cms_UT
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7,494 rows
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| Link | rowid ▼ | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 1 | HERITAGE PARK HEALTHCARE AND REHABILITATION | 465003 | 2700 WEST 5600 SOUTH | ROY | UT | 84067 | 2018-01-17 | 609 | D | 0 | 1 | 1JS611 | Based on record review and interview it was determined that the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury to the State Survey Agency. Specifically, an entity report of an abuse allegation was not submitted to the State Survey Agency until 48 hours after the incident occurred. Findings include: On 1/17/18 the facility abuse reports were reviewed. Review of the Abuse Report UT 287 of a resident to resident altercation revealed the date of the incident as 11/27/17 and the initial report was sent to the State Survey Agency on 11/29/17. On 1/17/18 at 11:36 AM an interview was conducted with the facility Social Worker (SW). The SW stated that she was responsible for sending in the entity report of an abuse allegation to the State Survey Agency. The SW stated that the initial report had to be reported in 24 hours if no serious bodily injury and within 2 hours if serious bodily injury. The SW confirmed that the report UT 287 was late and greater than 24 hours. | 2020-09-01 |
| 2 | 2 | HERITAGE PARK HEALTHCARE AND REHABILITATION | 465003 | 2700 WEST 5600 SOUTH | ROY | UT | 84067 | 2018-01-17 | 676 | E | 0 | 1 | 1JS611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, it was determined the facility did not give the appropriate services to maintain or improve the resident's activities of daily living for 5 of 30 sample residents. Specifically, residents did not receive assistance with eating. Resident identifiers: 7, 11, 36, 54 and 56. Findings include: 1. Resident 36 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 1/9/18, the noon meal service was observed on the Special Needs Unit (SNU). Resident 36 was served his meal at 12:07 PM. Resident 36 was not cued to eat until 12:17 PM at which time resident 36 consumed his first bite of food. Resident 36's medical record was reviewed on 1/16/18. On 11/14/17, the facility staff completed an annual Minimum Data Set (MDS) Assessment. The facility staff assessed resident 36 as needing extensive assistance with a one person physical assist when eating meals. The facility staff developed a nutritional care plan with documented goals of, no wt (weight) loss and Will maintain adequate nutritional status as evidenced by maintaining weight with no s/sx (signs or symptoms) of malnutrition through review date. One of the interventions developed to achieve the goals included Provide assistance or cueing with meals as needed. 2. Resident 56 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 1/10/18, the breakfast meal service was observed on the SNU. Resident 56 was served her meal at 8:03 AM. Resident 56 was not cued or assisted to eat until 8:21 AM at which time resident 56 consumed his first bite of food. Resident 56's medical record was reviewed on 1/11/18. On 11/30/17, the facility staff completed a quarterly MDS Assessment. The facility staff assessed resident 56 as needing extensive assistance with a one person physical assist when eating meals. The facility staff developed a nutritional care plan with documented goals of, Will have no significant weight change thru (sic) next rev… | 2020-09-01 |
| 3 | 3 | HERITAGE PARK HEALTHCARE AND REHABILITATION | 465003 | 2700 WEST 5600 SOUTH | ROY | UT | 84067 | 2018-01-17 | 677 | D | 0 | 1 | 1JS611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined the facility did not ensure that 1 of 30 sample residents who were unable to carry out activities of daily living, received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Specifically, a resident's nails were not clipped. Resident identifier: 79. Findings include: Resident 79 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 1/9/18 at 2:37 PM, resident 79's nails were observed to be an estimated 1/4 inch long, pointed, and unkempt. On 1/16/18 at 10:01 AM, resident 79's nails were observed to still be long and unkempt. On 1/16/18 at 10:35 AM, Certified Nurse Assistant (CNA) 1 stated that resident 79 nails were cut during his showers. CNA 1 stated that it would be documented on the shower logs. CNA 1 stated that sometimes resident 79 was combative with cares but that he should still get his nails cut as needed. Resident 79's shower skin assessments were reviewed and revealed the following information: a. On 1/2/18, resident 79's CNA documented that resident 79's nails were not clipped and did not need clipping. b. On 1/9/18, resident 79's CNA documented that resident 79's nails were not clipped and did not need clipping. c. On 1/12/18, resident 79's CNA documented that resident 79's refused his shower and that his nails were not clipped and did not need clipping. On 1/16/18 at 12:58 PM, the Director of Nursing (DON) was interviewed. The DON stated that residents who need their nails cut should have them cut has needed during showers. The DON stated that she had in-serviced CNA staff on nail care and on ensuring that shower sheets are filled out completely and properly. The DON stated that she would look at resident 79's nails. On 1/16/18 at 2:10 PM, the DON was re-interviewed. The DON stated that she asked the staff to cut resident 79's nails after she saw them. The DON stated that resident 79's nails should have… | 2020-09-01 |
| 4 | 4 | HERITAGE PARK HEALTHCARE AND REHABILITATION | 465003 | 2700 WEST 5600 SOUTH | ROY | UT | 84067 | 2018-01-17 | 684 | D | 0 | 1 | 1JS611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined that the facility did not ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Specifically, residents were observed to be coughing during meals and were not assessed for swallowing difficulties. In addition, a resident with a physicians order for thickened liquids was observed to receive regular liquids. Resident identifiers: 65 and 66. Findings include: 1. Resident 66 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 1/11/18 at 12:28 PM, an observation was made of resident 66 in the Secure Needs Unit (SNU) dining room. Resident 66 was observed to be coughing. Resident 66 was observed to be served thin liquid beverages. Resident 66 was observed to cough when she drank the beverages. Resident 66's medical record was reviewed on 1/11/18. A nutrition care plan dated 9/6/17 and updated 1/5/18 revealed, (Resident 66) has nutritional problems or potential nutritional problems r/t (related to) edentulous, requires mechanically altered diet. One of the goals developed was, Tolerate diet texture. An intervention developed was, Monitor/document/report to MD (medical doctor) prn (as needed) for s/sx (signs and symptoms) of dysphagia: Pocketing, Choking, Coughing, Drooling, Holding food in mouth, Several attempts at swallowing, Refusing to eat, Appears concerned during meals. Resident 66's progress notes revealed the following entries: a. 1/2/18 at 1:57 PM, Res (resident) currently showing s/sx of influenza. MD notified. Obtain influenza A and B culture. b. 1/2/18 at 2:23 PM, .MD notified of lab results. No new orders at this time. c. 1/3/18 at 6:00 AM, Result received for flu swab on 1/2, negative for Influenza at this time. MD notified. [MEDICATION NAME] ordered for all. d. 1/5/18 at 2:27 PM, Registered Dietitian Note .Resident with flu s/s n … | 2020-09-01 |
| 5 | 5 | HERITAGE PARK HEALTHCARE AND REHABILITATION | 465003 | 2700 WEST 5600 SOUTH | ROY | UT | 84067 | 2018-01-17 | 689 | D | 0 | 1 | 1JS611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined for 2 of 30 sampled residents that the facility did not ensure that the resident's environment remains as free of accident hazards as is possible and each resident received adequate supervision and assistance devices to prevent accidents. Specifically, the facility did not provide adequate supervision to prevent a fall from occurring and care planned interventions were not implemented. Additionally, another resident had sustained [MEDICAL CONDITION] smoking a cigarette. Resident identifiers 64 and 66. Findings include: 1. Resident 64 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. On 1/09/18 at 2:15 PM, an observation was made of the resident's room. A fall mat was observed next to bed and the bed was in the lowest position. Resident 64 was observed laying on her left lateral side facing the wall. On 1/10/18 at 11:25 AM, an observation was made of resident 64's room. Resident 64 was not located in her room and this surveyor was unable to locate resident 64 anywhere on the locked unit. On 1/10/18 at 11:30 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that resident 64 propelled herself around the unit in her wheelchair. RN 1 stated she might have gone to an appointment. When asked who would inform him of her departure from the unit, RN 1 stated transportation would let him know. An observation was then made of RN 1 and Certified Nurse Assistant (CNA) 5 conducting a room to room search of the locked unit to locate resident 64. An observation was then made of RN 1 calling the transportation staff to inquire about resident 64's location. Activities Staff (AS) 1 located resident 64 in room [ROOM NUMBER] on the floor. Resident 64 was observed to be located in front of her wheelchair on the floor laying on her left side with her left cheek resting on the ground. RN 1 was observed to assess resident 64 by performing… | 2020-09-01 |
| 6 | 6 | HERITAGE PARK HEALTHCARE AND REHABILITATION | 465003 | 2700 WEST 5600 SOUTH | ROY | UT | 84067 | 2018-01-17 | 692 | D | 0 | 1 | 1JS611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined that the facility did not maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range, unless the resident's clinical condition demonstrated that this was not possible. Specifically, there were 2 resident's that lost weight and nutritional interventions developed were not implemented. Resident identifiers: 11 and 66. Findings include: 1. Resident 11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 1/9/18 at 12:45 PM, resident 11 was observed in the Secured Unit (SNU) dining room. Resident 11 was observed to ask the Restorative Nurses Aide (RNA) to take her back to her room. Resident 11 was observed to eat 1 bite of food from her plate. RNA confirmed resident 11 ate 1 bite of food. On 1/10/18 at 8:02 AM, resident 11 was observed in the SNU dining room. Resident 11 was observed to drink coffee with milk. Resident 11 was observed to not be served nutritional supplement drink. Resident 11 did not eat more than 25 percent of her meal. On 1/17/18 at 7:57 AM, an observation was made of resident 11 in the SNU dining room. Resident 11 was observed to pour milk into her coffee. Resident 11 was not observed to be provided a nutritional supplement drink. On 1/17/18 at 8:00 AM, an interview was conducted with Certified Nursing Assistant (CNA) 6. CNA 6 stated that nutritional supplement drinks were served with resident's meal and not when coffee was served. Resident 11's medical record was reviewed on 1/11/18. Resident 11's weights documented in the electronic medical record were: (Note: All weights were in pounds.) a. 7/5/17 97.25 b. 8/2/17 95.25 c. 9/5/17 90.25 d. 10/5/17 90.75 e. 11/8/17 90.5 f. 12/8/17 90.5 e. 12/29/17 89.0 g. 1/5/18 89.5 h. 1/12/18 86.0 Resident 11's nutrition progress notes revealed the following: a. 10/20/17 at 4:15 PM, Registered Dietitian Note: Resident back to 90.75#, same as 10/5 wt (weight).… | 2020-09-01 |
| 7 | 7 | HERITAGE PARK HEALTHCARE AND REHABILITATION | 465003 | 2700 WEST 5600 SOUTH | ROY | UT | 84067 | 2018-01-17 | 697 | D | 0 | 1 | 1JS611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined for 1 of 30 sampled resident that the facility did not ensure that pain management was provided to residents who require such services. Specifically, a resident sustained [REDACTED]. Resident identifier 64. Findings include: Resident 64 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. On 1/10/18 at 11:30 AM, resident 64 was found on the floor in an unoccupied room. Resident 64 was observed to be located in front of her wheelchair on the floor laying on her left side with her left cheek resting on the ground. Registered Nurse (RN) 1 was observed to assess resident 64 by performing range of motion (ROM) flexion/extension exercise of resident 64's right lower extremity from the knee joint down. Resident 64 was observed to be non-verbal at this time and eyes were open. An observation was made of RN 1 and Certified Nurse Assistant (CNA) 3 assisting resident 64 into a sitting position and then transfer her into the wheelchair. RN 1 was then observed to assess ROM flexion/extension of bilateral lower and upper extremities, pupil response testing, and then squeeze resident 64's hips. An observation was made of resident 64's posture in the chair as forward leaning and resident 64 was unable to hold herself up independently. RN 1 was observed to hold resident 64 in place in wheelchair during the transfer back to her room. Resident 64 was transferred back to bed with a 2 person assist by RN 1 and CNA 3 by a pivot transfer method. Resident 64 was observed to be unable to bear weight on her left lower extremity and the knee was bent with the leg drawn upward. CNA 3 stated that resident 64 could normally stand with assistance for incontinence brief changes and that her current inability to stand was a change from her baseline. RN 1 noted to exit the room leaving CNA 3 alone to provide cares. On 1/10/18 at 11:47 AM, an observation was made of the Me… | 2020-09-01 |
| 8 | 8 | HERITAGE PARK HEALTHCARE AND REHABILITATION | 465003 | 2700 WEST 5600 SOUTH | ROY | UT | 84067 | 2018-01-17 | 744 | D | 0 | 1 | 1JS611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview it was determined for 1 of 30 sampled residents that the facility did not provide the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being for a resident diagnosed with [REDACTED]. Resident identifier 68. Findings include: Resident 68 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 01/09/18 at 10:43 AM an observation was made of Certified Nursing Assistant (CNA) 3 providing incontinence care to resident 68. An observation was made of resident 68 hitting and biting CNA 3 during the incontinence care and nearly striking CNA 3's face. CNA 3 was observed to continue with the care until finished. Resident 68 was observed to be agitated and combative the entire time. An immediate interview was conducted with CNA 3. CNA 3 stated, The resident gets agitated a lot. CNA 3 stated that the nurse usually gave resident 68 medication to calm her down, and further stated that nothing else calms resident 68 down. On 1/9/18, resident 68's electronic medical records was reviewed. Review of resident 68's orders revealed the following: a. [MEDICATION NAME] ([MEDICATION NAME]) tablet 0.5 milligram (mg) by mouth two times a day. b. Non-Pharmalogical interventions done: 1. Redirection, 2. Speak to/Approach in a calm manner, 3. Reposition, 4. Offer snacks/fluid/milk, 5. Assess for pain, 6. Provide a quiet environment, 7. Encourage to express feelings, 8. Take to activities, 9. Provide reassurance ([MEDICATION NAME]) every shift. Review of the progress note on 6/25/17 revealed, Resident was kicking and grabbing at staff to get their attention. Staff attempted redirection, giving snacks, and giving her an activity, resident continued to come to staff and kick and grab. Review of care plan revealed the following focus areas and interventions: a. Has impaired cognitive function/dementia with an intervention of refer to MY WAY plan of ca… | 2020-09-01 |
| 9 | 9 | HERITAGE PARK HEALTHCARE AND REHABILITATION | 465003 | 2700 WEST 5600 SOUTH | ROY | UT | 84067 | 2018-01-17 | 760 | D | 0 | 1 | 1JS611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined that residents were not free of significant medication errors for 2 of 30 sample residents. Specifically, a licensed nurse administered prescribed medications to the wrong residents twice. Resident identifiers: 65 and 73. Findings include: 1. Resident 65 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 65's medical record was reviewed on 1/11/18. Upon admission to the facility, orders were to administer the following medications to resident 65: a. [MEDICATION NAME] 100 mg (milligrams) daily; b. [MEDICATION NAME] 40 mg daily; c. [MEDICATION NAME] 60 mg daily; d. Vitamin D3 units daily; e. [MEDICATION NAME] 0.25 mg twice a day; and f. Potassium Chloride 30 meq (milliequivalents) twice a day; On 12/6/17 at 11:58 AM, Registered Nurse (RN) 2 documented in a progress note, Nurse came on shift with two new residents. One resident came to the nurses station and asked for her medications. Nurse asked for her name and resident did not reply. CNA (Certified Nurse Assistant) stated her name and nurse as resident 'are you _____?' resident replied yes. Res (Resident) was given wrong morning medications. Nurse assessed resident and her vitals are BP (blood pressure) 118/70 HR (heart rate) 71 Temp (temperature) 98.1 RR (respiration rate) 20. MD (Medical Doctor) assess Resident stated that resident was acting normal and that he had no issues or concerns. Approx. (approximately) 45 minutes after taking medications resident threw up. (Note: Resident 63 was given resident 73's ordered medications.) 2. Resident 73 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 73's medical record was reviewed on 1/11/18. Upon admission to the facility, orders were to administer the following medications to resident 73: a. Donepezil 10 mg daily; b. [MEDICATION NAME] 125 mcg (micrograms) daily; c. [MEDICATION NAME] 28 mg daily; d. Potassium Chloride 20 meq daily; and e. Api… | 2020-09-01 |
| 10 | 10 | HERITAGE PARK HEALTHCARE AND REHABILITATION | 465003 | 2700 WEST 5600 SOUTH | ROY | UT | 84067 | 2018-01-17 | 801 | D | 0 | 1 | 1JS611 | Based on interview and record review it was determined that the facility did not employ a clinically qualified full-time dietitian or another clinically qualified nutrition professional to serve as the director of food and nutrition services. Specifically, the facility did not a employee a full time Registered Dietitian (RD) and the Dietary Manager (DM) did not meet the requirements to serve as the director of food and nutrition services. Findings include: On 1/9/18 at 8:14 AM, an interview was conducted with the facility DM. The DM stated that the RD billed the facility for 59 hours during the month of (MONTH) (YEAR). The DM stated that the RD was not full time. On 1/17/18 at 10:30 AM, the Administrator provided an e-mail dated 10/9/17 from the facility RD. The e-mail revealed that the DM qualified . to take the 90 hour nutrition training for pathway III for CDM (Certified Dietary Manager). On 1/17/18 at 10:30 AM, an interview was conducted with the Administrator. The Administrator stated that the DM was not currently enrolled in a dietary course to obtain the qualifications. The Administrator stated that he thought the requirements were not in effect until 11/28/18. | 2020-09-01 |
| 11 | 11 | HERITAGE PARK HEALTHCARE AND REHABILITATION | 465003 | 2700 WEST 5600 SOUTH | ROY | UT | 84067 | 2018-01-17 | 802 | E | 0 | 1 | 1JS611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined that the facility did not employ sufficient staff with appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity and [DIAGNOSES REDACTED]. Specifically, meals were observed to be served late in the secured unit. Resident identifiers: 66 and 73. Findings include: 1. The following Meal Service Times were posted in the dining room: A & D Halls Breakfast 7:45 AM Lunch 12:00 PM Dinner 5:45 PM 2. On 1/10/18 at 8:00 AM, an observation was made in the secured/D hall dining room. Resident 73 was observed to be drinking other residents beverages at her table prior to her meal being served. Resident 73 was served at 8:02 AM. Resident 73 was observed to not take other residents beverages after the breakfast meal was served. (Note: The breakfast meal was served 15 minutes after the posted meal time.) 3. On 1/16/18 at 8:05 AM, observations were made in the secured/D hall dining room. A resident was yelling out, resident 73 was observed to stand up and walk around the dining room. Resident 73 was observed to not sit to eat until 8:21 AM when her breakfast meal was served. Resident 66 was observed to lean to the side in her booth. Resident 66 was observed to be moving sideways multiple times until her food was served. Another resident was observed yelling out until his food was served. (Note: The first tray was served 31 minutes after the posted meal time.) 4. On 1/17/18 at 10:49 AM, an interview was conducted with the Dietary Manager (DM) and Cook 1. The DM stated that she did not know why the breakfast meals were served late. Cook 1 stated that the food left the kitchen at 7:40 AM. Cook 1 stated that the C hall was served before the D hall on 1/16/18. 5. On 1/17/18 at 9:00 AM, an interview was conducted with the Registered Dietitian (RD). The RD state… | 2020-09-01 |
| 12 | 12 | HERITAGE PARK HEALTHCARE AND REHABILITATION | 465003 | 2700 WEST 5600 SOUTH | ROY | UT | 84067 | 2018-01-17 | 812 | E | 0 | 1 | 1JS611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview it was determined that the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, taco seasoning and dried herbs were open to the air; the oven doors were soiled with a white substance; the ice machine drain was not 2 inches above the floor drain; the ice cream refrigerator was soiled; and the dish machine chemicals had a small opening in the tube from the dish machine. Findings include: 1. On 1/9/18 at 8:14 AM, an initial tour was conducted of the facility kitchen. The following observations were made: a. There was taco seasoning, ground [MEDICATION NAME], and whole tarragon leaves open to air. b. The oven doors were soiled with a white substance. c. The ice machine had a drain that was not 2 inches above the floor drain. d. The ice cream refrigerator was soiled on the outside. e. The dish machine chemicals labeled Ultra San had a small opening that the tube from the dish machine was in. On 1/16/18 at 12:44 PM, an interview was conducted with the Registered Dietitian (RD). The RD confirmed the above observations. 2. On 1/17/18 at 10:49 AM, a follow up interview observation was made of the facility kitchen. a. The ice cream refrigerator was soiled. b. The oven doors were soiled with a white substance. c. The side of the stove was soiled with white substance. An interview was immediately conducted with the Dietary Manager (DM). The DM stated that the white substance on the oven doors was between the glass. The DM confirmed that the ice cream refrigerator was soiled. The DM stated she did not know why the Ultra San did not have the small opening covered. | 2020-09-01 |
| 13 | 13 | HERITAGE PARK HEALTHCARE AND REHABILITATION | 465003 | 2700 WEST 5600 SOUTH | ROY | UT | 84067 | 2018-01-17 | 880 | E | 0 | 1 | 1JS611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview it was determine for 5 of 30 sampled residents that the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, a resident was observed to handle the beverage carafes in the dining room and drink from other resident's glasses, a resident was observed to wipe her nose on the dining room table cloths, a residents tube feeding tubing connector was contaminated and reconnected to the resident without being changed, and multiple residents were observed to have a productive cough during dining in the dining room. Resident identifiers: 11, 54, 64, 68, and 73. Findings include: 1. Resident 68 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 1/9/18 at 12:07 PM and at 12:25 PM, an observation was made of resident 68 wiping her nose on the dining room table cloth during the lunch meal. No observation was made of the dining room table linens being changed. Resident 68 was also observed to have a wet productive cough during the lunch meal. On 1/09/18 at 10:43 AM, resident 68 was heard moaning and coughing from hallway. On 1/10/18 at 8:22 AM, an observation was made of resident 68 wiping her nose on the dining room table cloth during the breakfast meal. No observation was made of the dining room table linens being changed. Resident 68 was also observed to have a wet productive cough during the breakfast meal. On 1/9/18, resident 68's electronic medical records was reviewed. Review of the nursing progress notes on 1/2/18 stated, Note Text: Res (Resident) started on [MEDICATION NAME] 75 mg (milligrams) BID (twice a day) x (times) 5 days per MD (Medical Doctor) request for [MEDICATION NAME]. Review of the labs revealed no documentation to indicate that resident 68 was tested for influenza. Review of the temperature summar… | 2020-09-01 |
