Monument Healthcare Murray Creek

Based on observation, interview, and record review, the facility failed to provide 1 (Resident #399) of 1 sampled resident reviewed for activities with an activity calendar and further failed to ensure staff provided the resident with activities of their choice.Findings included: An admission Record indicated the facility admitted Resident #399 on 06/04/2025. According to the admission Record, the resident had a medical history that included a diagnosis of need or assistance with personal care. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/10/2025, revealed Resident #399 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated it was very important for the resident to be around animals such as pets. Resident #399's Care Plan Report included a focus area initiated 06/04/2025, that indicated the resident was a new admission adjusting to the facility. Interventions directed the staff to post an activity calendar in the resident's room, invite the resident to leisure diversionary…

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, record review, and facility policy review, the facility failed to ensure a resident received treatment and services to increase a range of motion (ROM) in their left hand contracture for 1 (Resident #47) of 3 sampled residents reviewed for position, mobility.Findings included: A facility policy titled, Rehabilitative/Restorative Care: Resident Mobility and Range of Motion, dated 02/01/2024, revealed 2. Residents with limited range of motion will receive treatment and services to increase and/or prevent a further decrease in ROM. An admission Record indicated the facility admitted Resident #47 on 12/16/2024. According to the admission Record, the resident had a medical history that included a diagnosis of hemiplegia and hemiparesis following cerebral infarction left non-dominant side. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) on 05/26/2025, revealed Resident #47 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated the resident had functional…

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, record review, and facility policy review, the facility failed to ensure the licensed nursing staff documented the refusal of medication for 1 (Resident #97) of 5 residents observed for medication administration. The facility further failed to ensure the licensed nursing staff documented why medication was not administered to 1 (Resident #82) of 1 sampled resident reviewed for insulin.1. A facility policy titled, Medication: Documentation of Medication Administration, dated 02/01/2024, indicated, A medication administration record [MAR] is used to document all medications administered. The policy specified, 2. Administration of medication is documented immediately after it is given. 3. Documentation of medication administration includes, as a minimum: a. the resident's name; b. name and strength of the drug; c. dosage; d. route of administration; e. date and time of administration; f. reason(s) why a medication was withheld, not administered, or refused (as applicable); g. initials, signature and title of the person administering the medication; h.…

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, record review, and facility policy review, the facility failed to ensure a resident's room provided enough space so that they could access their bathroom in a motorized wheelchair for 1 (Resident #15) of 5 sampled residents reviewed for the environment.Findings included: A facility policy titled, Resident Rights/Dignity: Homelike Environment, dated 02/01/2024, revealed Our facility's environment and staff behaviors are directed toward assisting the resident maintaining and/or achieving safe independent functioning dignity and well-being. The policy specified, 3. In order to accommodate individual needs and preferences, adaptations may be made to the physical environment, including the resident's bedroom and bathroom, as well as the common areas in the facility. An admission Record revealed the facility admitted Resident #14 on 11/22/2023. According to the admission Record, the resident had a medical history that included diagnoses of complete traumatic amputation at level between right hip and knee, difficulty in walking, muscle weakness, 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.

Based on observation, interviews, facility document review, and review of the United States Food and Drug Administration (FDA) 2022 Food Code, the facility failed to ensure dietary staff routinely monitored food temperatures on the meal service line. Specifically, the facility failed to take the temperatures of all food and drink items that required temperature control for safety to limit microorganism growth and failed to have temperature logs available on several days. This had the potential to affect 98 of 98 residents who received meals from the dietary department. Findings included: A review of the FDA's 2022 Food Code, Chapter 3 Food, revealed, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 57 C [Celsius] (135 F [Fahrenheit]) or above or (2) At 5 C (41 F) or less. A review of a facility document titled, Resource: Food Temperature Log, revealed the Cold Holding Reference for milk was listed as less than 45 degrees F. A review of the Food Temperature Logs for the timeframe from 08/14/2023 to 08/28/2023 revealed the following concerns: - On 08/14/2023, no…

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 observations, record review, interviews, and review of the facility policy, it was determined that the facility failed to ensure 3 (Residents #33, #39, and #262) of 4 residents who were self-administering medications, were assessed to determine whether it was safe to self-administer the medications and to keep the medications at the bedside. Findings included: A review of the facility's policy titled, Right to Self-Administer Medication, last revised 05/04/2023, indicated, The resident has the right to self-administer medications, if the interdisciplinary team has determined that this practice is clinically appropriate. 1. If a resident has requested to self-administer medications, it is the responsibility of the interdisciplinary team to determine it is safe before the resident exercises the right. A resident may self-administer medications after the interdisciplinary team has determined which medications may be self-administered. 2. Considerations in determining if the resident is clinically appropriate to self-administer include: a. Which medications are appropriate 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.

