Monument Healthcare South Salt Lake

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, for 1 of 61 sampled residents, the facility did not provide care and services to maintain or improve a resident's ability to carry out the activities of daily living. Specifically, a resident's bed was positioned against a wall so that his inoperable hand was facing his environment, diminishing his abilities in activities of daily living. Resident identifier: 67.Findings included:Resident 67 was admitted on [DATE] with diagnoses which included hemiplegia, cerebral infarction, contracture left elbow, memory deficit, major depressive disorder, contracture left knee, and mood disorder.On 6/9/25 at 1:08 PM, an observation was made of resident 67 lying slumped down in bed with his head of bed elevated to 90 degrees, shirt pulled up and blankets partially covering his lower extremities. Resident 67's legs were bare, knees were bent and lying sideways in the bed with feet against the footboard and resident 67's upper body positioned approximately at midpoint in his bed…

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, for 1 out of 61 sampled residents, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice and resident's choices. Specifically, a resident's diabetes was not managed with required documentation, timely referral to outside services or diet management according to physician's orders and resident's choice. Resident identifier: 36.Findings included: Resident 36 was re-admitted on [DATE] with diagnoses of hemiplegia/hemiparesis, chronic respiratory failure, morbid obesity, major depressive disorder, type 1 diabetes, epilepsy and generalized anxiety disorder.On 6/12/25 at 8:07 AM, an interview was conducted with resident 36. Resident 36 stated he was not doing so great. Resident 36 stated he had a reminder on his amazon echo in the evening on 6/11/25, to take his blood glucose level which was reading Hi (high) on his continuous monitor, indicating his blood glucose level was over 400 milligrams per…

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, for 2 out of 61 sampled residents, the facility did not ensure that residents were offered a therapeutic diet when the therapeutic diet was ordered. Specifically, a resident on a diabetic diet was not provided a low carbohydrate option. In addition, a resident complained of not being provided a renal diet. Resident identifier: 36 and 79. Findings included: 1. On 6/12/25 at 8:07 AM, an interview was conducted with resident 36. Resident 36 stated he was not doing so great. Resident 36 stated he had a reminder on his amazon echo in the evening on 6/11/25, to take his blood glucose level which was reading Hi (high) on his continuous monitor, indicating his blood glucose level was over 400 milligrams per deciliter (mg/dL). On 6/12/25 at 8:27 AM, an interview was conducted with resident 36's family member. The family member asked resident 36 if he was still alive. Resident 36 told the family member about the Hi blood glucose reading on the continuous monitor and 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 that for 1 of 61 sampled residents, the facility did not provide routine and emergency drugs and biologicals to its residents. Specifically, a resident did not have an Invega injection available when it was scheduled to be administered. Resident identifiers: 59.Findings included:Resident 59 was admitted to the facility on [DATE] with diagnosis which included severe dementia with agitation, paranoid schizophrenia, type 2 diabetes, generalized anxiety disorder, delusional disorders, insomnia, schizoaffective disorder, and essential hypertension.Resident 59's medical record was reviewed on 6/9/25 through 6/19/25.On 4/10/25, a 117 milligram (mg) Invega intramuscular injection was scheduled for administration. This order, which was started on 2/6/25 and discontinued on 4/14/25, was scheduled to be administrated every 21 days. On 4/10/25 at 4:21 PM, a Medication Administration Note stated that the ordered Invega injection was not administered because Injection…

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, for 2 of 61 sampled residents, the facility did not arrange services with an outside agency in a timely manner. Specifically, a resident that needed dental services did not have those services scheduled, and a resident did not have an endocrinology appointment scheduled after a referral from the physician. Resident identifiers: 36 and 64. Findings included: 1. Resident 64 was admitted to the facility on [DATE] with diagnoses that included Parkinson's disease, schizoaffective disorder, adult failure to thrive, dysphagia, dementia, and morbid obesity. On 6/9/25 at 11:00 AM, an interview was conducted with resident 64 who stated she had seen a dentist in 2024 and was told she needed to see an outside dentist for further treatment. Resident 64 stated she had not yet seen an outside dentist. Resident 64's medical records were reviewed between 6/9/25 and 6/19/25. A physician order dated 8/24/24 revealed, May have dental, vision & eye health, hearing, wound and podiatry consults as…