| 14 | 14 | HERITAGE PARK HEALTHCARE AND REHABILITATION | 465003 | 2700 WEST 5600 SOUTH | ROY | UT | 84067 | 2019-02-21 | 684 | D | 0 | 1 | R8D511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review it was determined, for 2 of 41 sample residents, that the facility did not ensure that a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choice. Specifically, one resident who had a tube feeding was not positioned appropriately to receive the feeding per the plan of care and one resident who had pressure ulcers did not have her heels floated per the plan of care. Resident identifiers: 9 and 57. Findings include: 1. Resident 9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 2/19/19 at 10:01 AM, an observation was made of resident 9 as she was lying in bed. Resident 9's bed was observed to be at approximately a 20 degree angle. Resident 9 was observed to have slid down in bed, lying flat with her chin resting on her chest. Resident 9's tube feeding was observed to be running. The care plan dated 2/4/19 for resident 9 revealed that resident 9 had a care area of (Resident 9) requires tube feeding r/t (related to) coma. The goal for resident 9 included Will remain free of side effects or complications related to tube feeding through review date. Feeding tube insertions site will be free of s/sx (signs and symptoms) of infection through the review date. Will maintain adequate nutritional and hydration status aeb (as evidenced by) weight stable, no s/sx of malnutrition or dehydration through review date. The interventions for resident 9 included HOB (head of bed) elevated 45 degrees during and thirty minutes after tube feed Elevate HOB at least 30-45 degrees at all times during feeding On 2/21/19 at 8:32 AM, an observation was made of resident 9 as she was lying in bed. Resident 9 was observed to be lying flat. Resident 9's tube feeding was observed to be running. On 2/21/19 at 8:40 AM, an interview was conducted with Certified Nursing Assistant (CNA) 2. CNA 2 stated that … | 2020-09-01 |
| 15 | 15 | HERITAGE PARK HEALTHCARE AND REHABILITATION | 465003 | 2700 WEST 5600 SOUTH | ROY | UT | 84067 | 2019-02-21 | 688 | D | 0 | 1 | R8D511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined that the facility failed to ensure a resident with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. Specifically, 1 of 41 sample residents did not receive appropriate range of motion services and experienced a decline in range of motion. Resident identifier: 17. Findings include: Resident 17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 2/19/19 at 9:45 AM, an observation was made of resident 17. Resident 17 was observed laying in a tilt and space wheelchair, and had contractures to the left upper area of his body. On 2/20/19, resident 17's care plans were reviewed. Resident 17's care plan related to his physical mobility, dated 9/25/17 and revised 1/5/18, documented the following information: a. Focus: (Resident 17) has limited physical mobility r/t (related to) Contracture to L wrist (left), hand, shoulder, hips, knees, and right ankle . b. Goal: Will remain free of complications related to immobility, including contractures, thrombus formation, skin-breakdown, fall related injury through the next review date . c. Interventions: MOBILITY: Is totally dependent on staff for locomotion . MOBILITY: Uses Tilt & (and) Space w/c (wheelchair) for locomotion . Monitor/document/report to MD (Medical Director) PRN (as needed) s/sx (signs or symptoms) of immobility: contracture forming or worsening, thrombus formation, skin-breakdown, fall related injury . Provide gentle range of motion as tolerated with daily care . On 2/21/19 at 8:40 AM, an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated she was not sure what the restorative therapy staff did for resident 17's contractures. On 2/21/19 at 8:09 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated she did not know what kind of range of motion services resident 17… | 2020-09-01 |
| 16 | 16 | HERITAGE PARK HEALTHCARE AND REHABILITATION | 465003 | 2700 WEST 5600 SOUTH | ROY | UT | 84067 | 2019-02-21 | 710 | E | 0 | 1 | R8D511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined for 1 of 41 sample residents, that the facility did not ensure that each resident's medical care was supervised by a physician. Specifically, a resident's Primary Care Physician (PCP) did not respond to a [MEDICAL CONDITION] meeting recommendation for approximately two and a half months. Findings include: Resident 21 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 2/21/19, a review of resident 21's medical record was completed. Resident 1's [MEDICAL CONDITION] Quarterly Review dated 8/13/18 revealed that resident 21 was on 12.5 milligrams (mg) [MEDICATION NAME] twice daily (BID) and that the committee recommended to discontinue the [MEDICATION NAME]. Resident 21's PCP signed the review in agreement on 10/23/18. On 11/13/18, a facility nurse signed and 'noted' the physician's agreement. (Note: The PCP did not respond to the [MEDICAL CONDITION] Committee's recommendation from 8/13/18 through 10/23/18. After the PCP agreed to the recommendation it was 3 weeks before the facility noted the agreement and discontinued resident 21's [MEDICATION NAME].) A review of resident 21's progress notes revealed the following information. a. On 8/15/18 at 11:41 AM, Resident reviewed in [MEDICAL CONDITION] meeting. Resident currently taking Duloxetine 30 mg Q (every) AM, tracking negative statements, 4 noted. Also taking [MEDICATION NAME] 12.5 mg BID, tracking hallucinations, 7 noted. Recommended to d/c (discontinue) [MEDICATION NAME]. Re-eval (evaluate) in 90 days. MD (Medical Director) agrees with recommendation at this time. Notified daughter of change. b. On 11/14/18 at 3:11 PM, clarification: reviewed in [MEDICAL CONDITION] meeting 8/13/18, just received response to recommendation on 11/12/18. c. On 11/13/18 at 3:11 PM, N.O. (new order) d/c (discontinue) [MEDICATION NAME] (QUEtiapine [MEDICATION NAME]) Give 12.5 mg by mouth two times a day for mood disorder DISCONTINUE Date/Reason… | 2020-09-01 |
| 17 | 17 | HERITAGE PARK HEALTHCARE AND REHABILITATION | 465003 | 2700 WEST 5600 SOUTH | ROY | UT | 84067 | 2019-02-21 | 761 | E | 0 | 1 | R8D511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview it was determined that the facility did not ensure safe and secure storage of drugs and biologicals in accordance with accepted professional principles; or include the appropriate accessory and cautionary instructions, and the expiration date on the medication. Specifically, opened multi-dose vials of insulin were not labeled with open dates and opened multi-dose vials of insulin were expired and still available for use. Additionally, an insulin pen with instructions to keep refrigerated was found on a medication cart. Findings include: On 2/20/19 at 7:30 AM, an observation was made of a medication cart on the A hall. Observations were made of the following insulin medications: [REDACTED] a. [MEDICATION NAME] 100 unit/ml (milliliter) vial opened with an expiration date of 2/16/18. b. [MEDICATION NAME] R 100 unit/ml vial opened with no open date. c. Humulog 100 unit/ml vial opened with no open date. On 2/20/19 at 7:35 AM, an interview was conducted with Registered Nurse (RN) 3 on the A hall. RN 3 confirmed the above insulin medication were opened and expired or had no open date on the vials. RN 3 stated insulin was to be discarded 28 days after it was opened. RN 3 stated the night shift audited the cart for expired medications. RN 3 stated she would discard then above mentioned insulin vials. On 2/20/19 at 7:45 AM, an observation was made of a medication cart on the C hall. Observations were made of the following insulin medications: [REDACTED] a. [MEDICATION NAME] 100 unit/ml (3 ml) insulin pen, unopened and not refrigerated. Instructions were attached to the pen to keep refrigerated. b. [MEDICATION NAME] 100 unit/ml vial opened and dated 1/15/19. c. [MEDICATION NAME] R 100 unit/ml vial, opened, with no open date. d. [MEDICATION NAME] 100 unit/ml vial, opened and dated 1/12/19. On 2/20/19 at 7:50 AM, an interview was conducted with RN 4 on the C hall. RN 4 stated the Unit Manager audited the medications cart… | 2020-09-01 |
| 18 | 18 | HERITAGE PARK HEALTHCARE AND REHABILITATION | 465003 | 2700 WEST 5600 SOUTH | ROY | UT | 84067 | 2019-02-21 | 810 | E | 0 | 1 | R8D511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined the facility failed to provide special eating equipment and utensils for residents who need them. Specifically, 1 of 41 sample residents did not receive a weighted spoon in accordance with physician's orders [REDACTED]. Findings include: Resident 28 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 2/19/19 at 12:15 PM, an observation was made of resident 28 during lunch service. Resident 28 was observed to scoop ground meat onto her fork and attempted to bring the fork to her mouth. Resident 28 was observed to visibly shake and struggled to guide the fork to her mouth, and the ground meat fell off of her fork and onto her lap. Resident 28 was then observed to use her hands to eat the remainder of the meal. (Note: Resident 28's silverware was not weighted.) On 2/20/19 at 12:16 PM, a follow up observation was made of resident 28 during lunch service. Resident 28 was observed to cut a piece of pie into smaller pieces using a spoon. Resident 28 was then observed to eat each bite of pie and a bowl of diced fruit with her hands. (Note: Resident 28's silverware was not weighted.) On 2/20/19, resident 28's physician orders [REDACTED]. a. Order: FORTIFIED diet, MECHANICAL SOFT - Chopped texture, HONEY THICK consistency b. Directions: scoop plate, SIPPY CUP, POSITION FULLY UP RIGHT, x (extra) -SAUCE/GRAVY TO MEAT WHEN APPLICABLE. Finger food as able. AM (morning) snack coffee & (and) health shake. WEIGHTED SPOON. Health shake TID (three times per day) with meals. Cheeseburger w/ (with) fries Q (every) L (lunch) & D (dinner) non ground hamburge (sic) On 2/20/19, resident 28's Registered Dietitian notes were reviewed. The notes documented the following information: a. 10/4/18; Diet: FORTIFIED MECHANICAL SOFT - Chopped texture, HONEY THICK consistency, scoop plate, SIPPY CUP, POSITION FULLY UPRIGHT . WEIGHTED SPOON . b. 3/15/18; Diet: FORTIFIED MECHANICAL SOFT, HONEY … | 2020-09-01 |
| 19 | 19 | HERITAGE PARK HEALTHCARE AND REHABILITATION | 465003 | 2700 WEST 5600 SOUTH | ROY | UT | 84067 | 2019-02-21 | 812 | E | 0 | 1 | R8D511 | Based on observation, record review, and interview, it was determined that the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service and safety. Specifically, food items were covered in frost, food items were not labeled and dated properly, food items were beyond the use by date, and steam table trays were unsanitary. Findings include: On 2/19/19 at 8:20 AM, the following observations were made during initial tour of the facility kitchen. a. In the walk-in refrigerator, i. A squeeze bottle of what appeared to be ranch lacked a date, food label and had residue around the bottle opening. Dietary Staff Member (DSM) 1 was interviewed. DSM 1 disposed of the ranch. ii. A 5 pound container of cottage cheese was open and lacking an open date. iii. A 5 pound container of sour cream was open and lacking an open dated. DSM 1 stated that both the sour cream and cottage cheese should have an open dated. DSM 1 stated that he was uncertain how long they could be kept once open but would say 30 days and could find out. iv. A carton of liquid eggs was open without an open dated. DSM 1 stated that the eggs are usually used within the day they are opened and he was surprised to see an opened container in the refrigerator. b. In the walk-in freezer, i. A box of lo mein was being stored on the floor. ii. Hot dogs stored in a zip-top bag had considerable frost. c. In the pan storage and dry food storage areas, there was considerable dirt and debris on the floors. d. In the reach in freezer, i. Deli chicken stored in a zip-top bag had considerable frost. ii. Black beans stored in a zip-top bag had considerable frost. iii. Red beans stored in a zip-top bag had considerable frost. On 2/19/19 at 11:50 AM, during lunch service an observation was made of the steam trays. The steam table had four tray wells. The first tray well did not contain water, food splatter and residue was observed on the interior sides and bottom of the tray. DSM 2 was observed to place the plate bases … | 2020-09-01 |
| 20 | 20 | HERITAGE PARK HEALTHCARE AND REHABILITATION | 465003 | 2700 WEST 5600 SOUTH | ROY | UT | 84067 | 2019-02-21 | 880 | E | 1 | 1 | R8D511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and interview, it was determined that the facility failed to establish and maintain an Infection Prevention and Control Program (IPCP) designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, staff did not place signage outside a resident's room identifying the need for transmission-based precautions, two resident rooms had signage that had fallen off the wall. Multiple rooms of residents with respiratory illness with resistant bacteria, had PPE (personal protective equipment) at the resident door, had garbage cans that were spilling over with PPE in the resident room and/or garbage cans that were within three feet of the resident when doffing PPE in resident rooms. Additionally, cross contamination was observed in the dining room. Resident identifiers: 9, 10, 15, 57 and 58. Findings include: 1. Resident 9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 2/20/19 at 9:25 AM, an observation was made of resident 9's pressure ulcer dressing change. When the dressing change was completed, an observation was made of facility staff and this surveyor, taking off PPE and placing it in the resident's regular garbage receptacle near the door. The garbage receptacle was observed to have multiple items of PPE and spilling over the top, thus allowing gloves and masks to fall to the floor. 2. Resident 10 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 2/19/19 at 11:10 AM, an interview was conducted with resident 10's daughter. An observation was made of resident 10's daughter in his room without the use of PPE. Resident 10's daughter was sitting at his side while in his recliner. Resident 10's daughter was observed to be touching resident 10, the arm of the recliner, the top of the overbed table and other surfaces in resident 10's room. Add… | 2020-09-01 |
| 21 | 21 | HERITAGE PARK HEALTHCARE AND REHABILITATION | 465003 | 2700 WEST 5600 SOUTH | ROY | UT | 84067 | 2017-05-03 | 225 | D | 1 | 0 | 74IB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review the facility did not thoroughly investigate or report an allegation of abuse or neglect for 2 of 11 sample residents. Resident identifiers: 8 and 11. Findings include: On 5/3/17 at 12:45 PM, an interview was conducted with resident 8 regarding the care she received at the facility. When asked whether she felt she was treated with respect and dignity, resident 8 stated that there was one Certified Nursing Assistant (CNA) who was rude. When asked to explain, resident 8 stated that CNA 2 had lied to her when she requested a snack, stating there weren't any available. Resident 8 also stated that CNA 2 had humiliated other staff members in front of her. Resident 8 also stated that CNA 2 had yelled at her when she asked for help, saying she did not have time to help the resident. Resident 8 stated that she refused to have CNA 2 assist her with any more cares. On 5/3/17 at 1:00 PM, CNA's 2 employee record was reviewed. CNA 2's employee record revealed a Corrective Action Plan (CAP) for the CNA dated 11/23/16. The CAP revealed that CNA 2 had been given a written warning regarding her work performance. The following items were listed as the performance issues that warranted the written warning: .10/1/16: Reported that aid refused to do showers because it is 'not her job'. Or that staff member states resident is refusing showers when the resident is stating that they really want one. 10/1/16: Ignoring specific resident rooms call light. 10/1/116 (sic): Transferring residents via hoyer lift without mandated second staff member present. 10/1/16: Leaving resident dirty linens in their rooms or left on the resident to sleep in. 10/1/16: Speaking Spanish in front of the residents with other staff in the resident rooms. 10/17/16: Not washing hands before and after resident cares. Not washing hands before serving food in the dining room. 10/17/16: Bringing a dead bird into the facility, into the resident dining area, pre… | 2020-09-01 |
| 22 | 22 | HERITAGE PARK HEALTHCARE AND REHABILITATION | 465003 | 2700 WEST 5600 SOUTH | ROY | UT | 84067 | 2017-05-03 | 333 | D | 1 | 0 | 74IB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, it was determined that the facility did not ensure that residents were free of significant medication errors for 1 of 11 sample residents. Specifically, an antibiotic ordered to treat a urinary tract infection was not administered as ordered. Resident identifier: 9. Findings include: Resident 9 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 5/3/17 at 10:49 AM, an interview was conducted with resident 9. Resident 9 stated that she had a urinary tract infection with [MEDICAL CONDITION] resistant staphylococcus aureaus and had been treated with an antibiotic. Resident 9's medical record was reviewed on 5/3/17. Review of the physician's orders [REDACTED]. The licensed nursing staff documented that resident 9 was to be on contact isolation precautions related to [MEDICAL CONDITION] resistant staphylococcus aureaus. On 4/28/17 an order was received to discontinue the Bactrim DS and start resident 9 on [MEDICATION NAME] 100 mg (milligrams) 1 tablet by mouth twice a day for 5 days. Review of the Nurse's Notes revealed the following nursing entries: a. 4/21/17 from 6:00 AM to 6:00 PM: N (nausea) V (vomiting) noted. new order for [MEDICATION NAME] on contact precautions r/t (related to)[MEDICAL CONDITION] ([MEDICAL CONDITION] resistant staphylococcus aureaus) in urine UTI (urinary tract infection). b. 4/21/17 from 6:00 PM to 6:00 AM: .continues on abx (antibiotic). C/O (complained of) nauseated (sic) (with) abx given [MEDICATION NAME] for nausea (with) effective results. c. 4/22/17 from 6:00 PM to 6:00 AM: .She continues on ABX for UTI, tolerating treatment well, she has reported some nausea that is relieved with PRN (as needed) [MEDICATION NAME], no other adverse effects observed/reported. d. 4/23/17 at 10:30: .Pt. (patient) continues on abx for UTI . e 4/23/17 from 6:00 PM to 6:00 AM: .continues on abx (with) no adverse effects, she is tolerating well . f. 4/24/17 from 6:00 PM to 6:00 AM… | 2020-09-01 |
| 23 | 23 | HERITAGE PARK HEALTHCARE AND REHABILITATION | 465003 | 2700 WEST 5600 SOUTH | ROY | UT | 84067 | 2017-05-03 | 353 | E | 1 | 0 | 74IB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, it was determined the facility did not employee a sufficient number of staff to provide the cares to the resident as care planned. Specifically, 3 out of 11 residents stated that there was not enough staff, 1 resident did receive timely assistance with her activities of daily living, 2 staff members stated that there was not enough staff to complete their tasks as assigned, and the Resident Council complained of call lights not being answered timely in January, February, (MONTH) and April. Resident identifiers: 1, 7 and 10. Findings include: 1. On 5/3/17 at 8:29 AM, resident 1 was interviewed. Resident 1 stated that his call light had not been answered for an hour at times. 2. Resident 7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 7's medical record was reviewed on 5/3/17. Resident 7's nurses notes documented that resident 7 was incontinent of bladder and continent of bowel. A quarterly Minimum Data Set (MDS) assessment dated [DATE] for resident 7 was reviewed. Staff documented on the MDS that resident 7 was always incontinent of bladder, but always continent of bowel. On 5/3/17 at 11:10 AM, an interview was conducted with resident 7 regarding the cares she received at the facility. Resident 7 stated that there were not enough staff at the facility. Resident 7 stated that she was incontinent and that after she soiled her brief, she would press her call light to alert the staff that she required assistance with a brief change. Resident 7 stated that after she pressed her call light, she would have to wait at least an hour for staff to assist her because staff are more interested in gossiping than they are in helping me. 3. Resident 10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 10's medical record was reviewed on 5/3/17. A quarterly MDS assessment dated [DATE] for resident 10 was reviewed. Staff documented on the MDS that resident 10 was alway… | 2020-09-01 |
| 24 | 24 | HERITAGE PARK HEALTHCARE AND REHABILITATION | 465003 | 2700 WEST 5600 SOUTH | ROY | UT | 84067 | 2017-05-03 | 467 | E | 1 | 0 | 74IB11 | > Based on observation, it was determined the facility did not provide adequate ventilation to control odors. Specifically, there was pervasive odors throughout the facility. Resident identifier: 10. Findings include: 1. On 5/3/17 at 8:10 AM, there was a pervasive fecal odor throughout the Monarch hallway. The fecal odor maintained until a staff member sprayed an air freshener throughout the hallway. 2. On 5/3/17 at approximately 8:30 AM, an observation was made of room 10 on the 300 hall. There was an odor of urine in the hallway outside of the room, as well as inside the room. 3. On 5/3/17 at approximately 8:30 AM, an observation was made of room 19 on the 300 hall. There was an odor of urine in the hallway outside of the room, as well as inside the room. 4. On 5/3/17 at approximately 8:27 AM, an observation was made of resident 10. Resident 10 was laying in her bed with her eyes closed. There was an odor of urine in the hallway outside of resident 10's room. 5. On 5/3/17 at approximately 10:14 AM, an observation was again made of resident 10. Resident 10 appeared to be in the same position as observed earlier. There was an odor of urine in the hallway outside of resident 10's room. 6. On 5/3/17 at approximately 8:35 AM, an observation was made of the 400 hall. Upon entering the hall, a strong odor of both urine and fecal matter was present. The odor was observed throughout the hall. 7. On 5/3/17 at 8:36 AM, a facility staff member was observed to spray air freshner throughout the 400 hall. | 2020-09-01 |
| 25 | 25 | HERITAGE PARK HEALTHCARE AND REHABILITATION | 465003 | 2700 WEST 5600 SOUTH | ROY | UT | 84067 | 2016-08-18 | 241 | E | 0 | 1 | AV3G11 | Based on observation, the facility did not promote care for residents in a manner and in an environment that maintained or enhanced each resident's dignity and respect in full recognition of his or her individuality for 6 of 32 sample residents. Specifically, residents in the Special Needs Unit waited for their meals to be served for up to 40 minutes. Resident identifiers: 42, 71, 84, 91, 94 and 179. Findings include: On 8/15/16, the lunch meal was observed in the Special Needs Unit. At 11:50 AM, the dining observation began. Residents 42, 71, 84, 94 and 179 were seated at their assigned tables. The first tray was not delivered until 12:22 PM, which left the residents waiting for their lunch meal for 32 minutes before being served. On 8/16/16, the lunch meal was observed in the Special Needs Unit. At 11:55 AM, the dining observation began. Residents 71 and 91 were seated at their assigned table. The following was observed: a. At 12:13 PM, resident 71's meal was delivered. However, the cutlery was not delivered until 12:25 PM. Resident 71 waited a total of 30 minutes before she was able to eat her meal. b. At 12:17 PM, resident 91's meal was delivered. Resident 91 waited 22 minutes before being served her meal. On 8/17/16, the breakfast meal was observed in the Special Needs Unit. At 8:09 AM, the dining observation began. Residents 84 and 91 were seated at their assigned table. The following was observed: a. At 8:13 AM, resident 91 was served a glass of milk and juice. At 8:17 AM, resident 91 leaned forward and attempted to lick the juice out of the glass. At 8:23 AM, resident 91 leaned forward again to attempt to lick the juice out of the glass. At 8:24 AM, resident 91's breakfast meal was served. At 8:27 AM, Certified Nurse Assistant (CNA) 1 assisted resident 91 to eat her breakfast. Resident 91 waited 27 minutes before she was able to eat her meal. b. At 8:37 AM, resident 84's breakfast meal was delivered. Resident 84 waited 28 minutes for his meal to be delivered. On 8/17/16, the noon meal was observed in the … | 2020-09-01 |