4. Review of a facility policy titled, Quality of Care: Accident Hazards/Supervision/Devices, revised on 05/04/2023, revealed, The resident's care plan will reflect the extent of supervision, if any, is needed during smoking. A review of an admission Record indicated the facility admitted Resident #96 on 06/01/2023 with a diagnosis that included hypertension. The admission Record included a diagnosis of acute respiratory failure with hypoxia with an onset date of 08/25/2023. Review of an admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/06/2023 revealed Resident #96 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated moderately impaired cognition. The resident required staff supervision for all activities of daily living. Review of Resident #96's Progress Notes revealed a note, dated 06/01/2023 at 6:17 PM, that indicated Resident #96 was admitted to the facility and was a current some day smoker. The note indicated Resident #96 reported smoking sometimes with friends. On 08/28/2023 at 9:02 AM, 08/29/2023 at 9:55 AM, and 08/31/2023…

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 observations, interviews, record review, and facility document and policy review, the facility failed to provide services to residents who were unable to carry out activities of daily living (ADL) necessary to maintain good grooming and personal hygiene for 3 (Residents #44, #51, and #261) of 4 sampled residents reviewed for ADL care. Specifically, Resident #44 and Resident #261 had long and dirty fingernails, Resident #51 and Resident #261 had facial hair that needed to be trimmed, and Resident #261 had debris around their mouth. Findings included: A review of a facility policy titled, Activities of Daily Living (ADLs)/ Maintain Abilities, revised 05/04/2023, indicated, Facility provides necessary care and services to support the resident's needs and choices. Further review revealed, 1. A resident is given appropriate treatment and services to maintain or improve his/her ability to carry out the activities of daily living, including those specified below: a. hygiene-bathing, grooming, dressing, oral care. Additionally, 2. A resident who is unable to carry out activities 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 observations, interviews, record reviews, and facility policy review, the facility failed to: 1) ensure cigarettes and lighters were stored safely at the nursing station for 3 (Residents #38, #44, and #96) of 3 sampled residents reviewed for smoking; 2) complete a smoking assessment for 1 (Resident #96) of 3 sampled residents reviewed for smoking in accordance with the facility's policy; and 3) ensure 2 (Resident #61 and Resident #47) of 5 sampled residents reviewed for accident hazards were safely transferred and/or transported. Staff failed to utilize a gait belt during a stand and pivot transfer for Resident #61 and failed to utilize footrests while transporting Resident #61 and Resident #47 in their wheelchairs. Findings included: 1. A review of the facility policy titled, Physical Environment Facility with Independent and Supervised Smokers, revised 05/04/2023, indicated, 3. Residents who wish to smoke will be assessed for smoking safety by nursing. 4. Smoking assessments will be completed on admission, quarterly, with significant change of condition and as needed 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record reviews, and facility policy review, the facility failed to provide appropriate respiratory care for 4 (Residents #33, #39, #97, and #262) of 6 sampled residents reviewed for respiratory care. Specifically, the facility failed to: 1) ensure there was a physician order for the use of continuous positive airway pressure (CPAP, a machine that uses mild air pressure to keep breathing airways opened during sleep) for Resident #97 and Resident #262; 2) store Resident #33's nebulizer mask when not in use; and 3) store the CPAP equipment for Resident #39 when not use. Findings included: A review of the facility policy titled, Quality of Care Respiratory Care/Tracheostomy Care & Suctioning, revised 05/04/2023, specified Purpose: To provide residents with necessary respiratory care and services that are in accordance with professional standards of practice, the resident's care plan and the resident's choice. The policy specified, 9. Obstructive Sleep Apnea (OSA) refers to apnea…

