Deficiencies (last 3 years)
Deficiencies (over 3 years)
6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
24% better than Utah average
Utah average: 7.9 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jan 29, 2024
Visit Reason
The inspection was conducted following complaints regarding resident safety hazards and inadequate care for urinary incontinence.
Complaint Details
The investigation was complaint-driven, focusing on resident safety hazards and inadequate urinary incontinence care. The findings substantiated that the laundry room was unsecured and that a resident did not receive appropriate bladder training services.
Findings
The facility failed to ensure the resident environment was free from accident hazards, specifically leaving the laundry room door open with hazardous chemicals accessible. Additionally, the facility did not provide appropriate treatment or services for a resident with urinary incontinence who was a likely candidate for a toileting program.
Deficiencies (2)
F 0689: The laundry room door was left open with no staff present, exposing residents to various hazardous chemicals accessible inside. The door between clean and dirty laundry was propped open contrary to posted instructions.
F 0690: The facility failed to provide appropriate care for a resident with urinary incontinence, not implementing a toileting program despite the resident being a likely candidate and cognitively capable.
Report Facts
Containers of chemicals observed: 35
Sampled residents: 37
Resident BIMS score: 15
Bowel and Bladder Evaluation score: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Housekeeping (HK) | Interviewed regarding laundry room door policy and resident access. | |
| Maintenance Director (MD) | Interviewed regarding laundry room safety and chemical access. | |
| Licensed Practical Nurse (LPN) 1 | Interviewed about bowel and bladder evaluation and resident 10's care. | |
| Director of Nursing (DON) | Interviewed about bowel and bladder assessment procedures and resident 10's candidacy for toileting program. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jan 29, 2024
Visit Reason
The inspection was conducted to investigate complaints regarding resident safety hazards and inadequate care related to urinary incontinence management.
Complaint Details
The investigation was complaint-driven, focusing on resident safety hazards and inadequate urinary incontinence care. The findings substantiated that the laundry room was unsecured and that a resident did not receive appropriate bladder training despite being a likely candidate.
Findings
The facility failed to ensure the resident environment was free from accident hazards, as the laundry room was left open with chemicals accessible to residents. Additionally, the facility did not provide appropriate treatment and services for a resident with urinary incontinence who was a likely candidate for a toileting program.
Deficiencies (2)
F 0689: The facility did not ensure the laundry room was secured, leaving chemicals accessible to residents, posing accident hazards.
F 0690: The facility failed to provide appropriate care and bladder training services to a resident with urinary incontinence who was cognitively capable and a likely candidate for a toileting program.
Report Facts
Containers of chemicals observed: 35
Sampled residents: 37
BIMS score: 15
Bowel and Bladder Evaluation score: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Housekeeping (HK) | Interviewed regarding laundry room access and safety. | |
| Maintenance Director (MD) | Interviewed regarding laundry room safety and chemical access. | |
| Licensed Practical Nurse (LPN) 1 | Interviewed about bowel and bladder evaluation and resident 10's care. | |
| Director of Nursing (DON) | Interviewed about bowel and bladder assessment and resident 10's candidacy for toileting program. |
Inspection Report
Routine
Deficiencies: 11
Date: May 4, 2022
Visit Reason
Routine inspection of City Creek Post Acute nursing home to assess compliance with regulatory requirements including resident rights, safety, abuse prevention, treatment, infection control, medication management, and COVID-19 protocols.
Findings
The facility was found deficient in multiple areas including delayed completion of POLST forms, inadequate housekeeping and maintenance of showers, failure to investigate resident abuse allegations, delayed and incomplete laboratory testing and notification, unsafe environment hazards, improper medication labeling and storage, inadequate infection control practices including PPE use and COVID-19 precautions, and incomplete COVID-19 testing and vaccination documentation for staff.
Deficiencies (11)
F 0578: Facility did not provide residents the right to choose medical treatment timely; POLST forms for 2 residents were signed 61 and 84 days after admission.
F 0584: Facility failed to maintain a safe, clean, and homelike environment; two showers on the third floor were in disrepair with rust, missing caulk, corrosion, and debris.
F 0600: Facility failed to protect residents from abuse; a resident was threatened by a roommate and no investigation was conducted.
