South Ogden Post-Acute (Cascades at South Ogden)

In the surveyor’s words

From the most serious findings on record at South Ogden Post-Acute (Cascades at South Ogden), in the surveyor’s own words.

• Immediate jeopardy, patternF600Apr 25, 2023

  Based on observation, interview and record review it was determined for 24 out of 80 sample residents, that the facility failed to protect residents from abuse, neglect and misappropriation of property. Specifically, residents were repeatedly physically, verbally and sexually abused without ongoing interventions to prevent further abuse. These identified deficient practices were found to have occurred at the Immediate Jeopardy (IJ) Level for residents 47, 51, 54, 68, 78, 79, and 86. Resident identifiers: 2, 9, 23, 32, 34, 37, 38, 44, 47, 51, 54, 58, 68, 73, 78, 79, 83, 85, 86, 87, 92, 359, 409, and 460. […]

• Immediate jeopardy, patternF609Apr 25, 2023

  Based on record review and interview it was determined for 20 of 80 sample residents, that the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury to the State Survey Agency. Specifically, entity reports of multiple abuse allegations were not submitted to the State Survey in a timely manner. These findings were determined to have occurred at an Immediate Jeopardy level for residents 47, 51, 54, 68, 78, 79 and 86. […]

• Immediate jeopardy, patternF610Apr 25, 2023

  Based on interview and record review it was determined that in response to allegations of abuse, neglect, exploitation, or mistreatment the facility failed to have evidence that all alleged violations were thoroughly investigated for 20 of 80 sample residents. Specifically, based on a review of Entity Reports, filed with the State Survey Agency (SSA) the facility has submitted multiple initial Entity Reports with no subsequent final investigation report. Multiple instances of resident to resident physical, verbal and sexual abuse occurred with an insufficient investigation. This was determined to have occurred at an Immediate Jeopardy level for residents 47, 51, 54, 68, 78, 79, and 86. […]

• Immediate jeopardy, patternF689Apr 25, 2023

  Based on observation, interview and record review it was determined, for 11 out of 80 sampled residents, that the facility failed to ensure that the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents. Specifically, a resident experienced 19 falls that resulted in an injury 14 times with multiple head injuries that required medical attention; a resident experienced 5 falls within 48 hours that resulted in bruising, pain, and a hip fracture; a resident experienced 17 falls that resulted in multiple fractures; a resident experienced 9 falls with head injuries that required medical attention; and a resident experienced 27 falls that resulted in lacerations that required medical… […]

• Immediate jeopardy, patternF725Apr 25, 2023

  Based on observation, interview and record review it was determined, for 21 of 80 sampled residents, that the facility did not have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment. These findings resulted in immediate jeopardy (IJ). In addition, staff and resident interviews revealed that staffing levels were not appropriate for the residents' needs. […]