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, record review, and facility document and policy review, the facility failed to submit a final investigative report within the required five working days to the state survey agency for 1 (Resident #13) of 3 sampled residents reviewed for abuse. Findings included: Review of a facility policy titled, Freedom from Abuse, Neglect and Exploitation, Abuse Reporting and Responsibilities of Covered Individuals, revised on 05/04/2023, revealed, 5. In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility will: a. Report immediately, but not later than 2 hours, all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, if the events that cause the allegation involve abuse or result in serious bodily injury. b. Report 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. The policy further indicated, d. The facility will report results of all…

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 record review, interviews, document review, and facility policy review, the facility failed to complete an admission Minimum Data Set (MDS) assessment for 1 (Resident #262) of 5 sampled residents reviewed for resident assessments. Findings included: A review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated October 2019, specified, The admission assessment is a comprehensive assessment for a new resident and, under some circumstances, a returning resident that must be completed by the end of day 14, counting the date of admission to the nursing home as day if: - this is the resident's first time in this facility, OR, - the resident has been admitted to this facility and was discharged return not anticipated, OR - the resident has been admitted to this facility and was discharged return anticipated and did not return within 30 days of discharge. A review of the facility policy titled, Resident Assessment, revised on 05/04/2023, indicated, The facility will conduct an initial and periodic…

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.

3. A review of an admission Record indicated the facility admitted Resident #44 on 07/28/2017 with diagnoses that included encephalopathy and generalized muscle weakness. A review of Resident #44's quarterly MDS, with an ARD of 07/02/2023, revealed the date the assessment was completed was 08/18/2023, which was beyond the required 14 days after the ARD. During an interview on 08/30/2023 at 4:10 PM, the Director of Nursing (DON) stated she expected MDSs to be completed timely per the RAI manual. During an interview on 08/30/2023 at 4:36 PM, the MDS Coordinator stated she had worked for the facility for about three weeks. She stated the facility had not had an MDS Coordinator temporarily, so some MDSs were not completed timely. During an interview on 08/31/2023 at 4:13 PM with the Administrator, he confirmed Resident #44's quarterly MDS, with an ARD of 07/02/2023, was completed late, and he expected MDSs to be completed on time. 2. A review of an admission Record indicated the facility admitted Resident #13 on 11/20/2019 with diagnoses that included dysarthria following cerebral…

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 interviews, record reviews, and facility policy review, the facility failed to ensure the Minimum Data Set (MDS) was coded accurately for 2 (Residents #58 and #76) of 27 sampled residents reviewed. Specifically, Resident #58's 06/06/2023 quarterly MDS assessment did not address the resident's cognitive status, and Resident #76's 04/04/2023 quarterly MDS assessment did not address the resident's fall with major injury. Findings included: Review of a facility policy titled, Resident Assessment, revised 05/04/2023, specified, The facility will conduct an initial and periodic comprehensive, accurate assessment of a resident's functional capacity which will include needs, strengths, goals, life history and preferences utilizing the RAI [Resident Assessment Instrument]. The assessments will be reproducible, transmitted to CMS [Centers for Medicare and Medicaid Services] and will be in accordance with the timeframes identified in the RAI regulations specified by CMS. 1. A review of an admission Record indicated the facility admitted Resident #58 on 05/02/2019 with diagnoses 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 observations, interviews, record review, and policy review, the facility failed to ensure procedures for receiving medication for residents was accurate and safe for 1 (Resident #96) of 7 residents reviewed for medications. Specifically, the facility placed medication found in Resident #96's backpack labeled as Methadone in the medication cart to be administered to the resident, even though the resident stated the medication in the bottles was ibuprofen. Findings included: An interview with the Director of Nursing (DON) on 08/30/2023 at 4:11 PM, revealed the facility had no policy regarding how to address residents bringing medications into the facility. A review of an admission Record indicated the facility initially admitted Resident #96 on 06/01/2023 and was readmitted on [DATE] with diagnoses that included encephalopathy and acute respiratory failure with hypoxia. A review of Resident #96's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/06/2023, revealed the resident…

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 interviews, record review, and facility policy review, the facility failed to thoroughly investigate an allegation of abuse for 2 (Residents #11 and Resident #83) of 5 residents reviewed for abuse prohibition. Findings included: A review of a facility policy titled, Freedom from Abuse, Neglect and Exploitation, revised 05/04/2023, indicated, 3. When the facility has identified abuse, the facility should take appropriate steps to remediate the noncompliance and protect residents from additional abuse immediately. This includes but is not limited to: c. Conduct a thorough investigation of the allegation. Review of a facility policy, titled, Freedom from Abuse, Neglect, and Exploitation Preventing and Prohibiting Abuse, revised 05/04/2023, specified, Investigation 1. Allegations of abuse, neglect, misappropriation and exploitation will be investigated, including: c. Identifying and interviewing involved persons, witnesses, and others who may have knowledge to the extent possible. and e. Documenting the investigation. A review of Resident #11's admission Record indicated 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.

