Deficiencies (last 3 years)
Deficiencies (over 3 years)
9.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
23% worse than Utah average
Utah average: 7.9 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Complaint Investigation
Deficiencies: 2
Mar 6, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding an allegation of sexual abuse reported by Resident #190 on 10/29/2024.
Findings
The facility failed to develop and implement written policies and procedures for thorough investigations of abuse allegations. The investigation into the sexual abuse allegation involving Resident #190 was incomplete, lacking documented interviews and thorough evidence collection. The facility concluded the allegation could not be verified due to insufficient investigation.
Complaint Details
The complaint investigation was triggered by a report of sexual abuse on 10/29/2024 by Resident #190, who stated a male staff member touched them inappropriately. The facility filed a two-hour state reportable notification on 10/31/2024 and a five-day follow-up report on 11/06/2024. The facility's investigation lacked thorough documentation and interviews, and the allegation was ultimately not substantiated.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to develop written procedures for investigating allegations of abuse, misappropriation, and exploitation, including identification of staff responsible, handling evidence, interviewing involved persons, and thorough documentation. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to have evidence that all allegations of abuse were thoroughly investigated for Resident #190. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 1
Dates related to investigation: Oct 29, 2024
Dates related to investigation: Oct 31, 2024
Dates related to investigation: Nov 6, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Interviewed staff and resident, summarized investigation, stated facility lacked abuse investigation policy | |
| Director of Nursing | DON | Filled out investigation form, conducted interviews, acknowledged incomplete documentation |
| Medical Director | Notified Administrator of Resident #190's report of being grabbed |
Inspection Report
Complaint Investigation
Deficiencies: 3
Mar 6, 2025
Visit Reason
The inspection was conducted following a complaint alleging sexual abuse by a staff member and to investigate medication error rates and infection control practices.
Findings
The facility failed to develop adequate policies and procedures for investigating abuse allegations, resulting in incomplete investigations. Medication error rates exceeded 5%, with 3 errors in 30 opportunities (10%). The facility also failed to ensure all staff were fit tested for N95 respirators, lacking a policy and not conducting fit testing for over two years.
Complaint Details
The complaint involved an allegation of sexual abuse reported by Resident #190 on 10/29/2024. The facility's investigation was incomplete and lacked thorough documentation. The facility concluded the allegation could not be verified due to insufficient investigation.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to develop written procedures for investigating allegations of abuse, misappropriation, and exploitation, including thorough investigation steps and documentation. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain a medication error rate of less than 5%, with 3 errors out of 30 opportunities (10%). | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide and implement an infection prevention and control program ensuring all staff were fit tested for N95 respirators. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Medication error rate: 10
Residents affected by infection control deficiency: 36
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Administered incorrect medication dosages during medication pass observation. |
| Administrator | Interviewed regarding abuse investigation and facility policies; stated lack of abuse investigation policy and incomplete documentation. | |
| Director of Nursing | DON | Interviewed regarding abuse investigation and medication administration policies; acknowledged lack of abuse investigation policy and fit testing for N95 respirators. |
| Infection Preventionist | IP | Interviewed regarding infection control and N95 fit testing; stated no fit testing had been done for over two years. |
Inspection Report
Complaint Investigation
Deficiencies: 4
Oct 19, 2023
Visit Reason
The inspection was conducted to investigate complaints related to timely reporting of suspected abuse, neglect, and theft, appropriate response to alleged violations, ensuring resident safety from accident hazards, and provision of pharmaceutical services.
Findings
The facility failed to timely report suspected abuse and neglect incidents to the State Survey Agency, failed to ensure adequate supervision and accident prevention leading to delayed diagnosis of fractures in a resident, and did not provide routine and emergency medications as ordered due to pharmacy supply issues.
