Deficiencies (last 4 years)
Deficiencies (over 4 years)
12.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
56% worse than Utah average
Utah average: 7.9 deficiencies/yearDeficiencies per year
32
24
16
8
0
Occupancy
Latest occupancy rate
72% occupied
Based on a September 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Oct 8, 2024
Visit Reason
A complaint investigation was initiated due to allegations regarding delayed care and neglect of a resident at the facility.
Complaint Details
The complaint investigation started on 2024-10-07 and ended on 2024-10-08. The allegation of delayed care and neglect was substantiated with cited deficiencies.
Findings
The investigation substantiated deficiencies related to delayed care for a resident who experienced leg numbness and weakness, resulting in a late hospital transfer and diagnosis of serious complications. The facility implemented corrective actions including staff re-education and monitoring procedures.
Deficiencies (1)
F684 Quality of Care: There was a delay in care for a resident complaining of leg numbness and weakness, resulting in late notification to the provider and delayed hospital transfer. The resident was diagnosed with peripheral neuropathy and serious spinal complications after discharge.
Report Facts
Dates of resident admission and discharge: Resident admitted on 2024-05-17 and discharged on 2024-06-30
Dates of complaint investigation: Investigation started on 2024-10-07 and ended on 2024-10-08
Audit schedule: Audits to be conducted bi-weekly for 4 weeks, then weekly for 4 weeks, then monthly for 1 month
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Practitioner | Nurse Practitioner (NP) | Interviewed regarding resident 1's condition and hospital transfer |
| Administrator | Administrator (ADM) | Interviewed about complaint and documentation of resident 1's fall and condition |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Oct 8, 2024
Visit Reason
The inspection was conducted due to a complaint regarding delayed care for a resident who experienced leg numbness and weakness, with concerns about staff response and possible neglect.
Complaint Details
The complaint involved a resident alleging a fall and inadequate care by staff. The complaint was substantiated by findings of delayed care and lack of provider notification regarding the resident's paralysis symptoms.
Findings
The investigation found a delay in care for one resident who complained of lower extremity paralysis. Documentation showed no timely provider notification of the resident's condition change, resulting in a late hospital transfer and diagnosis of serious complications.
Deficiencies (1)
F 0684: There was a delay in providing appropriate treatment and care for a resident with leg numbness and weakness. Licensed practical nurses documented complaints of paralysis without timely provider notification, leading to delayed hospital transfer and diagnosis of peripheral neuropathy and other serious conditions.
Report Facts
Residents affected: 4
Residents affected: 1
Hospital admission duration: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator (ADM) | Interviewed regarding resident's fall claims and documentation | |
| Nurse Practitioner (NP) | Interviewed about resident's symptoms and hospital transfer |
Inspection Report
Annual Inspection
Census: 86
Capacity: 120
Deficiencies: 3
Date: Sep 18, 2024
Visit Reason
A Comparative Federal Monitoring Survey was conducted on 9/18/24, following a State Agency Annual Survey on 8/27/24, to assess compliance with federal regulations for long term care facilities.
Findings
The facility was found not in compliance with several fire safety and equipment maintenance requirements, including improper installation and maintenance of kitchen hood extinguishing systems, unsealed smoke barrier penetrations, and lack of proper restraint for gas equipment. The census was 86 with a total capacity of 120 beds.
Deficiencies (3)
K324 Cooking Facilities: The facility 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 inspection initials on service tag.
K372 Subdivision of Building Spaces - Smoke Barrier: The facility failed to maintain smoke barriers, with unsealed holes of 5 inches, 2x2 inches, and 3 inches around sprinkler pipes allowing smoke passage.
K511 Utilities - Gas and Electric: The facility failed to properly install gas equipment by not providing a restraint system to limit movement of wheeled gas-fired oven and range, risking strain on connections.
Report Facts
Facility capacity: 120
Resident census: 86
Smoke barrier holes: 3
Hole sizes: 5
Inspection Report
Routine
Census: 36
Deficiencies: 14
Date: Aug 29, 2024
Visit Reason
Routine inspection of The Terrace at Mt. Ogden nursing home to assess compliance with regulatory requirements including resident care, medication management, staffing, infection control, and food services.
