The Suites at Jordan River

In the surveyor’s words

From the most serious findings on record at The Suites at Jordan River, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF636Mar 27, 2025

  Based on review of the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual, medical record review, and interview, the facility failed to complete a comprehensive assessment, using the Centers for Medicare & Medicaid Services-specific RAI process within the regulatory time frames for 10 of 33 ( Resident #3, #5, #13, #21, #26, #38, #42, #59, #78 and #286 ) sampled residents reviewed. The findings include: 1. Review of the MDS 3.0 RAI Manual v (version) 1.19.1 revised October 2024, pages 2-22 through 2-24, revealed .The Admission assessment must be completed by the end of day 14, counting the date of admission to the nursing home as day 1 .The MDS completion date (Item Z0500B) must be no later than day 14 . […]

• No harm, potential for more than minimal, patternF638Mar 27, 2025

  Based on review of the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual, medical record review, and interview, the facility failed to complete quarterly assessments, using the Centers for Medicare & Medicaid Services-specified RAI process within the regulatory time frames for 13 of 33 (Resident #2, #5, #11, #13, #21, #23, #26, #30, #33, #41, #42, #55, and #56) sampled residents reviewed. The findings include: 1. The MDS 3.0 RAI Manual v (version) 1.19.1 October 2024, page 2-35, revealed, .The Quarterly assessment is an OBRA (Omnibus Budget Reconciliation Act) non-comprehensive assessment for a resident that must be completed at least every 92 days following the previous OBRA assessment of any type. […]

• No harm, potential for more than minimal, patternF642Mar 27, 2025

  Based on review of the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual, medical record review, and interview, the facility failed to complete discharge and death in facility assessments using the centers for Medicare & Medicaid services specified RAI process for 9 of 33 (Resident #3, #12, #15, #18, #31, 59, #60, #61 and #224) sampled residents reviewed. The findings include: 1. Review of the MDS 3.0 RAI manual v 1.19.1 revised October 2024, pages 2-38 through 2-39, revealed .Discharge Assessment .Must be completed when the resident is discharged from the facility . Must be completed .within 14 days after the discharge date . 2. […]

• No harm, potential for more than minimal, patternF812Mar 27, 2025

  Based on policy review, observation, and interview, the facility failed to ensure a safe and sanitary environment in the kitchen and failed to clean the kitchen ice machine filter. The findings include: 1. The facility policy titled, Sanitation, dated 7/11/2024, revealed .The food service area shall be maintained in a clean and sanitary manner .All kitchens, kitchen areas, and dining areas shall be kept clean, free from litter and rubbish All utensils .and equipment shall be kept clean, maintained in good repair .Ice that is used in connection with food or drink shall be from a sanitary source and shall be .dispensed in a sanitary manner .Kitchen wastes that are not disposed of .shall be kept in clean, leakproof, nonabsorbent, tightly closed containers and shall be disposed of daily… […]

• No harm, potential for more than minimal, patternF880Mar 27, 2025

  Based on policy review, medical record review, observation, and interview the facility failed to ensure practices to prevent the potential spread of infection were maintained when 2 of 15 staff (Dietary Aide J and CNA l) failed to perform hand hygiene and perform proper handling of dinnerware during dining and when 3 of 3 nurses (Registered Nurse (RN) C, Licensed Practical Nurse (LPN) LPN D and LPN E) failed to perform sanitation of reusable equipment during medication administration. The findings include: 1. […]