies highlight a systemic issue in the facility's care planning process.
The facility failed to update and implement comprehensive care plans for residents, leading to unmet medical and psychosocial needs. A resident experienced issues with ostomy care, another had multiple falls without care plan updates, and a third faced unmanaged incontinence and pain due to delayed UTI diagnosis. Staff interviews revealed outdated care plans and communication gaps in handling lab results.
The facility failed to provide adequate assistance with activities of daily living for four residents, including bathing, nail care, and incontinence care. Residents reported infrequent showers, inadequate brief changes, and issues with call light systems. Observations confirmed inconsistencies in care provision, and documentation did not align with care plans.
The facility failed to maintain residents' nutritional status, with issues such as inadequate meal portions, missed weight checks, and incomplete nutritional assessments. A resident with diabetes and dementia was not weighed regularly, and another with Parkinson's lacked between-meal beverages and lab tests. A third resident experienced significant weight loss without follow-up, and a fourth faced supplement shortages. Staff struggled with responsibilities, leading to missed assessments and inadequate monitoring.
The facility failed to ensure appropriate use of psychotropic medications for five residents, lacking supporting diagnoses, gradual dose reductions, and documentation of non-pharmacological interventions. Residents were given PRN medications beyond 14 days without proper rationale, and monitoring for adverse side effects was insufficient. The DON acknowledged these deficiencies, highlighting a need for improved oversight and documentation.
The facility failed to maintain complete and timely laboratory records for several residents, resulting in missing or delayed documentation of test results in their medical records. The DON and nursing staff acknowledged issues with receiving results from the lab and inconsistent follow-up, impacting the care and treatment of the residents.
The facility failed to provide meals that met the nutritional needs of residents, with several instances of meals not matching posted menus or recipes. A resident with Parkinson's disease reported insufficient food and lack of snacks, while another resident with cerebral infarction expressed hunger and dissatisfaction with meal portions. Interviews revealed a lack of training and oversight in the dietary department, contributing to the facility's non-compliance with nutritional guidelines.
The facility failed to provide palatable and appetizing meals to residents, with observations and resident interviews revealing issues such as cold, undercooked, and repetitive meals. The kitchen lacked sufficient hot pellets to maintain food temperature, and a test tray confirmed the food was not served at an appetizing temperature. The Registered Dietitian had not conducted tray audits, contributing to the oversight in food quality.
The facility failed to provide meals that accommodated resident allergies and preferences, resulting in several incidents where residents were served food containing allergens. A resident with an onion allergy experienced an allergic reaction after being served a meal with onions. Another resident was not questioned about food allergies until months after admission, leading to inappropriate meals being served. Additionally, residents with allergies to tomatoes, dairy, and wheat were served meals containing these allergens, indicating a lack of communication and verification between dietary and nursing staff.
The facility failed to provide adequate hydration to residents, as four residents reported not receiving water between meals and having to request it from staff. One resident with muscular dystrophy had to wash her own mugs due to a lack of clean ones, while another with diabetes had to go to the nurse's station for water. A resident with lymphedema also reported needing to request water, and a resident with Parkinson's disease had to buy bottled water. Staff interviews revealed inconsistencies in water provision, and a resident's care plan was not followed regarding lab tests for kidney function.
A long-term care facility failed to provide meals and snacks according to residents' needs and preferences, affecting 12 residents. Meals were often late, cold, or insufficient, and snacks were inconsistently available, leading residents to rely on family-provided snacks. Staff interviews revealed inconsistencies in snack distribution, and the facility's Registered Dietitian was unaware of the snack program.
The facility failed to maintain complete and accurate medical records for six residents, including missing hospital documentation and incorrect resident information. This included missing discharge summaries and test results for hospital visits, unrecorded neuro checks, and documentation errors where information was placed in the wrong resident's chart. These deficiencies highlight systemic issues in the facility's record-keeping practices, potentially impacting resident care and safety.
The facility failed to document the COVID-19 vaccination status for three residents, including one who initially consented but later declined, and two who wanted to discuss it with their POA. The DON acknowledged the oversight, noting the immunization clinic occurred in early October.
A facility failed to maintain a functional call light system for three residents, including one with significant medical needs. The call lights in the rooms and bathrooms were either non-functional or missing, leading to residents being unable to call for assistance. Maintenance logs showed repeated reports of issues, but these were not promptly addressed. The Maintenance Supervisor and Director of Nursing acknowledged the deficiencies, highlighting a systemic issue with the call light system.
The facility failed to maintain resident dignity by serving meals on disposable dishes due to a shortage of non-disposable dishware. Two residents were observed eating from disposable containers, with one expressing a preference for larger bowls. The Registered Dietitian and Assistant Dietary Manager cited dishware shortages and inadequate return of dishes for washing as reasons for using disposables, while the Administrator was unaware of the issue.
A resident with complex medical and mental health conditions was not included in her care planning, as the facility failed to hold documented care conferences in 2024. Despite her desire to participate and normal cognitive status, the last recorded care conference was in December 2023. The DON indicated that care conferences should occur quarterly, but there was no evidence of this practice being followed.
Two residents with severe cognitive impairments and varying levels of physical assistance needs were found with their call lights out of reach, indicating a failure to accommodate their needs. The DON acknowledged that the residents could use their call lights if they were accessible.
A resident with moderately impaired cognition was denied access to a phone in her room, despite her request, and had to use the phone at the nurse's station. Staff interviews revealed confusion about the availability of landline phones in rooms, and the Maintenance Supervisor was unaware of the functionality of phone jacks. The Administrator confirmed the absence of phones in rooms, with cordless phones available at nurse's stations.
A resident's POLST form indicated a DNR status, but the electronic medical record incorrectly showed full treatment. Staff interviews revealed confusion and inconsistency in updating and documenting the resident's code status, leading to a potential risk of inappropriate medical intervention.
A resident with normal cognition was involved in an online scam with an individual claiming to be a celebrity. The facility's resident advocate took steps to protect the resident's financial assets, but the police were not notified of the potential exploitation until much later. The care plan was not updated to reflect changes in the resident's capacity to consent, leading to potential confusion among staff. The facility's failure to promptly report the suspected exploitation to law enforcement and update the care plan contributed to the deficiency.
A resident with a history of falls and multiple medical conditions sustained a major injury from a fall, which the facility failed to thoroughly investigate or report to the State Survey Agency within the required timeframe. The resident's care plan was not updated with new interventions to prevent further falls, despite staff acknowledging the resident's poor safety awareness and frequent falls.
The facility failed to ensure that three residents were transferred to the hospital with necessary medical documentation, crucial for safe and effective care transitions. A resident was sent to the ED for chest pain without accompanying records, while another with complex conditions was transferred without required documentation. A third resident was sent to the ED without documentation indicating the transfer basis. Staff interviews revealed inconsistencies in the transfer process, with some staff not documenting what was sent to the hospital.
A resident with cognitive impairments left the facility AMA and was later imprisoned for trespassing. Despite being deemed decisionally incompetent and requiring 24-hour supervision, the resident's discharge plan was not effectively implemented. The facility failed to ensure the resident's safety, as staff did not report the incident as an elopement and did not follow proper procedures for a resident lacking decision-making capacity.
A facility failed to obtain necessary physician orders for a resident's catheter care upon admission. The resident, with a history of Multiple Sclerosis and paraplegia, was admitted with an indwelling catheter but lacked documented orders for its care. The DON acknowledged the oversight, noting that orders should have been entered by the DON, MDS coordinator, or nurse manager, but not the provider. This lapse highlights a failure in the facility's processes for ensuring comprehensive care.
The facility did not transmit MDS data to CMS within the required timeframe for two residents. The MDS Coordinator, an LPN, relied on the DON or CRN to transmit the assessments, resulting in delays of 20 and 45 days past the ARD for the residents involved.
The facility failed to provide adequate activity programming for residents, with issues such as outdated calendars, lack of weekend activities, and scheduling conflicts with meal times. Residents expressed dissatisfaction, and the Activities Director cited staffing and scheduling challenges as contributing factors.
A resident with multiple medical conditions did not receive appropriate colostomy care due to the facility running out of necessary supplies and ordering the wrong items. The resident went a week without the required wafers, which are crucial for preventing skin breakdown. The DON admitted to a lack of tracking and ordering system for supplies, leading to this deficiency.
The facility failed to post daily nurse staffing information as required, with observations showing outdated postings and inaccessible information on multiple occasions. Interviews with the DON, Administrator, and CNA 1 confirmed that CNAs 1 and 4 were responsible for the postings, but discrepancies were noted, indicating non-compliance with the requirement to update and display staffing information daily.
A resident with dementia and a history of violent behaviors did not receive appropriate non-pharmacological interventions at an LTC facility. Staff frequently administered psychotropic medications without attempting or documenting alternative strategies. Observations and interviews revealed a lack of training and understanding of dementia care among staff, leading to inadequate management of the resident's exit-seeking and aggressive behaviors.
A resident did not receive prescribed medications, including Darbepoetin Alfa and Valbenazine Tosylate, due to issues with pharmacy delivery and insurance authorization. Facility staff, including an LPN and the DON, were unclear about the medication procurement process, leading to a deficiency in pharmaceutical services.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to protect residents from abuse and neglect, as evidenced by several incidents involving inappropriate sexual behavior and inadequate assessment of residents' capacity to consent to sexual relationships. Seven residents were affected, with specific incidents including unwanted sexual contact between residents and a resident leaving the facility against medical advice. The facility did not conduct proper assessments to determine the capacity of residents to consent to sexual activities, leading to situations where residents with impaired cognition were involved in inappropriate interactions. One resident, with a history of traumatic brain injury and cognitive impairment, exhibited repeated inappropriate sexual behaviors towards staff and other residents. Despite being on psychotropic medications and having a care plan addressing his impulsive sexual behaviors, the resident continued to make inappropriate comments and engage in unwanted physical contact. The facility's failure to adequately manage and monitor this resident's behavior contributed to the deficiency. Another resident, with a history of metabolic encephalopathy and cognitive impairment, was involved in a consensual kiss with the aforementioned resident. However, due to her impaired cognition, there was a lack of proper assessment to ensure her capacity to consent. Additionally, this resident was found wandering outside the facility, indicating a lapse in supervision and safety measures. These incidents highlight the facility's failure to implement effective strategies to prevent abuse and ensure the safety and well-being of its residents.
Insufficient Staffing Leads to Delayed Care and Resident Distress
Penalty
Summary
The facility was found to have insufficient nursing staff to meet the needs of its residents, as evidenced by multiple incidents involving delayed or inadequate care. Resident 60, who has a history of falls and requires assistance due to conditions such as dementia and diabetes, reported waiting excessively for help to use the bathroom, resulting in incontinence and a fall. Observations confirmed that Resident 60's call light was not promptly answered, and the resident was found soiled and in distress. Additionally, the call light was not within reach, further compromising the resident's ability to receive timely assistance. Resident 49, who is cognitively intact but requires assistance with bathing, was observed wearing the same clothing over several days, indicating a lack of regular showers. The facility's documentation showed inconsistencies in recording shower care, with some entries marked as 'not applicable' or 'refused' without clear justification. Interviews with staff revealed uncertainty about the resident's shower schedule and the reasons for missed showers, highlighting a lack of coordination and communication among the care team. Other residents, such as Resident 15 and Resident 51, also experienced delays in receiving incontinence care, with observations showing extended periods without assistance. Resident 51, who has significant physical impairments, reported having to change her own brief due to staff unavailability. The facility's resident council notes and interviews with staff and residents consistently pointed to understaffing, particularly at night, leading to unmet care needs and dissatisfaction among residents. Despite the facility's staffing plan, the actual number of available staff was insufficient to provide the necessary care, as confirmed by both staff and resident testimonies.