Findings
The facility had multiple deficiencies including inadequate resident dignity and respect, privacy breaches, incomplete employee license verification, improper transfer documentation, inadequate supervision to prevent accidents, insufficient nursing staff, medication management errors, laboratory testing deficiencies, poor food quality and temperature, infection control lapses, and lack of an antibiotic stewardship program.
Deficiencies (14)
F 0550: The facility did not treat 1 of 36 sampled residents with respect and dignity; a resident was pulled backwards in a shower chair with buttocks exposed.
F 0583: The facility did not provide 4 of 36 sampled residents the right to have secured and confidential personal and medical records; computer screens and nurse reports were left unattended with resident information visible.
F 0607: The facility failed to implement policies to prevent abuse by not verifying licenses of 2 of 5 sampled staff prior to working with residents.
F 0622: The facility did not document or communicate transfer information for 1 of 36 sampled residents transferred to hospital.
F 0625: The facility did not notify 2 of 36 sampled residents or representatives in writing of the bed-hold policy during hospital transfers.
F 0689: The facility failed to provide adequate supervision to prevent accidents for 2 of 36 sampled residents; one eloped and another had an unwitnessed fall without neurological checks.
F 0725: The facility did not provide sufficient nursing staff to meet resident needs; call lights were often unanswered for long periods and residents complained of staffing shortages.
F 0755: The facility did not provide pharmaceutical services to meet resident needs; gabapentin was unavailable for 1 of 36 sampled residents.
F 0757: The facility did not ensure residents' drug regimens were free from unnecessary drugs; blood pressure medication was administered outside parameters and medications were missed or improperly given for 2 residents.
F 0761: The facility did not ensure drugs and biologicals were properly labeled and stored; expired insulin and taped-back medications were observed.
F 0770: The facility did not provide timely, quality laboratory services; multiple lab tests were not performed or delayed for 3 residents.
F 0804: The facility did not provide food that was palatable, attractive, or served at proper temperature; multiple residents complained about food quality and temperature, and a test tray was bland and overcooked.
F 0880: The facility failed to maintain an infection prevention program; medication was touched by bare hands and meal trays were delivered without proper hand hygiene.
F 0881: The facility did not implement an antibiotic stewardship program; staff were unaware of the rationale and prescriber of prophylactic antibiotics for 1 resident.
Report Facts
Residents sampled: 36
Residents affected by dignity deficiency: 1
Residents affected by privacy deficiency: 4
Staff with license verification issues: 2
Residents affected by transfer documentation deficiency: 1
Residents affected by bed-hold notification deficiency: 2
Residents affected by supervision deficiency: 2
Residents affected by staffing deficiency: 12
Missed doses of Abilify: 22
Missed doses of Torsemide: 21
Missed doses of gabapentin: 2
Missed doses of insulin: 1
Medication administration delays: 30
Pellets purchased for meal warming: 110
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 3 | Certified Nursing Assistant | Observed improper hand hygiene during meal delivery |
| CNA 4 | Certified Nursing Assistant | Observed improper hand hygiene during meal delivery and reported license verification process |
| CNA 5 | Certified Nursing Assistant | Observed improper hand hygiene during meal delivery |
| CNA 6 | Certified Nursing Assistant | Observed improper hand hygiene during meal delivery and reported smoking supervision practices |
| CNA 1 | Certified Nursing Assistant | Observed improper hand hygiene during meal delivery |
| RN 4 | Registered Nurse | Observed medication taped back into bubble pack and administered |
| LPN 1 | Licensed Practical Nurse | Interviewed about blood pressure medication administration and staffing |
| DON 1 | Director of Nursing | Interviewed about medication storage, staffing, and infection control |
| DON 2 | Director of Nursing | Interviewed about medication availability and antibiotic stewardship |
| CRN | Corporate Resource Nurse | Interviewed about lab testing and antibiotic stewardship |
| ADM | Administrator | Interviewed about staffing, food quality, and elopement incident |
Inspection Report
Routine
Census: 36
Deficiencies: 11
Date: Aug 29, 2024
Visit Reason
Routine inspection of The Terrace at Mt. Ogden nursing home to assess compliance with regulatory requirements including resident care, safety, medication management, staffing, food service, infection control, and laboratory services.
Findings
The facility had multiple deficiencies including failure to treat residents with dignity, inadequate supervision to prevent accidents and elopement, insufficient nursing staff leading to long call light response times, medication management issues including missing medications and improper administration, laboratory testing delays and omissions, food service problems with late and cold meals, and infection control lapses during medication and meal delivery.
