MSM Brigham City LLC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined, for 1 of 25, the facility did not promptly notify the ordering physician of laboratory results that fall outside of clinical reference ranges. Specifically, the physician was not notified after a laboratory specimen was clotted and not completed as ordered. Resident identifier: 33.Findings included: Resident 33 was admitted to the facility on [DATE] with diagnoses which included myopathy, sepsis, pneumonitis due to inhalation of food and vomit, Alzheimer's disease, type 2 diabetes mellitus, chronic kidney disease, and hereditary and idiopathic neuropathy. A physician's order dated 5/31/25 revealed to complete a CBC (complete blood count) and CMP (Comprehensive Metabolic Panel). A nursing progress note dated 5/31/25 at 1:29 PM revealed CBP and CMP drawn per nurse. Sent to the local hospital lab on STAT order for suspected pneumonia. The CBC was not located in resident 33's medical record. There was a CMP that was located. There were no nursing progress notes…

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 25 sampled residents the facility did not file in the resident's clinical record radiologic reports. Specifically, a resident's head Computed Tomography (CT) results were not in the medical record. Resident identifier: 14.Findings included:Resident 14 was admitted to the facility on [DATE] with diagnoses which included, paroxysmal atrial fibrillation, repeated falls, and unspecified tremor.Resident 14's medical record was reviewed 12/9/25 through 12/15/25.On 8/18/25 at 5:27 PM, a nurse's note documented, Provider ordered a head CT scan due to increased confusion and high INR [International Normal Ratio]. Resident transported to and from appointment at [local hospital] by staff around 1500 [3:00 PM]. Resident now in room with husband.It should be noted that resident 14's head CT results could not be located in the medical record.On 12/11/25 at 9:06 AM, an interview was conducted with the Director of Nursing. (DON). The DON stated that she had to…

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, 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 2 hours after the allegation was made to the State Survey Agency (SSA) and Adult Protective Services (APS). In addition, the facility did not ensure that all investigations were reported to the SSA within 5 working days of the incident. Specifically, for 4 out of 21 sampled residents, notification to the SSA and APS was not within 2 hours after allegations of abuse, neglect, and injuries of unknown origin were identified and an investigation was reported to the SSA 7 working days of the incident. Resident identifiers: 16, 23, 89, and 90. Findings included: 1. Resident 16 was admitted to the facility on [DATE] with diagnoses that included, but were not limited to, early onset cerebellar ataxia, muscle spasms, insomnia, depression, dysphagia,…

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 and interview, the facility did not ensure that drugs and biologicals used in the facility were labeled in accordance with accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable. In addition, the facility did not ensure that all drugs and biologicals were stored under proper temperature controls. Specifically, opened insulin injector pens were not labeled with open dates and the insulin injector pens were in the medication cart available for resident use. In addition, the medication refrigerator was found to have low temperatures not compatible with medication storage. Findings included: On 12/18/23 at 8:41 AM, an observation was conducted of Registered Nurse (RN) 1 preparing resident medications. RN 1 prepared an insulin Aspart injection pen. The insulin Aspart injection pen was observed and was open for administration and was not labeled with an open date. RN 1 was immediately interviewed. RN 1 stated that the insulin injection pens were to be dated with the open date. RN 1…

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 and interview, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, there were numerous undated and unlabelled items in both the walk-in refrigerator and freezer, items stored on the floor in both the walk-in refrigerator and freezer, and there was a significant layer of dust on vents located above food preparation and plating areas. Findings included: 1. On 12/11/23 at 8:25 AM, an initial kitchen walkthrough was conducted. In the walk-in fridge, there were boxes of cheese, liquid eggs, tomatoes, strawberries, zucchini, bell peppers, and honeydew stored on the floor. On a sheet pan rack in the walk-in fridge, there were several sheet pans with undated bowls of salad, undated fruit cups, undated cake slices, undated pasta cups, and undated bags of carrots. On the third shelf up from the floor, there was a Ziploc bag of cubed chicken with no date or label. In the walk-in freezer, there was a box of nutritional shakes, frozen rolls, and frozen vegetables stored on the floor.…