Inadequate Nursing Staff Competencies and Oversight in LTC Facility
Penalty
Summary
The facility was found to have multiple deficiencies related to inadequate nursing staff competencies and oversight, which compromised resident safety and well-being. Specifically, the Director of Nursing failed to provide adequate oversight, leading to system failures in resident care. This included the lack of comprehensive, person-centered care plans for several residents, which did not reflect current medical needs such as ostomy and wound care, bowel and bladder care, and necessary interventions after falls. Additionally, residents were not provided with appropriate assistance for activities of daily living, such as bathing, nail care, and incontinence care. The facility also failed to ensure that residents received necessary treatments and services to maintain their health. For instance, a resident with a pressure ulcer did not receive timely treatment, as the wound VAC was non-functional for 24 hours without physician notification. Furthermore, the facility did not provide adequate supervision and assistance devices to prevent accidents, resulting in falls and injuries. Residents were also not provided with timely assistance for toileting and hydration, and call lights were not answered promptly. Nutritional care was also inadequate, with residents not receiving meals that accommodated their allergies and preferences, and therapeutic diets were not provided as prescribed. The facility did not maintain an effective infection prevention and control program, as evidenced by staff not performing hand hygiene and the lack of a Legionella prevention plan. Additionally, the facility failed to ensure that residents were offered necessary immunizations, and there was a lack of documentation for influenza, pneumococcal, and COVID-19 vaccines. Behavioral health services were also insufficient, as a resident with suicidal ideations did not receive appropriate care, leading to an overdose incident.
Significant Deficiencies in Resident Care and Safety
Penalty
Summary
The facility was found to have significant deficiencies in its administration, impacting the well-being of 45 out of 65 sampled residents. Key issues included the failure to ensure residents' rights to be free from abuse and neglect, with some residents not assessed for their capacity to consent to sexual relationships, leading to unwanted sexual contact and a resident leaving the facility against medical advice. Additionally, a resident was improperly relocated to a locked memory care unit for not following the smoking policy, and another resident with a pressure ulcer did not receive timely treatment, resulting in a somnolent state before the physician was notified. The facility also failed to maintain a safe environment, as evidenced by residents falling due to damaged medical equipment and inadequate supervision. Neurological assessments were not completed after falls, and call lights were not within reach, leading to major injuries. Furthermore, residents who were continent upon admission did not receive appropriate services to maintain continence, with delays in treatment for urinary tract infections and inadequate bladder retraining programs. Staffing issues were prevalent, with insufficient nursing staff to meet residents' needs, resulting in unmet incontinence care, missed showers, and delayed response to call lights. Behavioral health services were lacking, as a resident with a history of suicidal ideation did not receive necessary support after a traumatic event, leading to an overdose. Additionally, the facility's dietary services were inadequate, with meals served late and residents expressing dissatisfaction with the delays.
Multiple Deficiencies in Resident Care and Safety
Penalty
Summary
The facility failed to ensure that residents were free from abuse and neglect, as evidenced by several incidents involving residents' rights and safety. Seven residents were not assessed for their capacity to consent to sexual relationships, leading to unwanted sexual contact and a resident leaving the facility against medical advice. Another resident was relocated to a locked memory care unit for not following the smoking policy, which constitutes involuntary seclusion. Additionally, a resident with a pressure ulcer did not receive timely treatment, as the wound VAC was non-functional for 24 hours without physician notification. The facility also failed to maintain a safe environment, as evidenced by incidents involving falls and inadequate supervision. Damaged medical equipment contributed to a resident's fall, and no updated interventions were implemented after falls, resulting in a major injury. Neurological assessments were not completed post-fall, and call lights were not within reach for some residents. Furthermore, the facility did not provide adequate continence care, as a resident's urinary tract infection went untreated for 12 days, and another resident was not provided with a bladder retraining program. Staffing issues were prevalent, with insufficient nursing staff to meet residents' needs, leading to unmet incontinence care, missed showers, and delayed response to call lights. The Director of Nursing's inadequate oversight resulted in multiple system failures, affecting resident care. Additionally, the facility's food and nutrition services were understaffed, causing meal delays and resident dissatisfaction. Behavioral health services were also lacking, as a resident with a history of suicidal ideation did not receive necessary support after a traumatic event, leading to an overdose.
Resident Involuntarily Secluded Due to Smoking Policy Non-Compliance
Penalty
Summary
The facility failed to protect a resident from involuntary seclusion, which is a form of abuse, by relocating her to a locked memory care unit due to non-compliance with the smoking policy. The resident, who had a history of hemiplegia, hemiparesis, aphasia, and cognitive communication deficits, was observed smoking in non-designated areas multiple times. Despite being placed on supervised smoking, she continued to smoke unsupervised and hid cigarettes and lighters in her bra. The facility's response to these behaviors was to move her to the memory care unit, which is typically reserved for residents with elopement risks or memory problems. The resident's medical records indicated that she was alert, fully oriented, and understood verbal content, despite her expressive aphasia. She was not considered an elopement risk, and her memory was assessed as intact. The decision to move her to the memory care unit was made without conducting a wander risk assessment or an Interdisciplinary Team meeting, as stated by the Director of Nursing. The resident's daughter was not informed prior to the move and expressed her disapproval, stating that the move was used as a form of punishment. Interviews with staff revealed that the resident was moved to the memory care unit to help her comply with the smoking policy. However, the resident's daughter and the Resident Advocate indicated that the move was not well communicated and was against the family's wishes. The resident was eventually moved back to her previous room after her daughter intervened. The facility's actions in relocating the resident to the memory care unit without proper assessments and against the family's wishes constituted a failure to protect the resident from involuntary seclusion.
Failure to Maintain Wound VAC Leads to Resident Hospitalization
Penalty
Summary
The facility failed to ensure that a resident with pressure ulcers received the necessary treatment and services to promote healing and prevent infection. A resident, who had been diagnosed with paraplegia, cognitive communication deficit, and pressure ulcers, was found to have a malfunctioning wound Vacuum-Assisted Closure (VAC) for approximately 24 hours. The nursing staff did not notify the physician about the malfunctioning device until the resident became somnolent. The resident's medical record indicated a history of sepsis related to the pressure ulcers, and the physician noted a strong odor from the wounds upon assessment, leading to the resident's transfer to the emergency department for possible septic shock. The resident was admitted to the hospital, where it was discovered that the wound VAC had been broken for several days. A CT scan revealed an abscess in the left gluteal region, suspicious for osteomyelitis, and inflammation in the right gluteal area. The resident was diagnosed with osteomyelitis of the sacrum and started on antibiotics. The Director of Nursing stated that wound VACs are typically checked only during changes, and if a device is not working, nurses are expected to troubleshoot and contact the provider if necessary. However, there was no documentation indicating that the physician was contacted about the malfunctioning wound VAC prior to the resident's decline in condition.
Deficiencies in Resident Safety and Supervision
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for its residents, leading to multiple incidents of falls and injuries. One resident, who was dependent on a Hoyer lift for transfers due to quadriplegia and other severe health conditions, fell when the sling snapped during a transfer. The sling was found to be damaged, and there was no immediate intervention to prevent further incidents. The maintenance supervisor was unaware of any issues with the Hoyer lifts, indicating a lack of communication and oversight regarding equipment safety. Another resident, with a history of falls and multiple health issues including neuropathy and chronic pain, experienced several falls resulting in significant injuries such as a fractured arm and nose. Despite these incidents, there were no updates to the resident's care plan to address the increased fall risk, and neurological assessments were not consistently completed after falls. The resident reported that staff were often too busy to assist her, contributing to her attempts to transfer herself, which led to further falls. A third resident, with moderate cognitive impairment and a history of falls, reported falling while waiting for staff to respond to his call light. Observations revealed that his bed was not consistently kept in the lowest position, and his call light was not always within reach, contrary to his care plan. This lack of adherence to the care plan interventions increased the risk of falls and injuries for the resident.
Deficiencies in Continence Care and UTI Management
Penalty
Summary
The facility failed to provide timely and appropriate care for three residents, leading to deficiencies in managing urinary tract infections (UTIs) and continence care. Resident 55, who was continent of bladder and bowel upon admission, experienced a delay in receiving treatment for a UTI. A urine analysis was obtained, but the results were not reviewed or acted upon for 12 days, during which the resident experienced significant flank pain. The delay was attributed to a system glitch and lack of follow-up by the nursing staff. Additionally, Resident 55 experienced changes in bladder function and increased incontinence, which were not addressed in a timely manner. Resident 60, who was occasionally incontinent of bladder upon admission, was not provided with a bladder retraining program. The resident reported incidents of incontinence due to delayed staff response to call lights, resulting in the resident attempting to ambulate independently and experiencing falls. Observations confirmed that the resident's call light was not always within reach, and staff did not consistently respond promptly to the resident's needs. The facility's failure to implement a toileting program and ensure timely assistance contributed to the resident's incontinence and risk of falls. Resident 1, who had a suprapubic catheter and a history of UTIs, did not receive consistent catheter care, leading to ongoing infections. The resident's catheter was not patent at times, and there were delays in obtaining and acting on urine culture results. The resident's care plan included catheter care and monitoring for UTI symptoms, but these interventions were not consistently followed. The resident's medication for a UTI was discontinued before completing the prescribed course, further compromising the resident's care. These deficiencies highlight the facility's failure to provide adequate continence care and timely medical intervention for residents with urinary issues.
Failure to Provide Adequate Behavioral Health Care Leads to Resident Overdose
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to a resident with a history of suicidal ideation, leading to a serious incident. The resident, who had multiple mental health diagnoses including bipolar disorder, major depressive disorder, and suicidal ideation, experienced a traumatic life event when her mother, who was also a resident, passed away. Despite the resident's documented history of suicidal thoughts and the recent loss of her mother, the facility did not provide adequate behavioral health services or monitoring, resulting in the resident overdosing on Tylenol and being sent to the emergency room. Interviews with facility staff revealed a lack of awareness and documentation regarding the resident's history of suicidal ideation. The Registered Nurse (RN) was unaware of the resident's past suicidal thoughts, and there was no clear documentation or communication of this history among the staff. The facility's care plan for the resident did not adequately address her mental health needs, and there was no safety plan in place despite the resident's known risk factors. The facility also failed to monitor the resident's behavior effectively, as evidenced by the lack of documentation of depressive statements and episodes of agitation leading up to the overdose. The facility's response to the incident highlighted several deficiencies in their processes. The Administrator and staff conducted a room sweep to remove unauthorized medications but did not have a protocol in place to prevent such incidents. The facility lacked a full-time Resident Advocate (RA) or Licensed Clinical Social Worker (LCSW) to provide necessary oversight and support for residents with mental health needs. The absence of a comprehensive care plan and inadequate staff training on recognizing and responding to signs of suicidal ideation contributed to the failure to prevent the resident's overdose.