Deficiencies (11)
F 0550: The facility failed to treat a resident with dignity and respect when the resident was pulled backwards in a shower chair with sides of her buttocks exposed.
F 0689: The facility failed to provide adequate supervision to prevent accidents and elopement for residents at risk, including failure to complete neurological assessments after falls and inadequate monitoring of a high-risk wanderer who eloped.
F 0725: The facility did not provide sufficient nursing staff with appropriate skills to meet resident needs, resulting in long call light wait times and resident complaints.
F 0755: The facility failed to provide pharmaceutical services ensuring accurate medication administration, including a resident not receiving gabapentin due to lack of prescription.
F 0757: The facility failed to ensure residents' drug regimens were free from unnecessary drugs, including administering blood pressure medication outside physician parameters and missed doses of antipsychotic, diuretic, and insulin medications.
F 0761: The facility failed to ensure safe and secure storage of drugs and biologicals, including expired insulin, undated insulin pens, and medication taped back into bubble packs.
F 0770: The facility failed to provide timely, quality laboratory services, including missed or delayed lab draws and unavailable lab results for multiple residents.
F 0802: The facility did not provide sufficient support personnel to safely and effectively carry out food and nutrition services, resulting in late meal delivery and resident complaints about cold food.
F 0804: The facility failed to ensure food and drink were palatable, attractive, and served at a safe and appetizing temperature, with multiple resident complaints about bland, cold, or poor quality food.
F 0880: The facility failed to implement an infection prevention and control program, including improper medication handling and failure to perform hand hygiene during meal delivery.
F 0881: The facility failed to implement an antibiotic stewardship program, with staff unaware of antibiotic use rationale and lack of provider information for prophylactic antibiotics.
Report Facts
Residents sampled: 36
Residents affected by dignity deficiency: 1
Residents affected by supervision deficiency: 2
Residents affected by staffing deficiency: 12
Residents affected by pharmaceutical deficiency: 1
Residents affected by unnecessary drug deficiency: 2
Residents affected by drug storage deficiency: 1
Residents affected by laboratory deficiency: 3
Residents affected by food service staffing deficiency: 2
Residents affected by food quality deficiency: 10
Residents affected by infection control deficiency: 1
Residents affected by antibiotic stewardship deficiency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 3 | Certified Nursing Assistant | Observed pulling resident backwards in shower chair; observed not performing hand hygiene during meal delivery |
| CNA 4 | Certified Nursing Assistant | Interviewed about elopement incident and meal tray delivery hand hygiene |
| CNA 5 | Certified Nursing Assistant | Observed not performing hand hygiene during meal delivery |
| CNA 6 | Certified Nursing Assistant | Observed not performing hand hygiene during meal delivery; interviewed about smoking supervision |
| CNA 1 | Certified Nursing Assistant | Observed multiple failures of hand hygiene during meal delivery |
| RN 4 | Registered Nurse | Observed taping medication back into bubble pack and administering it |
| LPN 1 | Licensed Practical Nurse | Interviewed about elopement incident and medication administration |
| DON 1 | Director of Nursing | Interviewed about medication storage, elopement, and infection control |
| DON 2 | Director of Nursing | Interviewed about medication administration and elopement |
| CRN | Corporate Resource Nurse | Interviewed about laboratory and antibiotic stewardship deficiencies |
| ADM | Administrator | Interviewed about staffing, food service, and elopement |
| DM | Dietary Manager | Interviewed about food service and pellet system for meal warming |
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 involving unauthorized bank transactions and a cashed check.
Complaint Details
The complaint was substantiated. Resident 1 reported unauthorized bank transactions totaling roughly $1400 and a $300 check cashed by Nurse Assistant 1 without permission. The facility reimbursed the resident and reported the incident to the police. The Nurse Assistant was terminated prior to the investigation completion.
Findings
The facility failed to ensure that one resident was free from abuse, neglect, and misappropriation of property. A Nurse Assistant was found to have cashed a $300 check without the resident's permission, and multiple fraudulent charges were made on the resident's bank account. The facility reimbursed the resident and terminated the employee.
Deficiencies (1)
F 0602: The facility did not protect a resident from wrongful use of belongings or money. A Nurse Assistant cashed a $300 check without the resident's consent and unauthorized bank transactions occurred.