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, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, including Coronavirus Disease 2019 (COVID-19). Specifically, for 2 out of 21 sampled residents, during a COVID-19 outbreak the facility staff did not dispose of their used Personal Protective Equipment (PPE) correctly, Transmission Based Precautions (TBP) and quarantine was discontinued for a COVID-19 positive resident after only six days of isolation, and staff face masks were observed worn down below the nose and mouth. Resident identifiers: 17 and 133. Findings included: 1. On 12/11/23 at 8:49 AM, an observation was made of Registered Nurse (RN) 4 at the nurse's medication cart near room [ROOM NUMBER]. RN 4 had their facemask down below their nose. RN 4 was observed to assist resident 1 in the hallway with their surgical facemask…

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, the facility did not ensure that the interdisciplinary team had determined that the resident's right to self administer medications was clinically appropriate. Specifically, for 1 out of 21 sampled residents, the Registered Nurse (RN) was observed to leave a residents medications at the bedside in a medication cup and the resident had not been evaluated to determine if they were safe to self administer medications. Resident identifier: 19. Findings included: Resident 19 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, type 2 diabetes mellitus, epilepsy, encephalopathy, alcohol abuse with unspecified alcohol induced disorder, and ataxia. On 12/18/23 at 8:58 AM, an observation was conducted of RN 1 preparing medications for resident 19. The medication cup that RN 1 prepared included pregabalin 50 milligrams (mg), Keppra 500 mg, metformin 1000 mg, aspirin 81 mg, Creon 24,000-76,000 units, omeprazole delayed release 20…

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, the facility did not ensure that in response to allegations of abuse, neglect, exploitation, or mistreatment that they prevented further potential abuse, neglect, exploitation, or mistreatment while the investigation was in progress. Specifically, for 1 out of 21 sampled residents, an allegation of neglect was made and the alleged perpetrator was not suspended pending the investigation and was allowed access to the resident/victim. Resident identifier: 16. Findings included: Resident 16 was admitted to the facility on [DATE] with diagnoses that included, but were not limited to, early onset cerebellar ataxia, muscle spasms, insomnia, depression, dysphagia, and dorsalgia. On 12/11/23 through 12/18/23, resident 16's medical record was reviewed. Review of the facility initial investigation, form 358, documented an allegation of neglect by Certified Nurse Assistant (CNA) 1 and CNA 2. On 8/9/23 at 1:00 AM, the report documented that CNA 3 and Licensed Practical Nurse (LPN) 1…

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, the facility did not ensure that the resident environment remains as free of accident hazards as was possible and that each receives adequate supervision and assistance devices to prevent accidents. Specifically, for 1 out of 21 sampled residents, facility staff attempted to transfer a resident from her bed to her wheelchair using a Hoyer lift without properly securing the Hoyer straps. Resident identifier: 17 Findings included: Resident 17 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, autonomic dysreflexia, neuromuscular dysfunction of bladder, atherosclerosis of aorta, morbid (severe) obesity due to excess calories, major depressive disorder, contracture of muscle, and dependence on wheelchair. On 10/3/23, the State Survey Agency received a facility reported incident that documented that resident 17 had fallen during a staff assisted transfer from her bed to her wheelchair using a Hoyer lift. Forms 358 and 359 were reviewed.…

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, the facility did not provide routine and emergency drugs and biologicals to its residents. Specifically, for 1 out of 21 sampled residents, a residents medications were not administered as ordered by the physician due to the medications not being available by the pharmacy. Resident identifier: 4. Findings included: Resident 4 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, dementia, acute kidney failure, acute on chronic diastolic heart failure, type 1 diabetes mellitus with diabetic chronic kidney disease, type 1 diabetes mellitus with foot ulcer, generalized anxiety, schizophrenia, major depressive disorder, and attention-deficit hyperactivity disorder. Resident 4's medical record was reviewed on 12/11/23. On 11/30/23 at 10:19 PM, an Orders - Administration Note documented Note Text: Latuda Oral Tablet 20 MG [milligrams] Give 1 tablet by mouth at bedtime related to SCHIZOPHRENIA, UNSPECIFIED . Medication was not delivered with…

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, the facility did not ensure the attending physician documented in the resident's medical record that the identified irregularity had been reviewed and what, if any, action had been taken to address the irregularity. If there was to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record. Specifically, for 2 out of 21 sampled residents, pharmacy recommendations including the physician's documentation was not included in the resident's medical record. Resident identifier: 1 and 4. Findings included: 1. Resident 4 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, dementia, acute kidney failure, acute on chronic diastolic heart failure, type 1 diabetes mellitus with diabetic chronic kidney disease, type 1 diabetes mellitus with foot ulcer, generalized anxiety, schizophrenia, major depressive disorder, and attention-deficit hyperactivity disorder. Resident 4's…