| 26 | 26 | HERITAGE PARK HEALTHCARE AND REHABILITATION | 465003 | 2700 WEST 5600 SOUTH | ROY | UT | 84067 | 2016-08-18 | 282 | E | 0 | 1 | AV3G11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined the facility did not provided services in accordance with each resident's written plan of care for 4 of 32 sample residents. Specifically, the facility staff did not assess the resident's food preferences. Resident identifiers: 71, 84, 91, and 179. Findings include: 1. Resident 91 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 91's medical record was reviewed on 8/17/16. Review of the care plans developed for resident 91 revealed a Nutritional risk m/b (manifested by) needs assist w (with)/meals/eating, cognitive and physical decline, mood & (and) behavior, restless, significant st (short term (memory) loss in six months r/t (related to) MS [MEDICAL CONDITIONS](gastro-esphageal reflux disease), gingivitis, risk caries & periodontal disease that was developed on 11/18/15. The Goals that were developed included, Will have no significant weight change through 10/25/16. The interventions developed to achieve the goal included, Honor my food likes and dislikes. There was no documentation in the medical record which indicated that resident 91's food preferences were assessed. On 8/16/16 at approximately 2:00 PM, an interview was conducted with the Dietary Manager (DM) 1. The DM 1 stated that resident 91's likes and dislikes had been assessed and would provide a copy of the likes and dislikes to the survey staff. (Note: A copy of resident 91's likes and dislikes were not provided to the survey staff on 8/16/16.) On 8/16/16, the DM 1 completed a Food Preferences Interview with resident 91's husband and consultation with the nursing staff. 2. Resident 179 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 179's medical record was reviewed on 8/16/16 On 8/16/16, resident 179's nutrition care plan was reviewed. Resident 179's nutrition care plan included to honor food and fluid likes and dislikes. Resident 179's likes and dislikes could not be loc… | 2020-09-01 |
| 27 | 27 | HERITAGE PARK HEALTHCARE AND REHABILITATION | 465003 | 2700 WEST 5600 SOUTH | ROY | UT | 84067 | 2016-08-18 | 309 | D | 0 | 1 | AV3G11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, it was determined for 1 of 32 sample residents that the facility did not provide the necessary care and services to maintain the highest practicable physical, mental, and psychosocial well-being. Specifically, the facility staff were not coordinating care with a contracted hospice company. Resident identifiers: 94. Findings include: Resident 94 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 8/16/16 at 1:00 PM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated there was a sticker in the front of the resident's medical record identifying if the resident was on hospice. RN 1 was not able to identify how the hospice agency communicates with the facility regarding resident 94's care. RN 1 stated that the hospice notes could be located under the hospice tab in the medical record. (Note: Resident 94's hospice tab in the medical record was one sheet of paper containing patient care notes dated 8/5/16, 8/9/16, and 8/12/16 written by the licensed facility staff.) On 8/16/16 at 1:25 PM, an interview was conducted with the Director of Nursing (DON). The DON stated the hospice agency faxes documentation related to resident 94's care to the facility. The DON stated that the recent faxes for resident 94 may not have been filed as yet. On 8/16/16 at approximately 2:30 PM, the health information employee provided hard copies of resident 94's hospice notes. The health information employee stated the medical record for resident 94 now contained the hospice documentation that had not been filed. Upon review of Resident 94's medical record, the hospice physician certified hospice services beginning 7/20/16. The hospice initial plan of care was dated 7/20/16. However, the notes were not accessible for facility staff to review and plan care. 8/16/16 at 2:53 PM, surveyor requested the DON locate the hospice notes for Resident 94 beginning 7/28/16 to current that were not in … | 2020-09-01 |
| 28 | 28 | HERITAGE PARK HEALTHCARE AND REHABILITATION | 465003 | 2700 WEST 5600 SOUTH | ROY | UT | 84067 | 2016-08-18 | 329 | D | 0 | 1 | AV3G11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined for 1 of 32 sample residents, the facility did not ensure that each resident's drug regimen was free from unnecessary drugs. An unnecessary drug is any drug when used without adequate indication for its use. Specifically, an antipsychotic medication was administered on an as needed basis for pacing up and down the hallway. Resident identifier: 91. Findings include: Resident 91 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 91's medical record was reviewed on 8/17/16. On 6/18/16, an order was received to administer [MEDICATION NAME] 5 mg (milligrams) as needed daily. Review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. The agitation was documented as Cont (continuous) Pacing. On two separate occasions, the licensed nurse administered the [MEDICATION NAME] along with two 5-325 mg [MEDICATION NAME] tablets and [MEDICATION NAME] 2 mg. Review of the (MONTH) (YEAR) MARs revealed that the [MEDICATION NAME] was administered twice for being restless and with agitation. The agitation was documented as Cont Pacing. The [MEDICATION NAME] was administered with two 5-325 mg [MEDICATION NAME] tablets and [MEDICATION NAME] 2 mg on one occasion. On 8/17/16 at 1:00 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that resident 91 went to a Neurologist appointment on 6/18/16 and returned with a new order to administer the [MEDICATION NAME] as needed. The DON stated that resident 91 had not had an increase in her behaviors. The DON was unable to state why the [MEDICATION NAME] was administered for continuous pacing. | 2020-09-01 |
| 29 | 29 | HERITAGE PARK HEALTHCARE AND REHABILITATION | 465003 | 2700 WEST 5600 SOUTH | ROY | UT | 84067 | 2016-08-18 | 333 | D | 0 | 1 | AV3G11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined the facility did not ensure that residents were free of significant medication errors for 2 of 32 sampled residents. Specifically, resident's did not receive insulin as ordered by the physician. Resident identifiers: 152 and 191. Findings include: 1. Resident 152 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 152's medical record was reviewed on 8/17/16. A physician's orders [REDACTED]. If blood sugar less than 80 notify the Medical Doctor (MD), If blood sugar 80 to 140, give no insulin; If blood sugar 141 to 180, give 3 Units; If blood sugar 181 to 220, give 4 Units; If blood sugar 221 to 260, give 6 Units; If blood sugar 261 to 300, give 8 Units; If blood sugar 301 to 340, give 10 Units; If blood sugar 341 to 380, give 12 Units; If blood sugar 381 to 420, give 14 Units; If blood sugar greater than 420 notify the MD. A review of resident 152's (MONTH) (YEAR), (MONTH) (YEAR), and (MONTH) (YEAR) Medication Administration Record [REDACTED] a. On 6/11/16 at 7:00 AM, a blood sugar of 197 was documented. Resident 152 received 3 Units of insulin instead of the 4 Units per the sliding scale. b. On 6/12/16 at 7:00 AM, a blood sugar of 143 was documented. Resident 152 received no insulin instead of the 3 Units per the sliding scale. c. On 6/15/16 at 11:30 AM, a blood sugar of 143 was documented. Resident 152 received no insulin instead of the 3 Units per the sliding scale. d. On 6/24/16 at 9:00 PM, a blood sugar of 179 was documented. Resident 152 received 4 Units of insulin instead of the 3 Units per the sliding scale. e. On 7/3/16 at 7:00 AM, a blood sugar of 141 was documented. Resident 152 received 1 Unit of insulin instead of the 3 Units per the sliding scale. f. On 8/3/16 at 4:30 PM, a blood sugar of 143 was documented. Resident 152 received no insulin instead of the 3 Units per the sliding scale. 2. Resident 191 was admitted to the facility on [DATE] with [DIAGN… | 2020-09-01 |
| 30 | 30 | HERITAGE PARK HEALTHCARE AND REHABILITATION | 465003 | 2700 WEST 5600 SOUTH | ROY | UT | 84067 | 2016-08-18 | 362 | E | 0 | 1 | AV3G11 | Based on observation it was determined the facility did not employ sufficient support personnel competent to carry out the functions of the dietary service. Specifically, observations were made of meals delivered late in the Special Needs Unit dining room. Findings include: The following meal times were posted in the dining rooms: Breakfast 8:00 AM Lunch 12:00 PM Dinner 5:00 PM The following meals were observed to be served late in the Special Needs Unit dining room: a. On 8/15/16 the first lunch tray was served at 12:22 PM. b. On 8/17/16 the first breakfast tray was served at 8:14 AM. c. On 8/17/16 the first lunch tray was served as 12:20 PM. d. On 8/18/16 the first breakfast tray was served at 8:12 AM. | 2020-09-01 |
| 31 | 31 | HERITAGE PARK HEALTHCARE AND REHABILITATION | 465003 | 2700 WEST 5600 SOUTH | ROY | UT | 84067 | 2016-08-18 | 364 | D | 0 | 1 | AV3G11 | Based on observation and interview, the facility did not provide food that was palatable, attractive and at the proper temperature. Specifically, a resident voiced a concern with the food quality of the pureed meals and a test tray revealed that the pureed food served was not palatable. Additionally, food was not served according to the menu. Resident identifiers: 50, 71, 108, and 179. Findings include: 1. On 8/16/16 at 12:08 PM, resident 71's lunch tray was observed. Resident 71's tray appeared to contain approximately 1 cup scoop of a thick white substance covered in gravy, approximately 1/4 cup of a thin white substance, and 1/4 cup of a pureed green vegetable. The two smaller portions did not hold their shape and spread into each other. On 8/16/16 at 12:10 PM, an interview was conducted with resident 179. Resident 179 had finished less than half of her pureed lunch and was eating gelatin. Resident 179 stated that the food had no flavor, she could not eat it and the bread was just sopping wet. Resident 179 further stated that she didn't think a dog would eat it. 2. During breakfast service on 8/17/16, the pureed meal consisted of pureed oatmeal, pureed eggs, and pureed sausage with gravy over a slurried (milk soaked) biscuit. Resident 50 received a pureed tray, and there was no gravy observed on resident 50's biscuit. Resident 108 received a pureed tray, and there was no gravy observed on resident 108's biscuit. On 8/17/16 at 8:22 AM, a tray was prepared for resident 71. A certified nurses assistant checked resident 71's meal card and asked dietary staff member (DSM) 1 if it was supposed to have gravy. DSM 1 stated that it should get gravy but she was waiting on a spoodle. DSM 1 had asked another staff member for a spoodle, and held resident 71's tray until she got a spoodle for gravy. On 8/17/16 at 8:27 AM, an interview was conducted with DSM 1. DSM 1 stated that some of the previously delivered puree trays were sent out without gravy because she did not have a spoodle to serve the gravy. DSM 1 stated that gr… | 2020-09-01 |
| 32 | 32 | HERITAGE PARK HEALTHCARE AND REHABILITATION | 465003 | 2700 WEST 5600 SOUTH | ROY | UT | 84067 | 2016-08-18 | 371 | E | 0 | 1 | AV3G11 | Based on observation, it was determined the facility did not store, serve, distribute and serve food under sanitary conditions. Specifically, kitchen floors were not cleaned sufficiently, dish storage racks were not clean, there were unlabeled food items and observations of cross contamination. Findings include: 1. On 8/15/16 at 8:02 AM, the following observations were made during a tour of the kitchen: a. Three puree food molds in the storage area were observed to have food residue on the edges. b. Storage racks in the pan and equipment area had a greasy residue on them. c. Floors in the storage rooms contained dirt and debris along the edges of the walls. On 8/17/16 at 2:06 PM, an interview was conducted with dietary manager (DM) 1 and DM 2. No further information was provided. 2. On 8/15/16 at approximately 8:15 AM, the following observations were made in the residents' snacks refrigerator on the special needs unit: a. An opened mighty shake carton was lacking an open date. b. A Gatorade drink was lacking a resident label. 3. On 8/17/16, during breakfast service the following observations of cross contamination were made: a. 8:03 AM, Dietary Staff Member (DSM) 3's bare hand made contact with the inside of a bowl while serving oatmeal. b. 8:08 AM, DSM 3's bare hand made contact with the inside of a bowl while serving cream of wheat. On 8/17/16, during lunch service the following observations of cross contamination were made: a. 12:00 PM, DSM 2's bare hand made contact with spaghetti noodles hanging over a resident's bowl while serving. b. 12:04 PM, a certified nursing assistant picked up a salad bowl with their thumb over the top of the salad bowl and proceeded to place the bowl on a residents tray. c. 12:12 PM, three plates were observed to have spaghetti noodles hanging over the edge of the plates touching the serving tray and diet card slips. On one plate, the noodles were observed to touch the DSM 2's hand as the plate was moved onto the serving tray. | 2020-09-01 |
| 33 | 33 | HERITAGE PARK HEALTHCARE AND REHABILITATION | 465003 | 2700 WEST 5600 SOUTH | ROY | UT | 84067 | 2016-08-18 | 428 | D | 0 | 1 | AV3G11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined the pharmacist did not identify medication irregularities for 1 of 32 sample residents. Specifically, a resident received an as needed antipsychotic without adequate indication for its use. Resident identifier: 91. Findings include: Resident 91 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 91's medical record was reviewed on 8/17/16. On 6/18/16 an order was received to administer Zyprexa 5 mg (milligrams) as needed daily. Review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. The agitation was documented as Cont (continuous) Pacing. On two separate occasions, the licensed nurse administered the Zyprexa along with two 5-325 mg Norco tablets and Valium 2 mg. Review of the (MONTH) (YEAR) MARs revealed that the Zyprexa was administered twice for being restless and with agitation. The agitation was documented as Cont Pacing. The Zyprexa was administered with two 5-325 mg Norco tablets and Valium 2 mg on one occasion. On 7/28/16, the contracted pharmacist documented that resident 91 had no medication irregularities. The pharmacist did not identify that resident 91 had not been on antipsychotics in the past and that there was no documentation that indicated that resident 91 had an increase in her behaviors to justify the use of the Zyprexa as needed. On 8/17/16 at 1:00 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that resident 91 went to a Neurologist appointment on 6/18/16 and returned with a new order to administer the Zyprexa as needed. The DON stated that resident 91 had not had an increase in her behaviors. The DON was unable to state why the Zyprexa was administered for continuous pacing. | 2020-09-01 |
| 34 | 34 | HERITAGE PARK HEALTHCARE AND REHABILITATION | 465003 | 2700 WEST 5600 SOUTH | ROY | UT | 84067 | 2016-08-18 | 514 | D | 0 | 1 | AV3G11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined that the facility did not maintain complete and accurate medical records for 1 of 31 sampled residents. Specifically,one resident's Medication Administration Record [REDACTED]. Findings include: 1. Resident 191 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 191's medical record was reviewed on 8/16/16. A physician's orders [REDACTED]. A review of resident 191's (MONTH) (YEAR) MAR indicated [REDACTED] a. On 8/2/16 at 5:30 PM, no documentation was present for the administration of the [MEDICATION NAME]. b. On 8/2/16 at 3:30 PM, no documentation was present for the administration of the [MEDICATION NAME]. c. On 8/2/16 at 5:00 PM, no documentation was present for the administration of the carvedilol. d. On 8/2/16 at 5:00 PM, no documentation was present for the administration of the [MEDICATION NAME] sulfate. (Note: Resident 191 was admitted to the facility on [DATE] at 1:39 PM.) A physician's orders [REDACTED]. A review of resident 191's (MONTH) (YEAR) MAR indicated [REDACTED] a. On 8/12/16 at 11:30 AM and 4:30 PM, no documentation was present for the administration of the insulin. b. On 8/13/16 at 11:30 AM and 4:30 PM, no documentation was present for the administration of the insulin. c. On 8/16/16 at 11:30 AM and 4:30 PM, no documentation was present for the administration of the insulin. On 8/17/16 at 9:50 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that she had interviewed the nursing staff and the nursing staff confirmed that they had administered the medications as prescribed to resident 191. On 8/17/16, late entry documentation notes were provided by the DON to justify that the medications in question were administered by the nursing staff as prescribed by the physician. | 2020-09-01 |
| 35 | 35 | HERITAGE PARK HEALTHCARE AND REHABILITATION | 465003 | 2700 WEST 5600 SOUTH | ROY | UT | 84067 | 2018-09-05 | 609 | E | 1 | 0 | UVZZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review it was determined that the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the event that cause the allegation involve abuse or result in serious bodily injury, to the administrator of the facility and to other officials in accordance with state law through established procedures. Specifically, there were resident to resident altercations that were not reported to the State Agency. Resident identifiers: 4, 5, and 8. Findings include: 1. Resident 8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 8's medical record was reviewed on 9/5/18. Resident 8's progress notes were reviewed and revealed the following entries: a. On 5/24/18 at 7:20 PM, Pt (patient) was being yelled at by a resident that he stole her money. Resident had a hold of pts sweat pants at the waist and would not let go. Nurse and aid (sic) saw what was happening and helped the 2 get separated. The resident then kicked the pt and the pt then punched the resident in the shoulder. Staff asked the pt to move away from the situation. Pt moved away from situation. No further incidents. b. On 6/20/18 at 5:20 PM, The CNA (Certified Nursing Assistant) walked into the resident room to let him know it was time to head down for dinner when she found him and another resident kissing and the other resident's sweatshirt was off and starting to take off the undergarments but was stopped by CN[NAME] Both of the residents were spoken to and told they were not to be going into the room together. Residents were removed from the room and sent to the dining room and put on 15 min (minute) checks. Family, MD (Medical Doctor), and DON (Director Nursing) notified. c. On 7/1/18 at 8:30 PM, Resident was found by nursing … | 2020-09-01 |
| 36 | 36 | HERITAGE PARK HEALTHCARE AND REHABILITATION | 465003 | 2700 WEST 5600 SOUTH | ROY | UT | 84067 | 2018-09-05 | 660 | D | 1 | 0 | UVZZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review it was determined that the facility did not develop and implement an effective discharge planning process that focused on the resident's discharge goals, and the preparation of residents to be active partners and effectively transition to post-discharge care. Specifically, facility staff did not appropriately fill out paperwork for the New Choice Waver for a resident to discharge home. Resident identifier: 1. Findings include: Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 9/5/18 at approximately 12:30 PM, an interview was conducted with resident 1. Resident 1 stated that her plan since admission was for her to discharge home with family and a personal aide. Resident 1 stated that she needed the New Choice Waver completed for her to discharge home with an aide. Resident 1 stated that the Resident Advocate (RA) did not fill out the New Choice Waver (NCW) paperwork correctly. Resident 1 stated that she was delayed in discharge for 30 days because the paperwork was filled out incorrectly. Resident 1's medical record was reviewed on 9/5/18. A care plan dated 5/9/18 revealed, (Resident 1) wishes to return home. The goal revealed, Will verbalize/communicate and understanding of the discharge plan and describe the desired outcome by the review date. The intervention revealed, Establish a pre-discharge plan with the resident, family/caregiver and evaluate progress and revise plan. Social service progress notes revealed the following entries: a. On 6/5/18 at 10:05 AM, Resident is A (alert) & (and) O (oriented) (times) 3. She is able to voice her needs and concerns to staff. Resident has high anxiety and depression. b. On 8/6/18 at 5:06 PM, Resident was notified she would be moving from A-13 to C-18. Resident was very upset and started yelling at me. She stated she didn't want to have a room mate. Resident spoke with (Administrator). Trying to help he (sic) find a new place where s… | 2020-09-01 |
| 37 | 37 | HERITAGE PARK HEALTHCARE AND REHABILITATION | 465003 | 2700 WEST 5600 SOUTH | ROY | UT | 84067 | 2019-10-03 | 584 | E | 1 | 0 | CR9Z11 | > Based on observation and interview it was determined that the facility did not provide a comfortable and homelike environment. Specifically, residents were residing in their rooms during construction. Additionally, the hallways had unidentified splatter on the walls, residents fans were soiled, lifts were soiled and a wheelchair in the hallway was soiled. Resident Identifiers: 9 and 10. Findings include: On 10/2/19 at 12:15 PM, an observation was made of the B hall. The following observations were made: 1. There was a dried fluid splatter on the wall outside room B-15. 2. There was a substance on the outside of the food cart in the B hall. 3. There was a lift soiled with debris and black substance on the bottom part of the hoyer with a red substance on 1 leg of the lift. 4. There was a black plastic set of drawers outside room B-13 with a cup mark and a clear dried substance on the top. 5. There was a fan in room B12 that was soiled with dust and a red substance. 6. The light switch by the nurses' station on the B hall had a dried red substance that was dripping down the wall. 7. There was a fan in room B6 that had dust and debris on it. 8. There was a picture in the hallway that had a dried substance on the glass. On 10/2/19 at 2:23 PM, an observation was made of a sit to stand lift in the B hall. The sit to stand lift was observed to be soiled with dust and debris. On 10/3/19 at 9:00 AM, an observation was made of the C hall. There was a splattered dry fluid on the hallway walls in the C hall outside room C16 and C6. There was a wheelchair in the hallway with a brown substance on the cushion and a white substance on the wheels. On 10/3/19 at 9:00 AM, an observation was made of room C11 and C13. The rooms were observed to have a temporary plastic construction wall. The construction workers were observed to remove the walls while the residents were in his bed. On 10/3/19 at 9:05 AM, an observation was made of the C hallway. A large hole was observed in the ceiling. The hallway walls were also observed to have u… | 2020-09-01 |
