Southern Utah Veterans Home - Ivins

Inspectors wroteOn 5/20/25 at 9:50 AM, a follow-up interview was conducted with Director of Nursing (DON). The DON stated hopefully staff were able to anticipate resident's pain. The DON stated the expectation was for staff to assess the general criteria of pain like where, how bad, and if it had happened before, and then complete a full assessment if it was not identified before. The DON stated nurses provided interventions and contacted the physician for pain medication. The DON stated if the interventions were not effective, staff should notify the provider for additional assistance. The DON stated resident 78 had multiple medications available and resident 78 was discussed in their clinical meeting. The DON stated the physicians were usually in the building so staff were able to report pain to them verbally. The DON stated sometimes staff did not document contacting the physician, but it was done. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not provide food that was palatable, attractive, and served at a safe and appetizing temperature. Specifically, for 9 out of 35 sampled residents, residents complained of food quality, a test tray was not attractive or palatable, and Dining Committee meetings revealed complaints of food. Resident identifiers: 5, 24, 29, 39, 58, 78, 91, 94, and 101.

Inspectors wroteBased on observation and interview it was determined, for 1 of 35 sampled residents, that the facility did not ensure that the resident had the right to self determination through support of the resident's choice. Specifically, a resident had their aerosolized can of deodorant removed from their possession. Resident identifier: 39.

Inspectors wroteBased on interview and record review it was determined, for 1 of 35 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 status or a need to alter treatment. Specifically, a resident had complaints of uncontrolled pain and the physician was not notified. Resident identifier: 75.

Inspectors wroteBased on interview and record review, it was determined, the facility did not inform each resident periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare/Medicaid or by the facility's per diem rate. Specifically, for 1 out of 3 sampled residents, a resident was not issued a Notice of Medicare Non-coverage (NOMNC) when the Medicare part A services were terminated. Resident identifier: 74.

Inspectors wroteBased on interview and record review, for 2 of 35 sampled residents, the facility did not ensure an assessment accurately reflected the resident's status. Specifically, a resident who was discharged home was coded as being admitted to an acute hospital. In addition, another resident with a Preadmission Screening Resident Review (PASRR) level II was not coded as having one. Resident identifiers: 22 and 104.

Inspectors wroteBased on interview and record review it was determined, for 1 of 35 sampled residents, that the facility did not develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframe's to meet the resident's medical, nursing, and psychosocial needs that were identified in the comprehensive assessment. Specifically, the resident's care plan did not address the resident's wrist splint. Resident identifier: 8.

Inspectors wroteBased on observation, interview, and record review, for 1 of 35 sampled residents, the facility did not provide appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living (ADL). Specifically, a resident was not provided oral hygiene to prevent tooth decay. Resident identifier: 22.

Inspectors wroteBased on observation, interview, and record review it was determined, for 1 out of 35 sampled residents, that the facility did not ensure that a resident who had limited range of motion received the appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. Specifically, a resident had a hand/wrist splint that was not being applied consistently and the resident did not have any physician orders for the application of the medical device. Resident identifier: 8.

Inspectors wroteBased on interview and record review it was determined, for 1 out of 35 sampled residents, that the facility did not ensure that the resident environment remained as free of accident hazards as was possible and that each resident received adequate supervision and assistance devices to prevent accidents. Specifically, a resident who was identified as a two-person assist for bed mobility and incontinence care sustained a fall during a one-person assist for incontinence care. Resident identifier 8.

Inspectors wroteBased on interview and record review it was determined, for 1 of 35 sampled residents, that the facility did not ensure that the irregularities identified by the pharmacist were acted upon by the attending physician. Specifically, the pharmacist identified that the resident's as needed (PRN) order of Lorazepam exceeded 14 days and did not have a stop date or a rationale to extend the use or duration of treatment and the provider did not act upon the pharmacists recommendations. Resident identifier: 8. Resident 8 was admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses which included encounter for palliative care, vascular dementia, cognitive communication deficit, anxiety disorder, post-traumatic stress disorder, and major depressive disorder. Resident 8's medical records were reviewed. Resident 8's Lorazepam orders revealed the following: a. [...]

Inspectors wroteBased on interview and record review, it was determined the facility did not complete a quarterly Minimum Data Set (MDS) Assessment every three months for 3 of 26 sample residents. Specifically, quarterly MDS Assessments were not completed within 14 days of the Assessment Reference Date for 3 residents. Resident identifiers: 13, 75, and 94.