Deficiencies (last 4 years)
Deficiencies (over 4 years)
11.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
49% worse than Utah average
Utah average: 7.9 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: 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.
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.
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.
Deficiencies (1)
Delay in care for a resident complaining of leg numbness and weakness, with failure to notify the provider of change in condition.
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
Complaint Investigation
Deficiencies: 1
Date: Oct 8, 2024
Visit Reason
The inspection was conducted following a complaint regarding delayed care for a resident who experienced leg numbness and weakness, with concerns about staff not responding appropriately to the resident's condition.
Complaint Details
The complaint involved a resident who reported leg numbness and weakness and alleged staff had not been taking care of them. The complaint was substantiated by findings of delayed care and lack of timely provider notification.
Findings
The investigation found a delay in care for one resident who complained of lower extremity paralysis. Documentation showed licensed practical nurses noted the paralysis, but there was no evidence the provider was notified in a timely manner. The resident was eventually sent to the hospital with serious diagnoses including cauda equina compression and epidural abscess.
Deficiencies (1)
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Report Facts
Residents sampled: 4
Residents affected: 1
Hospital admission duration: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator (ADM) | Interviewed regarding resident's claims and documentation | |
| Nurse Practitioner (NP) | Interviewed regarding last encounter with resident and hospital referral |
Inspection Report
Annual Inspection
Census: 86
Capacity: 120
Deficiencies: 3
Date: 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.
Deficiencies (3)
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.
Failed to properly maintain smoke barriers with unsealed penetrations around sprinkler pipes allowing passage of smoke.
Failed to properly install gas equipment and appliances; wheeled oven and range lacked restraint system to limit movement and prevent strain on connections.
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
Routine
Deficiencies: 11
Date: Aug 29, 2024
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements including resident rights, accident prevention, staffing, pharmaceutical services, laboratory services, food and nutrition services, infection control, and antibiotic stewardship.
Findings
The facility was found deficient in multiple areas including failure to treat residents with dignity, inadequate supervision to prevent accidents, insufficient nursing staff, pharmaceutical service deficiencies, improper medication storage, delayed and poor quality food service, inadequate infection control practices, and lack of an effective antibiotic stewardship program.
Deficiencies (11)
Resident was pulled backwards in a shower chair with sides of buttocks exposed, violating dignity and respect.
Facility failed to ensure adequate supervision to prevent accidents, including elopement and lack of neurological assessments after falls.
Facility did not have sufficient nursing staff to meet resident needs, resulting in long call light response times and resident complaints.
Pharmaceutical services deficiencies including failure to provide gabapentin as ordered.
Resident drug regimens included unnecessary drugs or improper administration, such as blood pressure medication given outside parameters and missed doses due to dialysis scheduling.
Drugs and biologicals were not stored securely or labeled properly; expired insulin and taped medications were observed.
Laboratory services were not timely or complete, including missed or delayed lab draws and unavailable lab results.
Insufficient support personnel in food and nutrition service led to late meal delivery and resident complaints about cold food.
Food served was bland, overcooked, and not palatable; multiple resident complaints documented.
Infection prevention and control program deficiencies including medication touched by bare hands and failure to perform hand hygiene during meal delivery.
Facility lacked an effective antibiotic stewardship program; staff unaware of antibiotic use rationale for a resident on prophylaxis.
Report Facts
Resident sample size: 36
Missed doses of Abilify: 22
Missed doses of Torsemide: 21
Facility census: 80
Pellets purchased: 110
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 3 | Certified Nursing Assistant | Observed pulling resident backwards in shower chair and delivering meals without hand hygiene |
| CNA 4 | Certified Nursing Assistant | Observed elopement incident and interview about supervision |
| Director of Nursing (DON) 1 | Director of Nursing | Interviewed regarding dignity violation, medication storage, and lab processes |
| Director of Nursing (DON) 2 | Director of Nursing | Interviewed regarding elopement, medication administration, and lab results |
| Administrator (ADM) | Facility Administrator | Interviewed regarding staffing, meal service, and elopement incident |
| Corporate Resource Nurse (CRN) | Corporate Resource Nurse | Interviewed regarding elopement, medication administration, and lab processes |
| Nursing Assistant (NA) 1 | Nursing Assistant | Interviewed regarding resident pain and call light response |
| Registered Nurse (RN) 1 | Registered Nurse | Interviewed regarding staffing and medication administration |
| Licensed Practical Nurse (LPN) 1 | Licensed Practical Nurse | Interviewed regarding elopement and medication administration |
| Dietary Manager (DM) | Dietary Manager | Interviewed regarding meal service and pellet system use |
Inspection Report
Routine
Deficiencies: 13
Date: Aug 29, 2024
Visit Reason
The inspection was a routine survey to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including resident dignity and respect, confidentiality breaches, inadequate abuse prevention policies, incomplete transfer documentation, insufficient bed-hold notifications, inadequate supervision to prevent accidents, insufficient staffing, pharmaceutical service deficiencies, unnecessary drug use, laboratory service delays, poor food quality, infection control lapses, and lack of an antibiotic stewardship program.