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 2 of 61 sampled residents, that the facility failed to maintain medical records on each resident that was complete, accurately documented, readily accessible, and systematically organized; and failed to ensure the medical record contained the results of any preadmission screening and resident review evaluations and determinations conducted by the State; and physician, nurse, and other licensed professionals progress notes. Specifically, one resident had an updated Pre-admission Screening/Resident Review (PASRR) that was not located in the medical record and one resident had no documentation regarding an elopement. Resident identifiers: 82 and 103.Findings included:1. Resident 82 was admitted to the facility on [DATE] with diagnoses which included severe vascular dementia, hypertension, attention and concentration deficit following cerebral infarction, depression, and cognitive communication deficit.Resident 82's medical record was reviewed 6/9/25…

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 and interview, the facility failed to maintain a safe and sanitary environment to prevent the potential transmission of communicable diseases and infections for 1 out of 61 sampled residents. Specifically, staff were not wearing Enhanced Barrier Precautions (EBP) for a resident with chronic wounds and a tube feed when caring for the resident and the tube feed was not capped when not in use. Resident identifier: 90.Findings included:Resident 90 was admitted to the facility on [DATE] with diagnoses which included, pressure ulcer of sacral region stage 4, adult failure to thrive, and unspecified severe protein-calorie malnutrition.On 6/9/25 at 10:58 AM, an interview was conducted with resident 90. Resident 90 stated that his tube feed was continuous, but was stopped and disconnected when he went outside the facility to smoke. Resident 90 stated that staff wore gloves when changing him, but not gowns. On 6/9/25 at 1:03 PM, an observation was made of resident 90's tube feed. Resident 90 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 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 vials were not labeled with open dates and the insulin vials 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 and a pill was observed on the floor in the hallway accessible to residents. Findings included: 1. On 1/24/24 at 8:17 AM, an observation was conducted of Registered Nurse (RN) 1 performing medication pass to residents. An observation of RN 1's medication cart was made. The insulin Lispro glass via was observed and was open for administration and was not labeled with an open date. RN 1 was immediately interviewed. RN 1 stated…

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, food items in the walk-in freezer were open to air and the resident refrigerator was unclean and contained unlabeled and undated food items. Findings included: 1. On 1/22/24 at 8:15 AM, an initial walk-through was conducted in the kitchen. In the walk-in freezer, a box of frozen sausage patties was open to air and a box of frozen biscuits was open to air. On 1/25/24 at 9:59 AM, a second walk-through was conducted in the kitchen. In the walk-in freezer, a box of beef patties was open to air, a box of frozen sausage patties was open to air, a box of frozen biscuits was open to air, a box of peanut butter cookie dough was open to air, and a box of sugar cookie dough was open to air. On 1/25/24 at 10:28 AM, an interview was conducted with the Dietary Manager (DM). The DM stated when a food item was removed from the freezer, there was very little, if any, of the food product left so the few that were left would…

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). Specifically, for 1 out of 26 sampled residents, notification to the SSA and APS was not done when a resident with cognitive impairment eloped from the facility. Resident identifier: 7. Findings included: Resident 7 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included focal traumatic brain injury without loss of consciousness, schizoaffective disorder, vascular dementia, hemiplegia and hemiparesis following cerebral infarction affection left non dominant side, history of falling, need for assistance with personal care, anxiety disorder, and personal history of traumatic brain injury. Resident 7'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 interviews and record review, the facility did not develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care, and be developed within 48 hours of the resident's admission. Specifically, for 1 out of 26 sampled residents, a resident's baseline care plan was developed four days after the resident admitted to the facility. Resident identifier: 143. Resident 143 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included benign neoplasm of meninges, pressure ulcer of left buttock stage 4, and cognitive communication deficit. Resident 143's medical record was reviewed on 1/23/24. A care plan Focus initiated on 5/2/23, documented [Resident 143] has skin graft donor sites to bilateral thighs on admission to the facility. The interventions included, Wound care per orders. A care plan Focus initiated on 5/2/23, documented Code…

