City Creek Post Acute

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate supervision and assistive devices for 1 of 3 sampled residents (Resident 1), when Resident 1 returned to his room from the nurses ' station unattended and was unable to call for assistance to transfer from his wheelchair to bed when his call light was not within reach. This failure resulted in Resident 1's fall from his wheelchair and experienced bilateral feet pain and sustained an abrasion to the top of his left hand.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect one of three sampled resident (Resident 1) to be free from physical abuse by another resident (Resident 2) when Resident 1 was slapped by Resident 2. This failure increased the potential for Resident 1 to feel emotional distress.

Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety when: 1. Water pitchers and accompanying cups were stored upright and uncovered; 2. Foods were not labeled with received, opened and use by dates; and 3. Hair was not completely covered by a hair net while serving food. This failure increased the risk for foodborne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain infection prevention and control procedures and guidelines for nine of 30 sampled residents (Resident 32, 43, 29, 40, 42, 14, 81, 12, 291, 296), when: 1. Three unlabeled basins were found in the bathrooms of Resident 32 and Resident 43; 2. Three wheelchair armrests were in disrepair and unable to be sanitized for Resident 29, Resident 40, and Resident 42; 3. Two Licensed Nurses (LNs) with no PPEs (personal protective equipment) entered an enhanced standard precautions room and provided care to Resident 14; 4. An LN with no PPEs entered a transmission-based precautions room and picked up equipment used by Resident 81; 5. Resident 12's nebulizer (a small machine that turns liquid medicine into a mist that can be easily inhaled) machine was found on the floor and was bagged; and 6. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide adequate supervision and assistance to one of 30 sampled residents (Resident 40) when staff did not monitor Resident 1 during mealtimes. This failure had the potential to cause Resident 40 to choke or aspirate fluids (accidentally inhaling fluids into the airways).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the food preferences and allergies were accommodated for two of 30 sampled residents (Resident 48 and Resident 80), when: 1. Resident 48's food preferences were not honored; and 2. Resident 80's food allergies were not managed. These failures increased the potential risk for Resident 48 feeling disrespected and Resident 80 having allergic reactions from the food served.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medical records were accurate for one of 30 sampled residents (Resident 48) when a urinary catheter was discontinued and Licensed Nurses [LNs] continued documentation on monitoring and care. This failure resulted in inaccurate documentation for Resident 48 and had the increased potential for miscommunication among health providers who provided care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 30 sampled residents (Resident 62) was able to call for assistance when the call light was not in working order. This failure had the potential to result in unmet care needs for Resident 62 when her call light was not working.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure necessary treatment, services, and equipment were provided for one of three sampled residents (Resident 1) to improve or maintain mobility, when: 1. Resident 1's concerns about his personal wheelchair were not addressed; and 2. Physician's order to get Resident 1 out of bed daily was not followed. These failures had the potential for Resident 1 to not maintain or improve his mobility and not attain his highest physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a safe and accident-free environment for one resident (Resident 1) of three sampled residents, when staff providing care to Resident 1 turned around to grab supplies, which were located out of reach, and resulted in Resident 1 falling off the bed. This failure resulted in Resident 1 obtaining a fracture to the left, fifth metacarpal (broken finger) and a closed head injury (a nonpenetrating injury to the brain colliding with and no break in the skull).

Inspectors wroteBased on interview and record review, the facility failed to meet professional standards of quality for one of 3 sampled residents (Resident 1) when nursing staff did not follow the physician's order to manually irrigate (unplug) the foley catheter (a soft rubber tubing inserted into the bladder to drain the urine) every shift. This failure resulted in Resident 1 having persistent hematuria (blood in urine) and had the potential to cause complications.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the guidelines and procedures for infection prevention and control were maintained for one of three sampled residents (Resident 3), when the oxygen tubing was not dated or labeled. This failure had the potential to result in lung infection.

