Southern Utah Veterans Home - Ivins

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY On 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. On 5/20/25 at 10:28 AM, an interview was conducted with the DON. The DON stated according to resident 78's Medication…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Findings include: 1. On 5/13/25 at 9:17 AM, an interview was conducted with resident 5. Resident 5 stated the food was good and bad. Resident 5 stated the evening meal was awful and hot dogs were served 3 days a week. Resident 5 stated he felt like chicken was served too often. 2. On 5/12/25 at 3:29 PM, an interview was conducted with resident 39. Resident 39 stated that even with his dentures, he had a hard time chewing the meat because it was tough. Resident 39 stated that the food was not good. 3. On 5/13/25 at 9:56 AM, an interview was conducted with resident 78. Resident 78 stated that he did not like the food and it did not taste good. Resident 78 stated that he…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings included: Resident 39 was admitted to the facility on [DATE] with diagnoses which consisted of type II diabetes mellitus, chronic obstructive pulmonary disease, emphysema, cervicalgia, hypertension, low back pain, and pulmonary hypertension. On 5/12/25 at 3:31 PM, an interview was conducted with resident 39. Resident 39 stated that the facility took his deodorant and told him he could not have it because it was a metal can. Resident 39 stated that they just took it from him because of the state survey inspection, but they were never worried about it before. Resident 39 stated that it upset him. Resident 39 stated that the Resident Advocate (RA) took it and said he would give…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings included: Resident 75 was admitted to the facility on [DATE] with diagnoses which included encounter for palliative care, dementia, cognitive communication deficit, traumatic brain injury, post-traumatic stress disorder, cervical disc disorder, radiculopathy, hemiplegia and hemiparesis right side, and a history of falls. On 5/13/25 at 9:17 AM, an interview was conducted with resident 75. Resident 75 complained of pain in his right shoulder and neck. Resident 75 stated that he had 5 shoulder operations and it was aching him like crazy. Resident 75 stated that he had an Oxycodone this morning but it had worn off and his current…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Findings include: The facility provided a list of residents who had been discharged from Medicare covered Part A stay with days remaining. Resident 74 was on the list with a discharged date from Part A of 12/7/24 and he remained in the facility. Resident 74's medical record was reviewed. A NOMNC was not located in resident 74's medical record. On 5/14/25 at 8:37 AM, an interview was conducted with Medical Records. Medical Records stated the NOMNC's were provided by the Social Services Department. Medical Records stated that she uploaded any signed NOMNC's that were received into…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: 1. Resident 22 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included encounter for palliative care, Parkinson's disease, and dysphagia. A significant change Minimum Data Set (MDS) dated [DATE] revealed resident 22 was not currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. A review of resident 22's medical record revealed a PASRR level II dated 8/7/24. On 5/14/25 at 9:01 AM, an interview was conducted with Licensed Clinical Social Worker (LCSW) 1. LCSW 1 stated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings included: Resident 8 was admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses which included encounter for palliative care, hemiplegia and hemiparesis of the left side following a cerebral infarction, and vascular dementia. On 5/12/25 at 2:45 PM, an interview was conducted with resident 8. Resident 8 stated that he had limited movement in his left hand and arm. An observation was made of resident 8's left hand and wrist. The left wrist was observed contracted. Resident 8 stated that he had a brace for the left…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: Resident 22 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included encounter for palliative care, Parkinson's disease, and dysphagia. On 5/12/15 at 3:29 PM, an interview was conducted with resident 22's family member. The family member stated resident 22 did not get his teeth brushed regularly. The family member stated resident 22 had a cavity and needed a new crown from not receiving oral hygiene. The family member stated when she kissed him, she would know if his teeth had been brushed that day. On 5/12/15 at 3:29 PM, an observation was made of a sign on resident 22's door. The sign revealed, Attention [name of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings included: Resident 8 was admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses which included encounter for palliative care, hemiplegia and hemiparesis of the left side following a cerebral infarction, and vascular dementia. On 5/12/25 at 2:45 PM, an interview was conducted with resident 8. Resident 8 stated that he had limited movement in his left hand and arm. An observation was made of resident 8's left hand and wrist. The left wrist was observed contracted.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings included: Resident 8 was admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses which included encounter for palliative care, hemiplegia and hemiparesis of the left side following a cerebral infarction, vascular dementia, pain in right shoulder, contusion of right shoulder, complete rotator cuff tear of right shoulder, and unspecified fracture of left humerus. On 5/12/25 at 2:31 PM, an interview was conducted with resident 8. Resident 8 stated he fell out of bed one time and hit his head…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. On 1/9/25, an order was initiated for Lorazepam Oral Tablet 0.5 milligram (mg), give 1 tablet by mouth two times a day for chronic anxiety AND…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: 1. Resident 13 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included post-traumatic stress disorder, major depressive disorder, hyperlipidemia, chronic kidney disease, and muscle weakness. Resident 13's medical record was reviewed on 6/28/23. Review of resident 13's medical record indicated that a quarterly MDS had been initiated on 5/23/23. The MDS revealed it was in progress and had not been completed. 2. Resident 75 was admitted to the facility on [DATE] with diagnoses that included amyotrophic lateral sclerosis, chronic obstructive pulmonary disease, atherosclerotic heart disease, venous insufficiency, essential…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.