Inadequate Staffing in Food and Nutrition Services
Penalty
Summary
The facility failed to provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service, affecting 17 of 65 sampled residents. Meals were consistently served over an hour later than the posted meal times, causing distress among residents. Observations included residents waiting in hallways and dining rooms for meals, with some expressing hunger and frustration. Resident council minutes also revealed complaints about late meals, cold food, and inconsistent meal times. Resident 16, who has a history of cerebral infarction, cognitive communication deficit, diabetes mellitus, and major depressive disorder, was notably affected. He was observed yelling for food and expressing dissatisfaction with the meal service, stating that breakfast was always late and portions were too small. He reported having to rely on his sister for snacks and expressed frustration with the lack of timely meal delivery. Interviews with staff indicated that there was confusion about meal delivery locations, and the dietary manager acknowledged that meal trays were not monitored for consumption in the dining room. Staff interviews revealed that the kitchen was understaffed, with the dietary manager and aides working long hours to manage meal preparation and delivery. The Registered Dietitian noted that meal delivery had been problematic and that the kitchen staff were struggling to meet the needs of the residents. The facility's assessment indicated a need for more dietary personnel, but the current staffing levels were insufficient to meet the residents' needs, leading to delays and inconsistencies in meal service.
Deficiencies in Dietary Services and Kitchen Sanitation
Penalty
Summary
The facility failed to provide a nourishing, palatable, well-balanced diet that met the daily nutritional and special dietary needs of 30 out of 65 sampled residents. This deficiency was observed through late meal services, inappropriate portion sizes, and unpalatable food. Additionally, the facility did not honor resident food allergies and preferences, failed to offer beverages between meals, and did not follow therapeutic diets. The kitchen was found to be unsanitary, and adaptive equipment was not provided to residents who needed it. Furthermore, weights and nutritional assessments were not being completed, indicating a lack of comprehensive nutritional care. The facility also did not employ sufficient staff with the appropriate competencies and skills to carry out the functions of food and nutrition services. Meals were served over an hour later than the posted times, causing residents to express hunger and frustration. The Registered Dietitian (RD) acknowledged that the kitchen was a disaster and that the Dietary Manager (DM) was working on improvements. However, the RD admitted to not completing necessary audits or assessments, and there was a lack of communication and training among the dietary staff. The kitchen's cleanliness and food safety standards were not maintained, with observations of dirty equipment, unlabeled food items, and improper storage practices. The RD and DM were aware of these issues but had not implemented effective solutions. The RD's limited hours and the facility's inadequate staffing contributed to the ongoing deficiencies in dietary services, impacting the residents' nutritional status and overall well-being.
Food Safety and Sanitation Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to maintain food storage, preparation, and service in accordance with professional standards, leading to multiple deficiencies in the kitchen area. Observations revealed that the kitchen was unclean, with spills and dried food near burners, a large mixer with a white substance on its arms and floor, and an oven floor caked with spilled food. Food items in the walk-in freezer and reach-in refrigerator were found open to air and not labeled, while dry storage items were similarly exposed. Staff were observed not adhering to hygiene protocols, such as wearing beard covers, and personal cell phones were present in the food preparation area. Structural issues were noted, including damaged walls and missing tiles, contributing to an unsanitary environment. The facility's dishwashing practices were also found to be inadequate. The Assistant Dietary Manager (ADM) admitted to not knowing the appropriate temperature for the dish machine, which was a low-temperature model, and was unable to find strips to check the chemical sanitizer level. Observations showed that the dish machine temperatures were below the required levels, and there was no log kept for the dish machine's operation. The ADM's lack of knowledge and failure to verify sanitization processes indicated a significant oversight in maintaining food safety standards. A resident expressed concerns about the cleanliness of mugs provided by the facility, stating that they were not adequately cleaned by the kitchen staff. The resident resorted to washing the mugs with hand soap in her bathroom sink, which was challenging due to the sink's size. This resident's experience highlights the facility's failure to ensure that dining utensils were properly sanitized, further emphasizing the deficiencies in the facility's food service operations.
Inadequate Infection Control and Water Management
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple observations of staff not performing hand hygiene during meal service and medication pass. Specifically, a Certified Nurse Assistant (CNA) was observed delivering uncovered food trays to resident rooms and failing to perform hand hygiene while wearing gloves and touching their face. Additionally, a Registered Nurse (RN) was observed not performing hand hygiene between handling food trays and administering medications to residents, despite touching various surfaces and their face. Interviews with the Director of Nursing (DON) and other staff confirmed that the expectation was for hand hygiene to be performed between resident interactions and before medication preparation. Furthermore, the facility lacked a Legionella prevention and monitoring plan within their water management program. The newly hired Maintenance Supervisor (MS) was unaware of any such plan or the facility's water maintenance procedures to prevent contaminants, including Legionella. The facility's policy required the maintenance director or designee to assess risks for water-borne contaminants and implement prevention measures, but no evidence of such a plan was provided. This deficiency highlights a significant gap in the facility's infection control measures, potentially compromising resident safety.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for 13 out of 65 sampled residents. Residents reported issues such as cold temperatures in their rooms, uncleaned rooms, leaking toilets and sinks, and flooding showers. Additionally, there were complaints about missing personal belongings, including clothing and dentures, which were not resolved by the facility staff. The maintenance and housekeeping staff were found to be short-staffed and unable to keep up with the demands of maintaining a clean and safe environment. Several residents, including those with significant medical conditions such as osteomyelitis, diabetes, and depression, experienced discomfort due to the facility's inability to maintain appropriate room temperatures. Residents were observed using multiple blankets to keep warm, and some reported that maintenance efforts to address the cold temperatures were ineffective. The maintenance supervisor admitted to being unaware of certain issues, such as leaking sinks and toilets, and acknowledged that the facility's thermostats were not properly set to heat. The facility also failed to adequately address the issue of missing personal belongings. Residents reported missing clothing and other items, but there was no consistent process in place to track and resolve these grievances. The Resident Advocate and other staff members were not always informed of missing items, and the inventory lists were not regularly updated. This lack of organization and communication contributed to the residents' dissatisfaction and the facility's failure to uphold the residents' rights to a homelike environment.
Failure to Resolve Grievances Related to Missing Personal Property
Penalty
Summary
The facility failed to promptly resolve grievances related to missing personal property for two residents. Resident 29 reported missing clothing items to the staff, but there was no documentation of these grievances in the facility's records. Despite the resident's moderate cognitive impairment, as indicated by a BIMS score of 10, the staff did not take adequate steps to address or resolve the issue. Interviews with staff revealed a lack of awareness and follow-through on the grievance process, with no updated inventory list for the resident's belongings. Resident 51 also experienced unresolved grievances regarding missing personal items, including clothing and dentures. Despite being cognitively intact with a BIMS score of 14, the resident's complaints were not documented or addressed effectively. The staff's failure to update the resident's inventory list and the lack of communication between the resident and the Resident Advocate contributed to the unresolved grievances. Interviews with staff indicated a lack of clarity and consistency in handling missing items and updating inventory records. The facility's grievance process was found to be inadequate, with residents expressing confusion about how to file grievances and outdated information on the posted grievance procedure. The Resident Advocate and Director of Nursing were not effectively managing the grievance process, leading to unresolved issues and dissatisfaction among residents. The facility's resident council meeting minutes highlighted ongoing concerns about missing personal property, indicating systemic issues with the facility's handling of grievances and inventory management.
Failure to Implement Policies for Preventing Abuse and Inappropriate Sexual Behavior
Penalty
Summary
The facility failed to develop and implement adequate policies and procedures to prevent abuse, neglect, and exploitation of residents, as well as the misappropriation of resident property. This deficiency was identified in the cases of five residents who were involved in inappropriate sexual interactions without proper assessments of their capacity to consent. The facility's abuse policy, revised on June 11, 2024, mandates that a licensed nurse or social worker should assess a resident's capacity to consent to sexual relationships. However, this assessment was not conducted for the residents involved, leading to incidents of inappropriate sexual behavior. Resident 54, who has a history of traumatic brain injury and mental health issues, exhibited multiple instances of inappropriate sexual behavior towards staff and other residents. Despite being on psychotropic medications and having a care plan in place to manage his impulsive sexual behaviors, the resident continued to make inappropriate comments and advances. The facility's failure to reassess his capacity to consent and to effectively manage his behavior contributed to the deficiency. Similarly, Resident 121, with a history of cognitive impairment and behavioral disturbances, was involved in a consensual kiss with Resident 54. However, the facility did not conduct a capacity assessment for Resident 121, who scored moderately impaired on the BIMS assessment. Additionally, Resident 6, who expressed a desire for a non-sexual relationship, was involved in a romantic relationship with Resident 49 without proper capacity assessment. The facility's lack of adherence to its own policies regarding capacity assessments and the management of residents' sexual behaviors led to these deficiencies.
Failure to Timely Report Abuse and Neglect Incidents
Penalty
Summary
The facility failed to report several incidents of abuse, neglect, exploitation, or mistreatment to the State Survey Agency (SSA) within the required timeframe of two hours. This deficiency involved six residents and included incidents such as sexual abuse, a fall with a major injury, a fall from a hoyer lift, exploitation of a resident, involuntary seclusion, and an elopement. The facility's policy mandates immediate reporting of such incidents, but this was not adhered to in these cases. One incident involved two residents, where one was observed kissing the other. The facility administrator did not initially report this incident, believing it was consensual and not reportable. However, the administrator later submitted a report to the state. Another resident experienced a fall resulting in a shoulder fracture, which was not reported to the SSA within the required timeframe. Additionally, this resident was involved in an online scam, which was also not reported promptly. Other incidents included a resident who left the facility against medical advice despite being cognitively impaired and having a court-appointed guardian. This was not reported as an elopement to the SSA. Another resident was involuntarily secluded in a memory care unit due to noncompliance with smoking policies, and this was not reported. Lastly, a resident fell from a hoyer lift due to a frayed sling, and this incident was not reported in a timely manner either.
Failure to Notify Residents of Bed Hold Policy During Hospital Transfers
Penalty
Summary
The facility failed to provide written notification of the bed hold policy to three residents or their representatives when they were transferred to the hospital. Resident 8, who had multiple diagnoses including intracranial injury and acute respiratory failure, was sent to the emergency department for chest pain without being informed of the bed hold policy. Similarly, Resident 123, with conditions such as myotonic muscular dystrophy and type 1 diabetes, was transferred for evaluation and treatment without receiving the necessary notification. Resident 5, who had quadriplegia and chronic kidney disease among other diagnoses, was also transferred to the hospital due to respiratory distress and other symptoms without being informed of the bed hold policy. The Director of Nursing (DON) and the Administrator acknowledged the lack of documentation and notification regarding the bed hold policy for these residents. The facility's policy requires that residents be informed upon admission and prior to transfer, but this was not adhered to in these cases. Interviews with the DON and the Regional Nurse Consultant revealed that the bed hold policy was not consistently being communicated to residents or their representatives. The Administrator also confirmed the absence of documentation for Resident 5's transfer. This deficiency highlights a failure in the facility's process to ensure residents and their representatives are informed of their rights and the facility's policies regarding bed holds during hospital transfers.
