Deficiencies (last 3 years)
Deficiencies (over 3 years)
19 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
141% worse than Utah average
Utah average: 7.9 deficiencies/yearDeficiencies per year
24
18
12
6
0
Inspection Report
Complaint Investigation
Deficiencies: 8
Date: Oct 21, 2024
Visit Reason
The inspection was conducted due to allegations of sexual abuse and concerns about resident safety, medication administration, pain management, and food service safety.
Complaint Details
The complaint involved allegations of sexual abuse between residents in the memory care unit, failure to report suspected abuse timely, inadequate supervision leading to resident elopements, medication administration issues including family bringing medications, inadequate pain management for chronic mouth pain, and food service sanitation concerns. The sexual abuse allegations were investigated and found not verified, but the facility failed to protect residents adequately.
Findings
The facility failed to ensure residents were free from sexual abuse and had adequate supervision to prevent elopement. Medication administration was inconsistent, with some medications brought by family and not properly documented. Pain management was inadequate for a resident with chronic mouth pain. Food service areas were not maintained according to professional standards.
Deficiencies (8)
F 0600: The facility did not protect residents from sexual abuse by other residents, including failure to assess capacity to consent and inadequate monitoring of interactions.
F 0609: The facility failed to ensure timely reporting of suspected abuse and neglect to proper authorities for incidents involving residents with cognitive impairments.
F 0689: The facility did not provide adequate supervision to prevent elopement of residents with cognitive impairment, resulting in residents leaving the facility unsupervised.
F 0695: The facility did not ensure a resident requiring oxygen therapy had active physician orders specifying oxygen delivery system, administration times, and equipment settings.
F 0697: The facility failed to provide timely and effective pain management for a resident with chronic mouth pain, including delays in dental care and inconsistent medication availability.
F 0755: The facility did not provide routine and emergency drugs consistently, resulting in a resident experiencing pain, agitation, and depression without timely medication administration.
F 0757: The facility did not ensure a resident's drug regimen was free from unnecessary drugs, as a resident administered medications brought by family without proper documentation or physician notification.
F 0812: The facility did not store, prepare, distribute, and serve food in accordance with professional standards, with observations of soiled steam table, dusty hood vents, soiled wall behind dish machine, missing grout, and dust on a fan.
Report Facts
Residents sampled: 69
Residents affected by sexual abuse findings: 7
BIMS scores: 10
BIMS scores: 99
BIMS scores: 0
Medication doses missed: 2
Medication doses missed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 1 | Licensed Practical Nurse | Administered medications to resident 160 but failed to document refusal and family brought medications |
| DON | Director of Nursing | Interviewed regarding medication administration, resident supervision, and capacity to consent assessments |
| RN 1 | Registered Nurse | Reported family administration of medications to resident 160 |
| RN 3 | Registered Nurse | Described oxygen therapy procedures for resident 103 |
| Social Worker | Social Worker | Discussed capacity to consent assessments and resident rights |
| Medical Director | Medical Director | Interviewed about capacity to consent and medication orders |
| Dietary Manager | Dietary Manager | Interviewed about kitchen sanitation and cleaning procedures |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Oct 21, 2024
Visit Reason
The inspection was conducted due to allegations of sexual abuse and inadequate supervision of residents, including incidents of elopement and inappropriate sexual behavior among residents in the memory care unit.
Complaint Details
The complaint involved allegations of sexual abuse between residents 310 and 311, and other residents including 50, 70, 208, 209, and 409. Investigations revealed multiple incidents of inappropriate sexual behavior and abuse, some substantiated and some not verified. The facility also failed to ensure adequate supervision to prevent elopement of residents 50 and 70. The sexual abuse allegations were investigated with some findings of actual harm and failure to assess capacity to consent. The elopement incidents involved residents leaving the secured memory care unit unsupervised, resulting in potential harm.
Findings
The facility failed to ensure residents' rights to be free from abuse, neglect, and exploitation, with multiple incidents of sexual abuse between residents not properly prevented or assessed for capacity to consent. Additionally, the facility failed to provide adequate supervision to prevent elopements of cognitively impaired residents.
