Inspection Report
Complaint Investigation
Deficiencies: 1
Oct 8, 2024
Visit Reason
A complaint investigation was initiated due to allegations regarding delayed care and unreported falls involving a resident at the facility.
Findings
The investigation substantiated deficiencies related to delayed care for a resident experiencing leg numbness and weakness, with failure to timely notify the provider of the resident's change in condition, resulting in serious health consequences.
Complaint Details
The complaint investigation started on 10/07/2024 and ended on 10/08/2024. The allegation was substantiated with deficiencies cited related to quality of care and delayed provider notification.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Delay in care for a resident complaining of leg numbness and weakness, with failure to notify the provider of change in condition. | SS=D |
Report Facts
Deficiencies cited: 1
Dates of resident 1 admission and discharge: Admitted 2024-05-17, discharged 2024-06-30
Date of survey completion: Oct 8, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator (ADM) | Interviewed regarding complaint and facility awareness of resident condition | |
| Nurse Practitioner (NP) | Interviewed regarding resident 1's symptoms and hospital referral |
Inspection Report
Annual Inspection
Census: 86
Capacity: 120
Deficiencies: 3
Sep 18, 2024
Visit Reason
A Comparative Federal Monitoring Survey was conducted following a State Agency Annual Survey to assess compliance with the Requirements for Long Term Care Facilities under 42 CFR Part 483.
Findings
The facility was found not to be in compliance with several requirements including proper installation and maintenance of kitchen hood extinguishing systems, maintenance of smoke barriers, and installation of gas equipment and appliances. Deficiencies affected multiple smoke compartments, staff, and some residents.
Severity Breakdown
SS=D: 2
SS=E: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to properly install and maintain equipment protected by the kitchen hood extinguishing system, including lack of approved method to ensure appliance returned to approved location and missing monthly owner's inspection records. | SS=D |
| Failed to properly maintain smoke barriers with unsealed penetrations around sprinkler pipes allowing passage of smoke. | SS=E |
| Failed to properly install gas equipment and appliances; wheeled oven and range lacked restraint system to limit movement and prevent strain on connections. | SS=D |
Report Facts
Facility capacity: 120
Census: 86
Smoke compartments affected: 4
Smoke compartments with deficiencies: 2
Smoke compartments with kitchen hood extinguishing deficiency: 1
Smoke compartments with gas equipment deficiency: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Plant Operations Manager | Interviewed regarding kitchen hood extinguishing system and gas equipment deficiencies | |
| Building Maintenance Foreman | Interviewed regarding monthly owner's inspection of kitchen hood extinguishing system | |
| Nurse Manager | Verified census during inspection | |
| Staff Development Manager | Acknowledged findings during exit interview |
Inspection Report
Annual Inspection
Deficiencies: 6
Dec 15, 2022
Visit Reason
The inspection was conducted as an annual survey of The Terrace at Mt Ogden facility to assess compliance with Medicare and Medicaid requirements, including safety, care, and environmental standards.
Findings
The report details multiple deficiencies related to safe, clean, and homelike environment, activities of daily living, bowel/bladder incontinence care, bedrails safety, nutrition and food service, and food procurement. Corrective actions and plans of correction were submitted and accepted. The facility was found to be in compliance with life safety code and emergency preparedness requirements.
Deficiencies (6)
| Description |
|---|
| Facility did not provide a safe, clean, comfortable and homelike environment; resident wheelchairs and lifts were soiled. |
| Resident did not receive necessary care to maintain abilities in activities of daily living, including oral care. |
| Facility failed to ensure appropriate treatment and services for residents with bowel/bladder incontinence. |
| Facility failed to ensure bedrails were used safely and appropriately, resulting in a skin tear for one resident. |
| Facility failed to ensure food was prepared and served at safe and appetizing temperatures; residents complained about food quality. |
| Facility failed to store, prepare, distribute and serve food in accordance with professional food service safety standards. |
Report Facts
Number of sampled residents: 27
Number of residents affected by wheelchair deficiency: 5
Number of residents reviewed for oral care deficiency: 1
Number of residents reviewed for bowel/bladder incontinence deficiency: 1
Number of residents reviewed for bedrail deficiency: 1
Number of residents reviewed for food service deficiency: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| H. Flint | Executive Director | Accepted Plan of Correction for safe, clean, comfortable environment deficiency |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding wheelchair cleaning, oral care, and corrective actions |
| Certified Nursing Assistants | CNA | Interviewed regarding cleaning wheelchairs and oral care assistance |
| Dietary Manager | Dietary Manager (DM) | Interviewed regarding food service and food safety corrective actions |
| Cook 1 | Cook | Interviewed regarding kitchen cleanliness and food storage |
| Registered Nurse 1 | RN | Interviewed regarding resident skin tear and care |
| Registered Nurse 2 | RN | Interviewed regarding resident care and assistance |
| Corporate Resource Nurse | CRN | Interviewed regarding resident repositioning and care plans |
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