Canyonlands Care Center's team gathered together after administrator Kim Macfarlane announced that state inspectors gave the facility a "deficiency-free" assessment. Back row, left to right: Tom Lacy, Jennifer Costanza, Diane Hatch, Alison Hillis, Brenda Bennett. Middle row: Kimberly Blake, Jenny McDougall, Kristi Taylor, Jillian Fryer, Jeanette Taylor and Sylvia Fountain. Front row: Kim Macfarlane, Barberella Hill and Jennifer Hutchinson. [Photo by Rudy Herndon / Moab Sun News]

The Canyonlands Care Center’s staff party this weekend should be even more festive than usual.

State inspectors reported this month that the 36-bed facility is “deficiency-free,” and while they haven’t publicly announced their findings yet, Canyonlands Care Center Administrator Kim Macfarlane said her team has good cause to rejoice.

“It’s the shortest survey that we’ve ever been involved in,” she told the Moab Sun News. “It’s because they couldn’t find anything.”

Surveyors from Utah’s Bureau of Health Facility Licensing, Certification and Resident Assessment spent portions of three days last week inspecting the care center. During that time, they interviewed every single resident of the facility, along with staffers and anonymous family members.

Once they were done, they plugged all of the information they gathered into a software program that sharpens their investigative focus, and Macfarlane said the program only brought up a “couple of issues.”

“That’s the best they’ve ever seen,” she said.

To put the latest survey results in perspective, Macfarlane looked at data from 88 long-term care facilities in Utah, and she found that only six of them – or about 7 percent – obtained “deficiency-free” status in the last year.

“Seven percent: That’s a great percentage,” Macfarlane said.

The survey results haven’t always been so glowing, and Macfarlane credits much of the turnaround to the work that the care center’s employees accomplished under her predecessor, former administrator Barbara Grossman.

During the first survey of the facility, the bureau identified 28 deficiencies, and 26 deficiencies popped up the following year. Macfarlane said that under Grossman, the care center brought the total number of reported deficiencies last year down to two.

At that time, inspectors found flaws in the care center’s procedures to investigate residents’ injuries, and also reported that the facility’s privacy curtains weren’t always hung properly.

The care center has since addressed both issues, Macfarlane said, and today, employees take seriously any signs of injuries that they see on residents.

“If one of our residents bumps her hand underneath the table and gets a bruise, we investigate it,” she said.

Moab Regional Hospital CEO Jen Sadoff, whose father required long-term care in Moab, called the survey’s results a “remarkable achievement” and a testament to the “excellent care” that the facility’s employees provide.

“The relief is immeasurable when you know your loved one is being cared for in a safe, compassionate and loving environment,” Sadoff said. “Along with the smiles on the faces of the residents and the joyful sounds you can hear in the activity room, the top-notch results of the survey should reassure families of this.”

A representative from the Bureau of Health Facility Licensing, Certification and Resident Assessment said she cannot comment on the surveyors’ findings until an administrator formally signs off on them. That process could take up to 10 business days, the woman said.

However, Macfarlane has no reason to believe the official results will be any different. After all, she said, the surveyors who spent three days on the site presented their findings directly to her.

“When they do their exit, they tell you what’s in there,” she said. “They never come back (and change their minds).”

The federal government’s Medicare Nursing Home Compare website, which currently gives the facility an overall rating of one out of five stars, could take much longer to revise its assessment. Macfarlane estimates that it may take the federal agency perhaps as long as six months to post any updates.

And since the Nursing Home Compare website bases its ratings on survey results from a three-year period, she doesn’t expect the care center’s overall rating to go up until the 2017 results are in – although she’s optimistic about an improvement.

“I’m confident that we’ll be able to have a five-star rating on our next survey results,” she said.

Care center holds daily, monthly meetings to address residents’ needs

To stay on their toes, employees gather for staff meetings every morning to talk about each resident and her or his needs. As those needs change routinely, employees routinely update residents’ care plans, Macfarlane said.

Certified nurses aides work to keep residents clean and make sure that they aren’t losing – or gaining – too much weight, Macfarlane said, and everyone remains vigilant about a problem that is somewhat unique to long-term care facilities.

“Falls are a big deal here,” she said. “And we don’t want anybody to fall.”

Department heads also hold quality assurance, performance and improvement meetings once a month.

They’ll get together with Canyonlands Care Center Medical Director Dr. Paul Reay to go over everything from infection controls to the proper administration of medications.

“When we find out that we have a problem, we look at it from all of the different departments,” Macfarlane said.

Looking at the care center’s bigger-picture goals, Macfarlane said that the facility’s governing board has ramped up its efforts to retain employees; it currently has 48 in all.

In the past, the facility’s turnover rate soared to 300 percent, and in response, Macfarlane said the facility raised its wages to be more competitive with the market, while striving to treat its employees well.

“We work on employee satisfaction, to take care of the employees who take care of our residents,” she said.

Macfarlane said she expects that the facility will be better able to support itself by generating more revenue, and to that end, it’s turning to county voters for their help.

At the request of the care center’s governing board, the Grand County Council voted last month to place a proposed sales and use tax of up to half of 1 percent on voters’ Nov. 8 general election ballots. If voters approve the proposal, it would be imposed for a 10-year period, and could be extended for another 10 years, assuming that Grand County’s population does not increase significantly.

But Macfarlane said the facility can also generate revenue from other sources by bringing in more Medicaid and private-pay residents, and by keeping its resident numbers steady.

The care center was anticipating the arrival of two new residents this week, which brings its occupied bed count up to 36 and marks the first time that facility has reached full capacity since Macfarlane joined the staff last year.

“It will help us meet our expenses with our census numbers up,” she said.

For Sadoff and Macfarlane alike, the care center is ultimately invaluable to local residents, since it’s the only one of its kind in the immediate area.

“Being able to come and see your loved one right here is huge to the family members who come and place their loved ones in our care,” Macfarlane said. “If we weren’t here, they would have to place them in Price or Grand Junction, or down in Blanding.”

It’s not something that can be taken for granted, Macfarlane suggests.

“No one talks about long-term care until you need it, and then it’s super-important,” she said.

State inspectors say facility is “deficiency-free”

It’s the shortest survey that we’ve ever been involved in … It’s because they couldn’t find anything.