Mt Ogden Health and Rehabilitation Center

Inspectors wroteBased on interview and record review, the facility did not ensure that residents were free from abuse, neglect, misappropriation of resident property, and exploitation. Specifically, there were no interventions developed to prevent sexual abuse when 2 residents were in a relationship and one was cognitively impaired. This deficiency was found to have occurred at a past non-compliance. Resident Identifiers: 174 and 175.

Inspectors wroteBased on interview and record review, the facility did not implement their written policies and procedures for investigation of abuse allegations. Specifically, an incident of potential sexual abuse was not investigated timely. Resident identifiers: 174 and 175.

Inspectors wroteBased on interview and record review it was determined, for 2 out of 26 sampled residents, that the facility did not ensure that allegations of abuse, neglect, exploitation, or mistreatment were reported immediately, but not later than 2 hours after the allegation was made, if the allegation involved abuse or resulted in serious bodily injury, to the Administrator of the facility, the State Survey Agency (SSA), and adult protective services (APS), and the results of all investigations were reported to the Administrator and the SSA within 5 working days of the incident. Specifically, allegations of abuse were not reported at the time of the allegation to the SSA or APS. Resident identifiers: 174 and 175.

Inspectors wroteBased on interview and record review, it was determined, for 2 of 26 sampled residents, that the facility, in response to allegations of abuse, neglect, exploitation, or mistreatment, failed to provide evidence that all alleged violations were thoroughly investigated. Specifically, an allegation of suspected sexual abuse was not thoroughly investigated. Resident identifier: 174 and 175. 1. Resident 174 was admitted to 4/28/24 with diagnoses which included hemiplegia and hemiparesis, abnormalities of gait and mobility, essential hypertension, migraine, epilepsy and gastro-esophageal reflux disease. 2. [...]

Inspectors wroteBased on observation and interview, 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, one multi-dose vial was not labeled with an opened date, and a medication was taped back into the medication blister pack. Resident identifiers: 162.

Inspectors wroteBased on observation and interview, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service. Specifically, food items in the walk-in refrigerator and walk-in freezer located in the kitchen were open to air, and the resident snack refrigerator was not clean.

Inspectors wroteBased on observation, interview, and record review, it was determined, the facility did not provide the necessary care and 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, for 1 out of 24 sampled residents, a resident was not provided assistance with eating. Resident identifier: 48.

Inspectors wroteBased on observation, interview, and record review, it was determined the facility did not ensure residents who were unable to carry out activities of daily living (ADL), received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Specifically, for 1 out of 24 sampled residents, a resident did not receive timely feeding assistance that she needed at meal time. Resident identifier: 38.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that a feeding assistant had completed a state-approved training course before providing feeding assistance to residents. Specifically, for 1 out of 24 sampled residents, the Health Information Management (HIM) staff member was providing feeding assistance to a resident without having completed a state-approved training course. Resident identifier: 38.

Inspectors wroteBased on interview, observation, and record review, the facility did not notify the physician for 1 of 26 sampled residents after the residents experienced a significant change in condition or a need to alter treatment. Specifically, a resident experienced low blood sugar levels that were outside of physician-set parameters, and the physician was not notified. Resident identifier: 28.

Inspectors wroteBased on observation, interview, and record review it was determined the facility did not develop and implement a comprehensive person-centered care plan. The care plan needed to include measurable objectives and timeframe's to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment. Specifically, for 1 of 26 sampled residents, the care plan was not updated with suicidal ideation interventions after multiple expressions of suicidal ideations. In addition, a suicidal care plan was not initiated until approximately 4 months after the resident first expressed suicidal ideations and was readmitted from a Geropsych unit. Resident identifier: 45.

Inspectors wroteBased on observation, interview, and record review it was determined the facility did not provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Specifically, for 1 of 26 sampled residents, a resident with suicidal ideations was not provided interventions. Resident identifier: 45.

Inspectors wroteBased on interview and record review, it was determined the facility did not ensure residents' drug regimens were free from unnecessary drugs- an unnecessary drug is any drug when used without adequate monitoring. Specifically, for 1 of the 26 sampled residents, the facility provided a resident with blood pressure medication outside of the prescribed parameters for use. Resident identifier: 27.

Inspectors wroteBased on interviews and record reviews, it was determined the facility did not maintain medical records on each resident that are complete and readily accessible. Specifically, for 2 of the 26 sampled residents, the facility did not have all recent physician or nurse practitioner visit notes within the residents' electronic medical record. Resident identifiers: 15 and 39.