Report Facts
Unauthorized bank transaction amount: 1400
Cashed check amount: 300
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NA 1 | Nurse Assistant | Named in misappropriation of resident property involving unauthorized check cashing and bank transactions |
| Administrator | Administrator (ADM) | Conducted investigation and provided statements regarding the incident |
| Director of Nursing | Director of Nursing (DON) | Provided information on employee termination and dependability |
| Administrator in Training | Administrator in Training (AIT) | Reported police cases opened for fraudulent charges and check |
Inspection Report
Annual Inspection
Deficiencies: 6
Date: Dec 15, 2022
Visit Reason
The inspection was the annual survey conducted to assess compliance with Medicare and Medicaid participation requirements, including a Life Safety Code survey.
Findings
The facility was found to have multiple deficiencies related to safe and clean environment, activities of daily living, bowel/bladder incontinence care, bedrails safety, nutrition, and food procurement. Corrective actions and plans of correction were submitted for each deficiency. The Life Safety Code survey found no deficiencies.
Deficiencies (6)
F584 Safe/Clean/Comfortable/Homelike Environment: The facility did not provide a safe, clean, and comfortable environment as resident wheelchairs and lifts were observed to be soiled.
F676 Activities Daily Living (ADLs)/Mntn Abilities: Resident 33 was not provided necessary oral care, resulting in build-up on teeth and refusal of assistance by some CNAs.
F690 Bowel/Bladder Incontinence, Catheter, UTI: Resident 24 did not receive appropriate toileting services and was incontinent without brief changes or skin checks.
F700 Bedrails: Resident 3's bed rail was replaced after safety concerns; therapy reviewed all bed rails to ensure safety.
F804 Nutritive Value/Appear, Palatable/Prefer Temp: Facility did not serve food that was consistently palatable or at appropriate temperature; residents complained about food quality.
F812 Food Procurement, Store/Prepare/Serve-Sanitary: Kitchen staff failed to store and prepare food in accordance with food safety standards, including raw meat stored above breadsticks and missing grout in kitchen tiles.
Report Facts
Sampled residents: 27
Residents affected by wheelchair deficiency: 5
Residents reviewed for oral care deficiency: 1
Residents reviewed for bowel/bladder deficiency: 1
Residents reviewed for bedrail deficiency: 1
Residents reviewed for food quality deficiency: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| H. Flint | Executive Director | Signed Plan of Correction for F584 deficiency |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding wheelchair cleaning, oral care, and corrective actions |
| CNA 1 | Certified Nursing Assistant | Interviewed about oral care and resident assistance |
| CNA 2 | Certified Nursing Assistant | Interviewed about oral care and resident repositioning |
| CNA 3 | Certified Nursing Assistant | Interviewed about oral care and wheelchair cleaning |
| CNA 4 | Certified Nursing Assistant | Interviewed about wheelchair cleaning assignment |
| CNA 5 | Certified Nursing Assistant | Interviewed about resident care and skin integrity |
| CNA 6 | Certified Nursing Assistant | Interviewed about resident care and skin integrity |
| Registered Nurse 1 | Registered Nurse (RN) | Interviewed about resident skin integrity and care |
| Registered Nurse 2 | Registered Nurse (RN) | Interviewed about resident care and assistance |
| Cook 1 | Cook | Interviewed about kitchen conditions and food storage |
| Dietary Manager | Dietary Manager (DM) | Interviewed about food quality and kitchen sanitation |
Inspection Report
Routine
Deficiencies: 6
Date: Dec 15, 2022
Visit Reason
The inspection was a routine survey to assess compliance with regulatory requirements related to resident care, environment, food service, and safety at The Terrace at Mt. Ogden nursing facility.
Findings
The facility was found to have multiple deficiencies including unclean resident wheelchairs and equipment, inadequate oral care for a resident, insufficient care for an incontinent resident leading to risk of pressure ulcers, improper use and assessment of bed rails causing skin tears, poor food quality and temperature issues, and food safety violations in the kitchen such as improper storage and unsanitary conditions.
Deficiencies (6)
F 0584: The facility failed to provide a safe, clean, comfortable, and homelike environment for 5 of 27 sampled residents, with dirty wheelchairs and a soiled lift observed.