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 develop and implement a comprehensive person-centered care plan 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, for 1 out of 26 sampled residents, the resident's Care Area Assessment (CAA) Summary of the admission Minimum Data Set (MDS) assessment triggered a care plan for pressure ulcer/injury and the care plan was not developed until 5/8/23, after the resident developed a pressure ulcer/injury. Resident identifier: 143. Findings included: Resident 143 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included benign neoplasm of meninges, pressure ulcer of left buttock stage 4, and cognitive communication deficit. Resident 143's medical record was reviewed on 1/23/24. On 4/28/23 at 1:54 PM, a Nursing Note documented Note Text: . alert 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, the facility failed to ensure that each resident received adequate supervision to prevent accidents. Specifically, for 1 out of 26 sampled residents, a resident with cognitive impairment eloped from the facility on two separate occasions. Resident identifier: 7. Findings included: Resident 7 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included focal traumatic brain injury without loss of consciousness, schizoaffective disorder, vascular dementia, hemiplegia and hemiparesis following cerebral infarction affection left non dominant side, history of falling, need for assistance with personal care, anxiety disorder, and personal history of traumatic brain injury. Resident 7's medical record was reviewed on 1/24/24. A care plan Focus initiated on 6/19/2020, documented [Resident 7] is an elopement risk/wanderer. The Focus was revised on 4/18/23. The interventions included, but were not limited to: a. Monitor location as necessary. Initiated…

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 2 out of 26 sampled residents, medications were not administered as ordered by the physician due to the medications not being available by the pharmacy. One resident was not administered their mood disturbance medication, anti-tremor medication, and a medication for sleep. In addition, a resident was not administered their blood thinning medication to prevent blood clots and an antibiotic that was used to treat a wound infection. Resident Identifiers: 7 and 143. Findings Included: 1. Resident 7 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included focal traumatic brain injury without loss of consciousness, schizoaffective disorder, vascular dementia, hemiplegia and hemiparesis following cerebral infarction affection left non dominant side, history of falling, need for assistance with personal care, anxiety disorder, and personal…

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 establish and 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. Specifically, staff members were observed to touch the resident's medications and the inside of the medication cups with bare hands during medication administration. Resident identifier: 9. Findings included: On 1/24/24 at 8:26 AM, an observation was made of Registered Nurse (RN) 3 during medication administration. RN 3 grabbed a medication cup on the base of the cup, she then placed it on the medication cart and then grabbed it again placing a bare right hand finger inside of the medication cup. On 1/24/24 at 8:28 AM, an observation was made of RN 3. RN 3 took a medication bottle from the medication cart, she opened the bottle and shook the pill bottle until a pill was near the edge of the bottle. RN 3 took a bare right hand finger and touched the medication, placing it into the bottle lid and then…

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 it was determined that the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, the dishwasher did not meet the required minimum temperatures during the wash cycle. Findings include 1. On 3/14/22 at 7:29 AM, an initial tour of the kitchen was conducted. The dish machine log temperature form was reviewed. The following temperatures were documented: [Note: All temperatures were in degrees Fahrenheit.] a. On 2/21/22, the temperature for dinner dish washing cycle was 118 b. On 2/22/22, the temperature for the dinner dish washing cycle was 119. c. On 3/2/22, the temperature for the dinner dish washing cycle was 115. d. On 3/6/22, the temperature for the dinner dish washing cycle was 116. The bottom of the Dish Machine Log revealed Chemical Sanitizing (Low temp): Wash 120-140 and Rinse 120-140. 2. On 3/17/22 at 2:30 PM, an observation of the dishwasher was made. The wash cycle of the dishwasher reached 111.6 degrees Fahrenheit. The dishwasher was a low temperature…