Based on observations, interviews, and record review it was determined the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, foods in the resident communal refrigerators were not labeled, dated or disposed of when past expiration dates, also at the time of observation the facility dish machine was used without insurance of adequate sanitizer levels. Findings included: 1. On 12/2/21 observations were made of resident communal refrigerators located on the nursing units. The following observations were made; a. On 12/2/21 at 10:18 AM, the resident communal refrigerator on a nursing unit was observed to include the following items; i. A plastic grocery bag was observed labeled with a resident name and not labeled with a date. The bag contained a container with rice and a mango. ii. A bottle of blue cheese dressing was labeled Don't Throw- no name or date was labeled on the item. The food item was not passed the manufacturer's use by date. iii. A plastic bag with illegible writing contained a…

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 observations, interviews and record review it was determined the facility did not ensure residents had a safe, clean, comfortable, and homelike environment, while exercising reasonable care for the protection of the resident's property from loss or theft, and providing housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Specifically, resident interviews and observations were performed regarding uncleanly conditions in a resident communal shower room, and for 2 of 49 sample residents the facility did not ensure residents had reasonable protection of property from loss or theft. Resident identifiers: 11, 45, 60, 74. Findings include: 1. Resident 11 was admitted on [DATE] with medical diagnoses that included, but not limited to, Type 2 Diabetes Mellitus, multiple myeloma, anxiety disorder, cognitive communication disorder, hyperlipidemia, asthma, Coronavirus Disease 2019 (COVID-19), malignant neoplasm of the bone, history of fracture to the left tibia,…

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 4 of 49 sample residents, that the facility did not develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframe's to meet a resident's medical, nursing, mental and psychosocial needs that were identified in the comprehensive assessment. Specifically, one resident with difficulty communicating was not provided a communication book for staff to communicate with her, pressure ulcers were not noted, and pain was not addressed. Resident identifiers: 18, 34, 45 and 70. Findings include: 1. Resident 18 was admitted to the facility on [DATE] with diagnoses that included a cognitive communication deficit, type II diabetes mellitus, anxiety disorder, chest pain, insomnia, and dementia. Resident 18 speaks Russian. On 11/30/21 at 8:55 AM, resident 18 was observed outside her room requesting help from staff in Russian. A Certified Nursing…

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 of 49 sampled residents that the facility did not ensure that residents who are unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Specifically, a dependent resident was observed to go nearly 2 hours without being provided incontinence care or responded to by staff, and another dependent resident's scheduled bathing did not occur multiple times. Resident identifier: 8 and 67. Findings include: 1. Resident 8 was admitted to the facility on [DATE] with diagnoses that included: acute respiratory failure, type II diabetes mellitus, type I neurofibromatosis, and chronic kidney disease. On 11/30/21 a continuous observation of Resident 8 began at 12:07 PM and ended at 1:30 PM. During the continued observation the resident was observed to appear disheveled, unshaved, and malodorous. Resident 8 was also observed to be wearing a soiled brief. Resident 8…

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 the facility did not ensure that each resident received adequate supervision and assistive devices to prevent accidents for 2 of 49 sample residents. Specifically, a resident had multiple falls without interventions, and one resident was run into by a meal cart. Resident identifiers: 18 and 60. Findings include: 1. Resident 18 was admitted to the facility on [DATE] with diagnoses that included a cognitive communication deficit, type II diabetes mellitus, anxiety disorder, chest pain, insomnia, and dementia. Resident 18 speaks Russian. On 11/30/21 at 8:55 AM, resident 18 was observed outside her room requesting help from staff in Russian. A Certified Nursing Assistant (CNA) 1 was observed directing resident 18 back to her room. CNA 1 was immediately interviewed. CNA 1 stated that she did not speak Russian, but she could usually understand what resident 18 needed because resident 18 would point to things in her room. CNA 1 stated that resident 18…

