Inspection Reports for
Advanced Health Care of St George
1934 East Riverside Drive, Saint George, UT, 84790
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
4.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
41% better than Utah average
Utah average: 7.9 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Routine
Deficiencies: 4
Date: May 15, 2025
Visit Reason
The inspection was conducted to assess compliance with medication administration, drug labeling, laboratory testing, infection control, and related regulatory requirements at the nursing home.
Findings
The facility was found to have multiple deficiencies including a significant medication error involving anticoagulant dosing, unlabeled insulin pens in medication carts, laboratory tests drawn without physician orders, and failure to follow proper infection prevention practices during medication administration.
Deficiencies (4)
F 0760: The facility did not ensure residents were free from significant medication errors. One resident received two doses of warfarin on the same day contrary to physician orders.
F 0761: Drugs and biologicals were not labeled according to accepted professional principles. Five opened insulin injector pens for three residents were not labeled with open or discard dates.
F 0773: The facility did not obtain laboratory tests only when ordered by authorized practitioners. One resident had a BMP and CBC drawn without a physician's order due to a labeling error.
F 0880: The facility failed to implement an infection prevention program. A nurse was observed not performing hand hygiene and touching medication with bare fingers during medication administration.
Report Facts
Residents sampled: 22
Residents affected by medication error: 1
Insulin pens unlabeled: 5
Residents affected by unlabeled insulin pens: 3
Residents affected by lab order error: 1
Residents affected by infection control deficiency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding medication error, insulin labeling, and lab order deficiencies | |
| Licensed Practical Nurse 1 | Observed with unlabeled insulin pens in medication cart | |
| Licensed Practical Nurse 2 | Observed not performing hand hygiene and touching medication with bare fingers |
Inspection Report
Routine
Deficiencies: 1
Date: May 15, 2025
Visit Reason
The inspection was an unannounced routine visit to ensure compliance with nursing care facility regulations.
Findings
The facility was generally compliant with most regulations, with one rule noncompliance noted. The inspection covered a wide range of regulatory requirements including staffing, resident rights, care plans, medication management, and safety protocols.
Deficiencies (1)
R432-150-4(5)(a-e) The licensee did not comply with requirements for respite services including behavior management, medication administration, and emergency notification policies.
Report Facts
Number of rule noncompliances: 1
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Jun 29, 2023
Visit Reason
The inspection was conducted to investigate complaints regarding medication management, treatment and care according to orders, pharmaceutical services, and medication errors at Advanced Health Care of St. George.
Complaint Details
The complaint investigation substantiated that the facility failed to notify physicians of significant changes in residents' conditions, delayed medication administration, did not follow bowel protocols, had medication supply issues, and administered contraindicated medications concurrently.
Findings
The facility failed to notify the physician of significant changes in a resident's condition, delayed insulin administration, did not follow bowel protocol orders, had medication unavailability issues, and administered contraindicated medications concurrently, resulting in minimal harm or potential for harm to residents.
Deficiencies (4)
F 0580: The facility did not notify the physician of elevated blood glucose levels for a resident awaiting insulin supply, violating notification requirements for significant changes in condition.
F 0684: A resident with elevated blood glucose did not receive insulin for 4 days after admission and experienced constipation without proper bowel protocol administration.
F 0755: The facility did not provide routine and emergency drugs to a resident due to medication unavailability caused by pharmacy fax transmission issues.
F 0760: A resident was administered clonazepam and hydrocodone concurrently despite orders to avoid co-administration due to respiratory suppression risk.
Report Facts
Residents sampled: 23
Blood glucose readings: 306
Blood glucose readings: 335
Blood glucose readings: 329
Blood glucose readings: 377
Blood glucose readings: 221
Medication doses not administered: 6
Medication administration times: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) 1 | Interviewed regarding medication orders and insulin supply for resident 77 | |
| Director of Nursing (DON) | Interviewed multiple times regarding medication notification, bowel protocol, pharmacy issues, and medication administration practices | |
| Registered Nurse (RN) 1 | Interviewed and observed administering bowel protocol medications to resident 77 | |
| Licensed Practical Nurse (LPN) 2 | Interviewed regarding medication refill responsibilities and pharmacy communication | |
| Certified Nurse Assistant (CNA) 1 | Observed communicating about resident 77's bowel movement status and enema requests |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Jun 29, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding failure to notify the physician and resident representative of significant changes in a resident's condition, specifically related to elevated blood glucose levels and medication administration.
Complaint Details
The complaint investigation was substantiated based on findings that the facility failed to notify the physician and resident representative of significant changes in resident 77's condition and failed to provide timely medication and care.
Findings
The facility failed to notify the physician and resident representative of significant changes in resident 77's physical and psychosocial status, specifically elevated blood glucose levels. Additionally, the facility did not ensure timely administration of insulin and proper bowel care protocols, and medications were sometimes unavailable due to pharmacy delays.
Deficiencies (5)
F580: The facility did not promptly notify the physician or resident representative of significant changes in resident 77's condition, including elevated blood glucose levels and delayed insulin administration.
F684: The facility failed to provide treatment and care in accordance with professional standards, as resident 77 did not receive insulin for 4 days and lacked bowel protocol orders, resulting in constipation.
F755: The facility did not provide routine and emergency drugs timely due to pharmacy delays, affecting resident 15's medication administration.
F760: The facility failed to ensure residents were free of significant medication errors, as resident 181 was given pain medication and muscle relaxers simultaneously contrary to orders.
K321: Hazardous areas were not properly enclosed or separated by fire and smoke barriers in accordance with NFPA 101, with deficiencies in 2 of 5 smoke compartments.
Report Facts
Sampled residents: 23
Days insulin not administered: 4
Blood glucose levels: 377
Medication administration errors: 1
Smoke compartments deficient: 2
Smoke compartments total: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nicole Kololli | Plan of Correction Accepter | Accepted the Plan of Correction on 08/15/2023 |
| Director of Nursing | Named in interviews regarding medication delays and care issues for resident 77 | |
| Licensed Practical Nurse 1 | LPN | Interviewed about medication orders and pharmacy communication |
| Licensed Practical Nurse 2 | LPN | Interviewed about medication refills and pharmacy communication |
| Registered Nurse 1 | RN | Interviewed about bowel protocol and medication administration |
Inspection Report
Deficiencies: 0
Date: Sep 29, 2021
Visit Reason
The document is a statement of deficiencies and plan of correction for Advanced Health Care of St. George, related to a regulatory survey completed on 09/29/2021.
Findings
No health deficiencies were found during the inspection.
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