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, the facility did not ensure that each resident's drug regimen was free from unnecessary drugs. An unnecessary drug is any drug when used in excessive dose; or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or any combinations of the reasons above. Specifically, for 1 out of 21 sampled residents, the provider was not notified per the physician's order when a resident's blood glucose (BG) and systolic blood pressure (SBP) were outside of the physician's ordered parameters. In addition, a resident's long acting insulin was held when it should have been administered per the sliding scale physician's order. Resident identifier: 4. Findings included: Resident 4 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, dementia, acute kidney failure, acute on chronic diastolic heart failure,…

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, the facility did not obtain laboratory services to meet the needs of its residents. Specifically, for 1 out of 21 sampled residents, the facility did not obtain a specimen for a lab that was ordered by the provider. Resident identifier: 1. Findings included: Resident 1 was admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses which included hemiplegia affecting right dominant side, traumatic brain injury, neuromuscular dysfunction of the bladder, epilepsy, Crohn's disease, anxiety disorder, major depressive disorder, and osteoarthritis. On 12/11/23 through 12/18/23, resident 1's medical record was reviewed. Resident 1's laboratory orders revealed the following: a. On 2/3/23, a Complete Blood Count (CBC), lipid panel, and Keppra serum concentration level was ordered. b. On 2/24/23, a Levetiracetam (Keppra) serum level was ordered. Resident 1's laboratory results revealed no documentation of the above mentioned lab orders. On 2/23/23 at 11:01 AM, the…

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, the facility did not ensure that the antibiotic stewardship program that included antibiotic use protocols and a system to monitor the antibiotic use were implemented. Specifically, for 1 out of 21 sampled residents, a resident was prescribed and completed an antibiotic for a suspected urinary tract infection (UTI) even after the urine culture determined no bacterial growth. Resident identifier: 22. Findings included: Resident 22 was admitted to the facility on [DATE] with diagnoses which included sepsis, urinary tract infection, acute kidney failure, dementia, delirium, chronic kidney disease, heart failure, atrial fibrillation, and obstructive and reflux uropathy. On 12/18/23, resident 22's medical record was reviewed. Resident 22's progress notes revealed the following: a. On 8/12/23 at 12:14 AM, the nurse note documented, Resident's blood pressure was low at 88/50, CNA [Certified Nurse Assistant] told nurse at shift change and his medical POA [Power of Attorney] was…

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 it was determined the facility did not store, prepare and distribute food in accordance with professional standards for food service safety. Specifically, the dish machine wash temperature was not meeting the manufacture requirements and there were soiled areas in the kitchen. Findings include: 1. On 2/22/22 at 9:09 AM, an initial kitchen tour of the kitchen was conducted. The following was observed: a. There was whipped topping with no open date in the walk in refrigerator. b. There was debris on the floor in the walk in freezer. c. The inside of the microwave was soiled. e. The shelf above the steam table was soiled under the shelf which was above the prepared foods. f. There was food splatter on the wall behind the oven, fryer, griddle and stove. 2. On 2/22/22 at 9:15 AM, an observation was made of the facility dish machine. The wash temperature was 110 degrees Fahrenheit and the rinse temperature was 200 degrees Fahrenheit. The dishes were observed to be removed from the dish machine and placed in the clean dish area. A poster…

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 that the facility did not maintain evidence demonstrating the results of all grievances for a period of no less than 3 years from the issuance of the grievance decision. Specifically, facility grievance records could not be located prior to November 2021. Findings included: On 2/23/22 the facility grievance binder was reviewed. The Grievance Log documented complaints from 11/9/2021 to 2/10/2022. The log provided the date of the incident, name of person filing the report, name of person investigating, the dates the parties were informed of the findings and the disposition of the complaint. Additional documentation included a Grievance Tracking Report that documented the issue/concern, how the concern was corrected, the date the concern was corrected, and the responsible person. On 2/23/22 at 1:34 PM, an interview was conducted with the Corporate Resource Nurse (CRN) 1. The grievance log from May 2021 to November 2021 was also requested. CRN 1 stated that the previous Administrator had all the grievance forms in his office 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 that the facility did not ensure that the abuse policies and procedures were implemented to prevent abuse for 3 of 25 sample residents. Specifically, one resident experienced physical, verbal, financial, and emotional abuse and was involuntarily secluded. Resident identifiers: 4, 6, and 14. Findings include: 1. Resident 6 was admitted to the facility on [DATE] with diagnoses that included Down Syndrome, encephalopathy, respiratory failure, obesity, and depression. On 2/22/22 at 12:13 PM, an interview was conducted with resident 6. Resident 6 stated that there were two residents who said mean to her, naming resident 4 and resident 14. Resident 6 stated that the other residents told her to shut up and go to her room when they were at activities. Resident 6 stated that she had fought with her family member (FM 2) who was a resident in another area of the facility, who can visit resident 6 as desired. Resident 6 stated that she was kept in another room…