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 conduct and document a facility-wide assessment to determine what resources were necessary to care for its residents competently during both day-to-day operations and emergencies. The facility assessment must address or include both the number of residents and facility's resident capacity; the care required by the resident population considering the types of diseases, conditions, physical and cognitive disabilities, overall acuity, and other pertinent facts that were present within that population; the staff competencies that were necessary to provide the level and types of care needed for the resident population; the physical environment, equipment, services, and other physical plan considerations that were necessary to care for this population; and any ethnic, cultural, or religious factors that may potentially affect the care provided by the facility, including but not limited to, activities and food and nutrition services. Specifically, the facility did not have a facility assessment. Findings include: On 3/14/22, 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 observation, interview and record review it was determined, for 5 of 51 sample residents, that residents were not able to make choices about aspects of their life in the facility that were significant to residents. Specifically, the facility did not allow residents to smoke independently after being evaluated. In addition, a resident requested coffee and was not provided it. Resident identifiers: 47, 51, 52, 59 and 196. Findings include: 1. Resident 47 was admitted to the facility on [DATE] with diagnoses which included schizophrenia, post-traumatic stress disorder, polyneuropathy, unspecified asthma, and generalized anxiety disorder. On 3/14/22 at 11:15 AM, an interview was conducted with resident 47. Resident 47 stated that she wished that the facility .would let me smoke when I like. Resident 47 further explained They took away our cigarettes and lighters which I can understand, but they can't be taking away our smoking times. We have rights you know. Resident 47's medical record was reviewed on…

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, for 4 of 51 sample residents, that the facility did not immediately consult with the resident's physician when residents experienced a significant change in physical, mental, or psychosocial status. Specifically, the physician was not notified for 8 days of a resident's worsening wound condition and the physician was not notified when a resident experienced low blood glucose levels. In addition, the physician was not notified a resident was screaming out in pain during the night and the physician was not notified a open wounds on a resident's foot. Resident identifier: 4, 76, 194 and 198. Findings included: 1. Resident 76 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included multiple sclerosis, morbid obesity, paraplegia, unspecified, cognitive communication deficit, limitation of activities due to disability, schizoaffective disorder, bipolar type, major depressive disorder, muscle weakness, pain in unspecified limb,…

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 12 of 51 sample residents, that the facility did not provide a safe, clean, comfortable, and homelike environment, allowing the residents to use his or her personal belongings to the extent possible. Specifically, there were multiple complaints from residents and observations of rooms in the facility that were unclean, needed to be repainted, and had a urine odor. Additionally, certain areas in the facility had holes in the walls, and sinks that did not drain. Resident identifiers: 10, 15, 23, 41, 51, 58, 62, 68, 72, 82, 198 and 200. Findings included: 1. Resident rooms and areas that were not homelike: On 3/14/22 at 7:29 AM, an initial tour of the facility was conducted. The following observations were made: a. The dining room was observed to have open sugar packets on the floor. There were 2 dirty trays on the tables. There was a carton of open milk on a table. The tables were soiled with debris. b. The wall outside rooms [ROOM NUMBERS]…

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 4 of 51 sampled residents, that the facility did not implement written policies and procedures that prohibit and prevent abuse and neglect. Specifically, the facility did not demonstrate implementation of their abuse policy through timely investigation and reporting of suspected abuse to the Administrator (ADM), State Survey Agency (SSA), and Adult Protective Services (APS). Resident identifiers: 15, 19, 194, and 196. Findings included: 1. Resident 19 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included schizoaffective disorder, bipolar disorder, anxiety disorder, major depressive disorder, dementia, history of traumatic brain injury (TBI), cognitive communication deficit, type 2 diabetes mellitus and insomnia. Review of the facility final investigation report for sexual abuse on 3/11/22 documented that on 3/5/22 at 2:00 PM resident 19 reported to Registered Nurse (RN) 5 that she had asked resident 196 to stop…

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, for 3 out of 51 sampled residents, that the facility did not ensure that all alleged violations involving abuse and neglect were reported immediately, but not later than 2 hours after the allegation was made, to the administrator (ADM) of the facility and to the State Survey Agency (SSA) and Adult Protective Services (APS). Specifically, an incident of sexual abuse, an incident of neglect with verbal abuse, and an incident of physical abuse were not reported to the ADM, SSA or APS within 2 hours after the identification or occurrence of the incident happening. Resident identifiers: 19, 194, and 196. Findings included: 1. Incident of sexual abuse between resident 19 and resident 196. Review of the facility final investigation report for sexual abuse on 3/11/22 documented that on 3/5/22 at 2:00 PM resident 19 reported to Registered Nurse (RN) 5 that she had asked resident 196 to stop kissing her breasts and that he did not immediately stop. RN 5 reported the incident to the facility Administrator (ADM) and an investigation 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, it was determined that, for 3 of 51 sampled residents, the facility did not develop and implement a comprehensive person-centered care plan for each resident that described services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Specifically, a resident who was observed to be smoking was not identified as a smoker did not have a smoking care plan. In addition, the facility staff did not update a resident's care plan in a timely manner when a wound requiring treatment was identified and a resident with limited range of motion did not have interventions for therapy and splints on the care plan. In addition, Resident identifiers: 23, 38 and 76. Findings include: 1. Resident 38 was admitted to the facility on [DATE] with diagnoses that included chronic respiratory failure with hypoxia, schizoaffective disorder, type 2 diabetes mellitus, and obstructive sleep apnea. On 3/14/22 at 11:49…