Deficiencies (2)
F 0600: The facility did not protect residents from all types of abuse including sexual abuse by other residents. Several residents with cognitive impairment were sexually abused by other residents without proper assessment of capacity to consent or adequate protective measures.
F 0689: The facility failed to provide adequate supervision to prevent accidents, resulting in two residents with cognitive impairment eloping from the facility, including one resident who was found outside with injuries.
Report Facts
Residents sampled: 69
Residents affected by sexual abuse: 7
BIMS score: 1
BIMS score: 0
BIMS score: 10
BIMS score: 99
BIMS score: 0
Elopement risk: 2
Inspection Report
Annual Inspection
Census: 54
Deficiencies: 24
Date: Jan 30, 2023
Visit Reason
Annual state inspection survey to assess compliance with healthcare regulations and resident care standards.
Findings
The facility was found deficient in multiple areas including resident dignity and respect, pain management, advance directives, confidentiality, housekeeping, restraint use, abuse reporting, care planning, nutrition, wound care, fall prevention, medication management, infection control, and quality assurance.
Deficiencies (24)
F 0550: Facility failed to treat 2 of 54 residents with dignity and respect, including inadequate clothing and delayed pain medication response.
F 0578: Facility failed to ensure resident's right to formulate an advance directive; one resident's code status was not documented correctly.
F 0583: Facility failed to keep residents' medical records confidential; computers and paperwork with resident information were left unattended.
F 0584: Facility failed to maintain a safe, clean, and homelike environment; dirty wheelchairs, unclean IV poles and nightstands, and disrepair of walls were observed.
F 0600: Facility failed to protect residents from neglect; 7 residents were not assisted with ADLs, had untreated pain, weight loss, falls with injuries, and wounds.
F 0604: Facility failed to ensure residents were free from physical restraints unless medically necessary; one resident had a mitten restraint without proper assessment or removal.
F 0609: Facility failed to timely report an allegation of abuse involving a resident with cognitive impairment who alleged staff hit him; incident was not reported to the State Survey Agency.
F 0610: Facility failed to respond appropriately to an allegation of abuse; no investigation was completed for a resident alleging staff hit him.
F 0656: Facility failed to develop and implement a comprehensive, person-centered care plan for a resident requiring oxygen; no care plan was developed for oxygen use.
F 0676: Facility failed to provide appropriate treatment and services to maintain or improve ADLs; one resident did not receive help with feeding assistance and cueing.
F 0677: Facility failed to provide necessary assistance with toileting and bathing for 4 residents unable to carry out ADLs; resulted in harm for one resident.
F 0684: Facility failed to provide appropriate wound care and follow-up for a resident with a penile wound; no investigation was done on the cause of the wound.
F 0689: Facility failed to maintain a safe environment free of accident hazards; one resident fell out of bed and sustained an eye laceration, and others lacked fall interventions or were left unattended.
F 0690: Facility failed to provide appropriate catheter care for a resident with indwelling catheter; resident went to hospital for UTI treatment.
F 0692: Facility failed to maintain acceptable nutritional status for 3 residents with weight loss; timely and appropriate interventions were not provided.
F 0693: Facility failed to provide appropriate care for a resident with a feeding tube; multiple observations of dirty feeding tube without cleaning.
F 0695: Facility failed to provide safe and appropriate respiratory care; a resident requiring oxygen was not placed on wall oxygen on admission and lacked physician orders.
F 0697: Facility failed to provide timely pain management; two residents complained of pain but did not receive timely pain relief medication.
F 0761: Facility failed to store drugs and biologicals in locked compartments; medication cart was left unlocked with residents nearby.
F 0770: Facility failed to provide timely, quality laboratory services; lab orders for a resident were not completed and no documentation of refusal was found.
F 0757: Facility failed to keep a resident's drug regimen free from unnecessary drugs; resident was prescribed prophylactic antibiotic for over five years without adequate indications.
F 0880: Facility failed to maintain an infection prevention and control program; staff and outside providers did not wear appropriate PPE, cross contamination observed, and equipment was not cleaned properly.
F 0693: Facility failed to ensure feeding tubes were cared for properly; a resident's nasal gastric feeding tube was observed dirty over multiple days without cleaning.