F 0676: One resident was not provided necessary care to maintain activities of daily living, evidenced by oral care neglect and buildup on teeth.
F 0690: One resident incontinent of bladder did not receive appropriate brief changes, skin checks, and toileting services, increasing risk for urinary tract infections and pressure ulcers.
F 0700: The facility failed to reevaluate risks and benefits of bed rail use for one resident who sustained a skin tear from the side rail.
F 0804: Food served to 12 residents was often cold, unappetizing, overcooked, and repetitive, with resident complaints documented.
F 0812: The facility did not store, prepare, distribute, and serve food in accordance with professional standards, with uncooked meats stored above ready-to-eat foods and unsanitary kitchen conditions observed.
Report Facts
Sampled residents: 27
Residents affected: 5
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 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 | Interviewed regarding oral care and brief changes for residents 24 and 33 |
| CNA 2 | Certified Nursing Assistant | Interviewed regarding wheelchair cleaning and care for resident 24 |
| CNA 3 | Certified Nursing Assistant | Interviewed about wheelchair cleaning and oral care for resident 33 |
| CNA 4 | Certified Nursing Assistant | Interviewed about wheelchair cleaning procedures |
| CNA 5 | Certified Nursing Assistant | Interviewed about care and brief changes for resident 3 |
| CNA 6 | Certified Nursing Assistant | Interviewed about care and positioning for resident 3 |
| RN 1 | Registered Nurse | Interviewed about skin tear and care for resident 3 |
| RN 2 | Registered Nurse | Interviewed about care and repositioning for resident 24 |
| Director of Nursing | Director of Nursing | Interviewed about wheelchair cleaning, oral care, bed rail use, and repositioning |
| Corporate Resource Nurse | Corporate Resource Nurse | Interviewed about repositioning and bed rail use |
| Dietary Manager | Dietary Manager | Interviewed about food quality, plate warmers, and kitchen sanitation |
| Dietary Aide 1 | Dietary Aide | Observed and interviewed regarding food service and hygiene practices |
Inspection Report
Routine
Deficiencies: 6
Date: May 6, 2021
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident safety, smoking protocols, dental services, staffing qualifications, and food service safety at the nursing home.
Findings
The facility was found deficient in ensuring resident safety from accident hazards, proper use of smoking aprons during supervised smoking, timely dental services and follow-up, employment of a qualified full-time dietitian, and maintaining proper dishmachine sanitation and food storage protocols.
Deficiencies (6)
F 0689: The facility failed to ensure residents' environments were free from accident hazards and provide adequate supervision to prevent accidents, including failure to provide fall prevention equipment and supervision for multiple residents.
F 0689: The facility failed to ensure residents wore required smoking aprons during supervised smoking, increasing risk of injury.
F 0689: A resident sustained foot injuries while operating an electric wheelchair without a follow-up assessment or intervention.
F 0791: The facility failed to provide or obtain timely dental services for residents with painful teeth, bleeding gums, and ill-fitting dentures.
F 0801: The facility did not employ a clinically qualified full-time Registered Dietitian or nutrition professional as director of food and nutrition services.
F 0812: The facility failed to maintain dishmachine temperatures at required levels for sanitation and lacked a process to track dates for thawed health shake supplements.
Report Facts
Deficiencies cited: 6
Dishmachine temperature: 100
Dishmachine temperature: 110
Sanitizer concentration: 50
Dishmachine temperature log: 120
Sanitizer concentration log: 150
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 2 | Certified Nursing Assistant | Interviewed regarding resident 35's fall prevention equipment and supervision. |
| DON | Director of Nursing | Interviewed regarding resident care, smoking protocols, dental services, and staff education. |
| CRN 1 | Corporate Resource Nurse | Interviewed regarding smoking assessments and resident supervision. |
| CRN 2 | Corporate Resource Nurse | Interviewed regarding resident equipment and smoking apron education. |
| DM | Dietary Manager | Interviewed regarding dishmachine operation, temperatures, and health shake storage. |
| RD | Registered Dietitian | Interviewed regarding dietitian presence, kitchen audits, and dishmachine sanitation. |
| RN 1 | Registered Nurse | Interviewed regarding resident 50's foot injuries and wheelchair use. |
| RN 3 | Clinical Care Coordinator | Interviewed regarding dental services and resident appointments. |
Viewing
Loading inspection reports...