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 4 of 51 sampled residents, that the facility did not provide the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living (ADL's). Specifically, resident showers were not being completed according to their shower schedule. Resident identifiers: 41, 64, 82, 198. Findings include 1. Resident 64 was admitted to the facility on [DATE] with a diagnoses that included Parkinson's Disease, muscle weakness, difficulty in walking, polyneuropathy, and major depressive disorder. On 3/14/22 at 11:36 AM, an interview was conducted with resident 64. Resident 64 stated she had been in clothes since yesterday. Resident 64 stated she woke-up yesterday in urine and bowel. Resident 64 stated she wanted a shower but did not get a shower. On 3/17/22 at 10:45 AM, an interview with resident 64 was conducted. Resident 64 stated that her shower schedule was every Monday, Wednesday, and Friday. Resident 64 stated…

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, for 10 of 51 sample residents, that the facility did not have sufficient nursing staff with the appropriate competencies and skill set to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physicial, mental, and psychosocial well-being of each resident, as determined by resident assessment and individual plans of care and considering the number, acuity and diagnosies of the facility's resident population in accordance with the facility assessment. Specifically, there was no facility asssessment to determine staffing needs for resident. Resident identifiers: 6, 9, 15, 29, 36, 58, 62, 194, 198 and 201. Findings included: 1. On 03/14/22 at 7:41 AM, an interview was conducted with resident 9. Resident 9 stated the response time to call lights depended on who was working. Resident 9 stated that he usually had to wait about 30 minutes for someone to answer his call light. Resident 9 stated in the afternoons was when he had waited the longest for someone to answer…

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 and interview it was determined that, for 12 of 51 sampled residents, that the facility did not provide food prepared by methods that conserve nutritive value, flavor, and appearance; food and drink that was not palatable, attractive, and at a safe and appetizing temperature. Specifically, multiple residents complained about the palatability of the food, appearance of the food, and repetition of meals. Resident identifiers: 4, 10, 15, 32, 36, 48, 51, 58, 62, 64, 80 and 81. Findings include On 3/14/22 at 12:30 PM, an interview with resident 51 was conducted. Resident 51 stated that the food tasted like school lunch, and he refused to eat it. On 3/14/22 at 1:30 PM, an interview with resident 15 was conducted. Resident 15 stated the food was not good. Resident 15 stated that her family member brought in food for her so she did not have to eat the meals provided by the facility. On 3/14/22 at 10:34 AM, an interview with resident 62 was conducted. Resident 62 stated that the food often arrived cold or lukewarm. Resident 62 stated that the facility often did not…

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 failed to establish an infection prevention and control program designed to prevent the development and transmission of COVID-19. Specifically, food was observed to be transported through the hallways uncovered, the staff were observed entering resident rooms without proper Personal Protective Equipment (PPE), and soiled PPE was observed to be transported through the hallways, and resident care equipment was not sanitized. Findings include: 1. Dining Observations: On 3/14/22 at 8:30 AM, observations were made of the breakfast meal service in the 300 and 500 hallway. The cart in the 300 hallway was parked halfway down the hallway. Trays were observed to be transported through the hallway without a condiment cup with syrup covered. At 8:36 AM, an observation was made of the Dietary Manager transporting the 400 hall meal cart to the hallway. There was a tray observed on top with syrup that was uncovered. The meal cart had been transported from…