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 observation, 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, for 4 of 49 sample residents. Specifically, residents were required to wait for care in excess of an hour, and staffing levels prohibited proper infection control practices. Disinfectant was also not being provided to the laundry. Resident identifiers: 8, 60, 67, and 78. Findings include: 1. Resident 60 was admitted on [DATE] with medical diagnoses that included, but not limited to, cardiomyopathy, heart failure, chronic kidney disease, fibromyalgia, bipolar disorder, depressive disorder, anxiety disorder, 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 observations, interviews and record review it was determined the facility did not ensure each resident received and the facility provided food prepared by methods that conserved nutritive value, flavor, and appearance, as well as, food and drink that was palatable, attractive, and at a safe and appetizing temperature for 6 of 49 sample residents. Specifically, multiple residents complained of food that was not palatable or of appropriate temperature, resident council minutes revealed complaints of food, and the test tray was not attractive or palatable. Resident identifiers: 5, 10, 45, 54, 60, 97. 1. Resident 10 was admitted to the facility on [DATE] with medical diagnoses which included, but not limited to, paraplegia, hemiplegia, morbid obesity, dysphagia, mood disorder, hypertension, cognitive communication deficit, and hyper glycemia. On 11/29/21 at 12:00 PM, resident 10 stated the food on their meal trays were often cold. Resident 10 stated when they ordered an alternate meal of a hamburger,…

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 establish and maintain an IPCP designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, staff were observed to transport resident beverages uncovered through nursing units during meal delivery, PPE was not maintained for an outbreak, face masks were not disinfected adequately, sputum was left on the sidewalk, and cleaning rooms after residents were diagnosed with COVID-19 did not occur timely. Findings Include: 1. On 12/1/21 at 8:21 AM, Registered Nurse (RN) 9 and Certified Nursing Assistant (CNA) 13 were observed in room with droplet and contact precautions. RN 9 and CNA 13 were observed handling bedding and the resident's belongings, and performing resident cares without wearing gowns. 2. On 12/1/21 at 8:33 AM, a Central Supply (CS) employee was observed making a bed in a room on contact precautions without wearing…

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 conduct COVID-19 testing based on the criteria for conducting testing of asymptomatic individuals such as the positivity rate of COVID-19 in a county. Specifically, unvaccinated staff were not tested twice a week when the county positivity rate was High >10%) and during the facility's outbreak. This occurred for 4 out of 5 sampled staff members. Finding include: Center for Medicare and Medicaid Services (CMS) Memo QSO-20-38-NH, revised on 4/27/21, reads, Routine testing of unvaccinated staff should be based on the extent of the virus in the community. Fully vaccinated staff do not have to be routinely tested. Facilities should use their county positivity rate in the prior week as the trigger for staff testing frequency. [Community COVID-19 activity is High when the county positivity rate in the past week was >10% and minimum testing frequency of unvaccinated staff is twice a week. The Salt Lake County transmission rates used to determine the frequency 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility did not provide reasonable accommodation of resident needs and preferences. Specifically, a resident was not given a bed with a frame that would allow the resident to elevate her legs and feet. This occurred for 1 of 49 sample residents. Resident Identifier: 83. Findings include: Resident 83 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included type 2 diabetes mellitus with diabetic chronic kidney disease, muscle weakness, chronic pain, difficulty walking, hypokalemia, pseudobulbar affect, anxiety disorder, major depressive disorder, psychosis, post-traumatic stress disorder, and seizures. On 11/29/21 at 12:59 PM, resident 83 was observed awake lying flat on her back in bed. An interview was conducted with resident 83. Resident 83 stated she stays in her bed all day and that the lower part of her bed frame was not functioning. Resident 83 stated she wanted a bed where she could raise and lower her…