Inaccurate MDS Assessment for Resident Discharge
Penalty
Summary
The facility failed to accurately assess a resident's discharge status, leading to a deficiency in the resident's Minimum Data Set (MDS) assessment. Specifically, the MDS assessment for a resident, who was admitted with a fracture of the neck of the left femur, incorrectly indicated a discharge to a short-term general hospital. However, the discharge progress note documented that the resident was actually discharged to a private residence. During an interview, the MDS Coordinator was unable to explain why the MDS assessment inaccurately reflected the resident's discharge destination.
Failure to Implement Timely Baseline Care Plans
Penalty
Summary
The facility failed to ensure that baseline care plans were developed and implemented within 48 hours of admission for four residents, leading to deficiencies in meeting their immediate healthcare needs. Resident 51, admitted with multiple complex diagnoses including intracerebral hemorrhage and chronic kidney disease, had only limited care plan focus areas initiated within the first 48 hours, lacking comprehensive coverage of their medical needs. Resident 65, with conditions such as dementia and violent behaviors, had a baseline care plan initiated 39 days post-admission, far exceeding the required timeframe. The Director of Nursing confirmed the delay and acknowledged the responsibility of the MDS Coordinator in completing these plans. Resident 38, suffering from Parkinson's disease and other serious health issues, had their baseline care plan signed four days after admission, indicating a delay in addressing their care needs. Similarly, Resident 66, admitted with acute hepatic failure and a history of suicide attempts, did not have a baseline care plan completed during their stay, as confirmed by the facility's Administrator. These lapses in timely care planning highlight a systemic issue in the facility's process for developing and implementing baseline care plans, potentially impacting the quality of care provided to newly admitted residents.
Deficiencies in Care Plan Updates and Implementation
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for several residents, leading to deficiencies in meeting their medical, nursing, mental, and psychosocial needs. For Resident 3, the care plan was not updated to reflect current ostomy and wound care needs. Despite having physician orders for frequent ostomy care, the resident experienced issues such as a burst colostomy bag and frequent urostomy bag leaks. The resident also reported not being included in care conferences, indicating a lack of involvement in her care planning process. Interviews with staff revealed that the care plan was outdated and did not reflect the resident's current needs, particularly after transitioning from external to in-house wound care. Resident 13 experienced multiple falls, including one resulting in a major injury, yet the care plan was not updated to address these incidents. The resident had a history of falls and was at risk due to various medical conditions, including neuropathy and muscle weakness. Despite physician orders for fall prevention measures, the care plan lacked updates following significant falls, indicating a failure to reassess and modify interventions to prevent further incidents. Progress notes documented several falls and injuries, but the care plan did not reflect these changes, highlighting a gap in the facility's response to the resident's evolving needs. Resident 55's care plan did not address bowel and bladder care, despite the resident experiencing incontinence and pain potentially related to a urinary tract infection (UTI). The resident had a history of catheter use and reported new pain and incontinence issues, yet there was no care plan in place to manage these symptoms. The resident's medical record showed delays in obtaining and acting on urinalysis results, which contributed to prolonged discomfort and uncertainty about his condition. Interviews with nursing staff revealed communication and procedural gaps in handling laboratory results, further complicating the resident's care management.
Deficiencies in ADL Assistance and Care Documentation
Penalty
Summary
The facility failed to ensure that residents were provided with the necessary assistance to maintain or improve their ability to perform activities of daily living. Specifically, four residents were not given adequate bathing, nail care, and incontinence care. Resident 49, who was cognitively intact, expressed dissatisfaction with the frequency of showers due to poorly designed facilities and was observed in the same clothing for several days. The care plan indicated that the resident required supervision or assistance with bathing, but the documentation showed inconsistencies in the provision of showers. Resident 60, also cognitively intact, reported having only one shower since admission and expressed a desire for weekly showers. Observations noted long, dirty fingernails, and the facility's documentation lacked records of regular bathing or nail care. The care plan for Resident 60 included interventions for skin integrity and assistance with ADLs, but these were not consistently documented or provided. Resident 15, who was incontinent and required frequent brief changes, reported that changes were not made as often as needed. Observations confirmed a lack of incontinence care over several hours, despite the resident's care plan indicating a need for extensive assistance. Similarly, Resident 51, who had hemiplegia and required assistance with toileting, reported delays in receiving help and issues with the call light system. Observations showed a lack of incontinence care over a significant period, and the resident's care plan was not adequately followed to ensure timely assistance.
Nutritional Deficiencies and Inadequate Monitoring in LTC Facility
Penalty
Summary
The facility failed to ensure that residents maintained acceptable parameters of nutritional status, as evidenced by inadequate meal portion sizes, failure to obtain residents' weights, and incomplete nutritional assessments. Resident 60, who had multiple diagnoses including type 2 diabetes mellitus and dementia, was not weighed regularly, and their nutritional assessment was incomplete. The Registered Dietitian (RD) struggled to obtain weights and complete assessments due to a backlog and lack of support, which hindered accurate nutritional evaluations. Resident 55, diagnosed with Parkinson's disease and other conditions, reported not receiving beverages between meals, relying on personal bottled water. Despite a care plan addressing nutritional problems, the facility failed to conduct weekly lab tests as ordered, which were crucial for monitoring kidney function and hydration status. Interviews with staff revealed inconsistencies in providing water and monitoring fluid intake, further contributing to the deficiency. Resident 65 experienced significant weight loss without adequate follow-up or intervention. Despite a care plan for nutritional risk, the facility did not obtain repeat weights as requested by the RD, and the resident's nutritional needs were not reassessed. The RD and staff were overwhelmed with responsibilities, leading to missed assessments and inadequate monitoring of residents' nutritional status. Additionally, Resident 3 faced issues with the availability of nutritional supplements, which were frequently out of stock, impacting their nutritional intake and weight management.
Inadequate Monitoring and Documentation of Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that psychotropic medications were administered appropriately and in accordance with regulatory guidelines for five residents. For Resident 54, the facility did not have a supporting diagnosis for the prescribed antipsychotic medication, Fanapt, and no gradual dose reduction was initiated. The resident's behavior was not consistently monitored, and non-pharmacological interventions were not documented prior to medication administration. The Director of Nursing (DON) acknowledged the oversight in not reaching out to the prescribing provider to initiate a tapering process. Resident 65 was prescribed multiple psychotropic medications, including Haloperidol and Risperidone, without adequate documentation of non-pharmacological interventions or monitoring for adverse side effects. The resident's care plan was not initiated until nearly two months after admission, despite ongoing use of psychotropic medications. The DON admitted that there was no physician rationale or re-evaluation for the continued use of PRN antipsychotic medication beyond 14 days. For Resident 270, there was a lack of documentation for monitoring behaviors and adverse side effects related to the use of Risperidone and Buspirone. The care plan for psychotropic medication use was not initiated until several weeks after admission. Similarly, Resident 13 was administered Hydroxyzine PRN for anxiety without a documented rationale for extended use beyond 14 days. Resident 46 was given Clonazepam PRN for anxiety, but the facility did not provide a rationale for extending the order beyond the 14-day limit. The DON confirmed the absence of necessary documentation and monitoring for these residents.
Failure to Maintain Complete Laboratory Records
Penalty
Summary
The facility failed to maintain complete and dated laboratory records in the clinical records of seven residents. For Resident 13, laboratory results from tests conducted at an outside facility were not filed in the resident's medical record. The Director of Nursing (DON) acknowledged that the results were supposed to be faxed to the facility but were not, and they were only uploaded to the resident's medical record after being provided to the state agency. Resident 1's medical records lacked documentation of a urinalysis with culture and sensitivity results, despite a physician's order for the test. The DON stated that the laboratory process involved the lab picking up specimens twice a day, and results were expected within a few days. However, the results were not uploaded into the resident's electronic medical record in a timely manner, and the DON had to access the laboratory computer portal to obtain them. Similar issues were observed with Residents 2, 50, 52, 54, and 55, where laboratory results were either missing or not uploaded into the electronic medical records promptly. The DON and nursing staff acknowledged difficulties in receiving results from the laboratory, and there was a lack of consistent follow-up to ensure that results were obtained and documented in the residents' records. This deficiency in maintaining accurate and timely laboratory records could potentially impact the care and treatment of the residents involved.
Nutritional Deficiencies in Meal Service
Penalty
Summary
The facility failed to provide menus that met the nutritional needs of residents, as evidenced by several observations and interviews. On multiple occasions, meals served did not match the posted menus or the recipes outlined in the facility's dietary guidelines. For instance, on one occasion, a lunch meal included a piece of chicken and sides that did not align with the specified portion sizes and menu items. Similarly, a dinner meal was observed to deviate from the planned savory ham wrap, instead serving a grilled tortilla with cheese. These discrepancies were noted over several days, indicating a pattern of non-compliance with established nutritional guidelines. The report highlights specific cases involving residents 15, 16, and 55, who were affected by the facility's failure to adhere to dietary plans. Resident 55, diagnosed with Parkinson's disease and other conditions, expressed dissatisfaction with the quantity of food provided, stating he was not offered snacks. Resident 16, with a history of cerebral infarction and other health issues, was observed expressing hunger and dissatisfaction with meal portions, which did not meet his dietary order for double protein portions. Resident 15, who has hereditary ataxia and other medical conditions, also reported not receiving enough food, despite her diet order specifying a regular diet with chopped meat texture. Interviews with dietary staff and the Registered Dietitian (RD) revealed a lack of training and oversight in the dietary department. The RD, who started working at the facility recently, acknowledged not having completed any tray audits and expressed uncertainty about her role in training dietary staff. The Assistant Dietary Manager (ADM) admitted to making substitutions without verifying their nutritional adequacy, and the Dietary Manager (DM) was noted to have limited experience in long-term care. These factors contributed to the facility's inability to consistently provide meals that met the nutritional needs of residents, as required by state and federal regulations.
Deficiency in Food Quality and Temperature
Penalty
Summary
The facility failed to provide food that was palatable, attractive, and at an appetizing temperature for 11 out of 65 sampled residents. Observations revealed that meals were not prepared in a manner that conserved flavor and appearance. For instance, during a dinner meal, the Dietary Manager was observed adding hot water to noodles that were drying out, indicating a lack of proper preparation. Additionally, a breakfast meal included a banana that appeared brown and mushy, further demonstrating the facility's failure to maintain food quality. Interviews with residents highlighted consistent dissatisfaction with the meals provided. Residents reported that the food was often cold, undercooked, or lacking in flavor. Some residents mentioned that the same menu items were repeated frequently, and the food temperatures were inconsistent. One resident even resorted to ordering meals from a local delivery service due to dissatisfaction with the facility's meals. The interviews also revealed that the facility had gone through multiple cooks, which may have contributed to the inconsistency in food quality. Further observations in the kitchen showed that there were not enough hot pellets to keep the trays warm, resulting in some trays being served without them. A test tray revealed that the food was not at an appetizing temperature, with items like ranch macaroni and cheese and marinara macaroni being below the desired warmth. The Registered Dietitian admitted to not conducting any tray audits since starting at the facility, which could have contributed to the oversight in food quality. Resident council minutes also documented ongoing concerns about food quality, including issues with expired food and inadequate portion sizes.