Deficiencies (13)
Resident dignity and respect was not maintained when a resident was pulled backwards in a shower chair with exposed buttocks.
Facility did not keep residents' personal and medical records private and confidential; computer screens and nurse reports were left unattended with resident information visible.
Facility failed to implement policies and procedures to prevent abuse, neglect, and theft, including failure to verify employee licenses prior to working with residents.
Transfer or discharge documentation was missing for a resident transferred to hospital; appropriate information was not communicated.
Facility did not notify residents or representatives in writing about bed-hold policies during hospital transfers.
Facility failed to provide adequate supervision to prevent accidents; residents at high risk for falls and elopement were not properly monitored.
Facility did not have sufficient nursing staff to meet resident needs; call lights were often unanswered for long periods and residents reported staffing concerns.
Pharmaceutical services were deficient; a resident did not have gabapentin available as ordered.
Facility did not ensure residents' drug regimens were free from unnecessary drugs; blood pressure medication was administered outside physician parameters and other medications were missed or improperly administered.
Laboratory services were not timely or complete; several residents had missing or delayed lab tests including TSH, Valproic acid levels, and urinalysis with culture and sensitivity.
Food served was often bland, overcooked, cold, or unpalatable; multiple residents and resident council members complained about food quality.
Infection prevention and control program was deficient; medications were handled with bare hands, medication bubble packs were taped and reused, and hand hygiene was not performed consistently during meal delivery.
Facility did not implement an antibiotic stewardship program; staff were unaware of the rationale and provider for prophylactic antibiotic use for a resident.
Report Facts
Residents sampled: 36
Residents with dignity deficiency: 1
Residents with confidentiality deficiency: 4
Staff with license verification deficiency: 2
Residents with transfer documentation deficiency: 1
Residents with bed-hold notification deficiency: 2
Residents with supervision deficiency: 2
Residents with staffing complaints: 12
Missed doses of Abilify: 22
Missed doses of Torsemide: 21
Resident 185 wander guard elopement risk score: 11
Resident 185 wander guard elopement risk score: 6
Facility pellet heating system quantity: 110
Facility census: 80
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 3 | Certified Nursing Assistant | Observed pulling resident backwards in shower chair |
| Director of Nursing | Director of Nursing | Interviewed about dignity and privacy deficiencies |
| LPN 2 | Licensed Practical Nurse | Observed leaving computer screen open on medication cart |
| RN 5 | Registered Nurse | Observed leaving computer screen open on medication cart |
| Human Resources | Human Resources | Interviewed about employee license verification |
| Administrator | Administrator | Interviewed about license verification and staffing |
| CNA 4 | Certified Nursing Assistant | Involved in elopement incident with resident 185 |
| LPN 1 | Licensed Practical Nurse | Interviewed about elopement and supervision |
| CNA 5 | Certified Nursing Assistant | Described supervised smoking procedures |
| Nursing Assistant 1 | Nursing Assistant | Interviewed about resident 14 pain and assistance |
| Certified Nursing Assistant 6 | Certified Nursing Assistant | Interviewed about resident 14 pain and smoking supervision |
| Director of Nursing 2 | Director of Nursing | Interviewed about gabapentin availability |
| RN 3 | Registered Nurse | Interviewed about insulin storage and medication handling |
| RN 4 | Registered Nurse | Observed medication bubble pack misuse |
| DON 1 | Director of Nursing | Interviewed about medication handling and lab processes |
| Corporate Resource Nurse | Corporate Resource Nurse | Interviewed about medication and lab deficiencies |
| Dietary Manager | Dietary Manager | Interviewed about food service and pellet system |
| CNA 6 | Certified Nursing Assistant | Observed and interviewed about meal service and smoking supervision |
| CNA 1 | Certified Nursing Assistant | Observed multiple hand hygiene failures during meal delivery |
| CNA 2 | Certified Nursing Assistant | Observed hand hygiene failure during meal delivery |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 16, 2023
Visit Reason
The inspection was conducted following a complaint alleging misappropriation of resident property by a Nurse Assistant (NA 1), specifically involving unauthorized bank transactions and a cashed check.
Complaint Details
The complaint investigation substantiated that NA 1 misappropriated resident 1's property by cashing a $300 check without permission and unauthorized bank transactions totaling roughly $1400. NA 1 was terminated, the resident was reimbursed, and the police were notified with two cases opened.
Findings
The facility failed to protect a resident from misappropriation of property when NA 1 cashed a $300 check without the resident's permission. The resident reported multiple unauthorized bank transactions, and the facility reimbursed the resident and terminated NA 1. The police were notified and investigations were opened.
Deficiencies (1)
Failure to protect resident from wrongful use of belongings or money, including unauthorized bank transactions and a cashed check by a Nurse Assistant.