| 38 | 38 | HERITAGE PARK HEALTHCARE AND REHABILITATION | 465003 | 2700 WEST 5600 SOUTH | ROY | UT | 84067 | 2019-10-03 | 686 | D | 1 | 0 | CR9Z11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview and record review it was determined, for 1 of 10 sample residents, that the facility did not ensure that each resident received care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrated that they were unavoidable. In addition, a resident that developed a pressure ulcer received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. Specifically, facility staff did not document a resident's pressure ulcers upon admission. After identifying a resident's pressure ulcers treatments were not completed according to physician's orders [REDACTED]. Findings include: Resident 3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 10/2/19 at 2:42 PM, an interview and observation was conducted of resident 3. Resident 3 stated that she had wounds on her back and hips. Resident 3 stated that she had wounds Off and On at various times. Resident 3 stated that she had wounds of her feet. Resident 3's feet were observed to be wrapped with soft booties on both feet and a cushion in her wheelchair. On 10/3/19 at 12:30 PM, an observation was made of resident 3's feet with Registered Nurse (RN) 3. RN 3 was observed to remove a dressing from resident 3's right toe area. RN 3 stated that there was no bandage on the lateral foot. RN 3 stated that the wound must have been healed. RN 3 stated that the wound on resident 3's toes was probably sort of a pressure sore, I would think. Resident 3's left heel was observed to be boggy with a red area approximately 1 by 2 cm that was non-blanchable. Resident 3's feet were observed to be very dry. Resident 3 refused to have her other pressure ulcers observed. Resident 3's medical record was reviewed on 10/2/19. An admission assessment dated [DATE] at 10:2… | 2020-09-01 |
| 39 | 39 | MT OLYMPUS REHABILITATION CENTER | 465006 | 2200 EAST 3300 SOUTH | SALT LAKE CITY | UT | 84109 | 2018-04-30 | 578 | D | 0 | 1 | C87F11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, it was determined, for 1 of 43 sample residents, that the facility did not include provisions to inform and provide written information concerning the right to accept or refuse medical or surgical treatment and at the residents option formulate an advance directions. Resident identifier: 264. Findings include: 1. Resident 264 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 264's medical record was reviewed on 4/24/18. Review of resident 264's physician orders [REDACTED]. On the facility's documenting system, a header displayed a resident's code status so it could be quickly identified. On 4/24/18 at 9:31 AM it was noted that resident 264 did not have a code status listed in the header. The hard chart was searched and the POLST form within was blank. The advanced directives or POLST form could not be found when searched for in the facility's documenting system. In that documenting system, there was a form titled Advanced Directives which was signed by the resident and a facility representative on 4/5/18. This form stated that a facility representative was made aware by the resident or resident representative that advance directives exist, but a copy was not provided to the facility. It did not indicate what the resident's wishes for advanced directives were. The form stated The Resident acknowledges that it is the Resident's responsibility to provide (facility's name) with copies of the Resident's advance directives for incorporation into the Resident's medical record. The form also stated (Facility's name) shall act in accordance with the residents advance directives if the advance directives were executed in accordance with applicable State law. On 4/24/18 at 9:45 AM an interview was conducted with resident 264. Resident 264 stated she did have an advanced directive, but it was at a different facility. Resident 264 stated she didn't remember ever filling out a POLST while at th… | 2020-09-01 |
| 40 | 40 | MT OLYMPUS REHABILITATION CENTER | 465006 | 2200 EAST 3300 SOUTH | SALT LAKE CITY | UT | 84109 | 2018-04-30 | 580 | E | 1 | 1 | C87F11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review it was determined, for 4 of 43 sample residents, that the facility did not immediately inform the resident representative when there was a need to alter the resident's treatment and commence a new form of treatment. Specifically, one resident's physician was not notified of a change in condition, and three resident's physician's were not notified of medications that had not been administered nor of multiple medications that had not been given timely. Resident identifiers 4, 37, 163 and 170. Findings include: 1. Resident 170 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 4/30/18 resident 170's medical record was reviewed. Nursing progress notes revealed the following entries: a. 1/12/18 New order by MD (Medical Doctor) for the patient: DC [MEDICATION NAME] Inhaler; amt (amount): 2 inhalations; Special Instructions: Dx (diagnoses) [MEDICAL CONDITIONS] Four Times A Day New order: Re-start on 1/16/2018 [MEDICATION NAME] inhaler; amt: 1 inhalations; Four Times A Day Increase monitoring for any respiratory issues. Notified (sic) to MD for any acute respiratory problem. Asses (sic) the patient every shift for respiratory problem. b. 1/28/18 at 21:30 (9:30 PM), (Recorded as Late Entry on 1/29/18 at 23:59 (11:14 PM), CNA (Certified Nursing Assistant) came to tell LN (Licensed Nurse) to come check on pt (patient) out of concern. LN went to observe pt. Called pt name and gently shook her shoulder, pt easily roused and responded. Ask how she was feeling and if she was in any pain, stated that she was just tired. Denies pain/discomfort at this time. Pt in no apparent distress. Pt was laying flat, LN raised HOB (head of bed) to semi fowlers. VS (vital signs) checked (Temperature) 98.2, (Pulse) 112, (Respirations) 14, (Blood Pressure) 96/62, (Oxygen Saturations) 92% 5L (liters) via NC (nasal cannula). Blood sugar 350. Lung sounds CTA (clear to auscultation) bilaterally. Respirations even and unlab… | 2020-09-01 |
| 41 | 41 | MT OLYMPUS REHABILITATION CENTER | 465006 | 2200 EAST 3300 SOUTH | SALT LAKE CITY | UT | 84109 | 2018-04-30 | 636 | E | 1 | 1 | C87F11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, and record review, it was determined that for 4 of 43 sample residents, that the facility did not conduct initially and periodically a comprehensive Minimum Data Set (MDS) Assessments within the timeframes prescribed. Specifically, multiple MDS Assessments were documented as accepted with warnings for being submitted late. Residents identifiers: 22, 37, 38, and 45. Findings include: 1. Resident 22 was admitted on [DATE] with [DIAGNOSES REDACTED]. On 4/30/18 resident 22's medical record was reviewed. According to the medical record, the MDS Assessments that had been completed on an annual and quarterly basis, revealed that multiple MDS Assessments had been submitted with a warning indicator by their dates. Two MDS assessment records dated 2/6/18 and 9/3/17 were pulled for review. The MDS record dated 9/3/17 revealed the code: 3749A-warning and the message: Assessment Completed late. On 4/30/18 at 3:48 PM, an interview was conducted by the facility MDS Coordinator. The facility MDS Coordinator stated that the MDS Assessment had a target date of 9/3/17 and was due to be submitted to the Center for Medicare and Medicaid Services (CMS) on 9/16/17. The facility MDS Coordinator stated that the MDS Assessment was submitted late on 10/2/17. 2. Resident 45 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 4/30/18 resident 45's medical record was reviewed. According to the medical record, the MDS assessments that had been completed on an annual and quarterly basis, revealed that multiple MDS Assessments had been submitted with a warning indicator by their dates. Two MDS Assessment records dated 12/17/17 and 3/17/18 were pulled for review. The MDS record dated 12/17/17 revealed the code: 3749A-warning and the message: Assessment Completed late. The MDS assessment dated [DATE] revealed the code: 3749A-warning and the message: Assessment Completed late. On 4/30/18 at 3:48 PM, an interview was conducted … | 2020-09-01 |
| 42 | 42 | MT OLYMPUS REHABILITATION CENTER | 465006 | 2200 EAST 3300 SOUTH | SALT LAKE CITY | UT | 84109 | 2018-04-30 | 656 | E | 0 | 1 | C87F11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined, for 2 of 43 sample residents, that the facility did not develop and implement a comprehensive person-centered care plan for each resident consistent with the resident rights, that included measurable objectives and timeframe's to meet the resident's medical, nursing, mental and psychosocial needs that were identified in the comprehensive assessment. Specifically resident's MDS and careplan contained conflicting information. Resident identifiers 7 and 18. Findings include: 1. Resident 18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 4/25/18, Resident 18's medical record was reviewed. Resident 18's MDS section G0110 1B revealed that resident 18 required a 2+ person extensive assistance for transfers. Resident 18's care plan revealed that resident 18 required 1-2 extensive assistance for ADL's. 2. Resident 7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 4/25/18, Resident 18's medical record was reviewed. Resident 7's MDS section G0110 1B revealed that resident 7 required a 2+ person extensive assistance for transfers. Resident 7's care plan revealed that resident 7 required extensive/max/total dependence of 1-2 persons. Cross Refer F-689 | 2020-09-01 |
| 43 | 43 | MT OLYMPUS REHABILITATION CENTER | 465006 | 2200 EAST 3300 SOUTH | SALT LAKE CITY | UT | 84109 | 2018-04-30 | 657 | D | 0 | 1 | C87F11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, it was determined, for 1 of 43 sample residents, that the facility did not review and revise the comprehensive care plan. Specifically, one resident's care plan was not revised to reflect that a resident who had a tibia/fibula fracture, was placed as a non weight bearing status. Resident identifier: 37. Findings include: Resident 37 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 4/23/18 at 4:30 PM, an interview was conducted with resident 37. Resident 37 stated that she had had a fall from an inappropriate transfer which resulted in a right tibia/fibula fracture. On 4/26/18 resident 37's medical record was reviewed. Nursing progress notes revealed the following entries: a. 1/26/18 at 22:49 (10:49 PM), X-ray results received per fax. Poss. (possible) Fx. (fracture) at RLE (right lower extremity). (Physician 1) called T.O. (telephone order) send res to E.R. (emergency room ) of choice for F/U. Daughter called, no answer, message left. Res is alert and oriented x 2. Res informed of report and trans (transport) to hospital. Res cant (sic) remember which hosp (hospital) she goes to. Res (resident) reports little pain at this time. PRN pain medication given r/t transport and repositioning. Daughter just returned call and stated (Name of Hospital) is fine. b. 1/27/18 at 00:15 (12:15 AM), 2330 (11:30 PM) (Name of Ambulance) here to trans res to (Name of Hospital) for X-rays to Rt lower leg. All HS (hour of sleep) and prn pain medication provided prior to trans. c. 1/27/18 at 3:14 AM, 0300 (3:00 AM) Res returned from hospital per (Name of Ambulance). Fx confirmed at RLE. F/U appt (appointment) to be made with (Physician 2) MD. Phone (phone withdrawn) ASAP (as soon as possible). Paperwork from Hospital states this Fx is non-operative. Res is to be non-wt (weight) bearing and leg should be protected during transfers. Res is alert and oriented. Res does not want a PRN pain pill. She stat… | 2020-09-01 |
| 44 | 44 | MT OLYMPUS REHABILITATION CENTER | 465006 | 2200 EAST 3300 SOUTH | SALT LAKE CITY | UT | 84109 | 2018-04-30 | 684 | D | 1 | 1 | C87F11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, and record review it was determined, for 2 of 43 sample residents, that the facility did not ensure that a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choice. Specifically, one resident's leg was not monitored after a fall and increase in pain and one hospice resident did not receive his medications and had to be sent back to the hospital. The deficient practice identified for the change in condition was found to have occurred at a harm level. Resident identifiers: 37 and 171. Findings include: 1. Resident 37 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 4/23/18 at 4:30 PM, an interview was conducted with resident 37. Resident 37 stated that she had had a fall from an inappropriate transfer which resulted in a right tibia/fibula fracture. On 4/26/18 resident 37's medical record was reviewed. Nursing progress notes revealed the following entries: a. 1/24/18 at 15:04 (3:04 PM), CNA (Certified Nursing Assistant) notified nurse for assistance with resident on floor. CNA states that during transfer when patient was on the bed that she was not quite far enough on the bed when slide board was removed and pt (patient) slid from bed to floor and landed on her buttocks and did not hit her head. Vitals taken and within normal limits. Pt assess (sic) before transfer and pt is able to bend knees and toes have good ROM (range of motion) with a minor increase in pain. Pt is also able to move bottom half of legs with some difficulty but normal ROM for patient. Pt transferred back into bed and skin check done with a little patch of [DIAGNOSES REDACTED] to knee and no other injuries noted. ROM continues to be normal for patient when assessed in bed. Patient continues to c/o (complain of) minor increase pain to right lower leg, [MEDICATION NAME] 5-325 mg (milligrams) administered and tolerated … | 2020-09-01 |
| 45 | 45 | MT OLYMPUS REHABILITATION CENTER | 465006 | 2200 EAST 3300 SOUTH | SALT LAKE CITY | UT | 84109 | 2018-04-30 | 689 | G | 1 | 1 | C87F11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview and medical record review, it was determined for 3 of 43 sample residents, that the facility did not ensure that the resident environment remains as free of accident hazards as is possible. Specifically, one resident was transferred via use of a sliding board by a CNA (Certified Nursing Assistant) who had received no training for the transfer. In addition, observations were made of a laundry chute that was unlocked and unattended, two chemicals were found in an unlocked and unattended housekeeping closet and multiple oxygen tanks were found to be stored near an exit doorway as well as empty and full oxygen tanks being stored in the same closet. Resident identifiers: 7, 56 and 37. Findings include: HARM 1. Resident 37 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 4/23/18 at 4:30 PM, an interview was conducted with resident 37. Resident 37 stated that she had had a fall from an inappropriate transfer which resulted in a right tibia/fibula fracture. On 4/26/18 resident 37's medical record was reviewed. Nursing progress notes revealed the following entries: a. 1/24/18 at 15:04 (3:04 PM), CNA (Certified Nursing Assistant) notified nurse for assistance with resident on floor. CNA states that during transfer when patient was on the bed that she was not quite far enough on the bed when slide board was removed and pt (patient) slid from bed to floor and landed on her buttocks and did not hit her head. Vitals taken and within normal limits. Pt assess (sic) before transfer and pt is able to bend knees and toes have good ROM (range of motion) with a minor increase in pain. Pt is also able to move bottom half of legs with some difficulty but normal ROM for patient. Pt transferred back into bed and skin check done with a little patch of [DIAGNOSES REDACTED] to knee and no other injuries noted. ROM continues to be normal for patient when assessed in bed. Patient continues to c/o (complain of) minor in… | 2020-09-01 |
| 46 | 46 | MT OLYMPUS REHABILITATION CENTER | 465006 | 2200 EAST 3300 SOUTH | SALT LAKE CITY | UT | 84109 | 2018-04-30 | 725 | E | 1 | 1 | C87F11 | > Based on observation, interview and record review it was determined, for 7 of 43 sample residents, that the facility did not provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psycohosical well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diganosis of the facility's resident population in accordance with the facility assessment. Specifically, residents complained to the surveyors and in resident council meetings about the staffing level, and waiting time required for the call lights to be answered. Resident identifiers: 1, 2, 22, 30, 39, 60 and 62. Findings include: 1. On 4/23/18 at 11:49 AM, an interview was conducted with resident 22. Resident 22 stated that she felt that the facility did not have enough staff. Resident 22 stated that after she would use her call light, she would wait for half an hour or longer for someone to respond. Resident 22 stated that the staffing was worse in afternoon hours and on weekends. 2. On 4/23/18 at 4:10 PM, an interview was conducted with resident 2. Resident 2 stated that the facility did not have enough staff available. Resident 2 stated that the facility had no consistency with staffing and that some days the facility would have multiple agency staff who would not know the residents or what to do with them. Resident 2 stated that he would wait for an hour or longer at times for someone to help him out of the bed and to his wheelchair. Resident 2 stated that the administration was aware of this problem because residents would mention the staffing issue during resident council meetings. Resident 2 stated that often the staff would walk into a room, would turn the call light off and inform the resident that they would be back in few minutes, then never return. Resident 2 stated that the call light would have to be reactivated. 3. On 4/26/18 at 6:10 PM, an interview was conducted with resident 39. Resident 39 was… | 2020-09-01 |
| 47 | 47 | MT OLYMPUS REHABILITATION CENTER | 465006 | 2200 EAST 3300 SOUTH | SALT LAKE CITY | UT | 84109 | 2018-04-30 | 726 | E | 1 | 1 | C87F11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and interview, it was determined for 11 of 43 sample residents, that the facility did not have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. The facility must ensure that licensed nurses have the specific competencies and skill set necessary to care for residents' needs as identified through resident assessments, and described in the plan of care. The facility must ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs. Specifically, one resident was transferred via a sliding board resulting in a tibial/fibula fracture without the CNA (Certified Nursing Assistant) staff being trained for sliding board transfers, one resident who twisted her ankle and sustained a tibial/fibula fracture was not reported to licensed nursing staff and one resident's change in condition did not get reported to oncoming nursing staff. Additionally, multiple residents medications were either not administered or administered late due to facility staff having to help and train agency staff and residents complained about the issues in resident council meetings. Resident identifiers: 1, 2, 4, 18, 22, 30, 37, 39, 60, 62 and 170. Findings include: 1. Resident 37 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On [DATE] at 4:30 PM, an interview was conducted with resident 37. Resident 37 stated that she had had a fall from an inappropriate transfer which resulted in a right tibia/fibula fracture. On [DATE] resident 37's medical record was reviewed. Nursing progress notes revealed the following entries: a. [DATE] at 15:04 (3:04 PM), CNA (Certified Nursing Assistant) notified nurse for assistance with resident on floor. CNA states that during transfer when patient wa… | 2020-09-01 |
| 48 | 48 | MT OLYMPUS REHABILITATION CENTER | 465006 | 2200 EAST 3300 SOUTH | SALT LAKE CITY | UT | 84109 | 2018-04-30 | 755 | E | 0 | 1 | C87F11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 6 of 43 sample residents, that the facility did not provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident. Specifically medications were not available from the pharmacy for administration. Resident identifiers: 22, 37, 56, 63, 163 and 165. Findings include: 1. Resident 56 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 4/23/18 resident 56's Medication Administration Record [REDACTED] For (MONTH) (YEAR), resident 56 had the following physician orders: a) [MEDICATION NAME], 1/4/18-1/28/18, 5 mg(milligrams)/mL (milliliter), amount to administer: 0.25 mL; oral, every 6 hours The order was changed to the following: [MEDICATION NAME], 1/28/18-1/30/18, 10 mg/5L, amount to administer 1 mL=2 mg; oral, every 8 hours. The medication was not available on the following dates: a) 1/4/18 at 6:00 PM Not administered: Drug/item unavailable. Comment: Notified hospice. b) 1/5/18 at 12:00 AM Not administered: Other. Comment: med not available; will f/u w/ hospice. c) 1/5/18 at 6:00 AM Not administered: other. Comment: med not available; will f/u w/ hospice. d) 1/5/18 at 12:00 PM Not administered: Drug/Item unavailable. Comment: Notified hospice, administered prn pain medication. e) 1/29/18 at 8:00 AM Not administered: Other. Comment: Hospice to deliver. f) 1/30 at 12:00 AM Not administered: drug/item unavailable. Comment: day nurse reported contacting hospice. Resident also reported contacting them. Not sent to facility. On 1/30/18 at 3:00 AM, a nursing progress note revealed, Resident activated call light and asked after the status of his Methadose (sic). Nurse reported that he has been having conversations with hospice .and that he is trying to get the situation resolved ASAP (as soon as possible). Resident stated that he will be making anothe… | 2020-09-01 |
| 49 | 49 | MT OLYMPUS REHABILITATION CENTER | 465006 | 2200 EAST 3300 SOUTH | SALT LAKE CITY | UT | 84109 | 2018-04-30 | 757 | E | 1 | 1 | C87F11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, it was determined that for 5 of 43 sample residents, the facility did not ensure that each resident's drug regimen was free from unnecessary drugs. An unnecessary drug is any drug when used in excessive dose; or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or any combinations of the reasons above. Specifically, multiple residents had multiple medications administered late as well as medications that were not available for administration. Resident identifiers: 4, 25, 37, 45 and 59. Findings include: 1. Resident 37 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 4/26/18 resident 37's medical record was reviewed. physician's orders [REDACTED]. a. 10/18/17, [MEDICATION NAME]/[MEDICATION NAME] 2.5/0.05 Nebulizer every 8 hours. b. 12/1/16, [MEDICATION NAME] 20 mg (milligrams)/ml (milliliter) subcutaneous at Bedtime. c. 12/27/18 through 2/8/18, [MEDICATION NAME] 1 mg to 3.5 mg daily (QD). d. 7/17/18, [MEDICATION NAME] 70 mg weekly. e. 9/26/18, [MEDICATION NAME] 40 mg QD. f. 1/6/18, [MEDICATION NAME] 100 mg three times daily (TID). g. 1/2/18, [MEDICATION NAME] 2.5 mg QD. h. 10/9/17, [MEDICATION NAME] 20 mg QD. i. 1/11/18, Potassium Chloride 20 mEq twice daily (BID). j. 5/11/18, [MEDICATION NAME] 40 mg QD. k. 5/1/17, Sprionolactone 25 mg QD. l. 5/11/17, [MEDICATION NAME] 50 mcg QD. m. 12/12/18, [MEDICATION NAME] 200 mg at bedtime. The Medication Administration Record [REDACTED] a. On 1/8/18 and 1/14/18 [MEDICATION NAME] 20 mg injection was not administered due to Drug/Item unavailable. According to the MAR for (MONTH) (YEAR), (MONTH) (YEAR), (MONTH) (YEAR) and (MONTH) (YEAR) resident 37 had multiple medications administered late including the following dates: a. [MEDICATION NAME]/[MEDICATION NAME] TID, 2.5/0.05 every 8 hours 1/1/18, 1/2… | 2020-09-01 |
| 50 | 50 | MT OLYMPUS REHABILITATION CENTER | 465006 | 2200 EAST 3300 SOUTH | SALT LAKE CITY | UT | 84109 | 2018-04-30 | 760 | E | 1 | 1 | C87F11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review it was determined that the facility did not ensure that 17 of 43 sample residents were free of significant medication errors. Specifically, multiple residents had medications that were not administered, received the wrong medication, were administered late or medications were not available. One resident received a double dose of [MEDICATION NAME]. Resident identifiers: 3, 4, 18, 20, 25, 30, 37, 45, 56, 59, 63, 163, 165, 166, 168, 169 and 263. Findings include: 1. Resident 37 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 4/26/18 resident 37's medical record was reviewed. physician's orders [REDACTED]. a. 1/16/18 through 1/22/18, [MEDICATION NAME] 1 gram; intravenous (IV) once a day for UTI. b. 12/1/16, [MEDICATION NAME] 20 mg (milligrams)/ml (milliliter) subcutaneous at Bedtime. c. 1/6/18, [MEDICATION NAME] 100 mg Three Times a Day (TID) for [MEDICAL CONDITION]. d. 3/5/18, [MEDICATION NAME] 3 mg on Sunday, Tuesday, Thursday, Saturday. The Medication Administration Record [REDACTED] a. On 1/16/18, [MEDICATION NAME] 1 gram IV was not administered to resident 37 due to waiting on med (medication) from pharmacy. b. On 1/8/18 and 1/14/18, [MEDICATION NAME] 20 mg injection was not administered due to Drug/Item unavailable. c. On 3/10/18, [MEDICATION NAME] 100 mg was administered at 16:19 (4:19 PM), 2 hours and 19 minutes after it was due, due to Drug/Item unavailable. d. On 4/22/18, [MEDICATION NAME] 100 mg was Not Administered due to condition. e. On 4/22/18, [MEDICATION NAME] 3 mg was Not Administered, On Hold, Pt (patient) is very sleepy. 2. Resident 4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 4/26/18 resident 4's medical record was reviewed. physician's orders [REDACTED]. a. 8/15/17, [MEDICATION NAME] 0.5 mg twice daily (BID). b. 9/30/17, [MEDICATION NAME] 5 mg every six hours; at 2:00 AM, 8:00 AM, 2:00 PM and 8:00 PM, Hold if asleep. c. 8/15/17, [MEDICATION… | 2020-09-01 |