Failure to Accommodate Resident Allergies and Preferences
Penalty
Summary
The facility failed to ensure that residents received meals that accommodated their allergies, intolerances, and preferences, leading to several incidents where residents were served food containing allergens. One resident, who was allergic to onions, was served a meal containing onions, resulting in an allergic reaction. Despite the resident's allergy being documented in their medical chart, the dietary staff and nursing staff failed to prevent the exposure. The resident experienced symptoms of anaphylaxis and required monitoring, although no severe symptoms were reported at the time of the incident. Another resident was not questioned about food allergies until several months after admission, resulting in meals being served that did not account for their allergies to grapefruit, salmon, tuna, and green peas. This oversight highlights a gap in the facility's process for identifying and documenting resident allergies upon admission. Additionally, a resident with a severe allergy to tomatoes was repeatedly served meals containing tomatoes, despite their allergy being documented. The resident was able to avoid consuming the allergen, but the repeated exposure indicates a failure in the facility's meal preparation and delivery process. Further deficiencies were noted with residents who had allergies to dairy and wheat. One resident with a dairy allergy was served pudding likely containing milk, and another resident with a wheat allergy was served stuffing made with wheat bread. These incidents demonstrate a lack of communication and verification between the dietary staff and nursing staff, as well as a failure to adhere to documented dietary restrictions. The facility's inability to consistently provide meals that accommodate resident allergies and preferences poses a significant risk to resident safety and well-being.
Failure to Provide Adequate Hydration to Residents
Penalty
Summary
The facility failed to ensure that residents received drinks consistent with their needs and preferences, leading to issues with hydration. Four residents, identified as 26, 27, 55, and 120, reported not receiving water between meals and having to seek out staff to obtain fresh water. Resident 26, who has a history of muscular dystrophy and malnutrition, stated that she had to ask for water or go to the nurse's station, and that the kitchen did not provide clean mugs, forcing her to wash them herself. Resident 27, with a history of joint replacement and diabetes, also reported having to go to the nurse's station for water due to unresponsive call lights. Resident 120, who has lymphedema and morbid obesity, similarly reported needing to request water at the nurse's station. Resident 55, with Parkinson's disease and diabetes, stated that beverages were not offered between meals and that he had to purchase bottled water for himself. His medical records indicated a nutritional problem related to enteral feedings and difficulty swallowing, with lab results showing elevated blood urea nitrogen and creatinine levels, suggesting potential dehydration. Interviews with staff, including CNAs and the Director of Nursing, revealed inconsistencies in the provision of water to residents. While some staff stated that water was offered during rounds, others indicated that residents typically had to request water at the nurse's station. The Director of Nursing acknowledged that residents should be asked if they wanted something to drink during rounds, but it was common for residents to go to the nurse's station for water. Additionally, there was a lack of adherence to the care plan for Resident 55, as weekly lab tests to monitor kidney function were not consistently performed.
Inconsistent Meal and Snack Provision in LTC Facility
Penalty
Summary
The facility failed to provide meals and snacks in accordance with residents' needs, preferences, and requests, affecting 12 out of 65 sampled residents. Meals were not served at regular times comparable to normal mealtimes in the community, and meal times were changed without resident input. Residents reported that meals were often late, cold, or insufficient in portion size. Additionally, snacks were not consistently provided to residents who wanted to eat at non-traditional times or outside of scheduled meal service times, as per their care plans. Several residents expressed dissatisfaction with the meal service, citing issues such as cold food, late meal delivery, and inadequate portion sizes. For instance, one resident reported that dinner was served inconsistently between 6 and 7 PM, and snacks were rarely available in the evenings. Another resident mentioned that they had been hungry for an extended period due to small portion sizes and a lack of snacks, leading them to rely on family-provided snacks. The facility's failure to adhere to residents' dietary preferences and care plans was evident in multiple cases, with residents expressing frustration over the lack of available snacks and the need to request them from specific staff members. Interviews with staff members revealed inconsistencies in snack availability and distribution. Some staff reported that snacks were available only 80% of the time, and residents were sometimes advised to provide their own snacks. The facility's Registered Dietitian was unaware of the snack program, and the Director of Nursing acknowledged that residents' snack preferences had not been considered. The facility's resident council minutes further highlighted ongoing concerns about the availability and variety of snacks, with residents frequently noting the lack of options and the need for dietary accommodations.
Incomplete and Inaccurate Medical Records in LTC Facility
Penalty
Summary
The facility failed to ensure that medical records for six residents were complete and accurately documented, leading to several deficiencies. For Resident 221, the facility did not obtain or include hospital summary or discharge documentation, laboratory tests, or CT test results in the resident's medical record after a hospital visit. Similarly, Resident 13's medical records lacked hospital documentation for multiple hospital visits, including discharge summaries and test results. This lack of documentation could hinder the continuity of care and the ability to make informed medical decisions. Resident 10's medical record was missing hospital documentation following a visit for stabilization of mental health medications. The facility's process for obtaining and documenting hospital records was not followed, as evidenced by the absence of these critical documents. Additionally, Resident 220's medical record lacked documentation of neuro checks, which were reportedly completed but not recorded, indicating a failure in maintaining accurate medical records. Further, the facility made errors in resident documentation, as seen with Resident 371, where a physician's progress note was inaccurately placed in the wrong resident's chart. Similarly, Resident 26's medical record contained information pertaining to another resident, demonstrating a breach in maintaining resident-identifiable information. These documentation errors reflect a systemic issue in the facility's record-keeping practices, potentially impacting resident care and safety.
Lack of COVID-19 Vaccine Documentation for Residents
Penalty
Summary
The facility failed to ensure that three residents were offered the COVID-19 immunization and that their medical records included documentation of either receiving the immunization or declining it due to medical contraindications or refusal. Specifically, the medical records for residents identified as 49, 61, and 269 lacked documentation regarding the administration or declination of the COVID-19 vaccine for the current season. This deficiency was identified during a review of the residents' medical records on November 12, 2024. Resident 49, who was admitted with diagnoses including dementia and heart failure, initially consented to the vaccine but declined on the day of the clinic, with no documentation of this refusal. Resident 269, with conditions such as encephalopathy and severe sepsis, and resident 61, diagnosed with fibromyalgia and dementia, both declined the vaccine to discuss it with their Power of Attorney (POA) first. The Director of Nursing (DON) acknowledged the lack of documentation for these residents' vaccine declinations and stated that the immunization clinic was held in early October.
Deficient Call Light System in LTC Facility
Penalty
Summary
The facility failed to ensure that a working call system was available in each resident's bathroom and bathing area, affecting three residents. Resident 51, who had multiple diagnoses including intracerebral hemorrhage and hemiplegia, reported that her call light did not always work, leading to situations where she had to change her brief herself due to lack of assistance. Observations confirmed that both the bedside and bathroom call lights for Resident 51 were not functioning. The maintenance logs indicated repeated reports of non-functioning call lights in various rooms, including Resident 51's, but these issues were not promptly addressed. Resident 23 and Resident 44 also experienced deficiencies in the call light system. In Resident 23's room, there was no call light cord for bed B, and in Resident 44's room, there was no call light cord for bed A. Interviews with staff revealed that all residents should have access to call light cords, but these were missing in the observed rooms. Resident 55, who had moved rooms due to the lack of a call light, reported feeling abandoned without the ability to call for assistance, although he had not experienced any accidents as a result. The Maintenance Supervisor, who had recently started at the facility, acknowledged the issues with the call light system and described the process for addressing maintenance requests. However, there was a lack of verification with maintenance logs, and the system for ensuring all call lights were registered and functioning was not effectively implemented. The Director of Nursing was unaware of the specific deficiencies affecting Resident 55 and confirmed that every resident should have access to a call light. The report highlights a systemic issue with the maintenance and functionality of the call light system, impacting residents' ability to call for assistance when needed.
Use of Disposable Dishes Affects Resident Dignity
Penalty
Summary
The facility failed to treat residents with respect and dignity by serving meals on disposable dishes, which did not promote the maintenance or enhancement of their quality of life. During multiple meal services, it was observed that food was served on disposable dishes for two residents. On one occasion, a resident's pudding dessert was served in a disposable bowl, and on another, a resident was served cereal in Styrofoam bowls. Interviews with the Registered Dietitian and the Assistant Dietary Manager revealed that the use of disposable dishware was due to a shortage of non-disposable dishes, as only about two-thirds of the dishware returned to the kitchen for washing. Resident 27, who had a history of joint replacement surgery, difficulty walking, and other medical conditions, expressed a preference for eating cereal out of a larger bowl rather than a small disposable container. The facility's Administrator was unaware of the use of disposable dishes and believed there were enough supplies. However, the Assistant Dietary Manager confirmed the shortage and expressed a desire for residents to have real dishes, acknowledging that the residents were not receiving fancy food and deserved better presentation. This situation highlights a failure in the facility's operations to ensure adequate dishware supply and timely return of dishes for washing, impacting the residents' dining experience.
Failure to Include Resident in Care Planning
Penalty
Summary
The facility failed to uphold a resident's right to participate in the development and implementation of her person-centered care plan. A resident, who was admitted with multiple complex medical conditions including Arnold Chiari Syndrome with spina bifida and hydrocephalus, severe protein-calorie malnutrition, and several mental health disorders, expressed a desire to be involved in her care planning. However, she reported that care conferences were not being held, and there was no documentation of such meetings in 2024, despite her normal cognitive status as indicated by a BIMS score of 15. The resident's care plan included interventions that she would have the opportunity to attend care conferences upon admission and at least quarterly, but the last documented care conference was in December 2023. Interviews with the Director of Nursing revealed that care conferences were supposed to be held quarterly or with significant changes in condition, and the Activities Director was responsible for planning these meetings. However, there was a lack of documentation and evidence that these conferences were being conducted, leading to the deficiency in providing the resident the right to participate in her care planning.
Failure to Ensure Call Light Accessibility for Residents
Penalty
Summary
The facility failed to ensure the reasonable accommodation of resident needs and preferences for two residents, as evidenced by the improper placement of call lights. Resident 1, who has severe cognitive impairment and is fully dependent on staff for assistance, was observed with their call light on the floor at the foot of the bed, under a trash can, and out of reach. This resident has a complex medical history, including cerebral infarction, chronic obstructive pulmonary disease, and multiple other conditions, and requires total assistance for bed mobility, transfer, and toilet use. Similarly, Resident 30, who also has severe cognitive impairment and requires limited assistance for bed mobility, transfer, and toilet use, was observed with their call light on the floor under the bed, at the head of the bed, and out of reach. This resident has diagnoses including Alzheimer's disease, osteoporosis, and major depressive disorder. The Director of Nursing acknowledged that both residents could utilize their call lights if they were within reach, indicating a failure to accommodate the residents' needs and preferences adequately.
Resident Denied In-Room Phone Access
Penalty
Summary
The facility failed to ensure that a resident had reasonable access to a telephone in her room, as requested. Resident 28, who was admitted with diagnoses including hypertension, severe persistent asthma with acute exacerbation, and muscle weakness, was not provided with a phone in her room despite her request. The resident, who had a BIMS score indicating moderately impaired cognition, reported that multiple staff members informed her that she could not have a phone in her room and had to use the phone at the nurse's station. This was corroborated by an observation where a registered nurse informed the resident that the phone had to remain at the nurse's station due to it getting lost. Interviews with staff revealed a lack of clarity regarding the availability of landline phones in residents' rooms. A CNA was unsure if residents could have landline phones, while another stated that no residents had them and would report requests to the CNA Coordinator. The Maintenance Supervisor was unaware of the functionality of phone jacks in resident rooms and noted that no requests for phone repairs were documented in the maintenance log. The Administrator confirmed that the facility did not have phones in resident rooms but provided cordless phones at nurse's stations and on nurse's carts, emphasizing the need for residents to have a private place to talk on the phone.
