City Creek Post Acute

Inspectors wroteBased on interview and record review, the facility did not ensure each resident received adequate supervision to prevent accidents. Specifically, for 1 out of 43 sampled residents, one resident sustained a third-degree burn to his left wrist from spilling a prepackaged soup prepared and served by facility staff. Resident identifier: 3. It was determined the provider's non-compliance with the requirements of participation had caused harm. The harm was related to the State Operations Manual, Appendix PP, S483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents, F689, at a scope and severity of G. However, based on the facility's corrective actions and a review of its current compliance in this regulatory area, the deficiency was determined to be past noncompliance. [...]

Inspectors wroteBased on observation and interview, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, a Bluetooth speaker was stored on a shelf used to store items used in food preparation and a male staff member with a beard was observed to be preparing food without wearing a beardnet.

Inspectors wroteBased 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, for 3 out of 43 sampled residents, staff did not wear personal protective equipment (PPE) when residents were on Enhanced Barrier Precautions (EBP) and hand hygiene was not performed during wound care. Resident identifiers: 14, 73, and 74.

Inspectors wroteBased on interview and record review, the facility did not ensure that when they transferred or discharged a resident that it was documented in the resident's medical record and that the information contained the contact information of the practitioner responsible for the care of the resident; resident representative information; Advanced Directive information; all special instructions for ongoing care; comprehensive care plan goals; and all other necessary information to ensure a safe and effective transition of care. Specifically, for 1 of 43 sampled residents, the facility did not document in the residents' medical record the information that was given to the receiving provider when the resident was transferred to the hospital. Resident identifier: 9.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that when a bed rail was utilized that the resident was assessed for the risk of entrapment from the bed rail prior to installation. Specifically, for 1 out of 43 sampled residents, the facility did not evaluate a resident for entrapment from the bed rail prior to use and the resident reported that her hand was caught in the bar. Resident identifier: 65.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that each resident received food that accommodated the resident allergies, intolerances, and preferences. Specifically, for 1 out of 43 sampled residents, the facility did not provide the resident with the food preferences as outlined on their meal ticket. Resident identifier: 8.

Inspectors wroteBased on interview and observation, the facility did not ensure that the resident environment remained as free of accidents as possible. Specifically, the laundry room was left open with no staff present; the laundry room was observed to have various chemicals inside.

Inspectors wroteBased on interview and record review it was determined, for 1 of 37 sampled residents, that the facility failed to ensure that a resident with urinary incontinence, based on the resident's comprehensive assessment received appropriate treatment and services to restore continence to the extent possible. Specifically, a resident who was incontinent of bladder and was assessed to be a likely candidate for a toileting program was not provided treatment and services to achieve as much normal bladder function as possible. Resident identifier: 10.

Inspectors wroteBased on interview and record review it was determined, for 2 of 23 sample residents, that each resident did not have the right to be free from abuse. Specifically, a resident was threatened by a roommate and there was no investigation to rule out abuse. Resident identifier: 33 and 89.

Inspectors wroteBased on interview and record review it was determined, for 1 of 23 sample residents, 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 residents' choices. Specifically, a resident was not treated for a urinary tract infection (UTI). Resident identifier: 38.

Inspectors wroteBased on observation, interview and record review it was determined the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to prevent the development and transmission of communicable diseases and infections. Specifically, appropriated signage was not placed outside resident rooms identifying the need for transmission-based precautions (TBP), staff were observed in a patient's isolation room without personal protective equipment (PPE) and unvaccinated COVID-19 newly admitted residents were not put on TBP. [...]

Inspectors wroteBased on interview and record review it was determined, for 5 out of 6 sampled staff, that the facility did not conduct testing based on parameters set forth by the Secretary. Specifically, routine testing of unvaccinated staff members, based on community transmission, was not completed.

Inspectors wroteBased on observation, interview and record review, it was determined the facility did not develop and implement policies and procedures to ensure that all staff were fully vaccinated for Coronavirus Disease-2019 (COVID-19). The facility did not ensure that the policies and procedures applied to individuals who provided care, treatment, or other services for the facility and/or its residents, under contract or by other arrangement. Also, the facility did not implement policies and procedures that included, at a minimum, a process for ensuring the implementation of additional precautions, intended to mitigate the transmission and spread of COVID-19, for all staff who were not fully vaccinated for COVID-19. Specifically, the facility was unaware and did not keep documentation of the vaccination status for their contracted staff. [...]

Inspectors wroteBased on observation, interview, and record review it was determined, for 2 of 23 sample resident, the facility did not provide the right for residents to choose medical treatment. Specifically, residents Physicians Orders for Life Sustaining Treatment (POLST) forms were not filled out timely after the residents were admitted to the facility. Resident identifiers: 8 and 30.

Inspectors wroteBased on observation and interview, the facility did not provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Specifically, the two showers in the third floor shower room were in disrepair.

Inspectors wroteBased on interview and record review it was determined, for 4 of 23 sample residents, that in response to an allegation of abuse, neglect, exploitation or mistreatment, the facility did not ensure that all alleged violations were report no later than 2 hours after the allegation was made and the results of all investigations were reported within 5 working days of the incident. Specifically, two resident to resident altercations were not reported within 2 hours to the state survey agency. Resident identifiers: 9, 31, 33 and 89.

Inspectors wroteBased on interview and record review it was determined, for 2 of 23 sample residents, that in response to allegations of abuse, neglect, exploitation, or mistreatment, the facility did not have evidence that all alleged violations were thoroughly investigated. Specifically, a resident threatened another resident and there was no investigation. Resident identifiers: 33 and 89.

Inspectors wroteBased on observation, interview, and record review it was determined, for 1 of 23 sample residents, the facility did not ensure that the residents' environment remained as free of accident hazards as was possible or that each resident received adequate supervision to prevent accidents. Specifically, a resident had access to hazardous chemicals and there was a hallway rug outside of a resident's room which a resident tripped over when using a walker. Resident identifier:

Inspectors wroteBased on observation and interview, it was determined that the facility did not label all drugs and biologicals used in the facility in accordance with currently accepted professional principles, and did not include appropriate accessory instructions and the expiration date when applicable. Specifically, insulins were not labeled with an open date and administered to residents. The medication cart was not locked when the nurse was not by it. Resident identifier: 8, 19, and 194.

Inspectors wroteBased on interview and record review it was determined, for 1 of 23 sampled residents, the facility did not obtain laboratory (lab) services to meet the needs of the residents. Specifically, a resident had physician's orders to obtain a glycated hemoglobin (A1C), Phosphorous (Phos), Complete Metabolic Panel (CMP), C-reactive protein (CRP), and Pre-Albumin for medical monitoring and the labs were not completed timely as ordered. Resident identifiers: 30.

Inspectors wroteBased on interview and record review it was determined, for 1 of 23 sample residents, that the facility did not promptly notify the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of laboratory results that fell outside of clinical reference ranges in accordance with facility policies and procedures for notification of a practitioner or per the ordering physician's orders. Specifically, a resident's urine culture and sensitivity was not reported to the physician. Resident identifier: 38.