| 51 | 51 | MT OLYMPUS REHABILITATION CENTER | 465006 | 2200 EAST 3300 SOUTH | SALT LAKE CITY | UT | 84109 | 2018-04-30 | 761 | D | 0 | 1 | C87F11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview it was determined that the facility did not ensure safe and secure storage of drugs and biologicals in accordance with accepted professional principles; or include the appropriate accessory and cautionary instructions. Specifically, multi dose vials of [MEDICATION NAME] were found in two medication rooms without open dates. Findings include: On 4/23/18 at 7:19 AM, an observation was made of the medication room on the Ensign Hall. One multi dose vial of [MEDICATION NAME] was noted to be without an open date. On 4/23/18 at 7:19 AM, an interview was conducted with Registered Nurse (RN) 5. RN 5 confirmed that there was no open date and did not know how long the [MEDICATION NAME] had been opened. RN 5 stated that the [MEDICATION NAME] should have had an open date. On 4/23/18 at 7:30 AM, an observation was made of the Cedar Cove Medication Room. One multi dose vial of [MEDICATION NAME] was noted to be without an open date. On 4/23/18 at 7:30 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 confirmed that there was no open date and did not know how long the vial had been opened. LPN 1 stated that there should have been an open date. A review of the Centers for Disease Control (CDC) Website under Info for providers: FAQ's (Frequently Asked Questions) regarding safe practices for medication injections revealed the following: 1. What is a multi-dose vial? A multi-dose vial is a vial of liquid medication intended for the [MEDICATION NAME] administration (injection or infusion) that contains more than one dose of medication. Multi-dose vials are labeled as such by the manufacturer and typically contain an antimicrobial preservative to help prevent the growth of bacteria. The preservative has no effect [MEDICAL CONDITION] and does not protect against contamination when healthcare personnel fail to follow safe injection practices. 2. Can multi-dose vials be used for more than one patient? Multi-… | 2020-09-01 |
| 52 | 52 | MT OLYMPUS REHABILITATION CENTER | 465006 | 2200 EAST 3300 SOUTH | SALT LAKE CITY | UT | 84109 | 2018-04-30 | 842 | D | 0 | 1 | C87F11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 1 of 43 sample residents, that the facility did not maintain medical records on each resident that were accurately documented. Specifically, a resident on hospice did not have visits from hospice staff available in the medical record. Resident identifier: 56. Findings include: 1. Resident 56 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 4/23/18 resident 56's medical record was reviewed. It was noted that the last hospice visit documented in the medical record was from 3/20/18. In the resident's progress notes the hospice RN had charted on 3/28, 4/10, 4/23, 4/26 and 4/30. On 4/26/18 at 9:40 AM an interview was conducted with the RN Case Manager of the hospice company. The RN Case Manager stated that she had notes with her from about 4/12/18 to current that needed to be given to the facility. On 4/30/18 at 2:50 PM an interview was conducted with the Medical Records Director (MRD). The MRD stated that the hospice staff was supposed to send over copies of their charting. The MRD stated that the facility would like to receive hospice notes within a week. Requested the MRD to search resident 56's record for notes beyond 3/20/18 from the hospice staff. The MRD was unable to find further documentation. The MRD acknowledged there was an incomplete medical record. | 2020-09-01 |
| 53 | 53 | MT OLYMPUS REHABILITATION CENTER | 465006 | 2200 EAST 3300 SOUTH | SALT LAKE CITY | UT | 84109 | 2018-04-30 | 849 | D | 0 | 1 | C87F11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, it was determined for 2 of 43 sample residents that the facility did not ensure that ensure that the hospice services meet professional standards and principles that apply to individuals providing services in the facility, and to the timeliness of the services. Specifically, two resident who were admitted to the facility on hospice, did not receive medications timely. Resident identifiers: 63 and 165. Findings include: 1. Resident 63 was admitted to the facility on [DATE] on hospice care with [DIAGNOSES REDACTED]. On 4/26/18 resident 63's medical record was reviewed. Nursing progress notes revealed the following entries: a. 1/24/18 at 15:55 (3:55 PM), Patient (pt) admitted to (Name of Facility) for hospice and comfort care. Discharge dx (diagnoses): hepatocellular [MEDICAL CONDITION]. Depression and/or anxiety features due to general medical condition; [MEDICAL CONDITION]. Past medical hx (history): DM; [MEDICAL CONDITION]; GERD; dementia. Hx of Hep ([MEDICAL CONDITION]) C; chronic back pain; hepatic [MEDICAL CONDITION] in (MONTH) (YEAR); portal vein [MEDICAL CONDITION]; DM II; [MEDICAL CONDITION]; [MEDICAL CONDITION]; DGD (diabetes and glandular disease); restless leg syndrome; hearing loss; abdominal aortic aneurysm; [MEDICAL CONDITION]; claudication; kidney stones; hx of UTIs (urinary tract infections). Patient is under (Name of Hospice) care/MD (Medical Doctor: (Name of MD). b. 1/24/18 at 18:55 (6:55 PM), Pt is alert and oriented to self only. Pt arrived to facility via (Name of Transportation). Pt admitted with liver failure and [MEDICAL CONDITION]. Pt being admitted to hospice upon arrival .Pt c/o (complains of) some belly pain r/t [MEDICAL CONDITION] .Pt has a history of aggressive behaviors while at home but have diminished since starting [MEDICATION NAME]. c. 1/24/18 at 19:09 (7:09 PM), Recorded as late entry on 1/25/18 at 7:13 PM, Discussed with Hospice nurse medications that they were D… | 2020-09-01 |
| 54 | 54 | MT OLYMPUS REHABILITATION CENTER | 465006 | 2200 EAST 3300 SOUTH | SALT LAKE CITY | UT | 84109 | 2019-05-23 | 580 | D | 0 | 1 | PDL911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 1 of 28 sampled residents, that the facility did not immediately consult with the resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status, or a need to alter treatment significantly. Specifically, a resident would refuse scheduled doses of insulin and the physician was not consistently notified of those refusals. Resident identifier: 49. Findings include: Resident 49 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 5/22/19, resident 49's medical record was reviewed. Resident 49's physician's orders [REDACTED]. a. Start Date 11/1/18, 0600 (6:00 AM) [MEDICATION NAME] Solution 100 UNIT/ML (units per milliliter) (Insulin Detemir) Inject 50 unit subcutaneously one time a day for DM (diabetes mellitus) b. Start Date 11/1/18 1815 (6:15 PM) [MEDICATION NAME] Solution 100 UNIT/ML (Insulin Detemir) Inject 45 units subcutaneously one time a day for DM Resident 49's Medical Administration Record (MAR) was reviewed for (MONTH) and (MONTH) of 2019. The MAR indicated [REDACTED]. Resident 49 had refused the scheduled dose of insulin on the following dates: a. 4/2/19 at 6:15 PM; b. 4/26/19 at 6:00 AM and 6:15 PM; c. 4/27/19 at 6:00 AM and 6:15 PM; d. 4/30/19 at 6:00 AM and 6:15 PM; e. 5/1/19 at 6:15 PM; f. 5/2/19 at 6:00 AM; g. 5/12/19 6:00 AM. The nursing progress notes for resident 49 were reviewed. They revealed that for the above dates, there was no documentation that the doctor or nurse practitioner had been notified of the refusals. On 5/23/19 at 9:50 AM, an interview was conducted with Licensed Practical Nurse (LPN) 3. LPN 3 stated that if a scheduled medication was held, the doctor should be notified. LPN 3 stated that the refusal and notifying the doctor should be documented in the progress notes. On 5/23/19 at 12:53 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that if a resid… | 2020-09-01 |
| 55 | 55 | MT OLYMPUS REHABILITATION CENTER | 465006 | 2200 EAST 3300 SOUTH | SALT LAKE CITY | UT | 84109 | 2019-05-23 | 622 | D | 1 | 1 | PDL911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review it was determined, for 1 of 28 sampled residents, that the facility did not ensure that the transfer or discharge was documented in the resident's medical record and appropriate information was communicated to the receiving provider. Specifically, the resident's physician did not document the reason for discharge in the medical record. In addition, the receiving provider did not receive contact information of the practitioner responsible for the care of the resident, resident representative information including contact information, Advance Directive information, all special instructions or precautions for ongoing care, as appropriate, comprehensive care plan goals, and all other necessary information to ensure a safe and effective transition of care. Resident identifiers: 124. Findings include: Resident 124 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 124's medical record was reviewed on 5/21/19. an order for [REDACTED]. (Note: The temporary guardianship was to expire on 3/15/19.) A physician's orders [REDACTED]. A Social Service Note dated 2/24/19 at 12:04 AM, documented (Resident 124) is a [AGE] year old male with 'hx (history) alcohol and drug abuse' admitted [DATE] from (Hospital name) where he was taken 'after being found pulseless in asystole.' Hospital discharge notes indicate that (Resident 124) 'has been hospitalized since 12/21 with severe Korsakoff' and 'has very poor/no insight and is unable to care for himself long term.' Office of Public Guardianship appointed guardianship to act on resident's behalf. LCSW (Licensed Clinical Social Worker) met with (Resident 124) for welcome, information gathering, and review of resident rights and facility grievance policy. (Resident 124) was alert and oriented x (times) 3. His mood and affect seemed appropriate, short term memory and insight limited. He did not report (nor did he appear to be attending to) any internal stimu… | 2020-09-01 |
| 56 | 56 | MT OLYMPUS REHABILITATION CENTER | 465006 | 2200 EAST 3300 SOUTH | SALT LAKE CITY | UT | 84109 | 2019-05-23 | 641 | D | 0 | 1 | PDL911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review it was determined, for 1 of 28 sampled residents, that the facility assessment did not accurately reflect the resident's status. Specifically, a resident who did not have a urinary catheter was coded as having one. Resident identifier: 52. Findings include: Resident 52 was admitted to the facility on [DATE] and readmitted after a hospital stay on 3/15/19 with [DIAGNOSES REDACTED]. On 5/20/19 at 11:00 AM, an interview was conducted with resident 52. Resident 52 stated that he has never had an indwelling urinary catheter. Resident 52 indicated that he had two urinals at his bed side and one of the urinals was observed to be half full of urine. Resident 52's medical record was reviewed on 5/22/19. A Medicare 30 Day scheduled Minimum Data Set (MDS) assessment dated [DATE], documented that resident 52 had an indwelling catheter. On 5/22/19 at 12:26 PM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that she has worked at the facility for approximately three and a half months. RN 1 stated that during the time she has worked at the facility resident 52 has not had an indwelling urinary catheter. On 5/22/19 at 12:30 PM, an interview was conducted with the MDS coordinator. The MDS coordinator stated that on 4/9/19, resident 52 was coded as having an indwelling urinary catheter according to the Certified Nursing Assistant task charting for resident 52. The MDS coordinator stated that if resident 52 had the indwelling urinary catheter for one day it would be coded on the MDS. No records were located in resident 52's medical record indicating that resident 52 had an indwelling urinary catheter. | 2020-09-01 |
| 57 | 57 | MT OLYMPUS REHABILITATION CENTER | 465006 | 2200 EAST 3300 SOUTH | SALT LAKE CITY | UT | 84109 | 2019-05-23 | 661 | D | 1 | 1 | PDL911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review it was determined, for 1 of 28 sampled residents, that the facility that anticipates discharge did not have a discharge summary that included a recapitulation of the resident's stay that includes, but is not limited to, diagnoses, course of illness/treatment or therapy, and pertinent laboratory, radiology, and consultation results. Specifically, a resident did not have a complete discharge summary that included a post discharge plan of care. Resident identifiers: 124. Findings include: Resident 124 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 124's medical record was reviewed on 5/21/19. A Discharge Summary note dated 3/13/19 at 11:09 AM, documented: Reason for DC (discharge) (Met Goals, Change of Condition, etc.): Patient met goals discharge date : 3/13/19 Discharge Time: 1100 (11:00 AM) Discharge Location: Ogden with Friend (name of friend) Transported by: (name of friend) (friend) Home Health/hospice agency (specify agency if applicable): N/a (not applicable) Order Summary sent & (and) signed with resident/responsible party: Yes Medications sent with resident/responsible party: All medications including narcotics signed by resident. Resident left with all personal belongings: Yes Resident verbalized understanding of discharge education: Yes Follow with PCP (primary care physician) scheduled? (if no, educate resident to schedule): Resident knows to schedule an appointment A Transfer/Discharge Report dated 3/13/19, documented the following information: a. Resident Information: Resident Name, Unit, Room/Bed, admitted , Resident number, Sex, Birthdate, Age, Marital Status, Religion, Primary Language, Medicaid number, and Social Security number. b. Other Information: allergies [REDACTED]. c. Primary Contact: Name and Relationship. d. Primary Physician: Physician e. Diagnoses: [REDACTED]. f. Last Vital Signs: Blood pressure dated 2/24/19, Pulse dated 2/28/19, Temperature dated … | 2020-09-01 |
| 58 | 58 | MT OLYMPUS REHABILITATION CENTER | 465006 | 2200 EAST 3300 SOUTH | SALT LAKE CITY | UT | 84109 | 2019-05-23 | 677 | D | 0 | 1 | PDL911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 2 of 28 sampled residents, that the facility did not ensure that a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Specifically, 2 residents complained of not receiving showers and the facility's documentation was unable to prove that they had been provided. Resident identifiers: 48 and 52. Findings include: 1. Resident 48 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 5/20/19 at 1:30 PM, an interview was conducted with resident 48. Resident 48 stated she was not provided showers on a consistent basis. Resident 48 stated that on the 8th of (MONTH) she had received a shower, and was not showered again until (MONTH) 17th. Resident 48 stated prior to (MONTH) 8th she believed she had gone three and a half weeks without a shower. Resident 48 stated she had to beg for showers. On 5/21/19, resident 48's medical record was reviewed. Resident 48 had a Quarterly Minimum Data Set (MDS) assessment completed on 4/21/19. Under section G0120 titled Bathing resident 48 was coded as needing physical help in part of the bathing activity. For the amount of support provided resident 48 was coded as needing two person physical assist. Resident 48 also had a Quarterly MDS assessment completed on 1/19/19. Under section G0120, resident 48 was coded as requiring total dependence for bathing. Resident 48's care plan was reviewed and under a section titled focus the following was revealed: .The resident has an ADL (activities of daily living) self-care performance deficit r/t (related to) disease process, impaired balance, limited mobility, limited ROM (range of motion) chronic pain to lower lumbar. (At) risk for altered ADL's r/t: decline in functional ADL activity such as bed mobility .transfer .walking .dressing .toileting .and personal hygiene and bathing. The facility'… | 2020-09-01 |
| 59 | 59 | MT OLYMPUS REHABILITATION CENTER | 465006 | 2200 EAST 3300 SOUTH | SALT LAKE CITY | UT | 84109 | 2019-05-23 | 684 | D | 0 | 1 | PDL911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 1 of 28 sampled residents, that the facility did not ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choice. Specifically, physician ordered physical therapy was not provided to a resident. Resident identifier: 43. Findings include: Resident 43 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 5/20/19 at 10:53 AM, an interview was conducted with resident 43. Resident 43 stated that he had been on physical and occupational therapy a while ago, but not in the recent months. Resident 43 stated they've given up on me. On 5/21/19 resident 43's medical record was reviewed. A Physician's progress note dated 5/9/19 at 4:38 PM, revealed, PT (physical therapy) evaluation and Rx (prescription) for L (left) shoulder rotator cuff strain. A copy of resident 43's physical therapy notes were requested. The last therapy notes were completed in (MONTH) 2019. Resident 43's physician's orders [REDACTED]. On 5/22/19 at 12:15 PM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated she had not had experience putting in a physical therapy order. RN 1 stated she would assume she would inform the therapists or go to the Director of Nursing (DON) to find out what to do. On 5/22/19 at approximately 1:00 PM, an interview was conducted with Licensed Practical Nurse (LPN) 2. LPN 2 stated that if a resident appeared to need therapy, she would talk to therapy. LPN 2 stated if a physician ordered therapy, then she would put the order in and go inform therapy of the order. On 5/23/19 at 9:50 AM, an interview was conducted with LPN 3. (Note: LPN 3 was the nurse who put in the physician's orders [REDACTED]. LPN 3 stated that if she were to receive a physician's orders [REDACTED]. LPN 3 stated she knew resident 43 had physical therapy recently because she had put the… | 2020-09-01 |
| 60 | 60 | MT OLYMPUS REHABILITATION CENTER | 465006 | 2200 EAST 3300 SOUTH | SALT LAKE CITY | UT | 84109 | 2019-05-23 | 689 | E | 0 | 1 | PDL911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review it was determined, for 4 of 28 sample residents, that the facility did not ensure that the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents. Specifically, one resident was not on supervised smoking, had repeated falls outside while smoking, and did not have documentation that neurological checks were performed after the resident had a fall and hit his head. The same resident had repeated interventions. Another resident's fall was not assessed nor were appropriate interventions put in place. Another resident had an incident with her power wheelchair and an assessment for her safely utilizing the powerchair was not completed until a month later. Another resident had multiple falls with no new interventions. Resident identifiers: 3, 13, 32, and 43. Findings include: 1. Resident 3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 5/21/19, resident 3's medical record was reviewed. Resident 3's progress notes revealed the following: a. On 1/1/19 at 10:54 AM, resident 3 was on 72 Hour Event Charting for an unwitnessed fall. The actual event was not documented in the progress notes. The note on 1/1/19, appeared to be the only note charted for that particular fall. b. On 1/2/19 at 1:59 PM, a Fall note was completed which stated Resident found sitting on floor in front of chair. States that he got dizzy and fell . Resident tried getting up without walker. Assessment complete .Freq (frequent) visual checks performed. Resident reminded to use walker when getting up or call for assistance . c. On 1/4/19 at 2:57 PM, an IDT (interdisciplinary team) Event Review was completed. It stated it was for an unwitnessed fall on 12/31/18. It stated: .Resident went outside to smoke .Resident was found outside on ramp, Resident was feeling tired earlier in the day, nurse encouraged res… | 2020-09-01 |
| 61 | 61 | MT OLYMPUS REHABILITATION CENTER | 465006 | 2200 EAST 3300 SOUTH | SALT LAKE CITY | UT | 84109 | 2019-05-23 | 690 | D | 0 | 1 | PDL911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 1 of 28 sampled residents, that the facility did not ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections. Specifically, a resident with a suprapubic catheter developed two urinary tract infections. Resident identifier: 25. Findings include: Resident 25 was admitted to the facility on [DATE] and was readmitted on [DATE] and 5/17/19 with [DIAGNOSES REDACTED]. On 5/20/19, an observation was made of resident 25 resting in her room. Resident 25 had contact precautions on the door to her room. Resident 25 stated that she was very sick and [MEDICAL CONDITION]. On 5/23/19, a review was conducted of resident 25's medical record. A physician's orders [REDACTED]. for suprapubic catheter. The order had a hold date from 3/1/19 to 3/4/19, when resident 25 was hospitalized , and a discontinue date of 3/4/19. A physician's orders [REDACTED]. The order was discontinued on 3/4/19. On 12/16/18, resident 25's care plan for recurrent urinary tract infections (UTIs) was updated. The care plan included the following intervention: Suprapubic catheter care Q shift & (and) PRN. Monitor insertion site & provide tx (treatment) to site as directed. Refer to TAR (Treatment Administration Record) for current tx orders & special instructions for daily care of SP (suprapubic) catheter to bladder. A review of resident 25's TAR revealed no orders for catheter cares between 3/4/19 and 5/22/19. A pharmacy review note dated 3/5/19 at 7:49 PM, revealed . Res (resident) readmitted p (with) urosepsis and pneumonia. A review of nursing notes revealed the following: a. On 4/1/19 at 4:50 PM, Resident c/o (complained of) 'urinating through her urethra'. Refused to allow assessment both yesterday and then today, until this afternoon. DON (Director of Nursing) came to room and assisted LN (licensed nurse) in convincing Resident to cooperate with assessme… | 2020-09-01 |
| 62 | 62 | MT OLYMPUS REHABILITATION CENTER | 465006 | 2200 EAST 3300 SOUTH | SALT LAKE CITY | UT | 84109 | 2019-05-23 | 757 | D | 0 | 1 | PDL911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 2 of 28 sampled residents, the facility did not ensure that resident's drug regimen was free from unnecessary drugs. An unnecessary drug is any drug when used in excessive dose; or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or any combinations of the reasons above. Specifically, the facility did not administer blood pressure medications as ordered by the resident's physician. Resident identifiers: 16 and 39. Findings include: 1. Resident 16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 5/23/19, a medical record review was conducted for resident 16. A physician's orders [REDACTED]. A review of resident 16's Medication Administration Record [REDACTED] a. On 4/14/19, for the PM dose, BP 99/62 b. On 4/18/19, for the PM dose, BP 90/51 c. On 4/19/19, for the PM dose, BP 97/62 On 5/22/19 at 12:29 PM, an interview was conducted with Registered Nurse (RN) 2. RN 2 stated that the MAR indicated [REDACTED]. RN 2 was able to identify that resident 16's blood pressure medication was ordered to be held if the SBP was below 110. RN 2 stated that she would have contacted the physician when the blood pressure was out of parameters and would not administer the medication. RN 2 identified that the medication should have been held for resident 16. On 5/22/19 at 12:55 PM, an interview was conducted with the Director of Nursing (DON). The DON identified that the medication for resident 16 was given outside of the physician's orders [REDACTED]. 2. Resident 39 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 5/23/19, a record review was completed for resident 39. Resident 39's physician's orders [REDACTED]. a. On 3/6/19, [MEDICATION NAME] HCL ([MEDICATION NAME]) tablet, 60 mg, give 60 mg by mouth three times … | 2020-09-01 |