Failure to Honor Resident's Advance Directive
Penalty
Summary
The facility failed to ensure that a resident's right to refuse medical treatment and formulate an advance directive was honored. A resident, who had been diagnosed with schizophrenia, cognitive communication deficit, and generalized anxiety, had a signed Provider Order for Life-Sustaining Treatment (POLST) form indicating a Do Not Resuscitate (DNR) status. However, the electronic medical records banner incorrectly documented the resident as wanting full treatment. This discrepancy was not addressed, and the resident's code status was not accurately reflected in the facility's records. Interviews with staff revealed confusion and inconsistency in handling the resident's code status. Licensed Practical Nurses (LPNs) and the Director of Nursing (DON) acknowledged the inconsistency between the POLST form and the electronic medical record. The DON admitted uncertainty about the process of updating the POLST forms and physician orders, which contributed to the discrepancy. The facility's failure to ensure accurate documentation of the resident's wishes could have led to inappropriate medical interventions, as staff would have followed the incorrect full code status in the event of an emergency.
Failure to Prevent Resident Exploitation
Penalty
Summary
The facility failed to take necessary steps to prevent the exploitation of a resident, identified as Resident 13, for personal gain. Resident 13, who had a normal cognition score, was involved in an online relationship with an individual claiming to be a celebrity. The resident advocate (RA) discovered that this relationship was a scam and took steps to protect Resident 13's financial assets by contacting the bank to close accounts and freeze a fraudulent deposit. Despite these actions, the facility did not notify the police when they became aware of the potential exploitation. Resident 13's care plan indicated a potential for online exploitation and included interventions to support her autonomy and decision-making. However, the care plan was not properly updated to reflect changes in Resident 13's capacity to consent, which could lead to confusion among staff providing care. The Director of Nursing (DON) acknowledged that the police should have been contacted if financial exploitation was suspected, but there was no evidence that this was done until much later. The facility's abuse policy required immediate reporting of any alleged violations involving exploitation, but the police were not notified until months after the initial discovery of the scam. The facility's failure to promptly report the suspected exploitation to law enforcement and update the care plan contributed to the deficiency. The report indicates that Adult Protective Services (APS) and the ombudsman were involved, but the lack of timely police notification and care plan updates were significant oversights.
Failure to Investigate and Report Resident Fall
Penalty
Summary
The facility failed to thoroughly investigate and report an incident involving a resident who sustained a fall resulting in a major injury. The incident was not reported to the State Survey Agency within the required 5 working days, and the facility did not provide evidence of a comprehensive investigation into the causative factors of the fall. The resident, who had a history of falls and multiple medical conditions including neuropathy and chronic respiratory failure, was found with a hematoma, laceration, and severe pain after the fall. The resident's care plan, which included interventions for fall prevention, was not updated following the incident to include new strategies to prevent further falls. The only change made was a note indicating that risk management was done and the resident was educated. Despite the resident's history of falls and poor safety awareness, no new interventions were documented to address these issues. Interviews with facility staff, including an LPN and the MDS coordinator, revealed that the resident had been encouraged to call for help but did not always do so. The MDS coordinator acknowledged that the fall was discussed in a morning meeting, but no documentation was provided to show that new interventions were implemented. The Director of Nursing stated that for residents with frequent falls, care plan evaluations and new interventions should be put in place, which was not done in this case.
Failure to Provide Necessary Documentation During Resident Transfers
Penalty
Summary
The facility failed to ensure that three residents were transferred to the hospital with the necessary medical documentation, which is crucial for a safe and effective transition of care. Resident 8 was sent to the emergency department for chest pain without any accompanying medical records, including a transfer/discharge assessment. Similarly, Resident 123, who had multiple complex medical conditions, was transferred to the hospital for evaluation and treatment without the required documentation, such as a transfer/discharge assessment or paperwork. Resident 371 was also sent to the emergency department without documentation indicating the basis for the transfer. Interviews with facility staff revealed inconsistencies in the process of transferring residents to the hospital. RN 2 stated that vital information, including an SBAR, face sheet, medication list, and POLST form, should accompany the resident, but this was not documented in the medical records. The DON acknowledged that there was a period when the facility could not use the e-interact form and expected staff to print out and send the discharge/transfer form with the transport. However, it was noted that some nursing staff might not document what was sent to the hospital, leading to the deficiency in ensuring proper documentation accompanied the residents during transfers.
Failure to Ensure Safe Discharge of Cognitively Impaired Resident
Penalty
Summary
The facility failed to provide and document sufficient preparation for the safe and orderly transfer or discharge of a resident with cognitive impairment, leading to a deficiency. Resident 419, who had been diagnosed with metabolic encephalopathy, schizophrenia, and other cognitive impairments, was deemed decisionally incompetent and required 24-hour supervision. Despite these assessments, the resident left the facility against medical advice (AMA) and was later imprisoned for criminal trespassing. The resident's medical records indicated a high risk of wandering and elopement, with a history of impaired decision-making and previous elopement attempts. A care plan was initiated to address the resident's desire to discharge into the community, but it was not effectively implemented. The resident left the facility on foot, stating they were heading to a local homeless center, which was later found to be above their level of care. The facility's staff contacted the resident's guardian, the police, and Adult Protective Services, but the resident's whereabouts remained unknown until they were found in jail. Interviews with facility staff, including the Director of Nursing and the Administrator, revealed that the resident's departure was not reported as an elopement, as it was considered an AMA discharge. The facility did not ensure the resident's safety or follow proper procedures for a resident lacking the capacity to make informed decisions. The deficiency highlights a failure in the facility's discharge planning and risk management processes, particularly for residents with significant cognitive impairments.
Failure to Obtain Physician Orders for Catheter Care Upon Admission
Penalty
Summary
The facility failed to obtain the necessary physician orders for a resident's catheter care upon admission, which is a critical aspect of the resident's immediate care needs. The resident, who was admitted with an indwelling catheter, did not have physician orders for catheter care documented in their medical record. This oversight was identified during a review of the resident's medical records and interviews with the resident and facility staff. The resident, who has a history of Multiple Sclerosis, paraplegia, and an infection related to the indwelling catheter, was able to communicate their needs and reported that staff would attend to the catheter when called. The deficiency was further highlighted during an interview with the Director of Nursing (DON), who acknowledged that there should have been an order for catheter care upon the resident's admission. The DON explained that the responsibility for entering physician orders into the medical record typically falls on the DON, MDS coordinator, or nurse manager, but not the provider. The absence of a catheter care order was attributed to a possible oversight, and the nursing staff should have notified the DON to correct the missing order. This lapse in obtaining and documenting physician orders for essential care upon admission represents a failure in the facility's processes for ensuring comprehensive care for its residents.
Delayed MDS Data Transmission for Two Residents
Penalty
Summary
The facility failed to ensure the timely transmission and completion of the Minimum Data Set (MDS) data to the Centers for Medicare and Medicaid Services (CMS) System for two residents. Specifically, the MDS assessments for these residents were not encoded and transmitted within the required 14 days after the facility completed the resident assessment. Resident 13's MDS assessment was accepted 20 days after the Assessment Reference Date (ARD), while Resident 32's assessment was accepted 45 days after the ARD. The delay in transmission was attributed to the facility's process, where the MDS Coordinator, a Licensed Practical Nurse, relied on a Registered Nurse, the Director of Nursing (DON), or the Corporate Resource Nurse (CRN) to transmit the assessments. The MDS Coordinator acknowledged the 14-day submission requirement, and the DON confirmed that the assessments for Resident 13 and Resident 32 were not transmitted on time. This oversight resulted in a deficiency in meeting the regulatory requirements for timely MDS data submission.
Deficiency in Resident Activity Programming
Penalty
Summary
The facility failed to provide an ongoing program of activities that met the interests and supported the physical, mental, and psychosocial well-being of its residents. This deficiency was observed in three out of 65 sampled residents. The facility did not have an updated activity calendar, and there were no activities scheduled on weekends. Additionally, activities were sometimes scheduled during meal times, which led to resident dissatisfaction and complaints documented in resident council minutes. Resident 49, who was admitted with diagnoses including dementia and chronic pain, expressed a desire for more stimulating activities such as chess and horseshoe games. His care plan included a variety of activities tailored to his interests, but he reported a lack of these activities being available. The Director of Nursing and Activities Director acknowledged issues with scheduling and communication, which resulted in activities overlapping with meal times and a lack of weekend programming. Resident 26, diagnosed with muscular dystrophy and other health issues, also reported disappointment with the cancellation of activities and their occurrence during meal times. Her care plan highlighted the importance of activities for her social and spiritual well-being. The Activities Director admitted to being overwhelmed with additional responsibilities, such as scheduling care conferences, which impacted her ability to conduct activities. The facility relied on volunteers for weekend activities, but cancellations and lack of staff support led to reduced programming.
Failure to Provide Adequate Colostomy Supplies
Penalty
Summary
The facility failed to provide appropriate colostomy care for a resident, identified as Resident 3, who required specific colostomy supplies. The resident, who had a history of Arnold Chiari Syndrome with spina bifida and hydrocephalus, among other conditions, reported that the facility ran out of the necessary wafers for her colostomy care. When the supplies were eventually ordered, the wrong items were received, leaving the resident without the required supplies for a week. This lapse in supply management was confirmed by a Licensed Practical Nurse (LPN) who stated that the facility waited until the supplies were completely depleted before placing an order, and the incorrect wafers were ordered, resulting in a delay in care. The Director of Nursing (DON) acknowledged the issue, stating that there was a lack of clarity on how often supplies were ordered and tracked. The DON mentioned that the facility had previously borrowed supplies from neighboring facilities when they ran out and noted that the wafers were back-ordered due to supply chain issues. The DON also highlighted the importance of the wafers in preventing skin breakdown and irritation, which could occur if the wafers were not in place. Despite these challenges, the facility did not have a system in place to prevent running out of essential supplies, leading to a deficiency in providing care consistent with professional standards and the resident's care plan.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility was found to be deficient in posting daily nurse staffing information as required. Observations revealed that the nurse staffing information was not updated daily, with postings dated incorrectly on several occasions. Specifically, on 11/3/24, the posting was dated 11/1/24, and similar discrepancies were noted on 11/5/24 and 11/6/24. Additionally, on 11/8/24, the nurse staffing information was not readily accessible at two different times. This failure to post accurate and timely staffing information was confirmed through interviews with the Director of Nursing, the Administrator, and CNA 1, who were responsible for ensuring the postings were up to date. The Director of Nursing and the Administrator both indicated that CNAs 1 and 4 were responsible for posting the staffing sheets. CNA 1 confirmed her responsibility for filling out the daily nurse staff posting and stated that the shifts for nursing staff were from 6:00 AM to 6:00 PM and 6:00 PM to 6:00 AM. She also mentioned that the postings were located outside the business office on the wall and claimed that there had never been a day when the posting was not completed. However, the observations and interviews indicated otherwise, highlighting a lapse in the facility's compliance with the requirement to post daily nurse staffing information in a timely and accessible manner.