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 51 sample residents, that the facility did not treat each resident with respect, dignity and care, in a manner and in an environment that promoted maintenance and enhancement of his or her quality of life. Specifically, residents were observed to have urine soaked beds. Resident identifiers: 58 and 82. Findings included: 1. Resident 82 was admitted to the facility on [DATE] with diagnoses which included cerebral palsy (CP), chronic myeloid leukemia, schizoaffective disorder, post-traumatic stress disorder (PTSD) and major depressive disorder. On 3/14/22 at 10:08 AM, an interview was conducted with resident 82. Resident 82 stated staff changed his brief before bed the pervious night and then again just now. An observation was made of resident 82's bed. Resident 82's bed was observed to be saturated with urine and had a strong urine odor. Resident 82 stated his bed was saturated with urine and smelled. Resident 82 stated he was not…

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 reviews it was determined, for 1 of 51 sample residents, that the facility failed to assure Pre-admission Screening and Resident Review (PASARR) screening was accurately completed. Resident identifiers: 16. Findings include: Resident 16 was admitted to the facility on [DATE] with diagnoses that included post-traumatic stress disorder, other stimulant abuse, chronic obstructive pulmonary disease, and right foot drop. On 3/21/2022 at 1:15 PM, a record review was conducted of Resident 16's electronic health record. No PASARR screening was found. On 3/21/2022 at 4:06 PM, an interview was conducted with the facility's Director of Mental Health Services/Master's of Social Work (MSW). MSW stated there was not a PASARR completed. MSW stated the resident was private pay and she was not aware that a PASARR needed to be completed.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined, for 1 of 51 sample residents, that the facility did not develop a baseline care plan for each resident that included instructions needed to provide effective and person-centered care of the resident that met professional standards of quality care. Specifically, a resident had wounds identified on their admission assessment and the baseline care plan did not address the skin condition or wound care treatment. Resident identifier: 198. Findings included: Resident 198 was admitted to the facility on [DATE] with diagnoses of fracture of right humerus, ground level fall, alcohol dependence, type 2 diabetes mellitus, chronic obstructive pulmonary disease, cellulitis of left lower limb, hypertension, hyperlipidemia, hypothyroidism, sleep apnea, dorsalgia, major depressive disorder, anxiety disorder, gastro-esophageal reflux disease, and chronic pain. On 3/14/22 at 1:18 PM, an interview was conducted with resident 198. Resident 198 stated that he had open wounds on…

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 51 sample residents, that the facility did not ensure a resident who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain good grooming and personal hygiene. Specifically, a resident was not provided showers according to their schedule. Resident identifier: 36. Findings included: Resident 36 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included congestive heart failure (CHF), chronic respiratory failure with hypoxia, muscle weakness and major depressive disorder. On 3/14/22 at 1:43 PM, an interview was conducted with resident 36. Resident 36 stated she would like to be showered 3 to 4 times per week. Resident 36 stated she was showered one to two times per week. Resident 36 stated she was showered a few days ago because she went a long time without a bed bath. Resident 36's roommate stated that resident 36's hair was matted and it was not healthy to go 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 51 sample residents, that the facility did not ensure residents received proper treatment and care to maintain good foot health. Specifically, staff did not review the podiatrist's recommendations in a timely manner, resulting in the delay of proper treatment of a resident's foot issues. Resident identifier: 76. Findings included: Resident 76 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included multiple sclerosis, morbid obesity, paraplegia, cognitive communication deficit, limitation of activities due to disability, schizoaffective disorder, bipolar type, major depressive disorder, muscle weakness, pain in unspecified limb and borderline personality disorder. On 3/21/22 at 3:29 PM, an interview was conducted with unit manager (UM) 2. UM 2 stated the latest podiatry visit note for resident 76 was not in the electronic health record (EHR) but she would provide a copy for review. On 3/21/22 at 5:57 PM, 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 observation, interview, and record review, it was determined, for 2 of 51 sample residents, that the facility did not ensure that residents with limited range of motion received appropriate treatment and services to increase and/or prevent further decrease in range of motion. In addition, the facility did not ensure that residents with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence. Specifically, a resident with limited range of motion did not have a splint that was recommended by Occupational Therapy. In addition, a resident was not provided bilateral positioning bars so she was able to reposition herself. Resident identifiers: 23 and 48. Findings included: 1. Resident 23 was admitted to the facility on [DATE] with diagnoses that included cerebral palsy, paralytic syndrome, age-related osteoporosis, difficulty in walking, mood disorder, cognitive communication deficit, and muscle weakness. On 3/15/22 at…