| 63 | 63 | MT OLYMPUS REHABILITATION CENTER | 465006 | 2200 EAST 3300 SOUTH | SALT LAKE CITY | UT | 84109 | 2019-05-23 | 761 | D | 0 | 1 | PDL911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview it was determined that the facility did not ensure safe and secure storage of drugs and biologicals in accordance with accepted professional principles; or include the appropriate accessory and cautionary instructions, and the expiration date on the medication. Specifically, a multi-dose vial of insulin was expired and available for use and administered to the resident. In addition, a resident was observed to have 2 medication cups on the bedside table with pills in the cups. Resident identifiers: 25 and 27. Findings include: 1. On [DATE] at 8:49 AM, an interview was conducted with resident 27. Resident 27 was observed to have two medication cups on his bed side table with pills in the cups. Resident 27 stated that the nursing staff always leave his medications on the bedside table. Resident 27 stated that he does not like the staff standing over him while he takes his medications. On [DATE] at 8:03 AM, an interview was conducted with Licensed Practical Nurse (LPN) 2. LPN 2 stated that if a resident had medications left at the bed side it should be on the resident's care plan. LPN 2 stated that there were not any residents on her hall that self administer medications or that can have there medications at the bedside. LPN 2 stated that resident 27 was very particular about his medications and he was aware of what medications he takes. On [DATE] at 8:49 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that if a resident request to self administer medications they should have an assessment and a physician's orders [REDACTED]. The DON stated that the staff should notify the Physician regarding the resident request and what medications the resident will be self administering. The DON stated that she would prefer that the nursing staff not leave any medications at the residents bed side. (Note: A physician's orders [REDACTED].) 2. On [DATE] at 7:38 AM, the medication cart on the En… | 2020-09-01 |
| 64 | 64 | MT OLYMPUS REHABILITATION CENTER | 465006 | 2200 EAST 3300 SOUTH | SALT LAKE CITY | UT | 84109 | 2019-05-23 | 773 | D | 0 | 1 | PDL911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined for 1 of 28 sampled residents that the facility did not provide or obtain laboratory (lab) services when ordered by the physician. Specifically, results of a basic metabolic panel (BMP) blood test were not reported to the physician. Resident identifier: 16. Findings include: Resident 16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 5/23/19, a medical record review was conducted for resident 16. A review of a nursing note dated 2/16/19 at 2:04 PM, revealed, Labs: BMP collected and MD (Medical Doctor) reviewed all lab values, New Orders; repeat BMP X (times) 1 week. Results for a BMP obtained on 2/20/19 were faxed to the facility on [DATE] at 7:35 AM. On 5/23/19 at 7:15 AM, an interview was conducted with Registered Nurse (RN) 3. RN 3 stated that nurses signed lab reports when they received them and then nurses contacted the physician. RN 3 stated that the faxed test results were received this morning, and were not received previously. RN 3 stated that he signed the order today. On 5/23/19 at 10:15 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that there was no record that nursing staff had received the results or contacted the physician about the results from the lab test on 2/20/19. | 2020-09-01 |
| 65 | 65 | MT OLYMPUS REHABILITATION CENTER | 465006 | 2200 EAST 3300 SOUTH | SALT LAKE CITY | UT | 84109 | 2019-05-23 | 775 | D | 0 | 1 | PDL911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined that for 1 of 28 sampled residents that the facility did not file, in the resident's clinical record, laboratory (lab) reports that were dated and contained the name and address of the testing laboratory. Specifically, one resident did not have laboratory reports filed in their medical record. Resident identifier: 16. Findings include: Resident 16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 5/23/19, a medical record review was conducted for resident 16. A review of nursing notes revealed the following: a. On 2/11/19 at 3:47 AM, Residents BMP (basic metabolic panel) Labs were not collected on 2/10/19. Notified Md (Medical Doctor) (resident's physician), received new orders to Re-check labs 2/11/19 BMP b. On 2/16/19 at 2:04 PM, Labs: BMP collected and MD reviewed all lab values, New Orders; repeat BMP X (times) 1 week. A review of scanned laboratory results revealed that no laboratory reports dated after 1/14/19 were located in resident 16's medical record. On 5/23/19 at 8:30 AM, an interview was conducted with a Medical Records (MR) staff member. The MR staff member stated that all laboratory reports that had been received by the facility before the current week had been scanned into the electronic medical record. On 5/23/19 at 7:15 AM, an interview was conducted with Registered Nurse (RN) 3. RN 3 stated that laboratory results were faxed from the testing laboratory and then acknowledged by the nurse. RN 3 stated that after the nurse received the results, the physician was contacted, and then the lab result was scanned into the resident's electronic medical record. RN 3 stated that he did not receive resident 16's BMP results dated 2/20/19 prior to today. On 5/23/19 at 10:20 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that there was no evidence that the lab results for the two BMP obtained on 2/20/19, were received by the facil… | 2020-09-01 |
| 66 | 66 | MT OLYMPUS REHABILITATION CENTER | 465006 | 2200 EAST 3300 SOUTH | SALT LAKE CITY | UT | 84109 | 2016-11-30 | 157 | D | 0 | 1 | 16UX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, it was determined the facility did not immediately consult with the resident's physician for 1 of 34 sample residents. Specifically, the facility nursing staff did not notify the Medical Doctor (MD) of an abnormal blood sugar per the physician's orders [REDACTED]. Findings include: Resident 24 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 24's medical record was reviewed on 11/30/16. A physician's orders [REDACTED]. If blood sugar is greater than 414, give 22 units. If blood sugar is greater than 414, call MD . A review of resident 24's (MONTH) (YEAR) and (MONTH) (YEAR) Medication Administration Record [REDACTED] a. 10/26/16 at 8:00 PM, a blood sugar of 460 was documented. The nursing staff documented that 22 Units of Humalog was administered. b. 11/17/16 at 8:00 PM, a blood sugar of 438 was documented. The nursing staff documented that 22 Units of Humalog was administered. No documentation could be located indicating that the MD had been notified. On 11/20/16 at 1:58 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that the nurse did not contact the MD per physician's orders [REDACTED].> | 2020-09-01 |
| 67 | 67 | MT OLYMPUS REHABILITATION CENTER | 465006 | 2200 EAST 3300 SOUTH | SALT LAKE CITY | UT | 84109 | 2016-11-30 | 371 | E | 0 | 1 | 16UX11 | Based on observation and interview, it was determined that the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service and safety. Specifically, concerns were identified related to cross contamination during food preparation, expired food items, and dating, labeling, and covering food items. Findings include: On 11/28/16 at 7:45 AM, the following observations were made during an initial tour of the main kitchen: a. Cracked and peeled caulking along the left-hand side of the dishmachine between the wall and the stainless steel counter. b. A dented can of Ensure within the dry storage area. c. A large container of brown sugar was open to the air within the dry storage area. d. A plastic container of strawberries was visibly moldy within the walk-in refrigerator. e. An opened container of ranch dressing was dated 2/15.17, indicating a two-year expiry period within the walk-in refrigerator. f. A container of salsa was undated within the walk-in refrigerator. g. Two containers of lemon juice were dated BEST BEFORE (YEAR) NOVEMBER 14 within the walk-in refrigerator. h. One container of lemon juice was dated BEST BEFORE (YEAR) NOVEMBER 15 within the walk-in refrigerator. i. Five containers of pesto appeared to have visible, white mold growth within the walk-in refrigerator. j. A plastic bag of grapes, with an individual package of Oreo cookies inside the bag, was labeled with an indecipherable date and resident identifier within the walk-in refrigerator. k. A reusable ice pack was stored among food items within the standing refrigerator. l. A plastic bag of chicken fingers was undated within the standing refrigerator. m. A plastic package of raw chicken breasts was stored on the top shelf, above berries and pre-cooked fish products, within the standing refrigerator. On 11/28/16 at 8:35 AM, an observation was made of the cook during breakfast preparation. The cook was observed to crack three eggs into a frying pan, wipe her hands on her apron, and then procee… | 2020-09-01 |
| 68 | 68 | MT OLYMPUS REHABILITATION CENTER | 465006 | 2200 EAST 3300 SOUTH | SALT LAKE CITY | UT | 84109 | 2016-11-30 | 502 | D | 0 | 1 | 16UX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined for 1 of 34 sample residents, that the facility did not provide or obtain laboratory (lab) services timely to meet the needs of the residents. Specifically, labs were not obtained as ordered by the physician. Resident identifiers: 24. Findings include: Resident 24 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 24's medical record was reviewed on 11/30/16. A physician's orders [REDACTED]. A review of the laboratory values revealed that a CBC and CMP for resident 24 was completed on 10/10/16. The Medical Doctor documented to increase resident 24's [MEDICATION NAME] to 80 milligrams for five days and check a BMP (basic metabolic panel) on Sunday (10/16/16). No documentation could be located in resident 24's medical record indicating that the BMP blood draw was completed on 10/16/16. On 11/30/16 at 1:58 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that the BMP blood draw for resident 24 was missed. | 2020-09-01 |
| 69 | 69 | HARRISON POINTE HEALTHCARE AND REHABILITATION | 465009 | 3430 HARRISON BOULEVARD | OGDEN | UT | 84403 | 2017-06-22 | 248 | E | 0 | 1 | WP7B11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined that the facility did not provide activities, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choices of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for 5 of 25 sample residents. Specifically, residents complained that activities did not meet their needs and there were no activities on the weekends to meet their needs. Resident identifiers: 29, 38, 53, 55 and 56. Findings include: 1. The facility activities calendar for (MONTH) (YEAR) was reviewed and revealed the following scheduled activities for 6/19/17 through 6/22/17. a. 6/18/17:10:30 AM LDS Services 2:00 PM Therapy Animals b. 6/19/17: 10:30 AM Exercise 12:00 AM, Reminiscing 3:00 PM Prize Bingo c. 6/20/17: 10:00 AM Horse Races 12:00 AM Trivia 2:00 PM Resident Council 7:00 PM Baptist Bible Study d. 6/21/17: Use Your Noodle Day!!! 10:00 AM Movie Channel 3 Ocean's Eleven 10:30 AM LDS Services 12:00 PM Sensory Hand Washing 3:00 PM Reading outdoors e. 6/22/17: 9:30 AM Exercise Group 10:00 AM Catholic Service 10:30 AM Music & Motion with Marsha 12:00 PM Time Slips 2:00 PM Van Outing f. 6/23/17: 10:30 AM Yardzee 12:00 PM Current Events 4:00 PM Violin Students 4:00 PM LDS Missionaries 7:00 PM Bingo g. 6/24/17: 10:30 Baptist Service 12:00 PM Music Reminiscing 2:00 Root Beer Float Social (Note: There are 2 scheduled evening activities on Tuesday nights at 7:00 PM and Friday nights at 7:00 PM. Tuesday nights were scheduled for a religious event. The scheduled activities on Sundays were LDS services and Therapy Animals.) On 6/19/17 at 12:00 PM, an observation was made of the Reminiscing activity. The activity was compl… | 2020-09-01 |
| 70 | 70 | HARRISON POINTE HEALTHCARE AND REHABILITATION | 465009 | 3430 HARRISON BOULEVARD | OGDEN | UT | 84403 | 2017-06-22 | 253 | E | 0 | 1 | WP7B11 | Based on observation and interview it was determined that the facility did not provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Specifically, there was a brown substance on a hand rail in a resident bathroom, there were bugs observed in the facility, there was a liquid on the floor in a bathroom and residents complained the facility was not clean. Resident identifiers: 93 and 94. Findings include: 1. On 6/19/17 at 8:18 AM, an interview was conducted with resident 94. Resident 94 stated that her bathroom was not cleaned regularly. Resident 94 stated that there had been a brown substance on the hand rail in her bathroom for at least 2 days. Resident 94 stated she can only imagine what it was. Resident 94 stated that her bathroom always smelled. An observation was immediately conducted of resident 94's bathroom. There was a brown substance on the hand rail and the bathroom had a strong odor. At 3:30 PM, an observation was made of resident 94's bathroom. There was still a brown substance on the hand rail and the bathroom had a strong odor. 2. On 6/19/17 at 10:23 AM, an observation was made of the bathroom in room 17. There was a liquid substance on the floor and there was a strong urine odor. 3. On 6/20/17 at approximately 12:30 PM, an observation was made of three box elder bugs crawling on the inside window of the Northeast exit door. 4. On 6/20/17 at 2:37 PM, an interview was conducted with resident 93. Resident 93 stated that he had just killed a big black spider in his bathroom. An observation was immediately conducted on resident 93's bathroom. There was a black object that was crumpled in the corner of the bathroom which appeared to resemble a spider. On 6/22/17 at approximately 12:30 PM, an interview was conducted with the House Keeper (HK). The HK stated that she was hired a week ago. The HK stated that the day shift cleaned the front half of the facility resident room and the night house keeper cleaned the back half. The HK stated that bathro… | 2020-09-01 |
| 71 | 71 | HARRISON POINTE HEALTHCARE AND REHABILITATION | 465009 | 3430 HARRISON BOULEVARD | OGDEN | UT | 84403 | 2017-06-22 | 323 | G | 0 | 1 | WP7B11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, it was determined that for 1 of 25 sample residents, the facility did not ensure that each resident was safe from accident hazards. Specifically, a resident sustained [REDACTED]. The findings were cited at a harm level due to the resident not having adequate supervision to prevent falls. Resident identifier: 35. Findings include: Resident 35 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 6/22/17 at approximately 9:10 AM, an observation was made of resident 35 laying in bed. The bed was not in the low position. Certified Nurse Assistant (CNA) 1 who was in the room confirmed that bed was not in lowest position. CNA 1 lowered the resident's bed approximately 12 - 18 inches to the lowest possible position. CNA 1 stated that staff will lower resident's bed but resident had access to bed control and would often return the bed to a normal height. Resident 35's medical record was reviewed on 6/22/17. Review of the admission MDS (Minimum Data Set) Assessment, dated 2/13/17, revealed that the facility staff assessed resident 35 as requiring limited assistance with a one person physical assist for transfers, ambulating, toileting, and bed mobility. The facility staff also identified that resident 35 had sustained falls in the last 2-6 months prior to admission. A Care Area Assessment (CAA) triggered for falls. The facility staff documented that the care area would be addressed in a care plan. Review of resident 35's care plan revealed an Activities of Daily Living (ADL) Self Care Performance Deficit care plan that was initiated on 2/7/17. The goal developed was Will safely perform Bed mobility, Transfers, Eating, Dressing, Grooming, Toilet Use and Personal Hygiene) (sic) with modified independence) through the review date. The interventions developed to achieve the goal included: Occupational (OT), Physical (PT), Speech-Language Therapy (ST) evaluation and treatment to establish fu… | 2020-09-01 |
| 72 | 72 | HARRISON POINTE HEALTHCARE AND REHABILITATION | 465009 | 3430 HARRISON BOULEVARD | OGDEN | UT | 84403 | 2017-06-22 | 353 | E | 0 | 1 | WP7B11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined that the facility did not have sufficient nursing staff, for 6 of 25 sample residents, with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and [DIAGNOSES REDACTED]. Specifically, residents and family complained there were not enough staff and resident council minutes revealed call lights were not answered timely. Resident identifiers: 23, 43, 53, 55, 80 and 92. Findings include: 1. On 6/19/17 at 1:45 PM, an interview was conducted with resident 43's family member. Resident 43's family member stated that Certified Nursing Assistant's (CNA's) will leave resident 43 in bed because there were not enough staff to watch her. Resident 43's family member stated that she was in the facility on 6/18/17 visiting and as she was assisting resident 43 back to her room, a CNA asked her if she wanted resident 43 back in bed. Resident 43's family member stated that the CNA told her that there were not enough staff to monitor resident 43 when she was out of bed. 2. On 6/19/17 at 1:30 PM, an interview was conducted with resident 23. Resident 23 stated that her call lights was not answered for over an hour on a regular basis. 3. On 6/19/17 at 1:26 PM, an interview was conducted with resident 92. Resident 92 stated that he had waited 3 hours to get a cup of coffee. Resident 92 stated there were not enough staff. 4. On 6/19/17 at 2:51 PM, an interview was conducted with resident 80. Resident 80 stated that he waited 30 minutes to an hour for his call light to be answered. 5. On 6/19/17 at 2:39 PM, an interview was conducted with resident 53. Resident 53 stated that there were not enough staff and she waited for an average of 20 minutes to … | 2020-09-01 |
| 73 | 73 | HARRISON POINTE HEALTHCARE AND REHABILITATION | 465009 | 3430 HARRISON BOULEVARD | OGDEN | UT | 84403 | 2017-06-22 | 371 | F | 0 | 1 | WP7B11 | Based on observation, interview and record review it was determined that the facility did not store prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, the dish machine temperatures and sanitizer were not at the levels required to sanitize, there were soiled area and there was shelving with paint chipping that were not sanitizable. Findings include: 1. On 6/19/17 at 8:18 AM, an initial tour of the kitchen was conducted. The following observations were made: a. There were white shelves that had food stored on them. The paint was chipped on some areas of the shelves. The shelves were soiled. b. There were 2 oven mitts with brown and black substances on them. c. There was a metal cover on the floor near the tray line that had 2 handles. The metal cover was soiled with debris in the handle area. 2. On 6/22/17 at 9:05 AM, a follow up observation was made of the facility kitchen. The following observations were made: a. The items listed above remained soiled. b. There were loose tiles on the wall by the door. c. There was a hole in the wall between the freezer and refrigerator that was covered with tape. d. There there was a large crack in the wall behind the dish machine. e. The hood vents were soiled with a brown and black substance. 3. On 6/22/17 at 9:18 AM, an observation was made of the facility dish machine. The following cycles were observed: (Note: All temperatures were in degrees Fahrenheit.) a. The wash cycle was 115 and the rinse was 120. Cook 1 was observed to document the wash temperature of 115 and the rinse temperature of 120 with the sanitizer solution of 100 on the Dish Machine Temperature Log form. An interview was immediately conducted with Cook 1. Cook 1 stated that the sanitizer was not tested because the temperatures were fine so the staff documented 100 because that's what we do. b. The wash cycle was 115 and the rinse was 122. c. The wash cycle was 115 and the rinse was 121 and the sanitizer was 50 parts per million (PPM). The dishe… | 2020-09-01 |
| 74 | 74 | HARRISON POINTE HEALTHCARE AND REHABILITATION | 465009 | 3430 HARRISON BOULEVARD | OGDEN | UT | 84403 | 2019-11-06 | 580 | D | 0 | 1 | F3KR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 1 of 21 sampled residents, that the facility staff did not immediately consult with the resident's physician when there was a significant change in the residents status. Specifically, a resident had elevated blood glucose levels with a physician's orders [REDACTED]. There was no documentation the the physician was notified. Resident identifier: 20. Findings include: Resident 20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 20's medical record was reviewed on 11/5/19. A physician's orders [REDACTED].= 2 (Units); 200-249 = 4; 250-299 = 6; 300-349= 8; 350-399 = 10; [PHONE NUMBER]=12 notify MD (Medical Doctor) if > (greater than) 400, subcutaneously before meals and at bedtime for [MEDICAL CONDITION]. Resident 20's Medication Administration Record (MAR) for (MONTH) 2019 revealed the following blood glucose (BG) levels on 9/27/19. A BG of 468 at 11:30 AM, a BG of 429 at 3:30 PM, and a BG of 434 at 8:00 PM. There was no documentation that the physician was notified. Resident 20's MAR for (MONTH) 2019 revealed on 10/2/19 at 3:30 PM, a BG of 405. There was no documentation that the physician was notified. A physician's orders [REDACTED].= 3; 200 - 249 = 5; 250 - 299 = 7; 300 - 349 = 9; 350 - 399 = 11; 400 - 9999 = 13 notify MD if >400, subcutaneously four times a day for [MEDICAL CONDITION]. Resident 20's MAR for (MONTH) 2019 revealed the following BG levels. On 10/3/19 a BG of 442, on 10/4/19 a BG of 459, on 10/5/19 a BG of 420, on 10/8/19 a BG of 407, on 10/12/19 a BG of 425, and on 10/15/19 a BG of 415. There was no documentation that the physician was notified. On 11/5/19 at 3:10 PM, an interview was conducted with the Director of Nursing (DON). The DON stated when a resident blood glucose was over 400, the nurse documented the blood glucose, administered the insulin according to physician orders, and notified the physician. The DON stated there was a box for… | 2020-09-01 |
| 75 | 75 | HARRISON POINTE HEALTHCARE AND REHABILITATION | 465009 | 3430 HARRISON BOULEVARD | OGDEN | UT | 84403 | 2019-11-06 | 756 | E | 0 | 1 | F3KR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 3 of 21 sampled residents, that the facility did not ensure that the drug regimen of each resident was reviewed at least once a month by a licensed pharmacist. Specifically, residents did not have monthly pharmacy reviews completed by the pharmacist. Resident identifiers: 4, 20, and 23. Findings include: 1. Resident 4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 4's medical record was reviewed on 11/5/19. The drug regimen reviews for resident 4 were reviewed. Resident 4 was not listed on the form provided by the pharmacist that revealed there were no irregularities for (MONTH) 2019. There was no form with recommendations for resident 4 for (MONTH) 2019. 2. Resident 20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 20's medical record was reviewed on 11/5/19. The drug regimen reviews for resident 20 were reviewed. Resident 20 was not listed on the form provided by the pharmacist that revealed there were no irregularities for (MONTH) and (MONTH) 2019. There was no form with recommendations for resident 20 for (MONTH) and (MONTH) 2019. 3. Resident 23 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The drug regimen review for resident 23 were reviewed. Resident 23 was not listed on the form provided by the pharmacist that revealed there were no irregularities for (MONTH) and (MONTH) 2019. There was no form with recommendations for resident 20 for (MONTH) and (MONTH) 2019. On 11/6/19 at approximately 2:00 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that the resident's were reviewed monthly by the pharmacist. The DON stated that she did not have the recommendation forms for resident 4, 20, and 23. | 2020-09-01 |