Inadequate Dementia Care and Lack of Non-Pharmacological Interventions
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident diagnosed with dementia, leading to a deficiency in care. The resident, who had a history of dementia, seizures, hypothyroidism, obstructive sleep apnea, depression, and violent behaviors, was not given adequate non-pharmacological interventions to manage his condition. Despite having a care plan that included non-pharmacological interventions, staff were unable to identify or implement these strategies effectively. Instead, the resident was frequently administered psychotropic medications such as Haloperidol and Hydroxyzine to manage agitation and anxiety, with no documentation of attempts to use non-pharmacological methods. Observations and interviews revealed that staff often ignored the resident's behaviors or relied solely on medication to manage them. The resident exhibited exit-seeking behavior and aggression, which were not adequately addressed through person-centered care approaches. Staff interviews indicated a lack of training and understanding of dementia care, with some staff unable to recall specific interventions beyond redirection. The facility's Director of Nursing acknowledged the need for better documentation and implementation of non-pharmacological interventions, but these were not consistently applied or recorded in the resident's care plan. The deficiency was further compounded by inadequate staff training and communication regarding dementia care. Some staff members had not received formal dementia training, and there was no system in place to ensure that care plan interventions were communicated effectively to all staff. The facility's reliance on medication without exploring or documenting alternative interventions highlights a significant gap in the care provided to the resident, ultimately failing to support his highest practicable physical, mental, and psychosocial well-being.
Deficiency in Pharmaceutical Services for Resident
Penalty
Summary
The facility failed to provide necessary pharmaceutical services for a resident, resulting in the non-administration of prescribed medications. The resident, who had a history of Parkinson's disease, chronic obstructive pulmonary disease, type 2 diabetes mellitus, and anemia, did not receive Darbepoetin Alfa injections as ordered by the physician. The medication was not administered on multiple occasions due to issues such as waiting for pharmacy delivery and prior authorization from insurance. Additionally, there were no progress notes explaining the lack of administration on certain dates. The resident also did not receive Valbenazine Tosylate capsules for Tardive dyskinesia on several occasions. The reasons for non-administration included waiting for insurance approval, the medication being out of stock, and awaiting delivery from the pharmacy. Despite these issues, there was a lack of documentation and follow-up to ensure the resident received the necessary medications. Interviews with facility staff, including an LPN and the Director of Nursing (DON), revealed a lack of clarity and communication regarding the medication procurement process. The LPN was unsure if the Darbepoetin Alfa was in the facility's fridge or required preauthorization. The DON was unable to provide a clear explanation for the unavailability of the medications and did not follow up with additional information. This lack of coordination and communication contributed to the deficiency in pharmaceutical services for the resident.
Latest citations in Utah
Surveyors found that the facility did not ensure residents or their representatives were informed of and able to participate in decisions about psychotropic medications. Several residents with conditions such as dementia, early-onset Alzheimer’s disease, major depressive disorder, psychotic disorder, and Parkinson’s disease were started on drugs including haloperidol, donepezil, buspirone, quetiapine, zaleplon, and sertraline without documentation that risks, benefits, or alternative treatments were discussed in advance. The DON reported that staff notify families when medications are started or changed but do not review risks and benefits, offer alternative options, or obtain signed consent, resulting in no evidence of informed decision-making for these psychotropic treatments.
Surveyors determined that the facility failed to consistently manage psychotropic medications for three residents. Two residents with dementia and psychiatric conditions had only one documented psychotropic medication review and gradual dose reduction (GDR) attempt, completed in January, with no evidence of quarterly reviews or additional GDR efforts. Another resident with hemiplegia, psychotic disorder, dementia, and major depressive disorder had a PRN IM haloperidol order written without an end date, which remained active and was administered on multiple occasions beyond 14 days, and the DON confirmed there was no physician documentation justifying the extended PRN antipsychotic order.
The facility failed to ensure that alleged abuse and serious injuries were reported to the State Survey Agency as required, instead either reporting only to a state patient safety system or not reporting at all. One resident with severe cognitive impairment sustained bilateral femur fractures after a fall, another cognitively impaired resident with Parkinson’s disease was later found to have a femur fracture after being discovered on the floor, and a third cognitively impaired resident required ORIF surgery for fractures following a fall; none of these incidents were reported through the State Survey Agency’s incident reporting website, per the ADM. In addition, an allegation that a resident with dementia and sensory impairments may have been molested was documented in the abuse binder but not in the medical record, and the ADM did not report the allegation to agencies or law enforcement after deeming it not credible, despite interviewing the resident and family. These actions and omissions resulted in multiple unreported events that met criteria for immediate reporting of alleged abuse and injuries of unknown source.
The facility failed to investigate multiple major injuries and an allegation of sexual abuse involving three residents with severe cognitive impairment and significant medical conditions. One resident, dependent for transfers, was found on the floor after attempting to get out of bed and was later found to have bilateral femur fractures. Another resident with Parkinson’s disease was found on the floor after a wheelchair alarm sounded and was later diagnosed with a femur fracture following complaints of leg pain. A third resident, described as very independent, triggered a bed alarm and was found kneeling by a recliner, later requiring ORIF for fractures of the right 4th and 5th metacarpals. In each case, the ADM acknowledged awareness of the fractures, stated there was no belief of neglect or abuse, and confirmed that no investigation into the cause of the injuries or the alleged abuse was initiated or documented.
Surveyors found that the facility failed to ensure monthly pharmacist drug regimen reviews were completed and documented for several residents with conditions such as Parkinson’s disease, dementia, and Alzheimer’s disease, with no pharmacist notes present for at least two consecutive months. Additionally, a pharmacist’s recommendation to add a low-dose daytime antipsychotic for a resident with dementia, psychotic disorder, and behavioral symptoms was not communicated to the physician or implemented for several months, despite documented behavioral concerns. An LPN reported not relaying the pharmacist’s recommendation because PRN Haldol had not been needed at that time, and the DON confirmed that the pharmacist reviews for the missing months were not done and that she did not have time to monitor follow-through on such recommendations.
Surveyors identified a failure to properly label medications when two open insulin pens were found in a medication refrigerator bin marked only with a resident’s first name, with no labels directly on the pens. During an observation, an RN confirmed the pens belonged to a resident and acknowledged that pens are supposed to be labeled with the resident’s name but could not explain why these were not labeled. In a subsequent interview, the DON confirmed the pens had been unlabeled and stated they should have been labeled in accordance with professional standards.
The facility failed to sustain effective QAPI processes related to pharmacist medication regimen reviews, resulting in repeated noncompliance with F756. Surveyors found that medical records for four residents lacked documentation showing that a pharmacist had reviewed medications, identified potential irregularities, or made recommendations to attending physicians, an issue previously cited. The DON reported she did not have time to maintain this documentation, and the Administrator acknowledged there was no formal performance improvement project in place, though some plans were noted in QAPI minutes, and no supporting documents were produced to demonstrate ongoing compliance.
Staff failed to follow infection control practices during medication administration and did not maintain organized infection surveillance documentation. An LPN was observed handling an oral medication with bare hands before administering it to a resident, contrary to the DON’s stated expectation that pills be dispensed directly into medication cups without hand contact and that any contaminated dose be discarded. Additionally, the DON, who also served as the Infection Preventionist, reported that several residents had influenza during a past holiday season but had no list of affected residents or rooms, and the requested infection control surveillance logs and a formal tracking system were not available.
The facility lacked an antibiotic stewardship program, with no protocols to ensure appropriate indication, dose, and duration of antibiotic prescriptions and no system to monitor antibiotic use or resistance patterns. When surveyors requested Infection Control Surveillance Logs, including antibiotic tracking information, the logs were not available. In an interview, the DON, who also functioned as the Infection Preventionist, acknowledged that she did not track resident antibiotic utilization, clinical indications, or treatment durations.
A resident with multiple chronic conditions, including DM, HTN, anxiety, major depressive disorder, and PTSD, reported that a CNA on night shift failed to hold open a smoking-area door, leading the resident to grab the door and sustain a finger cut that bled. The resident completed a grievance with the RA, who documented that the CNA swung the door open and walked away and that no abuse or neglect allegation was initially identified. However, the grievance lacked documentation of investigative steps, a summary of findings, a conclusion on whether the grievance was confirmed, and any decision date or required signatures, and leadership later reported they had not been informed of the incident, demonstrating the grievance was not promptly resolved or fully tracked through conclusion.
Failure to Inform Residents of Risks, Benefits, and Alternatives Before Starting Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents, or their representatives, were informed of and allowed to participate in decisions regarding psychotropic medication treatment, including being informed in advance of the risks, benefits, and treatment alternatives. For four sampled residents, medical record review showed new orders for multiple psychotropic medications without any documentation that the resident or representative had been informed of these elements prior to initiation. Resident 8, with diagnoses including hemiplegia and hemiparesis following cerebral infarction, psychotic disorder with delusions, dementia, and major depressive disorder, was started on haloperidol lactate, donepezil, buspirone, quetiapine, and sertraline on various dates, with no documentation of informed discussion or consent. Resident 4, with unspecified dementia and anxiety disorder, was started on zaleplon, quetiapine, and buspirone, again with no record that risks, benefits, or alternatives were discussed in advance. Resident 54, diagnosed with early-onset Alzheimer’s disease and dementia in other diseases classified elsewhere, was started on sertraline and quetiapine, and Resident 6, diagnosed with Parkinson’s disease without dyskinesia, was started on buspirone, quetiapine (Seroquel), and sertraline, with no documentation that either resident or their representative had been informed of the risks and benefits or treatment options before these psychotropic medications were initiated. During an interview, the DON stated that the facility notifies families when medications are started or doses are changed but does not discuss risks and benefits, provide alternative options, or obtain signed consent. This practice contributed to the lack of documented evidence that residents or their representatives were fully informed and able to participate in treatment decisions regarding psychotropic medications.
Failure to Perform Regular GDR and Limit PRN Antipsychotic Orders
Penalty
Summary
Surveyors found that the facility did not ensure appropriate management of psychotropic medications for three sampled residents. For two residents with dementia and related psychiatric diagnoses, the medical records from late April 2026 showed only one documented psychotropic medication review and gradual dose reduction (GDR) attempt, completed in January 2026. There was no documentation of any GDR attempts or psychotropic reviews prior to January 2026, despite the DON stating that such reviews and GDRs should be completed quarterly. The records for these residents did not contain additional GDR attempts beyond the January 2026 review. For a third resident with hemiplegia following cerebral infarction, psychotic disorder with delusions, dementia, and major depressive disorder, a physician’s order dated February 8, 2026, prescribed PRN intramuscular haloperidol lactate every 12 hours for delusions, hallucinations, paranoia, and agitation, without an end date. Review of the MARs for February through April 2026 showed that this PRN antipsychotic was administered on two occasions, and no end date was documented on the MAR. In an interview, the DON acknowledged that the PRN haloperidol order extended beyond 14 days and that the physician had not documented a reason for continuing the order beyond that period.