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 interviews and record review, it was determined the facility did not ensure a resident had the right to request, refuse, or discontinue treatment and to formulate an advance directive. Specifically, for 1 of 49 sample residents, the facility did not provide the resident with the right to have her advanced directives honored due to lack of lack of accessible Physician Orders for Life-Sustaining Treatment (POLST) for nursing staff review. Resident identifier: 60. Findings include: Resident 60 was admitted on [DATE] with medical diagnoses that included, but not limited to, cardiomyopathy, heart failure, chronic kidney disease, fibromyalgia, bipolar disorder, depressive disorder, anxiety disorder, and hypertension. On [DATE] at 1:05 PM, a review of resident 60's chart began in order to locate resident 60's advanced directives. Resident 60's Electronic Medical Record (EMR) did not include a copy of resident 60's POLST. Registered Nurse (RN) 1 stated there was a binder on each unit with a hard copy of 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 record review and interview it was determined, for 6 of 49 sample residents, that the facility did not ensure the prompt resolution of grievances. Additionally, the grievances completed by the resident council were not resolved. Resident identifiers: 3, 28, 45, 54, 60, and 75. Findings include: 1. The resident council meeting minutes for the previous three months were reviewed. Concerns and grievances included: a. missing laundry, misplaced laundry, slow laundry b. cold food, small serving sizes c. inadequate staffing Additional residents had complaints about the food: a. I can only describe it as brown. b. I wouldn't feed it to my dog. Additional residents had complaints about missing clothing: a. Missing 49ers jersey 2. On 12/2/21 at 4:21 PM, resident 28 was interviewed. Resident 28 stated that when laundry was marked and sent to be washed, there were many items that never returned. Resident 28 stated that the issues had not been resolved. Resident 28 stated that she attended resident council…

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 49 sample residents, with appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living. Specifically, one resident was provided with assistance as needed for mobility and communication. Resident identifiers: 18. Findings include: 1. Resident 18 was admitted to the facility on [DATE] with diagnoses that included a cognitive communication deficit, type II diabetes mellitus, anxiety disorder, chest pain, insomnia, and dementia. Resident 18 speaks Russian. On 11/30/21 at 8:55 AM, resident 18 was observed outside her room requesting help from staff in Russian. A Certified Nursing Assistant (CNA) 1 was observed directing resident 18 back to her room. CNA 1 was immediately interviewed. CNA 1 stated that she did not speak Russian, but she could usually understand what resident 18 needed because resident 18 would point to things in her room. CNA 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 interview, and record review it was determined, for 1 of 49 sampled residents, that the facility did not ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choice. Specifically, one resident's physician order for physical, speech and occupational therapies were not implemented. Resident identifiers: 70. Resident 70 was admitted to the facility on [DATE] then readmitted on [DATE] with diagnoses that included, encephalopathy, dysarthria, anarthria, cognitive communication deficit, muscle weakness, chronic obstructive pulmonary disease, type II diabetes mellitus, sepsis, bacterial infection, paraplegia, major depressive disorder, spina bifida, and morbid obesity. On 12/1/21 resident 70's medical record was reviewed. A care plan dated 5/3/21 had a focus of limited physical mobility r/t (related to) neurological deficits and weakness. A goal dated 9/29/21 that resident will demonstrate…

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 the facility did not ensure that residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 of 49 sample residents. Specifically, one resident admitted with two pressure ulcers received additional pressure ulcers which progressed to stage IV with osteomyelitis (bone infection) that required intravenous antibiotics. Resident identifier: 97. Findings include: Resident 97 was admitted to the facility on [DATE] with diagnoses that included type II diabetes, pressure ulcers of the sacral region and heel, obesity, cognitive communication deficit, a urostomy, neuromuscular dysfunction of the bladder, sepsis, disease of the spinal cord, and paraplegia. Subsequent to admission, resident 97 was diagnosed with reduced mobility, COVID-19, a colostomy, tremor, abnormal involuntary movements, and dehydration.…

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 that the facility did not maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range, unless the resident's clinical condition demonstrated that this was not possible and did not offer a therapeutic diet when there was a nutritional problem and the health care provider ordered a therapeutic diet. Specifically, Resident 67 did not have nutritional orders implemented or followed. Resident identifier: 67. Resident 67 was admitted to the facility on [DATE] with diagnoses that included: paraplegia, sacral pressure ulcers, acute respiratory failure with hypercapnia, neuromuscular dysfunction of bladder, and type II diabetes mellitus with hyperglycemia. Findings include: On 11/29/21 at 10:30 AM an interview was conducted with Resident 67. Resident 67 stated that he had doctor's orders for Ensure brand protein drink, specifically, the Ensure Max Protein variety. Resident 67 said I need all the protein…