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 3 of 25 sampled residents, that the facility did not ensure that medication error rates were not 5 percent or greater. Observations of 34 medication opportunities, on [DATE], revealed 5 medication errors which resulted in a 14.71% medication error rate. Specifically, two residents received Levothyroxine with meals, a full dose of Miralax was not administered, Fiber capsules were administered without verification of dosage, and a Symbicort inhaler was administered without verification of the medication expiration. Resident identifiers: 9, 12, and 125. Findings included: 1. Resident 12 was admitted to the facility on [DATE] with diagnoses which included major depressive disorder, atherosclerosis of aorta, benign prostatic hyperplasia, chronic obstructive pulmonary disease, emphysema, anxiety disorder, gastro-esophageal reflux disease, hypothyroidism, polyneuropathy, sleep apnea, and dementia. On [DATE] at 8:36 AM, an observation was made 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.

Based on observation, record review and interview the facility was not administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the facility was found to be in non-compliance with F880, which was cited at an Immediate Jeopardy, scope and severity of L. In addition, one resident was abused and involuntarily secluded with the permission of management, which was cited at an Immediate Jeopardy, scope and severity of H. Resident identifiers: 4,6, 14, 125, and 127. Findings included: 1. Based on interview and record review it was determined that the facility failed to establish an infection prevention and control program designed to prevent the development and transmission of COVID-19. Specifically, the facility failed to ensure that a symptomatic staff members, who subsequently tested positive for COVID-19, were screened accurately and notification and evaluation was completed per the facility protocol, that negative antigen tests…

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, the facility did not ensure that the Quality Assessment and Assurance (QAA) committee developed and implemented appropriate plans of correction to correct identified quality deficiencies. Specifically, the facility was found to be in non-compliance with F880, which was cited at an Immediate Jeopardy, scope and severity of L. In addition, F600, abuse was cited at an Immediate Jeopard, scope and severity of H. Resident identifiers: 6, 125, and 127. Findings include: 1. Based on interview and record review it was determined that the facility failed to establish an infection prevention and control program designed to prevent the development and transmission of COVID-19. Specifically, the facility failed to ensure that a symptomatic staff members, who subsequently tested positive for COVID-19, were screened accurately and notification and evaluation was completed per the facility protocol, that negative antigen tests were completed, and that symptomatic staff members were provided appropriate Personal Protective Equipment (PPE). The failure resulted…

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 it was determined the facility did not follow policy and procedures for residents with COVID-19 vaccination exemptions. Specifically, staff with COVID-19 vaccination exemptions were not wearing personal protective equipment according to the facility's policy and procedures. Findings include: On 2/23/22, the Administrator provided a list of staff who were fully vaccinated for COVID-19 or had an exemption. Registered Nurse (RN) 2 was listed to have a medical exemption. Certified Nursing Assistant (CNA) 3 had a religious exemption. On 2/23/22, an observation was made of RN 2. RN 2 was observed to be wearing a surgical mask with eye protection. On 2/24/22 at 2:45 PM, an observation was made of RN 2. RN 2 was observed to be wearing a surgical mask with eye protection. On 2/24/22 at 5:45 AM, an observation was made of CNA 3. CNA 3 was observed to be wearing a surgical mask with eye protection. The facility COVID-19 Vaccine Policies and Procedures with no date revealed, .The purpose of this policy and procedure is to outline the community…