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, observations, and record reviews it was determined that, for 2 of 51 sampled residents, the facility did not ensure that the resident environment remained as free of accident hazards as was possible; and each resident received adequate supervision and assistance devices to prevent accidents. Specifically, one resident was observed smoking without protective equipment that he was assessed to need. In addition, another resident was observed smoking and did not have a smoking assessment. Resident identifier: 5 and 38. Findings include: 1. Resident 5 was admitted to the facility on [DATE] with diagnoses that included acute respiratory failure with hypoxia, type 2 diabetes mellitus, schizophrenia, obesity, hypothyroidism, and hypertension. On 3/14/22 at 11:38 AM, an interview was conducted with Resident 5. Resident 5 stated staff had him sign a paper about smoking a few weeks back and all residents were on a schedule now. Resident 5 stated that he only got to go out when staff said he could. On…

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 51 sample residents, that the facility did not ensure based on resident's comprehensive assessment, that a resident who was incontinent received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible. Specifically, a resident was evaluated to be a good candidate for a bladder retraining program and the resident was not provided the program. In addition, the resident and another resident were observed to be in urine soaked beds. Resident identifiers: 58 and 82. Findings included: 1. Resident 82 was admitted to the facility on [DATE] with diagnoses which included cerebral palsy (CP), chronic myeloid leukemia, schizoaffective disorder, post-traumatic stress disorder (PTSD) and major depressive disorder. On 3/14/22 at 10:08 AM, an interview was conducted with resident 82. Resident 82 stated staff changed his brief before bed the pervious night and then just now. An…

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 establish an infection prevention and control program that included an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use for 1 of 51 sample residents. Specifically, a resident was receiving an antibiotic prophylactically, with no indication for use or periodic review of the necessity of the antibiotic. Resident identifier: 4. Findings include: Resident 4 was admitted on [DATE] and readmitted on [DATE] with diagnoses that included diabetes mellitus, protein calorie malnutrition, and schizoaffective disorder. Resident 4's medical record was reviewed on 3/15/22. Resident 4's physician orders and Medication Administration Record (MAR) for March 2022 were reviewed. The orders and MAR indicated that resident 4 had been receiving Doxycycline Hyclate 100 milligrams twice daily since 7/25/17. The diagnosis listed for the antibiotic medication was prophylaxis. On 2/24/22, the resident's physician assessed…

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 51 sample resident, that the facility did not follow the Centers for Disease Control and Prevention (CDC) and Advisory Committee on Immunization Practices (ACIP) guidelines to offer pneumococcal immunizations. Specifically, a resident had no record of receiving the pneumococcal vaccine per CDC and ACIP guidelines. Resident Identifier: 196 Findings include: Resident 196 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus, paranoid schizophrenia, hyperlipidemia, and encounter for immunization. On 3/21/22, Resident 196's medical record was reviewed. Resident 196's immunization history revealed that he consented to receive the pneumococcal vaccine on 2/11/2020. There was no documentation found in the medical record that the pneumococcal vaccine was administered. On 3/21/22 an interview was conducted with Unit Manager (UM) 3. UM 3 stated We normally always have a copy of the administration of a vaccine uploaded,…

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 51 sample residents, that the facility did not have each bed with ceiling suspended curtains, which extended around the bed to provide total visual privacy in combination with adjacent walls and curtains. Specifically, the curtains in a resident's room did not have the ability to close all the way, leaving the resident to not have full visual privacy. Resident identifier: 62 Findings include 1. Resident 62 was initially admitted to the facility on [DATE] and again on 8/6/21 with diagnoses that included atherosclerotic heart disease, epilepsy, asthma, major depressive disorder, muscle weakness, generalized anxiety disorder, and muscle weakness. On 3/21/22 at 10:20 AM, an observation was made in resident 62's room. It was observed that resident 62 shared a room with another resident. It was observed that the privacy curtain was unable to close completely, leaving approximately a 1-foot gap of open space near the entrance of the 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.