F 0690: Medication pass observed with poor infection control practices including lack of hand hygiene, touching medication with fingers, and placing medication cups on the floor.
Report Facts
Resident sample size: 54
Medication opportunities observed: 30
Medication errors: 2
Medication error rate: 6.67
Weight loss percent: 5.5
Weight loss percent: 12.4
Weight loss percent: 8
Weight loss percent: 7.4
Weight loss percent: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 6 | Licensed Practical Nurse | Named in pain management and medication pass findings |
| LPN 8 | Licensed Practical Nurse | Named in abuse allegation and fall incident findings |
| CNA 10 | Certified Nursing Assistant | Named in abuse allegation findings |
| DON | Director of Nursing | Named in multiple findings including pain management, infection control, and quality assurance |
| ADON 1 | Assistant Director of Nursing | Named in infection control and catheter care findings |
| ADON 2 | Assistant Director of Nursing | Named in abuse allegation findings |
| NP | Nurse Practitioner | Named in pain management findings |
| Wound Nurse | Named in wound care and infection control findings | |
| Wound Physician Assistant | Named in wound care and infection control findings | |
| CNA 4 | Certified Nursing Assistant | Named in wound care and infection control findings |
| CNA 6 | Certified Nursing Assistant | Named in infection control findings |
| CNA 12 | Certified Nursing Assistant | Named in infection control findings |
| LPN 9 | Licensed Practical Nurse | Named in pain management findings |
| RN 1 | Registered Nurse | Named in infection control and catheter care findings |
| RN 3 | Registered Nurse | Named in infection control findings |
| CNA 2 | Certified Nursing Assistant | Named in nutrition and catheter care findings |
| CNA 3 | Certified Nursing Assistant | Named in infection control findings |
| CNAC | Certified Nursing Assistant Coordinator | Named in nutrition and infection control findings |
| OT | Occupational Therapist | Named in nutrition findings |
| DORT | Director of Respiratory Therapy | Named in respiratory care findings |
| ADM | Administrator | Named in abuse allegation and quality assurance findings |
| ADON 1 | Assistant Director of Nursing | Named in multiple findings including infection control and catheter care |
| ADON 2 | Assistant Director of Nursing | Named in abuse allegation findings |
| LPN 1 | Licensed Practical Nurse | Named in nutrition and feeding tube care findings |
| LPN 7 | Licensed Practical Nurse | Named in medication storage findings |
| RN 2 | Registered Nurse | Named in feeding tube care findings |
| LPN 4 | Licensed Practical Nurse | Named in infection control findings |
| LPN 5 | Licensed Practical Nurse | Named in infection control findings |
| LPN 3 | Licensed Practical Nurse | Named in infection control findings |
| CNA 14 | Certified Nursing Assistant | Named in nutrition and infection control findings |
| CNA 15 | Certified Nursing Assistant | Named in nutrition findings |
| CNA 16 | Certified Nursing Assistant | Named in nutrition findings |
| LPN 2 | Licensed Practical Nurse | Named in fall incident findings |
| LPN 9 | Licensed Practical Nurse | Named in pain management findings |
| RN 3 | Registered Nurse | Named in infection control findings |
| LPN 1 | Licensed Practical Nurse | Named in feeding tube care findings |
| LPN 6 | Licensed Practical Nurse | Named in medication pass and pain management findings |
Inspection Report
Annual Inspection
Deficiencies: 23
Date: May 28, 2021
Visit Reason
The inspection was an annual survey to assess compliance with regulatory requirements and resident care standards.
Findings
The facility was found deficient in multiple areas including resident dignity and rights, medication administration, resident care and preferences, infection control, staffing adequacy, and quality of life issues. Several residents experienced neglect, abuse allegations, inadequate pain management, improper infection control practices, and insufficient staffing leading to unmet care needs.
Deficiencies (23)
F550 - The facility failed to honor residents' rights to dignity and self-determination, including privacy, choice of clothing, and respectful communication.
F554 - The facility failed to assess a resident's safety to self-administer medication, resulting in unsafe medication practices.
F558 - The facility failed to reasonably accommodate resident needs and preferences, including call light accessibility and staff gender preferences.