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 2 or 25 sampled residents, that the facility did not ensure that the interdisciplinary team (IDT) had determined that the resident's right to self administer medications was clinically appropriate. Specifically, two residents were not evaluated to determine if they were safe to self administer medications. Resident identifiers: 4 and 125. Findings included: 1. Resident 4 was admitted to the facility on [DATE] with diagnoses which included atherosclerosis of aorta, hypertension, insomnia, low vision right eye, and mild cognitive impairment. On 2/22/22 at 10:21 AM, an interview was conducted with resident 4. An observation was made of 4 medications at the bedside located in a medication cup. Resident 4 stated that they were her morning pills and she had not taken them yet. Resident 4 stated she had her own routine. Resident 4 was observed to swallow one pill and then set the remaining pills down. Resident 4 stated that she loved the medical…

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 25 sample residents, that the facility did not promote and facilitate the resident's self-determination through support of the resident's choice. Specifically, the resident requested that their breakfast meal tray be left at the bedside with the lid left on and the kitchen staff told the resident no, that it would be returned to the kitchen if not eaten within an hour. Resident identifier: 125. Findings included: Resident 125 was admitted to the facility on [DATE] with diagnoses which included encounter for orthopedic aftercare, depression, hypertension, asthma, gastro-esophageal reflux disease, irritable bowel syndrome, and obstructive sleep apnea. On 2/22/22 at 12:52 PM, an interview was conducted with resident 125. Resident 125 stated that the day before yesterday when the dietary staff delivered the breakfast tray she asked him to leave the tray with the lid on so she could get up in a minute and he said no. Resident 125 stated that the dietary…

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 25 sample residents, that the facility did not immediately consult with the resident's physician when there was a change in the resident's physical, mental, or psychosocial status or when a decision to transfer the resident from the facility was made. Specifically, the resident was transferred to the local hospital emergency room (ER) for evaluation and treatment of back pain and the physician was not notified. Resident identifier: 22. Findings included: Resident 22 was admitted to the facility on [DATE] with diagnoses which included Friedreich ataxia, mood disorder, cardiomyopathy, gastro-esophageal reflux disease, and muscle weakness. On 2/22/22 at 10:57 AM, an interview was conducted with resident 22. Resident 22 stated that she requested to go to the hospital for back pain and that she thought the rods in her back had been dislocated. Resident 22 stated that she had her family member take her to the ER. Resident 22 stated that it was determined…

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 of 25 sample residents, that the facility did not ensure that the resident had the right to personal privacy and confidentiality of their personal and medical records. Specifically, a licensed nurse was observed to provide a visitor with a resident's personal health information without determining who the visitor was first and if they had access to that information. Resident identifier: 127. Findings included: Resident 127 was admitted to the facility on [DATE] with diagnoses which consisted of congestive heart failure, acute kidney failure, type 2 diabetes mellitus, dementia, and hyperlipidemia. On 2/23/22 at 4:02 PM, an observation was made of a visitor attempting to enter resident 127's room. Resident 127's room had a sign posted on the door that stated isolation precautions, COVID isolation. Droplet precautions were check marked as indicated and the following instructions were listed: Patient to have private room; Surgical mask to be…

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 25 sample residents, that in response to allegation of abuse the facility did not ensure that all alleged violations involving abuse were immediately, but no later than 2 hours after the allegation was made, if the event that caused the allegation involved abuse. This involved reporting to other officials in accordance with State law. Specifically, the facility did not report when a resident was involuntarily secluded. In addition, the facility did not report within 2 hours to the State Survey Agency when same resident was physically and verbally abused by a family member. Other officials were not contacted regarding both incidents. Resident identifier: 6. Findings include: Resident 6 was admitted to the facility on [DATE] with diagnoses that included Down Syndrome, encephalopathy, respiratory failure, obesity, and depression. Resident 6's electronic medical record review was completed on 3/2/22. 1. Seclusion: On 2/22/22 at 1:13 PM, resident 6…

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 of 25 sample residents, that in response to allegations of abuse the facility did not have evidence that all alleged violations were thoroughly investigated to prevent further potential abuse. In addition if the alleged violation was verified appropriate corrective action was not taken. Specifically, a resident that was involuntarily secluded in a room that was unfamiliar to her and an investigated was not conducted regarding potential abuse. In addition, the same resident was verbally and physically abused by a family member and a thorough investigated was not conducted to prevent possible further abuse. Resident identifier: 6. Findings include: Resident 6 was admitted to the facility on [DATE] with diagnoses that included Down Syndrome, encephalopathy, respiratory failure, obesity, and depression. 1. On 2/22/22 at 12:13 PM, an interview was conducted with resident 6. Resident 6 stated that her voice was hoarse because she was screaming…