Inspectors wroteBased on interview and record review, the facility failed to suspend two staff members, an Occupational Therapist (OT) and Physical Therapist (PT), after an allegation of sexual abuse was made against them. This failure decreased the facility's potential to protect residents from potential abuse and mistreatment for a census of 96 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure sufficient staff with competent skills to carry out functions of the food and nutrition service for 87 residents, when: 1. The Dietary Manager (DM) did not meet the education qualification requirements as required to carry out the functions of the food and nutrition services; and 2. The facility failed to ensure a full-time Registered Dietitian (RD) provided frequently scheduled consultation to the DM on food safety and sanitation, food preparation, meal service and food storage for residents receiving meals from the kitchen. These failures had the potential to result in lapses in the delivery of food and nutrition services associated with meal distribution accuracy, and unsafe food handling and sanitation for food service operations.

Inspectors wroteBased on observation, interview, and record review the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety for a census of 89 when: 1. A facility ice machine located in the kitchen was found soiled with a significant amount of black, brown, green, and yellow slimy substances on the inner surfaces where the ice was produced. The dining room ice dispenser (uses the ice from the facility ice machine) was found with an orange slimy substance at the dispenser opening; 2. Food items were found with incorrect or no labeling for received, opened, and use-by dates in the freezer; 3. Expired food items were available for use in the dry storage area and refrigerator; 4. Food items were opened and not contained properly in the dry storage area; 5. Spoiled produce was found in the dry storage area and the refrigerator; 6. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure comprehensive assessment, treatment and care were provided in accordance with professional standards of practice for one of 25 sampled residents (Resident 593), when the resident's request for side rails to use for mobility was not appropriately evaluated. This failure resulted in the Resident's 593's inability to move around in bed, removing her neck collar frequently due to pain, and had the potential to result in not maintaining her highest practicable well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medications requiring refrigeration were kept in the refrigerator as specified by the pharmacy for a census of 89. This failure had the potential for residents to be given expired or deteriorated medications, which could be ineffective in treating their medical conditions.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the menu was followed for the therapeutic diet (a modification of a regular diet tailored to fit the nutritional needs of a resident, and a part of a treatment or medical condition prescribed by a physician) during the lunch meal for 31 residents in a census of 89, when: 1. Fourteen residents (Resident 3, Resident 9, Resident 11, Resident 13, Resident 15, Resident 18, Resident 36, Resident 38, Resident 43, Resident 52, Resident 62, Resident 67, Resident 73, and Resident 76) received green beans as a substitute for baked fresh zucchini; 2. Three residents (Residents 67, Resident 69, and Resident 590) were provided three ounces (#10 scoop) of polenta (yellow cornmeal) instead of two ounces (#16 scoop) of polenta for residents with small portions as part of their ordered diets; 3. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure essential equipment was working for four of 25 sampled residents (Resident 56, Resident 69, Resident 35, and Resident 38), when their call lights did not turn on. This failure had the potential to result in the residents not being able to ask staff for assistance.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dignity was provided for two of 25 sampled residents (Resident 19 and Resident 73), when: 1. Resident 19's room was bare and empty and personal belongings were removed; and 2. Resident 73's room was bare and empty. These failures had the potential to negatively impact the residents' quality of life and psychosocial well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the resident needs were accommodated for one of 25 sampled residents (Resident 73), when the call light button and pitcher of water was not reachable. These failures had the potential to result in Resident 73 not attaining his highest practicable physical and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a safe, clean and comfortable environment was provided for one of 25 sampled residents (Resident 19), when Resident 19's room was found with scattered food on the floor. This failure had the potential to result in Resident 19's not maintaining her highest practicable quality of life and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of 25 sampled residents (Resident 16) was free from restraints, when several pillows were lined on both sides adjacent to the resident's body. This failure had the potential to limit Resident 16's freedom of movement.