Failure to Report Alleged Abuse and Serious Injuries to State Survey Agency
Penalty
Summary
The deficiency involves the facility’s failure to ensure that all alleged violations of abuse, including injuries of unknown source and incidents involving major injuries, were reported immediately to the State Survey Agency and other officials as required by state law. For four sampled residents, the Administrator acknowledged that incidents were reported only to the state’s patient safety website and not to the State Survey Agency’s incident reporting website. This omission meant that the State Survey Agency did not receive timely notice of serious events, including an allegation of sexual abuse and multiple incidents resulting in significant fractures and surgery. For one resident with severely impaired cognition and diagnoses including hemiplegia and hemiparesis, nursing notes documented that the resident was found on the floor after attempting to get out of bed, was sent to the ER, and returned with immobilizing braces on both legs due to bilateral femur fractures. The resident’s bones were not strong enough for surgery, and he was placed on comfort care. Despite the seriousness of the injuries and the requirement to treat such events as potential abuse or neglect until ruled out, the Administrator stated that this incident was reported only to the state’s patient safety website and not to the State Survey Agency’s incident reporting system. Another resident with Parkinson’s disease and severely impaired cognition was found on the floor after a wheelchair alarm sounded, initially with no visible injury and able to bear weight. A few days later, staff documented complaints of left leg pain, tenderness, and wincing with movement, leading to an order for x‑rays and transfer for imaging. X‑ray results revealed a femur fracture, and surgery was not pursued. The Administrator reported this incident to the state’s patient safety website but not to the State Survey Agency’s incident reporting website. A third resident with severe cognitive impairment experienced a fall with complaints of pain in the left knee, left elbow, and fingers, and later underwent ORIF surgery for fractures of the right fourth and fifth metacarpals; this incident also was not reported to the State Survey Agency’s incident reporting system, according to the Administrator. For another resident with dementia, adjustment disorder with anxiety, hearing and visual loss, and age‑related debility, a document in the facility’s abuse binder described a possible molestation allegation originating from a phone call by the resident’s nephew. The nephew reported that his mother, the resident’s sister and then‑POA, was emotionally unstable and had stated she felt the resident had reported being molested. The Administrator documented that the nephew did not believe the allegation was credible, that the sister had dementia and emotional issues, and that the Administrator considered the report “not a viable allegation.” The Administrator noted that he interviewed the resident, who denied being touched, and that the sister could not provide more details beyond stating that a man had groped the resident’s breast. The Administrator concluded the allegation was not credible and did not report it to any agencies or law enforcement. The incident was not documented in the resident’s medical record, and the Administrator confirmed in interview that he did not report this sexual abuse allegation to the State Survey Agency’s incident reporting website. Across these four residents, the common deficiency was the facility’s failure to treat serious injuries and a sexual abuse allegation as reportable events to the State Survey Agency, as required. Instead, the Administrator limited reporting to the state’s patient safety website or chose not to report at all when he personally judged an allegation as not credible. This pattern of inaction regarding mandated reporting requirements formed the basis of the cited deficiency.
Failure to Investigate Major Injuries and Alleged Abuse
Penalty
Summary
The deficiency involves the facility’s failure to initiate and document investigations into multiple major injuries and an allegation of sexual abuse, as required for all alleged violations involving abuse and injuries of unknown source. For one resident with hemiplegia, hemiparesis, and severely impaired cognition (BIMS score of 6), nursing notes documented that his roommate activated the call bell after the resident fell while attempting to get out of bed by himself. He was found on the floor between his bed and the window, reported knee pain with a popping sensation, and was sent to the ER. On return from the hospital, he was noted to have bilateral femur fractures, immobilizing braces on both legs, and was placed on comfort care due to bones not being strong enough for surgery. The Administrator acknowledged awareness of the bilateral femur fractures, stated he did not believe neglect or abuse caused the injury, and confirmed he did not investigate the cause of this major injury. Another resident with Parkinson’s disease and a BIMS score of 0 (rarely/never understood) was documented in an incident note as sitting in a wheelchair in the dining room when his alarm sounded; he was found supine on the floor, denied hitting his head or injury, and was assisted back into the chair with no signs of injury noted. Several days later, nursing notes recorded that CNAs reported the resident complaining of left leg pain when getting him out of bed. On assessment, he had tenderness and wincing with movement of the left leg but was able to bear weight. The MD was notified, an x-ray was ordered, and the resident was transported for imaging, which revealed a femur fracture for which surgery was not pursued. The Administrator stated he was aware of the femur fracture, did not feel neglect or abuse caused the major injury, and did not investigate the cause of the injury. A third resident with COPD, scoliosis, and severely impaired cognition (BIMS score of 7) had an incident note documenting that her bed alarm sounded and staff found her in a kneeling position leaning into her recliner after she attempted to get up from bed to go to the bathroom, stating her walker “didn't go where she was going.” She complained of left knee, left elbow, and right pinky pain, with no visible injury except an abrasion on the right ring finger. A later nursing note documented that she underwent ORIF of fractures of the right fourth and fifth metacarpals at a hospital and returned from surgery the same day. The Administrator reported being aware of the fractures, described the resident as very independent and wanting to wander the facility, stated he did not feel neglect or abuse caused the major injury, and confirmed he did not investigate the cause of the injury. Across these three residents, the facility did not initiate or document investigations into the causes of the major injuries or the related allegation of sexual abuse, nor did it determine causation or responsible parties as required.
Failure to Complete Monthly Pharmacist Reviews and Timely Act on Medication Recommendations
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a licensed pharmacist conducted and documented monthly drug regimen reviews for multiple residents and to ensure that identified medication irregularities were acted upon by the attending physician. For four sampled residents, the medical records lacked monthly pharmacist medication regimen review notes for at least two consecutive months. Specifically, residents with diagnoses including Parkinson’s disease, unspecified dementia, Alzheimer’s disease with early onset, and dementia related to other diseases had no documented pharmacist review notes for March and April 2026. The DON confirmed that the pharmacist had not completed pharmacy reviews for those months and that the notes, which should have been uploaded into each resident’s electronic medical record, were absent. In addition, the facility failed to act promptly on a pharmacist’s recommendation for a resident receiving psychotropic medications. One resident with hemiplegia following cerebral infarction, psychotic disorder with delusions, dementia, and major depressive disorder had a pharmacist recommendation in November 2025 to add a low-dose daytime Seroquel due to behavioral issues and afternoon anxiety. Nursing documentation showed that the pharmacist discussed the resident’s response to Seroquel versus Abilify and suggested a low-dose daytime Seroquel, but this recommendation was not communicated to the physician at that time. The LPN later stated she did not speak to the physician about the pharmacist’s recommendation because the resident had not needed PRN Haldol around that time. The physician did not write the order for daytime Seroquel until early February 2026, after a nurse raised concerns about the resident’s behaviors and reminded the physician of the prior pharmacist recommendation. The DON acknowledged that the pharmacist’s November 2025 recommendation was not completed until February 2026 and stated she did not have time to stay on top of such issues.
Unlabeled Insulin Pens Found in Medication Refrigerator
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled in accordance with accepted professional principles when two open insulin pens belonging to resident 56 were found without the resident’s name on them. During an observation of the south medication refrigerator on 4/29/26 at 10:50 AM, surveyors noted a plastic bin labeled only with resident 56’s first name, containing two loose, open insulin pens that had no resident identification labels affixed directly to the pens. In a concurrent interview, RN 1 confirmed that the two insulin pens belonged to resident 56 and stated that staff always put residents’ names on insulin pens, but was unsure why these pens had not been labeled. Later that day at 2:17 PM, the DON stated in an interview that the two insulin pens in question had been unlabeled and acknowledged that the insulin pens should have been labeled with the resident’s information.
Failure to Sustain QAPI Actions and Documentation for Pharmacist Medication Reviews
Penalty
Summary
The deficiency involves the facility’s failure, as part of its performance improvement activities, to take actions aimed at performance improvement, measure the success of those actions, and track performance to ensure that improvements were realized and sustained, specifically related to F756. Record review and interviews showed that the facility did not maintain documentation in the medical records to demonstrate that a pharmacist reviewed residents’ medications, identified potential irregularities, or provided recommendations to the attending physician for four sampled residents, despite this same issue having been cited in the previous health survey in 2024. During an interview, the DON stated she did not have time to maintain this required documentation. In a separate interview, the Administrator stated he did not have a performance improvement project, though he had QAPI minutes that captured some improvement plans, and he believed the facility had achieved compliance with F756, which had been cited previously, but no documents demonstrating compliance were provided when requested by surveyors.
Failure in Medication Handling and Infection Surveillance Documentation
Penalty
Summary
The facility failed to ensure a safe and sanitary environment during medication administration and infection surveillance. During an observation of medication pass for resident 23, an LPN was seen popping an oral pill directly from a blister pack into her bare hand and then placing it into a medication cup, after which the medication was administered to the resident. In a subsequent interview, the DON stated that staff were expected to pop pills directly into medication cups and never touch medications with bare hands, and that any medication contacting a staff member’s bare hand was to be discarded and replaced, indicating that the observed practice did not follow facility expectations. The facility also failed to maintain infection control surveillance documentation and an organized tracking system for infections. When Infection Control Surveillance Logs were requested, the DON reported that several residents had contracted influenza during the 2025 holiday season, attributed to an increased number of visitors, and that symptomatic residents were kept in their rooms. However, the DON stated she did not have a list of affected residents or rooms, and the requested surveillance logs were unavailable for review. In a later interview, the DON, who also served as the facility’s Infection Preventionist, confirmed that the facility lacked an infection control surveillance manual or organized system for tracking infections.
Failure to Implement and Monitor an Antibiotic Stewardship Program
Penalty
Summary
The facility failed to develop and implement an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use. There was no established facility-wide system to ensure appropriate indication, dose, and duration for antibiotic prescriptions, and no process for monitoring antibiotic usage or resistance data. On 4/29/26 at 8:20 AM, when surveyors requested the facility’s Infection Control Surveillance Logs, including any prescribed antibiotic tracking information, these logs were unavailable. On 4/30/26 at 12:28 PM, during an interview, the DON, who also served as the facility’s designated Infection Preventionist, stated that she did not track resident antibiotic utilization, including the specific clinical indications for the medications or the prescribed durations of treatment. No specific residents, their medical histories, or clinical conditions at the time of the deficiency were described in the report.
Failure to Promptly Resolve and Document Resident Grievance Regarding Door Injury
Penalty
Summary
The deficiency involves the facility’s failure to promptly resolve and properly document a resident grievance in accordance with its grievance policy. A resident with type II DM, HTN, anxiety disorder, major depressive disorder, and PTSD reported that a CNA on night shift did not hold open the smoking door for her and another resident, and that when she went to grab the door, it slammed on or closed against her finger, causing a cut to bleed. The resident stated she reported this to the Resident Advocate (RA) and completed a grievance form, and that nursing staff applied Neosporin and a bandage to the finger. The resident did not know the CNA’s name but identified that the CNA worked nights and stated that no one should be treating residents that way. The grievance form dated 4/10/26 documented the concern that the CNA on night shift did not hold the smoking door open and instead swung the door open and walked away, and that upon initial interview no allegation of abuse or neglect was identified. However, the grievance form contained no documentation of investigative steps taken, no summary of findings or conclusion, and no indication whether the grievance was confirmed or not. The form also lacked a written decision date, resident signature, grievance officer signature, and Administrator signature. The RA reported that the resident told her the door incident caused a small cut to reopen and that the CNA seemed in a hurry, but did not state that the CNA acted intentionally or purposefully toward her. The Administrator and DON later stated they had not been informed of the incident, and the Regional Nurse Consultant noted that nothing was filled out on the back of the grievance form, indicating it remained incomplete despite having been initiated several days earlier.
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