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 25 sample residents, that the facility did not ensure that the transfer was documented in the resident's medical record and included the basis for the transfer, that the services were attempted and could not be provided in the facility, that the transfer was made by the resident's physician, and that the receiving provider was provided all the necessary information to ensure a safe and effective transition of care. Specifically, the resident was transferred to the local hospital emergency room (ER) for evaluation and treatment of back pain without a physician order for the transfer and no documentation could be found of a transfer assessment or documentation that was provided to the receiving provider. Resident identifier: 22. Findings included: Resident 22 was admitted to the facility on [DATE] with diagnoses which included Friedreich ataxia, mood disorder, cardiomyopathy, gastro-esophageal reflux disease, and muscle weakness. On 2/22/22 at 10:57…

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 that the facility did not develop and implement a comprehensive person-centered care plan for 1 of 25 sample residents, consistent with the resident right that included measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment. Specifically, activities of daily living function/rehabilitation potential, urinary incontinence and indwelling catheter, nutritional status, and dehydration/fluid maintenance were not developed as required. Resident identifier: 6. Findings included: Resident 6 was admitted to the facility on [DATE] with diagnoses that included Down Syndrome, encephalopathy, respiratory failure, obesity, and depression. On 3/2/22, resident 6's medical record review was completed. On 5/10/21, a Pre-admission Screening Applicant/Resident Review (PASRR) was completed for resident 6. Resident 6 had functional limitations in the areas of self-care,…

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 receive registry verification for a nurse aide prior to allowing the staff member to serve as a nurse aide. Findings include: On 2/22/22, an observation was made of Certified Nursing Assistant (CNA) 18. CNA 18 was observed to be working with residents as a CNA. CNA 18 was interviewed. CNA 18 stated her job title was a CNA. On 2/24/22, the Administrator provided a list of staff hired in the last 6 months. On 3/2/22 at 12:00 PM, CNA 18's employee file was reviewed. CNA 18 was hired on 3/12/21 for the nursing department. An Employment Authorization Form for the Direct Access Clearance System (DACS) did not reveal information regarding certification or License information. Review of the February 2022 CNA schedule for the facility revealed that CNA 18 worked on 2/7/22, 2/8/22, 2/10/22, 2/14/22, 2/15/22, 2/21/22, 2/24/22, and 2/28/22. A Nursing Assistant Registry form was provided by Corporate Resource Nurse (CRN) 1. The form was dated 3/2/22 at 12:37 PM. On 3/2/22 at 12:54 PM, CRN 1 was interviewed. CRN 1 stated that…

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 of 25 sample residents that the facility did not provide medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. Specifically, a resident with intellectual and behavior issues was not evaluated by or treated by a Licensed Clinical Social Worker (LCSW). Resident identifier 6. Findings include: Resident 6 was admitted to the facility on [DATE] with diagnoses that included Down Syndrome, encephalopathy, respiratory failure, obesity, and depression. Resident 6's electronic medical record review was completed on 3/2/22. An MDS was completed on 12/17/21 that revealed that resident 6 had a mood interview, a Patient Health Qustionnaire-9 (PHQ-9). Resident 6 scored 19/27, indicating moderately severe depression. A care plan with the focus of resident 6 exhibits/at risk for behaviors; yelling out, arguing with other residents/staff, grunting, rubbing legs 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 that the facility did not provide, for 1 of 25 sample residents, specialized rehabilitative services such as physical therapy and occupational therapy that were required in the resident's comprehensive plan of care. Specifically, a resident was not provided assessed specialized rehabilitation. Resident identifier 6. Findings include: Resident 6 was admitted to the facility on [DATE] with diagnoses that included Down Syndrome, encephalopathy, respiratory failure, obesity, and depression. Resident 6's electronic medical record review was completed on 3/2/22. Resident 6's Preadmission Screening Resident Review (PASRR) Level II, created on 7/31/21 revealed that resident 6 had a diability that limited her in learning, self-direction, and capacity for independent living. The functional assessment revealed that reident 6 showed an inability to learn new skills without aggressive and consistent training. The summary of Specialized Rehabilitative Services (SRS) for…

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.