Inspectors wroteBased on observation, staff interview and record review, the facility failed to implement pharmaceutical policies and procedures for one in a census of 89 when Resident 36 received an incorrect probiotic, a medication used for digestive and immune support. This failure had the potential to negatively affect Resident 36's quality of health.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the infection prevention and control program guidelines and practices were maintained for one of 25 sampled residents (Resident 61), when unlabeled oxygen (O2) tubing and outdated nebulizer mask were found at the bedside and not placed in a bag. This failure had the potential to result in Resident 61 acquiring a lung infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide privacy for two of 24 sampled residents (Resident 2 and Resident 8) when no privacy curtains were installed and available for use during resident care. This failure placed Resident 2 and Resident 8 at risk for humiliation and psychosocial distress.

Inspectors wroteBased on interview and record review, the facility failed to ensure a baseline care plan (BCP) for five of 24 sampled residents (Residents 182, 185, 186, 188 and 196) were completed and a copy provided to the resident or the resident's responsible party (RP). This failure had the potential to leave the residents and the responsible parties with no information summarizing the goals, medications, treatments, diet and discharge plans.

Inspectors wroteBased on observation, interview and record review of facility documents, the facility failed to provide resident-centered activities program with a sample of 24 on a census of 89 when five of the newly admitted residents (Residents 186, 188, 189, 190, and 191) did not have a baseline activities assessment. This failure placed Resident 186, Resident 188, Resident 189, Resident 190, and Resident 191 at risk for a decline in physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview and record review of facility documents, the facility failed to provide resident-centered activities program with a sample of 24 on a census of 89 when the activities personnel was not qualified to assess the residents. This failure had the potential risk for a decline in the residents' health status and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that it was free of medication error rates of five percent or greater for a census of 89 when, the facility medication error rate was 17.86%. This failure had the potential to result in a negative outcome.

Inspectors wroteBased on observation, interview, and record review, the facility failed to appropriately label and store drugs and biologicals for a census of 89 when, 1. An expired antibiotic medication was stored and available for use; and, 2. An accessed multi-vial dose vial was not labeled with opened date. These failures had the potential to result in unsafe administration of medication and contamination of biologicals.

Inspectors wroteBased on interview and review of facility documents, the facility failed to ensure access to the clinical record was readily available for one of 24 sampled residents (Resident 30) when physician progress notes were unavailable for reference in the electronic record for over one year. This failure increased the risk critical information would not be readily available to all departments.

Inspectors wroteBased on observation, interview and record review of facility documents, the facility failed to implement infection control and prevention practices in a census of 89 when: 1. A glucometer (a device used to measure blood sugar levels) with blood visible on the test strip, and a lancet (a small device used to puncture the skin to obtain a blood sample) were found on the bedside table of Resident 4. 2. Two windows with thick residues were observed in the clean side of the laundry area. 3. An electric fan covered with dust was found in the kitchen. 4. A licensed nurse entered an isolation room with no gloves. These failures increased the potential risk for the transmission of infectious diseases to the residents.

Inspectors wroteBased on observation, interview and review of facility documents, the facility failed to ensure one of 24 sampled residents (Resident 42) was treated with dignity when his catheter bag was not covered. This failure increased the potential risk for humiliation and psychosocial distress.

Inspectors wroteBased on observation, interview and review of facility documents, the facility failed to ensure essential equipment was working for one of 24 sampled residents (Resident 36) when Resident 36's call light was not consistently available to use, and Resident 36 relied on her roommate to call for help. This failure placed Resident 36 at risk of not being able to ask staff for assistance.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop an individualized comprehensive care plan for one of 24 sampled residents (Resident 73) when Resident 73's front tooth was broken. This failure had the potential to result in Resident 73 not receiving the necessary care and services to meet her highest practicable well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a low air loss (LAL) mattress (mattress used for prevention of skin breakdown) was working for one of 24 sampled residents (Resident 2) when the LAL was unplugged. This failure increased the the potential risk for Resident 2 to experience skin breakdown.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure adequate pain management consistent with professional standards of practice was provided for one of 24 sampled residents (Resident 182), when the resident complained of pain and there was no documented evidence of pain medication administered on the electronic medication administration record (eMAR). This failure had the potential to negatively affect the resident's highest practicable physical, mental and psychosocial well-being.