F 0609: Facility failed to timely report suspected abuse and complete investigations; two resident-to-resident altercations were not reported within 2 hours and investigations were incomplete.
F 0684: Facility failed to provide appropriate treatment; a resident with urinary tract infection was not treated timely according to abnormal urine analysis results.
F 0689: Facility environment was not free from accident hazards; hazardous chemicals were accessible to a cognitively impaired resident and a hallway rug caused a resident to trip with a walker.
F 0761: Facility did not label all drugs and biologicals properly; insulin vials and pens lacked open dates and medication cart was left unlocked with residents nearby.
F 0770: Facility did not obtain laboratory services timely; ordered labs for a resident were delayed by 6 days and unsuccessful draws were not communicated to management.
F 0773: Facility did not promptly notify ordering practitioner of abnormal lab results; a resident's abnormal urine culture and sensitivity were not reported to the physician.
F 0880: Facility failed to implement infection prevention and control program; residents on isolation lacked appropriate signage, staff did not consistently use PPE, unvaccinated residents were not isolated properly, and visitor screening was inadequate.
F 0886: Facility did not ensure all staff were vaccinated for COVID-19 or tested as required; documentation was incomplete and unvaccinated staff were not consistently tested weekly.
Report Facts
Days delayed for POLST completion: 84
Days delayed for POLST completion: 61
Urine protein level: 300
Urine glucose level: 150
Urine red blood cells: 16
Urine white blood cells: 6
Resident blood sugar: 441
COVID-19 community transmission rate: 11.28
COVID-19 community transmission rate: 6.63
COVID-19 community transmission rate: 5.36
COVID-19 community transmission rate: 4.07
COVID-19 community transmission rate: 3.27
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 3 | Registered Nurse | Named in abuse threat documentation and interview regarding resident 89 |
| Director of Nursing | Director of Nursing | Interviewed regarding multiple deficiencies including abuse, infection control, lab results |
| Nurse Practitioner | Nurse Practitioner | Interviewed regarding resident 89 threats and lab result notifications |
| Certified Nursing Assistant 2 | CNA | Reported resident 89 threats to nurse |
| Certified Nursing Assistant 3 | CNA | Reported resident 89 threats and interviewed about abuse |
| Operations Manager | Operations Manager | Interviewed regarding abuse investigations and COVID-19 testing |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding abuse and infection control |
| Licensed Practical Nurse 1 | LPN | Interviewed regarding resident 194 fall risk and infection control |
| RN 6 | Registered Nurse | Observed and interviewed regarding insulin labeling |
| RN 2 | Registered Nurse | Observed leaving medication cart unlocked |
| Housekeeper 1 | Housekeeper | Interviewed regarding housekeeping closet access |
Inspection Report
Routine
Deficiencies: 3
Date: Nov 7, 2019
Visit Reason
Routine inspection of City Creek Post Acute nursing home to assess compliance with healthcare regulations including medication administration, physician notification, and medical record accuracy.
Findings
The facility failed to notify a resident's physician of abnormal blood glucose levels as ordered, did not provide timely medications for two residents due to ordering and pharmacy follow-up issues, and had discrepancies between narcotic administration records and medication administration records for two residents.
Deficiencies (3)
F 0580: The facility did not notify the physician for 1 of 23 residents with blood glucose levels over 400 as per physician's standing order.
F 0755: The facility failed to provide routine and emergency medications to 2 of 23 residents due to delayed ordering and pharmacy delivery.
F 0842: The facility did not maintain accurate medical records for 2 of 23 residents; narcotic administration logs and medication administration records did not match.
Report Facts
Residents sampled: 23
Blood glucose readings over 400: 16
Medication administration discrepancies: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 1 | Licensed Practical Nurse | Interviewed regarding medication administration and physician notification |
| LPN 2 | Licensed Practical Nurse | Interviewed regarding medication ordering and documentation |
| RN 1 | Registered Nurse | Interviewed regarding medication administration and documentation |
| DON | Director of Nursing | Interviewed regarding staff education and medication administration policies |
| CRN | Corporate Resource Nurse | Interviewed regarding physician notification procedures |
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