Complaint Details
The complaint investigation revealed multiple incidents where the facility failed to timely report abuse allegations and investigation results to the State Survey Agency, including incidents involving residents 18, 24, 27, and 3. Additionally, the facility failed to provide adequate supervision and timely medical follow-up for a resident (139) who suffered fractures after a fall. Medication administration issues were also identified for resident 140 due to unavailable medications from the pharmacy.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 3
Level of Harm - Actual harm: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Level of Harm - Minimal harm or potential for actual harm |
| Respond appropriately to all alleged violations, including reporting investigation results to the State Survey Agency within required timeframes. | Level of Harm - Minimal harm or potential for actual harm |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Level of Harm - Actual harm |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents sampled: 33
Abuse allegations not timely reported: 3
Follow-up investigation report late submission: 6
Resident 139 BIMS score: 2
Pain scores for resident 139: 10
Days delay for X-ray after fall: 3
Medication doses: 7
Date of survey completion: Oct 19, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN 4 | Registered Nurse | Named in relation to delayed follow-up on resident 139's leg pain and injury |
| CNA 1 | Certified Nursing Assistant | Named in relation to resident 139's transfer incident and reporting |
| CNA 2 | Certified Nursing Assistant | Named in relation to resident 139's transfer incident and reporting |
| RN 1 | Registered Nurse | Interviewed regarding X-ray procedures and timelines |
| RNC 1 | Regional Nurse Consultant | Interviewed regarding investigation report and medication issues |
| RNC 2 | Regional Nurse Consultant | Interviewed regarding investigation report and medication issues |
| ADM | Administrator | Named as abuse coordinator responsible for reporting abuse allegations |
| RA | Resident Advocate | Named in relation to abuse investigation procedures |
| Director of Rehabilitation | Named in relation to resident 139's transfer and use of sit to stand device |
Inspection Report
Complaint Investigation
Deficiencies: 8
Oct 19, 2023
Visit Reason
The inspection was conducted to investigate complaints related to timely reporting of suspected abuse, neglect, and medication administration errors, as well as other regulatory compliance issues at the facility.
Findings
The facility failed to timely report suspected abuse and neglect incidents to the State Survey Agency, did not ensure adequate supervision to prevent accidents resulting in harm, did not provide medications as ordered due to pharmacy supply issues, had medication administration errors exceeding 5%, failed to properly label drugs and biologicals, did not maintain proper infection prevention and control practices, and did not ensure residents received or refused pneumococcal vaccinations as required.
Complaint Details
The complaint investigation revealed multiple incidents where the facility failed to timely report abuse and neglect to the State Survey Agency, including late submissions of entity reports and follow-up investigations for residents 18, 24, 27, and 3. The facility also failed to provide adequate supervision to prevent accidents, resulting in actual harm to resident 139 who suffered fractures after a fall. Medication administration errors and pharmaceutical service deficiencies were identified, including medication not administered due to pharmacy supply issues and crushing of enteric coated medications. Infection control lapses were observed, including improper handling of medications and glucometer use. Additionally, the facility did not ensure pneumococcal vaccination was administered to resident 3 despite consent.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 7
Level of Harm - Actual harm: 1
Deficiencies (8)
| Description | Severity |
|---|---|
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Level of Harm - Minimal harm or potential for actual harm |
| Respond appropriately to all alleged violations. | Level of Harm - Minimal harm or potential for actual harm |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Level of Harm - Actual harm |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Level of Harm - Minimal harm or potential for actual harm |
| Ensure medication error rates are not 5 percent or greater. | Level of Harm - Minimal harm or potential for actual harm |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Level of Harm - Minimal harm or potential for actual harm |
| Provide and implement an infection prevention and control program. | Level of Harm - Minimal harm or potential for actual harm |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Sampled residents: 33
Medication opportunities observed: 31
Medication errors observed: 2
Medication error rate: 6.45
Days late for follow-up investigation report: 1
Days delay in X-ray after fall: 3
Pain scores: Array
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN 1 | Registered Nurse | Interviewed regarding medication administration, X-ray procedures, and glucometer cleaning |
| RN 5 | Registered Nurse | Observed crushing enteric coated medication and improper medication handling |
| Resident Advocate (RA) | Interviewed regarding abuse reporting procedures and investigation | |
| Administrator (ADM) | Administrator and Abuse Coordinator | Interviewed regarding abuse reporting and investigation delays |
| Regional Nurse Consultant (RNC) 1 | Regional Nurse Consultant | Interviewed regarding medication administration, abuse reporting, and infection control |
| Regional Nurse Consultant (RNC) 2 | Regional Nurse Consultant | Interviewed regarding abuse reporting and vaccination procedures |
| CNA 1 | Certified Nursing Assistant | Provided statement regarding resident 139 transfer incident |
| Director of Rehabilitation | Interviewed regarding resident 139 transfer safety |
Inspection Report
Routine
Deficiencies: 12
Jan 13, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, care planning, treatment, dialysis services, housekeeping, facility assessment, COVID-19 testing, and medical record maintenance.
