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
8
6
4
2
0
Inspection Report
Complaint Investigation
Deficiencies: 4
May 15, 2025
Visit Reason
The inspection was conducted based on a complaint investigation regarding medication errors, improper labeling of drugs and biologicals, unauthorized laboratory testing, and infection prevention and control deficiencies.
Findings
The facility was found to have multiple deficiencies including a medication error where a resident received two doses of warfarin in one day, failure to label insulin injector pens with open or discard dates, unauthorized laboratory tests performed without physician orders, and inadequate infection prevention practices such as failure to perform hand hygiene during medication administration.
Complaint Details
The complaint investigation found substantiated deficiencies related to medication errors, labeling issues, unauthorized lab testing, and infection control breaches.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Resident 109 received two doses of warfarin on 5/9/25 instead of one as ordered. | Level of Harm - Minimal harm or potential for actual harm |
| Five opened insulin injector pens for residents 104, 107, and 109 were not labeled with open or discard dates. | Level of Harm - Minimal harm or potential for actual harm |
| Resident 15 had a basic metabolic panel and complete blood count collected without a physician's order. | Level of Harm - Minimal harm or potential for actual harm |
| A nurse did not perform hand hygiene and touched medication with bare fingers while administering medications to resident 97. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents sampled: 22
Medication doses given in error: 2
Insulin injector pens unlabeled: 5
Lab tests collected without order: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding medication error, insulin labeling, and lab order issues | |
| Licensed Practical Nurse 1 | Observed with unlabeled insulin injector pens | |
| Licensed Practical Nurse 2 | Observed not performing hand hygiene and touching medication with bare fingers |
Inspection Report
Routine
Deficiencies: 1
May 12, 2025
Visit Reason
The inspection was an unannounced routine visit conducted to ensure compliance with nursing care facility regulations.
Findings
The facility was found to be largely compliant with most regulatory requirements, with only one rule noncompliance noted during the inspection.
Deficiencies (1)
| Description |
|---|
| One rule noncompliance was identified during the inspection. |
Report Facts
Number of rule noncompliances: 1
Inspection Report
Complaint Investigation
Deficiencies: 4
Jun 29, 2023
Visit Reason
The inspection was conducted based on complaints regarding medication administration, treatment and care according to orders, pharmaceutical services, and medication errors at the facility.
Findings
The facility failed to notify the physician of significant changes in a resident's condition, delayed insulin administration for a diabetic resident, did not follow bowel protocol orders, failed to provide medications due to unavailability, and administered conflicting medications to a resident, resulting in minimal harm or potential for harm to a few residents.
Complaint Details
The complaint investigation focused on medication administration errors, failure to notify physicians of significant changes, failure to provide medications due to unavailability, and medication errors involving contraindicated drug combinations.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to notify physician of significant change in resident's condition related to elevated blood sugar levels. | Level of Harm - Minimal harm or potential for actual harm |
| Resident with elevated blood glucose levels did not receive insulin injection for 4 days after admission and bowel protocol orders were not followed. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide routine and emergency drugs due to medication unavailability. | Level of Harm - Minimal harm or potential for actual harm |
| Resident was given an opioid in conjunction with a medication ordered not to be administered with opioids, risking respiratory suppression. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Blood Glucose readings: 377
Days without insulin: 4
Days without bowel movement: 6
Medication doses not administered: 5
Medication administration times: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse 1 | LPN | Interviewed regarding medication orders and insulin availability for resident 77 |
| Director of Nursing | DON | Interviewed multiple times regarding medication administration, bowel protocol, physician notification, and medication order issues |
| Registered Nurse 1 | RN | Interviewed and observed administering bowel protocol medications to resident 77 |
| Licensed Practical Nurse 2 | LPN | Interviewed regarding medication refill responsibilities and pharmacy communication |
| Certified Nurse Assistant 1 | CNA | Observed reporting resident 77's bowel movement status and enema requests |
Inspection Report
Complaint Investigation
Deficiencies: 5
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 elevated blood glucose levels and delayed insulin administration.
Findings
The facility failed to notify the physician and resident representative about significant changes in resident 77's condition, including elevated blood glucose levels and delayed insulin administration. Additionally, the facility did not ensure residents received treatment and care according to professional standards, including bowel protocol and medication administration. Another finding involved failure to provide routine and emergency drugs to resident 15 due to medication unavailability. Resident 181 was found not free of significant medication errors related to opioid administration.
Complaint Details
The complaint investigation was substantiated as the facility failed to notify the physician and resident representative of significant changes in resident 77's condition, failed to provide timely insulin and medication, and failed to ensure residents were free from significant medication errors.
Severity Breakdown
SS=D: 4
SS=E: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to notify physician and resident representative of significant change in resident's condition (elevated blood glucose levels) and delayed insulin administration for resident 77. | SS=D |
| Failure to ensure residents received treatment and care in accordance with professional standards, including bowel protocol and medication administration for resident 77. | SS=D |
| Failure to provide routine and emergency drugs to resident 15 due to medication unavailability. | SS=D |
| Failure to ensure residents are free of significant medication errors, specifically opioid administration for resident 181. | SS=D |
| Hazardous areas not properly fire and smoke separated from other sections of the facility, deficiency affected 2 of 5 smoke compartments. | SS=E |
Report Facts
Resident sample size: 23
Deficiencies cited: 5
Medication administration times: 4
Bowel protocol audit times: 4
Hazardous area compartments deficient: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nicole Kololli | Administrator | Accepted Plan of Correction |
| Director of Nursing | Named in findings related to medication errors, insulin administration, and bowel protocol | |
| Licensed Practical Nurse 1 | LPN | Interviewed regarding medication orders and insulin administration |
| Licensed Practical Nurse 2 | LPN | Interviewed regarding medication refills and pharmacy communication |
| Registered Nurse 1 | RN | Interviewed regarding bowel protocol and medication administration |
| Certified Nurse Assistant 1 | CNA | Observed and reported bowel movement status |
Inspection Report
Plan of Correction
Deficiencies: 0
Sep 29, 2021
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction related to a regulatory survey of the nursing home facility.
Findings
No health deficiencies were found during the survey.
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