| 76 | 76 | HARRISON POINTE HEALTHCARE AND REHABILITATION | 465009 | 3430 HARRISON BOULEVARD | OGDEN | UT | 84403 | 2019-11-06 | 760 | D | 0 | 1 | F3KR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 1 of 21 sampled residents, that the facility did not ensure the residents were free of significant medication errors. Specifically, the facility did not administer [MEDICATION NAME] as ordered by the physician and the [MEDICATION NAME] order was not discontinued timely. Resident identifier: 2. Findings include: Resident 2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 2's medical record was reviewed on 11/5/19. 1. The Discharge Instructions/Order from the local hospital dated 7/19/19, documented that resident 2 had [DIAGNOSES REDACTED]. Resident 2 had a long term current use of anticoagulants related to [DIAGNOSES REDACTED] complicated by multiple [MEDICAL CONDITION] and ischemic [MEDICAL CONDITION]. Goal international normalized ratio (INR) was to be between 2 to 3. The hospital recommended continuing the [MEDICATION NAME] at 10 milligrams (mg) daily supplemented by [MEDICATION NAME] until INR in goal range. A review of the facility Order Summary Report documented the following physician's orders [REDACTED]. Continue until INR greater than (>) 2.0. A review of the PT ([MEDICATION NAME] time)/INR Dipstick Test documented that resident 2 had an INR of 2.7 on 7/22/19. Current Meds (Medications): [MEDICATION NAME] 7.5 mg and [MEDICATION NAME] discontinue when > 2.0. The Nurse Practitioner (NP) noted no change and check INR in one week on 7/29/19. A review of the PT/INR Dipstick Test documented that resident 2 had an INR of 3.6 on 7/29/19. Current Meds: [MEDICATION NAME] 7.5 mg daily and [MEDICATION NAME] discontinue when > 2.0. The NP noted to hold times 1 dose and check INR tomorrow on 7/30/19. A review of the PT/INR Dipstick Test documented that resident 2 had an INR of 2.7 on 7/30/19. Current Meds: [MEDICATION NAME] 7.5 mg held on 7/29/19. [MEDICATION NAME] 120 mg/0.8 ml continue until INR > 2.0. The NP noted to discontinue the [MEDICATION NAME] and check … | 2020-09-01 |
| 77 | 77 | PIONEER CARE CENTER | 465020 | 815 SOUTH 200 WEST | BRIGHAM CITY | UT | 84302 | 2017-03-16 | 252 | D | 0 | 1 | Q9V711 | Based on observation, interview and record review it was determined that the facility did not ensure that, 4 of 34 sampled residents had a clean, comfortable home-like environment, including supports for daily living safely. Specifically, there were soiled wheelchairs and residents stated their wheelchairs had not been cleaned. Resident identifiers: 5, 13, 14, and 20. Findings include: On 3/13/17 at 3:00 PM, an observation was made of resident 20's electric wheelchair. The wheelchair had debris and dust by the motor and on the area over the wheels. There was also debris on the foot rests. Resident 20 stated that her wheelchair was cleaned yearly but would like to have it cleaned more often. On 3/13/17 at 3:10 PM, an observation was made of resident 14's wheelchair. Resident 14's wheelchair had debris on the foot rests and was soiled on the seat. A follow up observation was conducted on 3/16/17 and resident 14's wheelchair had debris and was soiled on the foot rest and seat. On 3/14/17 at 8:49 AM, an observation was made of resident 5's wheelchair. Resident 5's wheelchair had dust and debris on the bottom area around the motor and on the plastic wheel covers. Resident 5 stated that she had to wipe her own wheelchair to clean it. Resident 5 stated that she would like the facility staff to clean her wheelchair. A follow up observation was conducted on 3/16/17 and resident 5's wheelchair was soiled on the footrest and on the wheel covers. On 3/16/17 at 12:29 PM, an observation was made of resident 13's electric wheelchair. Resident 13's wheelchair had food and debris on her foot rests and stated that she would like to have it cleaned. A follow up observation was conducted on 3/16/17 and resident 13's wheelchair was soiled on the foot rest and on the wheel covers. On 3/16/17 at 12:45 PM, an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated that wheelchairs were cleaned at night by the staff. On 3/16/17 at 1:00 PM, an interview was conducted with the Director of Nursing (DON). The DON state… | 2020-09-01 |
| 78 | 78 | PIONEER CARE CENTER | 465020 | 815 SOUTH 200 WEST | BRIGHAM CITY | UT | 84302 | 2017-03-16 | 325 | D | 0 | 1 | Q9V711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined that the facility did not assist 1 of 34 sample residents, with maintaining acceptable parameters of nutritional status, such as usual body weight or desirable body weight and electrolyte balance, unless the resident's clinical condition demonstrated that this was not possible or resident preference indicated otherwise. Specifically, a resident had lost a significant amount of body weight and had a low [MEDICATION NAME] level without documented interventions. Resident identifiers: 5. Findings include: Resident 5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 5's medical record was reviewed on 3/15/17. The following weights were documented in resident 5's electronic medical record: (Note: All weights were in pounds.) a. 3/6/17, 170 b. 2/27/17, 165.4 c. 2/20/17, 169.4 d. 2/13/17, 167.0 e. 1/9/17, 170 f. 1/2/17, 169.5 g. 12/29/16, 170.5 h. 12/19/16, 172.4 i. 12/6/16, 176 j. 11/30/16, 181 k. 11/23/16, 180 l. 11/17/16, 182 Resident 5 experienced a 5.1 % (percent) weight loss from 11/17/16 to 12/19/16. In addition, resident 5 experienced an 8.2 % weight loss from 11/17/16 to 2/13/17. (Note: The Minimum Data Set revealed that over 5% weight loss in 1 month and greater than 7.5 % in 3 months was considered a significant weight loss.) Resident 5's physician's orders [REDACTED]. Resident 5's laboratory values dated 1/19/17 were reviewed and revealed a low [MEDICATION NAME] level on 1/19/17 of 3.2 gm/dL (grams per deciliter) with a reference (normal) range of 3.4-5.0 gm/dL. Resident 5's total protein was low at 6.0 gm/dL with a reference range of 6.4-8.2 gm/dL. A Mini (miniature) Nutritional assessment dated [DATE] revealed that resident was at risk for malnutrition. The form revealed that resident 5's weight decreased 12 pounds in 3 months which was documented as not significant. It was documented that there was no weight since 1/9/17. There was no other information rega… | 2020-09-01 |
| 79 | 79 | PIONEER CARE CENTER | 465020 | 815 SOUTH 200 WEST | BRIGHAM CITY | UT | 84302 | 2019-05-01 | 755 | E | 1 | 0 | OCVO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview and record review it was determined, for 5 of 5 sample residents, that the facility did not establish a system of records of receipt and disposition of all controlled drugs in sufficient detail and enable an accurate reconciliation and determine that drug records were in order and that an account of all controlled drugs was maintained and periodically reconciled. Specifically, nursing staff had telephone orders signed by the physician that were available to fill in for scheduled 2 medications. In addition, residents narcotic record log did not match the Medication Administration Records (MAR) for narcotic administration. Resident identifiers: 1, 2, 3, 4 and 5. Findings include: 1. On 4/30/19 at 1:00 PM, an observation was made with Registered Nurse (RN) 1 of her medication cart narcotic drawer. There were 5 telephone orders that were signed by the MD with his Drug Enforcement Administration (DEA) number written on them. The telephone orders did not have a date, resident name, medication or dosing instructions. The telephone orders were stamped with V.O.R.B. (verbal order read back). 2. Resident 2 was admitted to the facility on [DATE] and discharged on [DATE] with [DIAGNOSES REDACTED]. Resident 2's medical record was reviewed on 5/1/19. Resident 2's physicians orders revealed the following: a. On 3/7/19, [MEDICATION NAME] immediate 5mg (milligrams) tablet (1) tab (tablet) po (oral) Q (every) 4h (hours) prn (as needed) pain (times) 30. The telephone order had Licensed Practical Nurse (LPN) 1's signature. There was a stamp V.O.R.B. with the Medical Director's (MD) signature and the MD's DEA number. b. On 3/18/19, [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg tab. Give 1 tab po Q4 hours prn pain. The telephone order had to dispense 60 tablets with no refills. The telephone order had a nurses signature with V.O.R.B stamped above it and the physicians signature with the DEA number. Review of the narcotic record log… | 2020-09-01 |
| 80 | 80 | PIONEER CARE CENTER | 465020 | 815 SOUTH 200 WEST | BRIGHAM CITY | UT | 84302 | 2019-05-01 | 842 | E | 1 | 0 | OCVO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review it was determined, for 5 of 5 sample residents, that the facility did not maintain accurate documentation of medical records for each resident. Specifically, residents Medication Administration Records (MARs) and narcotic record logs did not match. Resident identifiers: 1, 2, 3, 4 and 5. Findings include: 1. Resident 2 was admitted to the facility on [DATE] and discharged on [DATE] with [DIAGNOSES REDACTED]. Resident 2's medical record was reviewed on 5/1/19. Resident 2's physicians orders revealed the following: a. On 3/7/19, [MEDICATION NAME] immediate 5mg (milligrams) tablet (1) tab (tablet) po (oral) Q (every) 4h (hours) prn (as needed) pain (times) 30. The telephone order had Licensed Practical Nurse (LPN) 1's signature. There was a stamp V.O.R.B. (verbal order read back) with the physicians signature and Drug Enforcement Administration (DEA) number. b. On 3/18/19, [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg tab. Give 1 tab po Q4 hours prn pain. The order had to dispense 60 tablets with no refills. The telephone order had a nurses signature with V.O.R.B stamped above it and the physicians signature with the DEA number. Review of the narcotic record log entries with the corresponding MAR for [MEDICATION NAME] immediate 5mg every 4 hours as needed revealed that the medication was documented as signed out on the narcotic record log, but the medication was not documented on the MAR as being administered on the following dates; 3/6/19 at 12:30 AM, 3/7/19 at 8:00 PM, 3/8/19 at 5:00 AM and 3/12/19 at 6:30 AM. It should be noted that 4 doses were signed out on the narcotic record and were not signed out as administered on the MAR. The (MONTH) 2019 MAR revealed 3/9/19 at 1:25 AM that [MEDICATION NAME] was administered but the narcotic record sheet did not have the medication signed out. In addition, the MAR revealed that [MEDICATION NAME] 5 mg was administered on 3/27 at 4:27 PM and 3/31/19 at 5:59 PM. Ther… | 2020-09-01 |
| 81 | 81 | PIONEER CARE CENTER | 465020 | 815 SOUTH 200 WEST | BRIGHAM CITY | UT | 84302 | 2018-06-21 | 580 | D | 0 | 1 | EUNP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, it was determined the facility did not immediately consult with the resident's physician for 1 of 31 sample residents. Specifically, the facility nursing staff did not notify the physician of abnormal blood glucose results. Resident Identifier: 93. Findings include: Resident 93 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 93's medical record was reviewed on 6/20/18. Resident 93's (MONTH) (YEAR) Medication Administration Record [REDACTED] a. On 06/13/18 at 4:01 PM, low blood sugar of 37 mg/dL (milligrams per deciliter) b. On 06/14/18 at 6:21 PM, low blood sugar of 45 mg/dL c. On 06/16/18 at 8:10 AM, high blood sugar of 578 mg/dL On 6/20/18 at 10:55 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 reported that resident 93's blood sugars are not controlled. LPN 1 stated that she reported the blood sugar on 6/19/18 of 344 to the physician. On 6/20/18 at 11:12 AM, an interview was conducted with LPN 2. LPN 2 reported that if a resident had a blood glucose level under 60 mg/dL or over 400 mg/dL, she would notify the physician. LPN 2 stated if there was an order to notify the physician with a different parameter for blood glucose, she would follow the order. On 6/20/18 at 3:20 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that a resident's physician should be notified if a resident's blood glucose level was less than 60 or over 400. The DON did not provide additional information that the physician was contacted regarding the abnormal blood glucose levels on 6/13/18, 6/14/18 and 6/16/18. | 2020-09-01 |
| 82 | 82 | PIONEER CARE CENTER | 465020 | 815 SOUTH 200 WEST | BRIGHAM CITY | UT | 84302 | 2018-06-21 | 584 | E | 0 | 1 | EUNP11 | Based on observation and interview, it was determined for 8 of 31 sampled residents, that the facility did not ensure each resident's environment was safe, clean and comfortable. Specifically, a resident had a dusty fan that was blowing on him, the floors had debris and sticky substances on them. In addition, there were linens on the floor, there were rusted soap dishes in showers, a toilet with a brown substance on the rim and bathroom fans were not functioning. Resident identifiers: 2, 4, 13, 14, 28, 32, 39 and 93. Findings include: 1. The following observations were made of resident 2's room and bathroom: a. On 6/18/18 at 10:33 AM, resident 2 was observed laying in bed with a floor fan next to his bed. The fan was observed to have dust on the blades and front cover. The fan was on and blowing toward resident 2. In addition, resident 2's shower was observed to have a rusted soap dish in it. b. On 6/19/18 at 11:38 AM, resident 2 was observed laying in bed with a floor fan next to his bed. The fan was observed to have dust on the blades and front cover. The fan was on and blowing toward resident 2. c. On 6/21/18 at 8:53 AM, an observation was made with Housekeeper (HK) 1. HK 1 stated that the fan was soiled. 2. The following observation was made of resident 4's room: a. On 6/19/18 at 11:18 AM, resident 4's room was observed to have debris on the floor. 3. The following observations were made of resident 13's room and bathroom: a. On 6/18/18 at 11:03 AM, there was a dried dark substance on the floor in the room and bathroom. There was food debris observed next to the bed with ants on it. b. On 6/19/18 at 10:41 AM, there was a sticky, dark substance on the floor. c. On 6/21/18 at 8:48 AM, an observation was made with HK 1 of the dried dark substance on the floor in the room and bathroom, a spider web on the west window, dead bugs on the window sill, and dirty blinds. HK 1 stated the room needed to be cleaned. 4. The following observations were made of resident 14's room and bathroom: a. On 6/18/18 at 1:25 PM, the f… | 2020-09-01 |
| 83 | 83 | PIONEER CARE CENTER | 465020 | 815 SOUTH 200 WEST | BRIGHAM CITY | UT | 84302 | 2018-06-21 | 656 | D | 0 | 1 | EUNP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, it was determined for 1 of 31 sample residents that the facility did not develop a person-centered comprehensive care plan to meet the resident's medical, physical, mental or psychosocial needs. Specifically, a bladder incontinence care plan did not address how often incontinence care was to be provided. Resident identifiers: 9. Findings include: Resident 9 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 9's medical record was reviewed on 6/19/18. An annual Minimum Data Set (MDS) Assessment was completed by facility staff on 4/17/17. The facility staff assessed resident 9 as being always incontinence of urine. The facility staff documented that resident 9 was not on a toilet program (scheduled toileting or prompted toileting) at the time of admission /readmission or when urinary incontinence was identified. A quarterly MDS assessment was completed by facility staff on 3/28/18. The facility staff assessed resident 9 as being frequently incontinence or urine. The facility staff documented that resident 9 was not on a toileting program (scheduled toileting or prompted toileting) at the time of admission /readmission or when urinary incontinence was identified. Review of the care plans developed for resident 9 revealed a bladder incontinence care plan that was developed on 3/1/18. The facility staff documented, (Resident 9) has bladder incontinence related to Dementia, Impaired Mobility. The goal developed was, (Resident 9) will remain free from skin breakdown due to incontinence and brief use through the review date. The interventions developed to achieve the goal included, Utilizes briefs lined with incontinence pad, Clean peri-area with each incontinence episode, and Encourage fluids during the day to have adequate urinary output and prevent alterations in hydration. (Note: The bladder incontinence care plan did not include how often resident 9 was to be toileted o… | 2020-09-01 |
| 84 | 84 | PIONEER CARE CENTER | 465020 | 815 SOUTH 200 WEST | BRIGHAM CITY | UT | 84302 | 2018-06-21 | 658 | D | 1 | 1 | EUNP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, it was determined for 1 of 31 sample residents, that the facility did not ensure that services were provided as outlined by the comprehensive care plan. Specifically, a resident was not transferred with a two person assist which resulted in the resident being lowered to the floor. Resident identifier: 9. Findings include: Resident 9 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 9's medical record was reviewed on 6/19/18. On 11/15/17, a care plan related to resident 9's risk for falls was developed. The care plan documented that resident 9 had a history of [REDACTED]. The goal developed was, (Resident 9) will not sustain serious injury through the review date. On 3/1/18, an intervention of Staff educated to assist with two assist for transfers/gait belt; encourage the use of the walker was implemented. On 5/28/18 at 2:16 PM, a facility nurse documented in a progress note, Was called to resident room by the aid. Resident laying on the floor by her recliner. No injuries. Residnet (sic) did not hit her head, she was lowered to the floor during transferring from the wheelchair to her recliner. Staff to continue to monitor. On 5/30/18 at 11:18 AM, a facility nurse documented in a progress note, IDT (Interdisciplinary Team) Fall Review: Refer to PT (Physical Therapy) to increase strength to BLE (Bilateral Lower Extremities) and improve safety with transfers. (Note: There was not an investigation into the fall to ensure that the care plan was followed and interventions to prevent resident 9 from falling were implemented.) On 6/19/18 at 9:48 AM, an interview was conducted with the Director of Nursing (DON). The DON was unable to determine who was transferring resident 9 at the time resident 9 was lowered to the floor or whether two staff members were transferring resident 9 as care planned. | 2020-09-01 |
| 85 | 85 | PIONEER CARE CENTER | 465020 | 815 SOUTH 200 WEST | BRIGHAM CITY | UT | 84302 | 2018-06-21 | 676 | D | 0 | 1 | EUNP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, it was determined for 1 of 31 sample residents that the facility did not provided necessary services to ensure that a resident's abilities in activities of daily living did not diminish unless circumstances of the individual's clinical condition demonstrated that such diminution was unavoidable. Specifically, a resident did not receive oral hygiene for two days. Resident identifier: 32. Findings include. Resident 32 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 6/18/18 at 12:29 PM, an interview was conducted with resident 32. Resident 32 was observed to have food debris in her mouth that was light pink in color. There was a hand-written sign taped on the wall with care information documented. The hand-written sign instructed staff to, .Help her brush teeth daily. On 6/19/18 at 8:15 AM, resident 32 was observed. Resident 32 was observed to have light pink in color food debris in her mouth. Resident 32's medical record was reviewed on 6/20/18. Review of the Activities of Daily Living care plan that was developed for resident 32 on 2/2/18 and revised on 4/12/18 revealed that the facility staff were to provide extensive assistance of one staff member for oral care. On 6/19/18 at 12:56 PM, an interview was conducted with Certified Nurse Assistant (CNA) 6. CNA 6 stated that resident 32 needed assistance with personal hygiene including oral care. CNA 6 stated that she did not assist resident 32 with brushing her teeth on 6/18/18 or 6/19/18. On 6/19/18 at 1:05 PM, an interview was conducted with Licensed Practical Nurse (LPN) 3. LPN 3 stated that resident 32 was to have her teeth brushed twice a day. On 6/19/18 at 1:20 PM, an interview was conducted with CNA 8. CNA 8 stated that she did not assist resident 32 with brushing her teeth. | 2020-09-01 |
| 86 | 86 | PIONEER CARE CENTER | 465020 | 815 SOUTH 200 WEST | BRIGHAM CITY | UT | 84302 | 2018-06-21 | 684 | D | 0 | 1 | EUNP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review it was determined, for 1 of 31 sample residents, that the facility did not ensure a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choice. Specifically, facility staff did not monitor and reassess a resident after the resident experienced a change in condition, causing the resident to experience [DIAGNOSES REDACTED] (low blood sugar), [MEDICAL CONDITION] (high blood sugar) and discomfort. Resident identifier: 93 Findings include: Resident 93 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 93's medical record was reviewed on 6/21/18. An admission Minimum Data Set ((MDS) dated [DATE] revealed that resident 93 had a [DIAGNOSES REDACTED]. The MDS further revealed that resident 93 received 7 insulin injections in the last 7 days. A care plan dated 6/24/18 revealed a Focus of (Resident 93) had Diabetes Mellitus type 1. She is at risk for episodes of hyper and [DIAGNOSES REDACTED]. Signs of [DIAGNOSES REDACTED] are decreased alertness and lethargy. The Goals developed were, (Resident 93) will be free from any signs and symptoms of [MEDICAL CONDITION] through the next review date, . free from any signs and symptoms of [DIAGNOSES REDACTED] through the review date, .will have no complications related to diabetes through the review date. One of the interventions developed was, Diabetes medications as ordered by doctor. Monitor/document for side effects and effectiveness. Resident 93's physician's orders [REDACTED]. a. 6/7/18, Invokana tablet 300 mg (milligrams) one tablet per day for Type 1 diabetes mellitus with other specified complication. Resident's medication was scheduled to be administered at 8:00 AM. b. 6/7/18, [MEDICATION NAME] solution 100 units/mL (milliliter), inject 20 units subcutaneously one time a day related to T… | 2020-09-01 |
| 87 | 87 | PIONEER CARE CENTER | 465020 | 815 SOUTH 200 WEST | BRIGHAM CITY | UT | 84302 | 2018-06-21 | 689 | E | 1 | 1 | EUNP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, and record review it was determined for 2 out of 31 sampled residents that the facility did not ensure that the resident environment remains as free of accident hazards as is possible; and that each resident receives adequate supervision to prevent accidents. Specifically, a resident was observed to burn her hair, drop a lit cigarette down the inside of her smoking apron, and then smoke without an apron in place. Additionally, a resident was transferred with a one person assist when they were assessed as requiring two people. Resident identifiers: 9 and 38. Findings include: 1. Resident 38 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 6/18/18 at 1:00 PM, resident 38 smoking was observed smoking. The resident was observed wearing a smoking apron. The resident was supervised by the Social Service Worker (SSW), and the SSW was observed to cue the resident when to ash the cigarette. The resident was observed to be crying, agitated, and stating hurt during the smoke break. The resident was observed to lean forward in her wheelchair (WC) multiple times while holding her cigarette, and her arm and upper body movements appeared spastic. The resident's hair braid was observed to swing forward through her cigarette butt two times, singeing her hair, before the SSW noticed. The SSW was then observed to hold resident 38's hair away from the cigarette. The SSW was then observed to go back inside the building leaving resident 38 to be supervised by the Medical Records staff. The Medical Records staff was observed to stand in front of resident 38 while talking to another resident, and their attention was not focused on resident 38. Resident 38 was then observed to propel herself forward in her WC causing the resident's apron to be caught in her WC legs. This resulted in her upper body being pulled forward towards the ground. The resident was stabilized and the apron was untangled by the Medical Recor… | 2020-09-01 |