F561 - The facility failed to promote resident self-determination and choice, including respecting requests for female caregivers and timely assistance.
F583 - The facility failed to maintain confidentiality and privacy of resident medical records, including misfiling of wound notes.
F584 - The facility failed to provide a safe, clean, and homelike environment, including strong odors, soiled wheelchairs, torn wallpaper, and broken furniture.
F585 - The facility failed to establish and implement a grievance policy ensuring prompt resolution and documentation of resident grievances.
F600 - The facility failed to protect residents from abuse and neglect, including verbal and physical abuse allegations and neglect resulting in hospitalization.
F607 - The facility failed to provide appropriate pain management, including delayed or absent administration of pain medications and inadequate response to resident pain reports.
F686 - The facility failed to provide appropriate pressure ulcer care and timely treatment, resulting in an unstageable pressure ulcer and delayed interventions.
F689 - The facility failed to provide adequate supervision and assistance devices to prevent accidents, including a resident fall due to insufficient staff and a burn from improperly heated washcloth.
F690 - The facility failed to provide appropriate care for residents with bowel and bladder incontinence, including delayed toileting, refusal documentation, and lack of bowel/bladder retraining programs.
F692 - The facility failed to provide adequate restorative nursing services to residents with limited range of motion, including missed therapy sessions and incomplete documentation.
F742 - The facility failed to provide appropriate mental health services to a resident with a history of suicide attempt, including lack of timely mental health follow-up and incomplete care planning.
F725 - The facility failed to provide sufficient nursing staff with appropriate competencies and skills to meet resident needs, resulting in unmet care needs, delayed assistance, and unsafe conditions.
F742 - The facility failed to provide appropriate mental health services to a resident with a history of suicide attempt, including lack of timely mental health follow-up and incomplete care planning.
F780 - The facility failed to ensure medication administration was timely, with multiple instances of insulin given more than one hour late.
F804 - The facility failed to provide food and drink that was palatable, attractive, and at a safe and appetizing temperature, with multiple resident complaints and poor quality observations.
F812 - The facility failed to store, prepare, distribute and serve food in accordance with professional standards, including unsanitary kitchen conditions and equipment.
F867 - The facility failed to administer the facility in a manner that enabled it to use its resources effectively and efficiently, resulting in multiple resident harms related to abuse, neglect, falls, incontinence, pain, psychosocial concerns, and staffing.
F842 - The facility failed to safeguard resident-identifiable information and maintain complete, accurate, and readily accessible medical records, including missing restorative nursing notes.
F880 - The facility failed to provide and implement an infection prevention and control program, including failure to exclude symptomatic staff, improper PPE use, and lack of signage for isolation precautions.
F919 - The facility failed to ensure a working call light system in resident bathrooms and bathing areas, with broken call lights, lack of staff radios, and uncharged radios.
Report Facts
Deficiencies cited: 32
Resident sample size: 51
Facility capacity: 120
Facility census: No explicit census stated
Medication late administration: 40
Call light response time: 15
Shower refusals: 6
Pressure ulcer size: 4.7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 7 | Registered Nurse | Named in verbal and physical abuse allegation with resident 105 and resident 101 |
| CNA 8 | Certified Nursing Assistant | Named in rough incontinence care allegation with resident 17 |
| DON | Director of Nursing | Named in multiple interviews related to abuse investigations and facility management |
| RN 1 | Registered Nurse | Named in medication administration and pain management findings |
| CNA 11 | Certified Nursing Assistant | Named in resident 99 safety and toileting concerns |
| CNA 12 | Certified Nursing Assistant | Named in resident 112 incontinence and skin care concerns |
| RN 6 | Registered Nurse | Named in resident 103 burn care and medication administration |
| CNA 1 | Certified Nursing Assistant | Named in food handling and call light system findings |
| Maintenance Director | Named in kitchen sanitation and ventilation findings | |
| IP | Infection Preventionist | Named in infection control and COVID-19 outbreak management |
| Administrator | Named in multiple interviews related to facility operations and COVID-19 outbreak | |
| RNA 1 | Restorative Nursing Assistant | Named in restorative nursing service documentation issues |
| CNA 15 | Certified Nursing Assistant | Named in call light system and resident safety concerns |
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