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 for 1 of 49 sample residents that the facility did not ensure that pain management was provided to a resident consistent with professional standards, and the resident's goals and preferences. Specifically, a resident reported he had asked to have his pain medication administration times spread out throughout the day to alleviate his pain and this was not done. Resident identifier 45. Findings included: Resident 45 was admitted to the facility on [DATE] with diagnosis that included, emphysema, generalized muscle weakness, difficulty walking, cognitive communication deficit, fracture of lumbar vertebra, lumbago with sciatica, major depressive disorder, post-traumatic stress disorder, chronic pain, type II diabetes mellitus, and atherosclerotic hear disease. On 11/29/21 at 11:43 AM, an interview was conducted with resident 45. Resident 45 stated he had tried to get his pain medication times spread out because the medication did not work to control his pain…

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 ensure that each drug regimen was free from unnecessary drugs for 1 of 49 sample residents. An unnecessary drug is any drug when used in excessive dose; excessive duration; without adequate monitoring; without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued. Specifically, a resident's insulin was not administered according to physician's orders. Resident identifiers: 70. Findings include: Resident 70 was admitted to the facility on 5/321 then readmitted on [DATE] with diagnoses which included, encephalopathy, dysarthria, anarthria, cognitive communication deficit, muscle weakness, chronic obstructive pulmonary disease, type II diabetes mellitus, sepsis, bacterial infection, paraplegia, major depressive disorder, spina bifida, and morbid obesity. On 12/1/21 resident 70's medical record was reviewed. Physician orders revealed the following 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 store drugs and biologicals under proper temperature. Specifically two of four medication room refrigerators' temperatures were out the safe refrigerated storage temperature range of 36 degrees to 46 degrees Fahrenheit. Findings include: On 12/6/21 four medication rooms in the facility were sampled to inspect if drugs and biologicals were labeled and stored appropriately. There was a locked medication refrigerator in each of the four medication rooms. Near each medication refrigerator, was a Refrigerator Temperatures Log. Inside each refrigerator there were multiple medications and a thermometer. 1. Royal Front Medication Room: The medication refrigerator was clean, organized and the temperature in the refrigerator was within the safe refrigerated storage temperature range of 36 degrees to 46 degrees Fahrenheit. 2. Royal Back Medication Room: The medication refrigerator was clean, organized and the temperature in the refrigerator was within the safe refrigerated storage temperature range of 36 degrees to 46…

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 observations, interviews and record review it was determined the facility did not ensure each resident received drinks, including water and other liquids, consistent with the residents' needs and preferences to maintain resident hydration. Specifically, for 1 of the sample 49 residents, a resident with a physician order for thickened liquids was provided with thin, regular consistency water at meal time and during the day. Resident identifier: 22. Findings include: Resident 22 was admitted to the facility on [DATE] with medical diagnoses that included, but not limited to, dysphagia, respiratory failure, multiple sclerosis, cognitive communication deficit, seizures, contracture of muscle, hypertension, and hyperlipidemia. On 12/1/21 at 12:32 PM, an observation of tray line was made. Dietary Aide 1 plated beverages onto meal trays for service. On the lunch tray for resident 22, no beverage was supplied. At 12:42 PM, Dietary Aide 2 stated thickened liquids were sent on the trays for residents who required…

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 2. Resident 45 was admitted to the facility on [DATE] with diagnosis which included, emphysema, generalized muscle weakness, difficulty walking, cognitive communication deficit, fracture of lumbar vertebra, lumbago with sciatica, major depressive disorder, post-traumatic stress disorder, chronic pain, type II diabetes mellitus, and atherosclerotic hear disease. On 11/29/21 at 1143 AM, an interview was conducted with resident 45. Resident 45 stated he had tried to get his pain medication times spread out because they do not work to control his pain all day. Resident 45 stated he went to the pain clinic last week and the pain clinic recommended resident 45's pain medications be changed but nothing has happened. Resident 45 medical record was reviewed on 12/1/21. Resident 45 did not have scanned Pain Clinic paperwork from his appointment. Physician's orders were reviewed and the following were documented: a. On 10/26/21 referral to pain clinic. On 10/28/21 at 1:40 PM, a Physician progress note documented, Often…

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.