Report Facts
Unauthorized bank transaction amount: 1400
Cashed check amount: 300
Number of unauthorized checks missing: 3
Date of survey completion: Mar 16, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NA 1 | Nurse Assistant | Named in misappropriation of resident property finding; terminated for no call no show and performance reasons |
| Administrator | Administrator (ADM) | Conducted investigation and reported incident to police |
| Administrator in Training | Administrator in Training (AIT) | Reported police cases opened for fraudulent charges and cashed check |
| Director of Nursing | Director of Nursing (DON) | Noted NA 1 was not dependable and terminated NA 1 |
Inspection Report
Annual Inspection
Deficiencies: 6
Date: 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)
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 |
Inspection Report
Annual Inspection
Deficiencies: 6
Date: Dec 15, 2022
Visit Reason
The inspection was conducted as part of an annual survey to assess compliance with regulatory requirements related to resident care, safety, environment, and food service at The Terrace at Mt. Ogden nursing facility.
Findings
The facility was found to have multiple deficiencies including failure to maintain a safe, clean, and homelike environment; inadequate oral care leading to diminished resident abilities; insufficient care for incontinent residents resulting in risk of urinary tract infections and pressure ulcers; improper use and assessment of bed rails causing skin tears; serving food that was cold, unappetizing, and improperly prepared; and failure to store and handle food according to professional standards with unsanitary kitchen conditions.
Deficiencies (6)
Facility did not provide a safe, clean, comfortable and homelike environment; resident wheelchairs and lifts were soiled.
Resident was not provided necessary oral care, resulting in build-up on teeth and diminished ability to perform activities of daily living.
Resident incontinent of bladder did not receive appropriate brief changes, skin checks, and toileting services as outlined in care plan.
Facility failed to reevaluate risks versus benefits of installed bed rails; resident sustained skin tear from bed rail.
Food served was cold, unappetizing, repetitive, and overcooked; resident complaints documented.
Facility did not store, prepare, distribute, and serve food in accordance with professional standards; uncooked meats stored above ready-to-eat foods; kitchen had soiled areas, cracked paint, missing grout, broken tiles, and unsanitary conditions.
Report Facts
Residents sampled: 27
Residents affected by environment deficiency: 5
Residents affected by oral care deficiency: 1
Residents affected by incontinent care deficiency: 1
Residents affected by bed rail deficiency: 1
Residents affected by food quality deficiency: 12
Food temperatures: 162
Food temperatures: 121
Food temperatures: 115
Food temperatures: 52
Food temperatures: 59
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 1 | Certified Nursing Assistant | Mentioned in relation to wheelchair cleaning and resident oral care |
| CNA 2 | Certified Nursing Assistant | Interviewed about oral care and brief checking for resident 24 |
| CNA 3 | Certified Nursing Assistant | Interviewed about wheelchair cleaning and oral care |
| Director of Nursing | Director of Nursing | Interviewed about wheelchair cleaning, oral care, repositioning, and bed rail use |
| CNA 5 | Certified Nursing Assistant | Interviewed about resident 3's care and bed rail incidents |
| CNA 6 | Certified Nursing Assistant | Interviewed about resident 3's care and bed rail use |
| RN 1 | Registered Nurse | Interviewed about resident 3's skin tear and care |
| RN 2 | Registered Nurse | Interviewed about resident 24's care needs and brief changes |
| Dietary Manager | Dietary Manager | Interviewed about food service issues and kitchen conditions |
| Dietary Aide 1 | Dietary Aide | Observed not having hair restrained while rolling silverware |
| Corporate Resource Nurse | Corporate Resource Nurse | Interviewed about repositioning and bed rail use |
Inspection Report
Routine
Deficiencies: 5
Date: May 6, 2021
Visit Reason
The inspection was conducted to evaluate the facility's compliance with regulations regarding resident safety, accident prevention, smoking protocols, dental services, food and nutrition services, and food safety standards.
Findings
The facility was found deficient in ensuring resident safety from accident hazards, proper use of smoking equipment, provision of dental services, employment of qualified dietitian staff, and adherence to food service safety standards including dishmachine operation and tracking of health shake supplements.
Deficiencies (5)
Failure to ensure resident environment was free from accident hazards and provide adequate supervision to prevent accidents, including lack of fall prevention equipment for residents at high risk of falls.
Failure to ensure residents who smoked wore required smoking aprons and were properly supervised, leading to potential injury risk.
Failure to assist residents in obtaining routine and emergency dental services promptly, including lack of follow-up for residents with painful or ill-fitting dentures and bleeding gums.
Failure to employ a clinically qualified full-time dietitian or nutrition professional as director of food and nutrition services.
Failure to store, prepare, distribute and serve food in accordance with professional standards, including dishmachine not reaching required sanitizing temperatures and lack of process to track health shake supplement thawing dates.
Report Facts
Resident falls: 9
Dishmachine wash temperature: 100
Dishmachine rinse temperature: 110
Sanitizer concentration: 50
Smoking aprons required: 3
Wound size: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 1 | Registered Nurse | Reported resident 50's feet stuck out too far on wheelchair pedals causing injury |
| DON | Director of Nursing | Provided information on resident education, smoking apron policies, and dental service scheduling |
| CRN 1 | Corporate Resource Nurse | Discussed smoking assessments and supervision of residents during smoking |
| DM | Dietary Manager | Reported dishmachine temperatures and health shake supplement handling |
| RN 3 | Clinical Care Coordinator | Provided information on dental services and dentist visits |
Viewing
Loading inspection reports...