Findings
The facility was found deficient in multiple areas including failure to honor resident choice for shower scheduling, inadequate housekeeping services, incomplete and untimely resident assessments, incomplete and non-comprehensive care plans, poor communication and coordination with dialysis providers, failure to provide appropriate dialysis care, improper food storage and refrigerator maintenance, incomplete facility-wide assessment, inadequate COVID-19 testing of unvaccinated staff, and incomplete documentation of COVID-19 vaccination status for residents.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 12
Deficiencies (12)
| Description | Severity |
|---|---|
| Failure to honor resident's right to make choices about aspects of life, specifically shower scheduling for resident 33. | Level of Harm - Minimal harm or potential for actual harm |
| Inadequate housekeeping and maintenance services resulting in unsanitary resident rooms and cluttered exterior areas. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to conduct comprehensive and timely Minimum Data Set (MDS) assessments for residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to create and implement baseline care plans addressing residents' immediate needs within 48 hours of admission. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to develop and implement comprehensive person-centered care plans with measurable objectives and timeframes. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide treatment and care according to orders, resident preferences, and goals, including poor communication and coordination with dialysis centers and failure to maintain resident hygiene. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide safe and appropriate dialysis care and services consistent with professional standards, including lack of communication with dialysis providers. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to procure food from approved sources and store, prepare, distribute, and serve food in accordance with professional standards, including improper maintenance of resident refrigerators. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to conduct and document a complete facility-wide assessment to determine necessary resources for competent resident care during day-to-day operations and emergencies. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to safeguard resident-identifiable information and maintain complete and accurate medical records, including missing blood glucose documentation and incomplete COVID-19 vaccination records. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to perform COVID-19 testing on unvaccinated staff at the frequency required based on community transmission rates. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to educate residents and staff on COVID-19 vaccination, offer the vaccine to eligible individuals, and properly document vaccination status and refusals. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents sampled: 30
Staff sampled for COVID-19 testing: 5
Days overdue for MDS assessments: 39
Dialysis days per week: 3
Refrigerator temperature: 34
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Corporate Resource Nurse | Infection Preventionist | Interviewed regarding COVID-19 testing and care plan deficiencies |
| Assistant Director of Nursing | ADON | Interviewed regarding care planning, communication, and COVID-19 vaccination documentation |
| Housekeeping Manager | HKM | Interviewed regarding housekeeping observations and exterior conditions |
| Dialysis Worker 1 | Interviewed regarding dialysis communication and resident care issues | |
| Dialysis Worker 2 | Interviewed regarding dialysis communication and resident care issues | |
| Transportation Director | TD | Interviewed regarding dialysis transportation and communication |
| Director of Nursing | DON | Interviewed regarding refrigerator maintenance and facility assessment |
| Human Resources Director | HRD | Interviewed regarding phone system and communication issues |
| Registered Nurse 4 | RN 4 | Interviewed regarding phone system and resident communication |
| Certified Nursing Assistant 6 | CNA 6 | Interviewed regarding resident care and phone system |
| Dialysis Worker | DW 1 | Interviewed regarding dialysis care and communication |
| Dialysis Worker | DW 2 | Interviewed regarding dialysis care and communication |
| Same Day Surgery Worker | SDSW | Interviewed regarding coordination of surgery for resident 33 |
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