| 88 | 88 | PIONEER CARE CENTER | 465020 | 815 SOUTH 200 WEST | BRIGHAM CITY | UT | 84302 | 2018-06-21 | 690 | D | 0 | 1 | EUNP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, it was determined for 1 of 31 sample residents that a resident who was incontinent of urine received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible. Specifically, a resident who was incontinent was not checked or toileted for 3 1/2 hours. Resident identifier: 9. Findings include: Resident 9 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 9's medical record was reviewed on 6/19/18. An annual Minimum Data Set (MDS) Assessment was completed by facility staff on 4/17/17. The facility staff assessed resident 9 as being always incontinence of urine. The facility staff documented that resident 9 was not on a toilet program (scheduled toileting or prompted toileting) at the time of admission /readmission or when urinary incontinence was identified. A quarterly MDS assessment was completed by facility staff on 3/28/18. The facility staff assessed resident 9 as being frequently incontinent of urine. The facility staff documented that resident 9 was not on a toilet program (scheduled toileting or prompted toileting) at the time of admission /readmission or when urinary incontinence was identified. Review of the care plans developed for resident 9 revealed a bladder incontinence care plan that was developed on 3/1/18. The facility staff documented, (Resident 9) has bladder incontinence related to Dementia, Impaired Mobility. The goal developed was, (Resident 9) will remain free from skin breakdown due to incontinence and brief use through the review date. The interventions developed to achieve the goal included, Utilizes briefs lined with incontinence pad, Clean peri-area with each incontinence episode, and Encourage fluids during the day to have adequate urinary output and prevent alterations in hydration. (Note: The bladder incontinence care plan did not include how often resident 9 was to be toileted … | 2020-09-01 |
| 89 | 89 | PIONEER CARE CENTER | 465020 | 815 SOUTH 200 WEST | BRIGHAM CITY | UT | 84302 | 2018-06-21 | 697 | G | 0 | 1 | EUNP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review it was determined for 2 of 31 sampled residents that the facility did not ensure that pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. Specifically, a hospice resident reported that her pain medication was ineffective and her hourly pain medication was not being administered; and a vulnerable resident was observed to be in pain without any observed relief provided. The deficient practices identified was found to have occurred at a harm level. Resident identifiers 23 and 38. Findings include: 1. Resident 23 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 6/18/18 at 8:16 AM, resident 23 was interviewed. Resident 23 stated her pain was located in the head, neck, and back and was currently a 8/10 (On a numeric pain scale of 0 to 10. With 0 meaning no pain and 10 the worst pain.). Resident 23 stated that [MEDICATION NAME] was recently started for her pain and that the pain was not controlled with medication. On 6/18/18 at 9:00 AM, an observation was made of resident 23 ambulating to the smoking patio for the scheduled smoke time. On 6/18/18, resident 23's electronic medical records were reviewed. Review of the physician orders [REDACTED]. a. [MEDICATION NAME] (Concentrate) Solution 20 MG (milligrams)/ML (milliliter), Give 1 ml (milliliter)by mouth three times a day for pain. The order was initiated on 6/15/2018. b. [MEDICATION NAME] (Concentrate) Solution 20 MG/ML, Give 0.5 ml by mouth every 1 hours as needed for pain, SOB (shortness of breath). The order was initiated on 5/4/2018. c. [MEDICATION NAME] (Concentrate) Solution 20 MG/ML, Give 1 ml by mouth every 1 hours as needed for pain, SOB. The order was initiated on 5/4/2018. d. [MEDICATION NAME] HCl ([MEDICATION NAME]) Tablet 15 MG, Give 1 tablet by mouth every 4 hour… | 2020-09-01 |
| 90 | 90 | PIONEER CARE CENTER | 465020 | 815 SOUTH 200 WEST | BRIGHAM CITY | UT | 84302 | 2018-06-21 | 757 | G | 0 | 1 | EUNP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined that the facility did not ensure each resident's drug regimen was free from unnecessary drugs. An unnecessary drug was any drug when used in excessive dose, excessive duration, without adequate monitoring, or without adequate indication for its use. Specifically, 2 residents did not have adequate monitoring of PT/INR ([MEDICATION NAME] ratio/international normalized ratio) laboratory values. One resident was administered 2 additional doses of [MEDICATION NAME] after the INR was high. The findings for resident 15 were cited at a HARM level. Resident 143 was cited at a potential for harm. Resident identifiers: 15 and 143. Findings include: HARM 1. Resident 15 was admitted on [DATE], discharged on [DATE], readmitted on [DATE] and discharged on [DATE], readmitted on [DATE] and discharged on [DATE] with [DIAGNOSES REDACTED]. On 6/21/18, resident 15's medical record was reviewed. A care plan dated 3/13/18 and revised on 4/17/18 revealed a Focus of (Resident 15) has an alteration in hematological status. She is at risk for [MEDICAL CONDITION] related to epistaxis (nose bleed). (Resident 15) is also at risk for prolonged bleeding related to anticoagulant medication. Recent transfusion and alterations in labs. The goal developed was, (Resident 15) will remain free of complications related to altered hematological status through the review date. Some of the interventions developed revealed, Monitor/document/report PRN (as needed) following s/sx (signs and symptoms) of [MEDICAL CONDITION]:.low hgb/hct (hemoglobin/hematocrit). and Obtain and monitor lab/diagnostic work as ordered. Report results to MD (medical doctor) and follow up as indicated. Resident 15's History and Physical dated 5/16/18 revealed, CC (chief complaint)/Reason for admission: [MEDICAL CONDITION], hypovolemia. The laboratory values documented were hgb was 8.2 g/dL (grams per deciliter) which was low. The Hct was 27.4% which was lo… | 2020-09-01 |
| 91 | 91 | PIONEER CARE CENTER | 465020 | 815 SOUTH 200 WEST | BRIGHAM CITY | UT | 84302 | 2018-06-21 | 758 | D | 0 | 1 | EUNP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined for 2 out of 31 residents that the facility did not ensure that residents receiving [MEDICAL CONDITION] drugs are not given the medication unless necessary to treat a specific condition as diagnosed and documented in the clinical record and that they receive a gradual dose reduction unless clinically contraindicated. Additionally, as needed (PRN) orders are limited to 14 days unless the physician extends it beyond the 14 day requirement and documents the rationale and duration for the PRN order, and a PRN order for anti-psychotic drugs are limited to 14 days unless the physician evaluates the resident for the appropriateness of that medication every 14 days. Resident identifiers: 23 and 31. Findings include: 1. Resident 23 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 6/18/18, resident 23's medical records were reviewed. Review of the physician orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. No documentation could be found of the physician evaluating the resident every 14 days with a documented rationale for the continuation of the medication. On 6/21/18 at 11:47 AM, the DON was interviewed. The DON was informed of the new regulation regarding PRN orders for anti-psychotic medications. No documentation was provided of a physician evaluation every 14 days. The DON was observed to write down the regulation information on a sticky note. 2. Resident 31 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of physician orders [REDACTED]. Review of the Physician Rationale for Clinically Contraindicated Gradual Dose Reduction (GDR) for the [MEDICATION NAME] on 5/13/15 and on 6/10/17 revealed the rationale as noted increase/return behaviors with med (medication) changes. Side effects of [MEDICATION NAME] noted. Increased refusal of cares noted as well. On 6/20/18 at 11:11 AM, the Corporate Resource Nurse (CRN) was interviewed… | 2020-09-01 |
| 92 | 92 | PIONEER CARE CENTER | 465020 | 815 SOUTH 200 WEST | BRIGHAM CITY | UT | 84302 | 2018-06-21 | 760 | D | 0 | 1 | EUNP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined the facility did not ensure that resident's were free of significant medication errors. Specifically, a resident with an allergy to [MEDICATION NAME] received [MEDICATION NAME] instead of the ordered pain medication. Resident identifier: 14. Findings include: Resident 14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 14's medical record was reviewed on 6/20/18. Review of resident 14's ADMISSION RECORD revealed that resident 14 had an allergy to [MEDICATION NAME]. Review of the physician's orders [REDACTED]. On 12/27/17, an order was received to administer [MEDICATION NAME] ([MEDICATION NAME]-[MEDICATION NAME]) 7.5/325 mg (milligrams) 2 tablets by mouth every 6 hours as needed for pain. On 5/17/18 at 8:37 PM, a licensed nurse documented in a progress note, .Medication error: Gave 2 [MEDICATION NAME] 10 mg instead of 2 [MEDICATION NAME] 7.5 mg in error, discovered error in narcotic count. Patient has a listed allergy to [MEDICATION NAME]. MD (Medical Doctor) and wife notified. Error was approx (approximately) 2 hours ago and shows no ill effects to medication error. Wife requested we not tell him about error until possible effects would wear off as she feels his knowing would exacerbate his symptoms if any. She could not remember any ill effect to [MEDICATION NAME] in the past. VS (vital signs) stable, L[NAME] (level of consciousness) within normal limits. VS (temperature) 97.8 - (pulse) 71 - (respirations) 16 - (blood pressure) 118/67 Sats (oxygen saturation) 92%. On 6/21/18 at 10:55 AM, an interview was conducted with Licensed Practical Nurse (LPN) 3. LPN 3 stated that she did not look at the medication card prior to administering [MEDICATION NAME] to resident 3. | 2020-09-01 |
| 93 | 93 | PIONEER CARE CENTER | 465020 | 815 SOUTH 200 WEST | BRIGHAM CITY | UT | 84302 | 2018-06-21 | 761 | D | 0 | 1 | EUNP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview it was determined that the facility did not ensure safe and secure storage of drugs and biologicals in accordance with currently accepted professional principles; or include the appropriate accessory and cautionary instructions, and the expiration date on the medication. Specifically, multi-use vials of insulin were not dated with an open date and still available for use and medications were observed unattended on a resident's bedside table. Resident identifier 3. Findings include: 1. On 6/20/18 at 8:55 AM, the medication cart on the south hall was inspected. An observation was made of two multi-use vials of [MEDICATION NAME] opened without an open date labeled. The medication was available for use. An immediate interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 confirmed that the vials did not contain an open date. LPN 1 stated she would discard them and order new ones. 2. On 6/19/18 at approximately 10:00 AM, an interview was conducted with resident 3. There were two pills, appeared to be [MEDICATION NAME] and potassium, that had been placed on resident 3's bedside table. | 2020-09-01 |
| 94 | 94 | PIONEER CARE CENTER | 465020 | 815 SOUTH 200 WEST | BRIGHAM CITY | UT | 84302 | 2018-06-21 | 770 | D | 0 | 1 | EUNP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined for 1 of 31 sample residents that the facility did not provide or obtain timely laboratory services to meet the needs of its residents. Specifically, a resident's blood sample was collected at 4:00 PM and the laboratory did not receive the sample until 10:30 PM. Resident identifier: 143. Findings include: Resident 143 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 143's medical record was reviewed on 6/21/18. Resident 143's nurses notes revealed the following entries: a. 10/5/17 at 5:27 PM, .New orders . check PT/INR ([MEDICATION NAME] time/international normalized ratio ), CBC (complete blood count) and CMP (comprehensive metabolic panel) today instead of tomorrow. b. 10/5/17 at 11:59 PM, .Received a phone call from (local hospital) lab (laboratory) to (sic) critical results . Resident 143's laboratory results form revealed on 10/5/17 at 4:00 PM the blood sample was collected. The laboratory received the blood sample at 10:30 PM. The results were called to the facility nurse at 10:57 PM. (Note: There was a 6 and a half hour delay from the time the blood sample was collected and the laboratory received it.) On 6/20/18 at 9:30 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that PT/INR laboratory draws were completed Monday through Friday and the blood sample was sent to the local hospital laboratory. LPN 1 stated that the facility staff delivered the blood samples to the hospital laboratory if they were obtained after the laboratory had been to the facility to pick them up. LPN 1 stated she did not know why there was a delay in the collection of the blood sample and when the laboratory received the blood sample. | 2020-09-01 |
| 95 | 95 | PIONEER CARE CENTER | 465020 | 815 SOUTH 200 WEST | BRIGHAM CITY | UT | 84302 | 2018-06-21 | 773 | E | 0 | 1 | EUNP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined for 2 of 31 sample residents that the facility did not promptly notify the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of laboratory results that fall outside of clinic reference ranges in accordance with facility policies and procedures for notify of a practitioner or per the ordering physician's orders [REDACTED]. Resident identifiers: 4 and 15. Findings include: 1. Resident 4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 4's medical record was reviewed on 6/20/18. A laboratory result form revealed that a CMP (comprehensive metabolic panel) was completed on 6/11/18. There was a hand written note at the bottom which documented, 6/18/18 noted (and) faxed to MD (Medical Doctor). On 6/21/18 at 12:14 PM, an interview was conducted with the Director of Nursing (DON). The DON confirmed that resident 4's physician was not notified timely of the laboratory results. 2. Resident 15 was admitted on [DATE], discharged on [DATE], readmitted on [DATE] and discharged on [DATE], readmitted on [DATE] and discharged on [DATE] with [DIAGNOSES REDACTED]. Resident 15's medical record was reviewed on 6/21/18. Resident 15 had a laboratory results form dated 6/5/18 at 6:23 PM. Resident 15's PT ([MEDICATION NAME]) was 42.8 seconds with a reference range of 8.8-11.5. Resident 15's INR (International Normalization Ratio) was 4.4 with a reference range of 1.5-3.5. There was a written note signed by a nurse that documented, Faxed, noted (and) left message with MD 6/6/18 at 1810 (6:10 PM). An additional written note signed by a nurse with no date documented, Hold [MEDICATION NAME] re(check) PT/INR (on) 6/9/18. On 6/20/18 at 9:18 AM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated that she monitored the laboratory orders and results. The ADON stated that the physicians response to laboratory results wa… | 2020-09-01 |
| 96 | 96 | PIONEER CARE CENTER | 465020 | 815 SOUTH 200 WEST | BRIGHAM CITY | UT | 84302 | 2018-06-21 | 880 | E | 0 | 1 | EUNP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, a peripherally inserted central catheter (PICC) site was not clean, dirty trays were placed in the food cart while clean food trays were on the cart, staff touched clothing and equipment then served residents food, and wound care was not clean. Resident identifiers: 9, 17, 28, 93. Findings include: 1. Resident 93 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 6/18/18 at 11:26 AM, Resident 93's PICC dressing was observed to be with wet blood underneath the dressing at the insertion site. The PICC dressing was not dated. On 6/18/18 at 11:35 AM, resident 93 was interviewed. Resident 93 stated her PICC dressing was changed about a week ago, but could not state when it was changed or by whom. A reivew of resident 93's medical record was completed on 6/20/18. Resident 93's admission paperwork revealed that the PICC was placed before admission to the facility on [DATE]. There was no indication in resisdent 93's medical record that the PICC dressing had been changed while the resident had been in the facility from 6/6/18 through 6/20/18. On 6/19/18 at 9:51 AM, a nurses' note documented that the PICC line dressing was clean, dry and intact. On 6/20/18 at 9:32 AM, a second observation was made of resident 93's PICC dressing. The dressing had wet blood under the dressing and approximately one-fourth of the dressing was pulled up, away from her arm. There was no date on the dressing. On 6/20/18 at 10:55 AM, LPN 1 was interviewed. LPN 1 reported that resident 93 had left the facility for a short time, showered at home and returned to the facility about a week ago with her PICC dressing pulling up. LPN 1 stated that she had cha… | 2020-09-01 |
| 97 | 97 | PIONEER CARE CENTER | 465020 | 815 SOUTH 200 WEST | BRIGHAM CITY | UT | 84302 | 2018-06-21 | 923 | E | 0 | 1 | EUNP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, it was determined the facility did not have adequate ventilation to ensure good air circulation. Specifically, there were odors in the facility and some bathroom fans were not functioning. Findings include: 1. On 6/18/18 at 8:10 AM, during the initial tour of the facility there was an observation made in the hallway. There was a strong bowel movement odor that permeated into the hallway from room [ROOM NUMBER] on the east hall. 2. On 6/18/18 at 10:36 AM, the bathroom fan was not be functioning in room [ROOM NUMBER] on the south hall. 3. On 6/19/18 at 9:48 AM, the bathroom fan was not be functioning in room [ROOM NUMBER] on the south hall. 4. On 6/19/18 at 10:44 AM, an observation was conducted in the hallway. There was a strong bowel movement odor that permeated into the hallway from room [ROOM NUMBER] on the east hall. 5. On 6/21/18 at 8:43 AM, an interview was conducted with the Administrator. The Administrator stated he would check to see if the fan was functioning. The Administrator returned and stated that the fan was now working. 6. On 6/18/18 at 1:48 PM, the bathroom fan was not functioning in room [ROOM NUMBER] on the south hall. 7. On 6/19/18 at 10:27 AM, the bathroom fan not functioning in room [ROOM NUMBER] on the south hall. 8. On 6/21/18 at 11:19 AM, an observation was conducted in the hallway. There was a strong bowel movement odor that permeated into the hallway from room [ROOM NUMBER] on the east hall. On 6/21/18 at 8:43 AM, an interview was conducted with the Maintenance Director. The Maintenance Director stated that he checked fan and discovered a broken belt on the roof. The Maintenance Director stated that the belt was essential for all the bathroom fans on the east end of the east hall. On 6/21/18 at 8:07 AM, an interview was conducted with the Administrator and Maintenance Director. The Maintenance Director stated that for non-working bathroom fans, staff tell him in morning meeting. T… | 2020-09-01 |
| 98 | 98 | PIONEER CARE CENTER | 465020 | 815 SOUTH 200 WEST | BRIGHAM CITY | UT | 84302 | 2018-06-21 | 925 | D | 0 | 1 | EUNP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined that the facility did not maintain an effective pest control program so that the facility was free of pests and rodents. Specifically, the facility had ants, another insect, and spiders in multiple areas. Findings include: The following observations were made: a. On 6/18/18 at 11:03 AM, ants on a piece of food on the floor in room [ROOM NUMBER]. b. On 6/18/18 at 12:37 PM, a spider was observed descending from the door frame in the East hall. c. On 6/20/18 at 11:32 AM, a spider was on the floor in the charting office. d. On 6/21/18 at 8:48 AM, a large spider web observed in room [ROOM NUMBER]'s window. e. On 6/21/18 at 2:15 PM, a spider and an insect were observed during exit conference in the Admissions office. A review of the facility pest control records revealed spraying for pests had been completed monthly. On 6/20/18 at 12:54 PM, an interview was conducted with the Maintenance Director. The Maintenance Director stated that ants come in because of food that was dropped. The Maintenance Director stated that unless you spray a spider directly, you can't kill a spider. | 2020-09-01 |
| 99 | 99 | PIONEER CARE CENTER | 465020 | 815 SOUTH 200 WEST | BRIGHAM CITY | UT | 84302 | 2019-10-28 | 697 | D | 1 | 0 | KWP211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview and record review, it was determined, for 1 of 7 sampled residents, the facility did not ensure that pain management was provided for residents who required such services, consistent with professional standards of practice and the residents' goals and preferences. Specifically, one resident did not receive consistent and ongoing pain monitoring and prescribed pain medication while on respite care. Resident identifier: 1. Findings include: Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 10/28/19, resident 1 was observed in his room. Resident 1 stated that he did not receive all the medications he needed. Resident 1 stated that his pain was usually around 4 or 5 when he wasn't moving, but when he got himself out of bed, the pain was 8 or 9 out of 10. Resident 1 stated that his right shoulder was bone on bone so when he moved, he was close to screaming because of pain. Resident 1 stated that he had chronic back pain, and severe pain in his left thigh muscle. Resident 1 stated that the nurses haven't asked me about my pain. Resident 1 stated that he was taking narcotic pain medication twice a day at home, when he needed it. Resident 1 stated that the more he moved, the more pain he experienced. Resident 1 stated that he had been in severe pain dozens of times a day. Resident 1 stated that he could not call for help every time he went to the restroom because it was at least 4 to 5 times a day and he could not wait for staff. Resident 1 stated that he was in real bad pain when they talked to me a few days ago. On 10/28/19 a record review was conducted for resident 1's electronic medical record. Review of resident 1's physician orders [REDACTED]. This order was started on 10/26/19 at 11:00 AM. Review of resident 1's pain scores revealed the following: a. On 10/26/19, no pain scores were recorded for resident 1. b. On 10/27/19 at 12:49 AM, a pain score was recorded at 0/10. c. On 10/28… | 2020-09-01 |
| 100 | 100 | PIONEER CARE CENTER | 465020 | 815 SOUTH 200 WEST | BRIGHAM CITY | UT | 84302 | 2019-10-28 | 760 | G | 1 | 0 | KWP211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility did not ensure that 1 of 7 sample residents was free of significant medication errors. Specifically, a resident was given his roommate's medications, and was subsequently hospitalized . As of 10/27/19, the facility had identified the concern, and had implemented a Quality Assurance (QA) plan which included audits, monitoring, and preventative measures to prevent further incidences. Therefore, past non-compliance at a harm level was cited. Resident identifier: 1. Findings include: 1. Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 1's medical record was reviewed on 10/28/19. A nurses' progress note on 10/20/19 at 10:56 PM documented .Resident was given [MEDICATION NAME] and [MEDICATION NAME] in error. Resident responsive to stimuli. Neuro (neurological) checks within normal limits. Another nurses' noted dated 10/21/19 at 3:32 AM documented (Resident 1) in 21-B, reports c/o (complaints of) SOB (shortness of breath) with rales and crackles. that began on 10/20/2019 2:30 AM and have gotten worse since the onset. NA (?) make the symptoms worse, while Oxygen 4L (liter) improve the symptoms. Other relevant information - Medication error at about 2000 (10:00 PM) .The relevant areas to the change in condition is: Respiratory Status Changes, Shortness of breath, Abnormal lung sounds, Labored breathing. Assessment : The current problem seems to be related to Cardiac, Respiratory, .Medication error. Recommendation: (name redacted) NP (nurse practitioner) was notified and made aware of the resident's current status. The following orders were received: hospitalization with emergency transport. A follow up nurses' note dated 10/21/19 at 7:35 AM documented REsident (sic) taken to the hospital at about 3:30 am by EMTs (emergency medical transport). Pt (patient) was stabilized on a [MEDICAL CONDITION] (bilevel positive airway pressure) breathing machine and began improvi… | 2020-09-01 |
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CREATE TABLE [cms_UT] ( [facility_name] TEXT, [facility_id] INTEGER, [address] TEXT, [city] TEXT, [state] TEXT, [zip] INTEGER, [inspection_date] TEXT, [deficiency_tag] INTEGER, [scope_severity] TEXT, [complaint] INTEGER, [standard] INTEGER, [eventid] TEXT, [inspection_text] TEXT, [filedate] TEXT );